The accuracy of the clinical knee examination documented by arthroscopy. A prospective study

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review

OBJECTIVE

To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs).

DESIGN

Scoping review.

DATA SOURCES

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary.

RESULTS

Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups.

CONCLUSIONS

There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings

Background

Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a preliminary step to designing a primary point-of-care clinical decision support tool.

Methods

Electronic medical records (EMRs) of individuals aged 15–45 years, with ICD-9 codes corresponding to a knee condition, and confirmed (ACL⁺) or denied (ACL⁻) first-time ACL tear seen at a University-based Clinic between 2014 and 2016 were eligible for inclusion. Demographics, relevant diagnostic indicators and ACL status based on orthopaedic surgeon assessment and/or MRI reports were manually extracted. Descriptive statistics calculated for all variables by ACL status. Univariate between group comparisons, clinician surveys (n = 17), availability of data and univariable logistic regression (95%CI) were used to select variables for inclusion into multivariable logistic regression models that assessed the odds (95%CI) of an ACL-tear based on patient-reported variables alone (consistent with primary point-of-care practice), or in combination with clinician-generated variables. Model performance was assessed by accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95%CI).

Results

Of 1512 potentially relevant EMRs, 725 were included. Participant median age was 26 years (range 15–45), 48% were female and 60% had an ACL tear. A combination of patient-reported (age, sport-related injury, immediate swelling, family history of ACL tear) and clinician-generated (Lachman test result) variables were superior for ACL tear diagnosis [accuracy; 0.95 (90,98), sensitivity; 0.97 (0.88,0.98), specificity; 0.95 (0.82,0.99)] compared to the patient-reported variables alone [accuracy; 84% (77,89), sensitivity; 0.60 (0.44,0.74), specificity; 0.95 (0.89,0.98)].

Conclusions

A high proportion of individuals without an ACL tear can be accurately identified by considering patient-reported age, injury setting, immediate swelling and family history of ACL tear. These findings directly inform the development of a clinical decision support tool to facilitate timely and accurate ACL tear diagnosis in primary care settings.

Diagnostic Value of Stress Radiography and Arthrometer Measurement for Anterior Instability in Anterior Cruciate Ligament Injured Knees at Different Knee Flexion Position

PURPOSE

To evaluate diagnostic value of stress radiography and arthrometer measurements for anterior instability at different knee flexion angle positions.

METHODS

Forty-three patients with complete anterior cruciate ligament (ACL) rupture (group 1) and 37 normal subjects (group 2) were enrolled prospectively. Arthrometer (KT-1000) measurements and stress radiography by Telos were used to evaluate side-to-side differences. Results were recorded according to the knee position (30°, 45°, 60°, and 90°). Areas under the receiver operating characteristic curves (AUCs) were used to evaluate the diagnostic accuracy of each evaluation method. The calculated cutoff values at 30° position were used to evaluate the sensitivity and specificity of combined evaluation with stress radiography and arthrometer measurements.

RESULTS

The side-to-side differences on stress radiography and arthrometer measurements were significantly different between groups (P < .05), except for the values at the 90° position in arthrometer measurements (P = .844). The amount of anterior translation decreased in both arthrometer measurements and stress radiography between 30° and 45° positions (P < .000); however, no further decrease was observed beyond 45°. The AUC of stress radiography at the 30° position was significantly higher than other values (AUC = 0.955; P = .000). Moreover, the clinical cutoff value of 3 mm showed 86.0% sensitivity and 89.2% specificity in stress radiography at 30°, which were higher than those in arthrometer measurements. Combined use of stress radiography and arthrometer measurements at the 30° position showed 100% sensitivity and 59.5% specificity as a screening test.

CONCLUSIONS

Evaluation at the 30° knee position was significantly superior to that at other positions for both stress radiography and arthrometer measurements, whereas the 90° knee flexion position was not meaningful for any measurements. Evaluation needs to be performed with a 3-mm cutoff value for stress radiography at the 30° knee position; however, combined use of stress radiography and arthrometer measurements at the 30° knee flexion can have a higher diagnostic value.

LEVEL OF EVIDENCE

Level I, diagnostic study of established criteria.

Use of ultrasonography to evaluate the dynamics of the infrapatellar fat pad after anterior cruciate ligament reconstruction: a feasibility study

PURPOSE

There has been no specific study on the quantitative morphological changes that occur in the infrapatellar fat pad (IPFP) after anterior cruciate ligament (ACL) reconstruction. We used ultrasonography to evaluate the dynamics of the IPFP in knees after ACL reconstruction using the contralateral knees as controls.

METHODS

We enrolled 31 patients 3 months after they underwent ACL reconstruction. The thickness of the superficial part of the IPFP was measured using longitudinally oriented ultrasound images of the anterior part of both knees at 90° and 10° flexion. We then used these data to calculate the ratio of the change in thickness.

RESULTS

At 90° knee flexion, the superficial part of the IPFP was significantly thinner in the reconstructed knees (9.3 ± 3.4 mm) than in the contralateral knees (11.8 ± 4.6 mm). The thickness change ratio was significantly smaller in the reconstructed knees (188.6 ± 64.7%) than in the contralateral knees (249.7 ± 73.8%).

CONCLUSION

When assessed 3 months after ACL reconstruction, the thickness of the superficial part of the IPFP at 90° knee flexion and the thickness change ratio of the IPFP were both significantly lower in the reconstructed knees than in the contralateral knees.

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

Objective

To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.

Design

Prospective diagnostic study.

Settings

Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.

Participants

Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).

Interventions

Not applicable.

Main outcome measures

History elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.

Results

Forty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).

Conclusion

Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Association of ACL Laxity Tests with Arthroscopic Findings in Chronic ACL and PCL Deficient Knees

An anterior cruciate ligament (ACL) injury may be diagnosed by clinical examination and radiological investigation using magnetic resonance imaging or by arthroscopy. ^1,2 Based on our experience, the ACL tear in concomitant chronic ACL and posterior cruciate ligament (PCL) deficient knees may produce knee laxity, which is more difficult to assess on clinical examination, which in turn may affect the management algorithm of the patient. Our hypothesis is that, in a concomitant chronic ACL and PCL injury, posterior capsular contracture and abnormal reattachment of torn ACL will result in less clinical and subjective laxity, preoperatively. The aim of this study is to review a cohort of patients who had undergone PCL reconstructive surgery and compare the preoperative clinical assessments with and without anesthesia with arthroscopic finding of ACL. This is to assess the accuracy and reliability of clinical ACL laxity tests in detecting ACL tear in chronic ACL and PCL injury.

Assessment of knee laxity using a robotic testing device: a comparison to the manual clinical knee examination

PURPOSE

The purpose of this study was to collect knee laxity data using a robotic testing device. The data collected were then compared to the results obtained from manual clinical examination.

METHODS

Two human cadavers were studied. A medial collateral ligament (MCL) tear was simulated in the left knee of cadaver 1, and a posterolateral corner (PLC) injury was simulated in the right knee of cadaver 2. Contralateral knees were left intact. Five blinded examiners carried out manual clinical examination on the knees. Laxity grades and a diagnosis were recorded. Using a robotic knee device which can measure knee laxity in three planes of motion: anterior-posterior, internal-external tibia rotation, and varus-valgus, quantitative data were obtained to document tibial motion relative to the femur.

RESULTS

One of the five examiners correctly diagnosed the MCL injury. Robotic testing showed a 1.7° larger valgus angle, 3° greater tibial internal rotation, and lower endpoint stiffness (11.1 vs. 24.6 Nm/°) in the MCL-injured knee during varus-valgus testing when compared to the intact knee and 4.9 mm greater medial tibial translation during rotational testing. Two of the five examiners correctly diagnosed the PLC injury, while the other examiners diagnosed an MCL tear. The PLC-injured knee demonstrated 4.1 mm more lateral tibial translation and 2.2 mm more posterior tibial translation during varus-valgus testing when compared to the intact knee.

CONCLUSIONS

The robotic testing device was able to provide objective numerical data that reflected differences between the injured knees and the uninjured knees in both cadavers. The examiners that performed the manual clinical examination on the cadaver knees proved to be poor at diagnosing the injuries. Robotic testing could act as an adjunct to the manual clinical examination by supplying numbers that could improve diagnosis of knee injury.

LEVEL OF EVIDENCE

Level II.

Development of Manual Measurement System with Stereo Markers for Lachman Test

The objective of this paper is to develop a manual measurement system (MMS) for the Lachman test using stereo markers. A novel calculation method that is fit for stereo markers is proposed to analyze knee joint motion in real-time based on the extraction of markers attached on the femur and tibia. In our experiments, knee extension movement and tibial translation are performed with imitation bones to evaluate the accuracy of the system. Further, a simulation of the Lachman test is performed in vivo measurement. The mean error of the knee extension movement in ten cases (range 0° to 90°) was 0.41° with a standard deviation of 0.44°. The mean error of the tibial translation was approximately 0.3 ± 0.9 mm. Experimental results confirmed the acceptable performance of the proposed measurement system, which can be considered for application in clinical manual tests.

Gender differences in the accuracy of joint line tenderness for arthroscopically confirmed meniscal tears

INTRODUCTION

The reliability of joint line tenderness was previously investigated among other clinical tests for the diagnosis of meniscal pathology with variable results. The aim of this study was to evaluate and compare the accuracy of joint line tenderness as a clinical diagnosing test for arthroscopically confirmed meniscal tears between males and females.

MATERIALS AND METHODS

For the purpose of preoperative joint line tenderness accuracy calculations, this study included male and female groups of patients who have had knee arthroscopy following preoperative diagnosis of meniscal tear. Overall, 195 patients were included in the study, 134 males and 61 females. The mean age was 43.4 (13-76) years.

RESULTS

In the male group, the diagnosis of meniscal tear by joint line tenderness was correct in 84 (62.7%) of 134 knees for the medial side and in 115 (85.8%) for the lateral side. In the female group, the diagnosis was correct in 35 (57.4%) of 61 knees for the medial side and in 57 (93.4%) for the lateral side. In order to refine the accuracy of medial joint line tenderness, the data were recalculated for patients with medial meniscal tears and no chondral lesion or cruciate ligament tears; however, the accuracy remained low.

CONCLUSIONS

The physical finding of joint line tenderness of the knee as a test for lateral meniscal tear was found reliable in both males and females. For medial meniscal tears, the test had low reliability and thus less useful if used alone, in both genders.

Stress radiography for the diagnosis of knee ligament injuries: a systematic review

BACKGROUND

Stress radiography is a widely used diagnostic tool to assess injury to the anterior and posterior cruciate ligaments and the medial and lateral structures of the knee. However, to date, numerous techniques have been reported in the literature with no clear consensus as to which methodology is best for assessing ligament stability.

QUESTIONS/PURPOSES

The purpose of this review was to identify which stress radiographic techniques have support in the literature for the diagnosis of acute or chronic knee ligament injuries, to define which technique is most accurate and reliable for diagnosing knee ligament injuries, and to compare the use of stress radiography with other diagnostic tests.

METHODS

Two independent reviewers performed a systematic review of PubMed (MEDLINE), the EMBASE library, and the Cochrane Controlled Trials Register for English language studies published from January 1970 to August 2013 on the diagnosis of knee ligament injuries using stress radiography. Information describing the ligament(s) investigated, stress radiographic technique, magnitude of force, measures of accuracy and reliability, and comparative diagnostic tests were extracted. Risk of bias was assessed using the QUADAS-2 tool.

RESULTS

A total of 16 stress techniques were described for stress radiography of the knee. The diagnostic accuracy of stress radiography including the sensitivity, specificity, and positive and negative predictive values varied considerably depending on the technique and choice of displacement or gapping threshold. Excellent reliability was reported for the diagnosis of anterior cruciate ligament, posterior cruciate ligament, varus, and valgus knee injuries. Inconsistencies were found across studies regarding the efficacy of stress radiography compared with other diagnostic modalities.

CONCLUSIONS

Based on the multitude of stress techniques reported, varying levels of diagnostic accuracy, and inconsistencies regarding comparative efficacy of stress radiography to other diagnostic modalities, we are not able to make specific recommendations with regard to the best stress radiography technique for the diagnosis of knee ligament injuries. Additional comparative studies using consistent methodology and appropriate blinding are necessary to further define differences in accuracy and reliability both among stress radiography techniques and between stress radiography and other diagnostic tests.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Innovative technology for knee laxity evaluation: clinical applicability and reliability of inertial sensors for quantitative analysis of the pivot-shift test

There has been an increased interest in the quantification of the knee laxity secondary to anterior cruciate ligament (ACL) injury. In clinical practice, the diagnosis is performed by clinical examination and magnetic resonance imaging analysis and confirmed arthroscopically. The pivot shift phenomenon has been identified as one of the essential signs of functional ACL insufficiency. A reliable system to adequately assess patients with ACL injury, quantifying the pivot shift test outcome, is needed. Several studies have been conducted in this regard but the proposed methods remain confined to a research area. The goal of this article is to summarize the actual knowledge and current concepts.

A new quantitative method for pivot shift grading

PURPOSE

The purposes of the study were to evaluate and to quantify the pivot shift phenomenon by using a small and easy to handle measuring device for pivot shift quantification.

METHODS

Twenty patients (forty knees) with primary torn anterior cruciate ligaments (ACL) were tested under anesthesia, graded by the examiner and by the device according to the IKDC classification [normal (0), glide (1), clunk (2), and gross (3)]. For the grading by the device, a femoral and a tibial miniature inertial sensor measured the acceleration and the angular velocities. Three parameters were used for pivot shift identification and quantification: (1) difference between the positive and negative acceleration peak value (a(diff)), (2) the maximum jerk (j(max)), and (3) the standard deviation (SD(a)) of the acceleration. The ratio between the ACL-deficient and the intact knees was calculated in order to normalize the data.

RESULTS

The pivot shift phenomenon could be identified, and all three parameters showed significant higher values in the ACL-deficient knees compared to the intact knees (p < 0.05). The grading by examiner did not significantly correlate with a(diff) (p = 0.38; r = 0.21), j(max) (p = 0.36; r = -0.22), SD(a) (p = 0.65; r = 0.11), and grading by the device (p = 0.62; r = 0.12).

CONCLUSIONS

The present study has shown that the quantification of the pivot shift test is practicable when inertial sensors are used. The results have shown that the subjective grading of the pivot shift test does not correlate well with objective quantification.

Management of articular cartilage defects of the knee

Articular cartilage injuries of the knee present a difficult clinical dilemma and their treatment is controversial. Hyaline articular cartilage is an avascular, low-friction, and wear-resistant weightbearing surface that has limited capacity for self-repair. The optimal treatment for cartilage lesions has yet to be established. Various treatment methods are employed to reestablish a stable cartilage surface, including microfracture, autologous and allograft osteochondral transplantation, autologous chondrocyte implantation, matrix-associated chondrocyte implantation, and scaffold-assisted methods. Treatment algorithms help to guide physicians' decision making in the care of these injuries. In this article, results from outcomes studies as well as prospective randomized clinical trials comparing treatment methods are reviewed, and current practice guidelines are summarized.

Magnetic resonance imaging, knee arthroscopy, and clinical decision making: a descriptive study of five surgeons

OBJECTIVES

A randomized controlled trial (RCT) showed magnetic resonance imaging for patients waiting for knee arthroscopy did not reduce the number of arthroscopies. Our study aimed to identify decisions made by orthopedic surgeons about whether patients on a waiting list should proceed to arthroscopy, and to describe surgeons' decisions.

METHODS

Five surgeons were asked to Think Aloud (TA) as they made their decisions for twelve patients from the original RCT. Audiotapes of the decision making were transcribed for analysis.

RESULTS

For five patients, surgeons agreed about proceeding with arthroscopy, although reasoning differed. In no cases did surgeons agree about not proceeding to arthroscopy. Agreement was more likely in patients with clinically diagnosed meniscal abnormality, and less likely in patients with osteoarthritis.

CONCLUSIONS

Surgeons' decisions were influenced by patient wishes. For some patients, the decision to proceed with arthroscopy was based solely on clinical diagnosis; MRI may not be advantageous in these instances. Surgeons disagreed more often than they agreed about the decision to proceed with arthroscopy, particularly when OA was diagnosed. This has implications for decision making in the current NHS patient choice environment. Patients may choose a treatment provider from a list of available providers at time of original clinical assessment and diagnosis. The treating surgeon does not necessarily re-examine the patient until the day of surgery. Given the variation between surgeons about the merits of proceeding with arthroscopy, surgeons may end up in the invidious position of providing surgery to patients whom they do not believe will benefit from arthroscopy.

Accuracy of clinical diagnosis in patients undergoing knee arthroscopy

A retrospective analysis of patients who underwent knee arthroscopy was undertaken to determine the accuracy of clinical diagnosis when compared with arthroscopic findings, and to see whether any specific pathologies were difficult to diagnose. The preoperative diagnosis was compared with the operative findings and the accuracy, sensitivity and specificity of the clinical diagnosis calculated. Six hundred ninety-eight patients were included. The overall accuracy, sensitivity and specificity of clinical diagnosis was 99%, 70% and 99%, respectively. Ninety percent of patients underwent a beneficial procedure, while 10% had a normal knee diagnosed at operation. Medial meniscal tear was the hardest pathology to diagnose with accuracy, sensitivity and specificity rates of 82%, 92% and 79%, respectively. Clinical examination remains an accurate method of assessing whether patients would benefit from an arthroscopy, although the correct diagnosis may not be determined preoperatively, particularly if pain was located in the medial tibio-femoral joint.

Diagnostic value of history taking and physical examination to assess effusion of the knee in traumatic knee patients in general practice

OBJECTIVE

To assess the diagnostic value of history taking and physical examination for knee joint effusion in patients with a knee injury who consult their general practitioner (GP). In addition, to determine the association between effusion seen on magnetic resonance imaging (MRI) and internal derangement of the knee.

DESIGN

Prospective, observational cohort study.

SETTING

Primary care.

PARTICIPANTS

Patients (N=134) aged 18 to 65 years with a traumatic knee injury who consulted their GP.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients filled out a questionnaire, underwent a standardized physical examination and underwent an MRI scan to assess the presence of effusion. Multivariate logistic regression analysis was used to determine the diagnostic value of history taking and physical examination (P<0.10) as assessed by sensitivity, specificity, predictive values, and likelihood ratios. The relationship between effusion and internal derangement of the knee was assessed with a chi-square test.

RESULTS

Of the 134 participating patients, 42 had knee joint effusion seen on MRI. Multivariate analysis showed an association with knee joint effusion for the symptom "self-noticed swelling" (history taking) and for the "ballottement test" (physical examination). The likelihood ratio positive (LR+) was 1.5 for self-noticed swelling and 1.6 for the ballottement test. These 2 combined improved the diagnostic value to an LR+ of 3.6. Effusion showed a positive association with internal derangement of the knee (chi-square 9.5); 31 of the 42 patients with knee joint effusion had internal derangement of the knee.

CONCLUSIONS

In patients with traumatic knee injury, knee joint effusion is frequently seen on MRI. The combination of self-noticed swelling and the ballottement test was of diagnostic value. Knee joint effusion was associated with internal derangement of the knee.

Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries

BACKGROUND

The diagnostic accuracy of anterior drawer (AD) sign, Lachman test and the pivot shift test for anterior cruciate ligament injury and McMurray test for medial and lateral meniscus is varied with sensitivity and specificity ranging from 2 to 100%. Generally, it is accepted that the pivot shift test is the most specific test to diagnose anterior cruciate ligament (ACL) tears and that the Lachman test is more sensitive than AD sign. This study was undertaken to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and efficiency for the above-mentioned diagnostic tests.

MATERIALS AND METHODS

Twenty-eight male patients with clinical ACL injury were examined in the outpatient department and under anaesthesia, the findings were compared with arthroscopy.

RESULT

The sensitivity and specificity for the Lachman test, AD sign and pivot shift test performed in the outpatient setting are 78.6 and 100%, 89.3 and 100%, and 75 and 100%, respectively. The sensitivity and specificity for the Lachman test, AD sign, and pivot shift test performed under anesthesia are 92.9 and 100%, 92.9 and 100%, and 100 and 100%, respectively. The sensitivity and specificity of the McMurray test for medial and lateral meniscus were 35.7 and 85.7% and 22.2 and 100%, respectively.

CONCLUSION

The Lachman test, AD sign and pivot shift test are highly specific tests to diagnose ACL laxity in a non-acute setting; pivot shift test under anesthesia is the most sensitive and specific test for diagnosing ACL laxity in a non-acute setting and the McMurray test is not a sensitive test to diagnose meniscal injury in the presence of ACL injury.

Validity of the McMurray's Test and Modified Versions of the Test: A Systematic Literature Review

Clinical assessment of meniscal pathology in the knee has proven difficult due to the wide number of tests available and variations in their interpretation and application. The purpose of this paper was to assess the literature investigating the validity and diagnostic accuracy of the McMurray's test (and modifications) for determining meniscal pathology of the knee so that conclusions could be drawn regarding its clinical usefulness as a test. Electronic databases (Medline, CINhAL, AMED, SPORTSDiscus, and SCOPUS) were searched from March 1980 to May 2008. In addition, cited references of relevant articles were examined. Studies were included for analysis if they compared the McMurray's test with a gold standard of knee arthroscopy or magnetic resonance imaging (MRI). Eleven studies met the inclusion criteria. Collectively, these studies indicate that there is little consensus in the reported measures of validity of the McMurray's test and that this is mostly due to limitations in the methodological quality of the studies that were assessed. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) yielded scores from 10/25 to 20/25. Generally, the McMurray's test has relatively high specificity and low sensitivity. The studies that compared the diagnostic accuracy of the McMurray's test with that of modified versions of the test showed enhanced diagnostic accuracy for the modified tests. This review identified that the McMurray's test is of limited clinical value due to relatively low sensitivity, with modified tests (associated with the traditional McMurray's test) having higher diagnostic accuracy and thus these may be more useful clinically.

Assessing medial collateral ligament knee lesions in general practice

PURPOSE

To assess the diagnostic value of history-taking and physical examination of medial collateral ligament lesions after a knee injury presenting in general practice.

METHODS

Patients aged 18 to 65 years with a traumatic knee injury who consulted their general practitioner within 5 weeks after trauma filled out a questionnaire, underwent a standardized physical examination, and underwent a magnetic resonance imaging scan. Logistic regression analysis was used to test possible associations between determinants from history-taking/physical examination and medial collateral ligament lesions. The diagnostic value of history-taking and physical examination was determined for those variables indicating an association (P <.15) with medial collateral ligament lesions and was assessed by sensitivity, specificity, predictive value, and likelihood ratios.

RESULTS

Of the 134 patients included in this study, 35 had a medial collateral ligament lesion seen on magnetic resonance imaging scan. From history-taking, the determinants "trauma by external force to leg" and "rotational trauma" showed an association with medial collateral ligament lesion after multivariate analysis (P <.15). From physical examination, "pain valgus stress 30 degrees " and "laxity valgus stress 30 degrees " showed an association (P <.15). Isolated determinants from history-taking and physical examination showed some diagnostic value; the likelihood ratio positive was 2.0 for "trauma by external force to leg" and 2.3 for "pain valgus stress 30 degrees ." Adding "pain valgus stress 30 degrees " and "laxity valgus stress 30 degrees " from physical examination to history-taking improved the diagnostic value to a likelihood ratio positive of 6.4.

CONCLUSION

Medial collateral ligament lesions are frequently seen in patients with traumatic knee injury. History-taking has a diagnostic value, while adding physical examination increases the diagnostic value.

Reliability of the KT1000 arthrometer and the Lachman test in patients with an ACL rupture

The underlying study is a cross sectional study on the reliability of the KT1000 arthrometer and the Lachman test to determine the within-session inter-rater reliability and intra-rater reliability of the KT1000 arthrometer and the Lachman test. Twenty patients with a complete tear of the anterior cruciate ligament (ACL) were examined in a single session each. During the assessment, two physical therapists measured the anterior-posterior translation of the knee using both the KT1000 arthrometer and the Lachman test. One examiner performed a repeated measurement of each test for determination of intra-rater reliability. The examiners were blinded to the findings of their colleague. The intraclass correlation coefficient (ICC) was used to describe the degree of reliability of the measurements. High ICCs were found for the intra-rater reliability and the inter-rater reliability of the Lachman test (ICC=1.0 and 0.77). For the KT1000 arthrometer both ICCs were clearly lower (ICC=0.47 and 0.14). The KT1000 arthrometer shows inadequate reliabilities, even when measurements are repeated within a single measurement session. Contrastingly, the Lachman test is a reliable measurement to determine the anterior-posterior laxity of the ACL deficit knee. The results of the present study suggest good within-session intra-rater reliability as well as inter-rater reliability for the Lachman test.

A meta-analysis examining clinical test utilities for assessing meniscal injury

Objective: To systematically review the most recent literature with meta-analysis to summarize the accuracy of clinical tests for assessing meniscal lesions of the knee.

Methods and measures: A computerized database search was performed to identify eligible articles. Identified articles were reviewed to determine eligibility and methodological quality. Sensitivity, specificity, likelihood ratios and diagnostic odd ratios were reproduced or recorded from each study. Meta-analysis was performed using the reported study sensitivity and specificity values.

Results: Three tests — joint line tenderness, McMurray's and Apley's — were compared in the meta-analysis. The methodological quality of the studies was found to have a significant effect on both the test sensitivities and specificities. Summary receiver operating characteristic (ROC) curves, sensitivity values, mean likelihood ratios and diagnostic odd ratios (DOR) uniformly show joint line tenderness (DOR = 10.98) to be the best `common' test, followed by McMurray's (DOR = 3.99) and Apley's (DOR = 2.2). Thessaly's test reported the strongest DOR of 227, but samples were smaller (n = 410), than those for joint line tenderness (n = 1354), McMurray's (n = 1232) and Apley's (n = 479).

Conclusion: Methodological quality varied from poor to fair among studies, affecting test performance. Future studies should, where possible, utilize larger samples of individuals without meniscal lesions to better estimate test specificity and thus more accurately identify optimal clinical tests.

Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice

OBJECTIVE

To assess the diagnostic value of history-taking and physical examination of meniscal tears in general practice.

DESIGN

An observational study determining diagnostic values (sensitivity, specificity, predictive value, and likelihood ratios).

SETTING

General practice.

PATIENTS

Consecutive patients aged 18 to 65 years with a traumatic knee injury who consulted their general practitioner within 5 weeks after trauma.

ASSESSMENT

Participating patients filled out a questionnaire (history-taking) followed by a standardized physical examination.

MAIN OUTCOME

Assessment of meniscal tears was determined by means of magnetic resonance imaging (MRI) and was performed blinded for the results of physical examination and history-taking.

RESULTS

Of the 134 patients included in this study, 47 had a meniscal tear. From history-taking, the determinants "age over 40 years," "continuation of activity impossible," and "weight-bearing during trauma" indicated an association with a meniscal tear after multivariate logistic regression analysis, whereas from physical examination only "pain at passive flexion" indicated an association. These associated determinants from history-taking showed some diagnostic value; the positive likelihood ratio (LR+) reached up to 2.0 for age over 40 years, whereas the isolated test pain at passive flexion from physical examination has less diagnostic value, with an LR+ of 1.3. Combining determinants from history-taking and physical examination improved the diagnostic value with a maximum LR+ of 5.8; however, this combination only applied to a limited number of patients.

CONCLUSION

History-taking has some diagnostic value, whereas physical examination did not add any diagnostic value for detecting meniscal tears in general practice.

The effect of magnetic resonance imaging scans on knee arthroscopy: randomized controlled trial

PURPOSE

The purpose of this study was to investigate whether magnetic resonance imaging (MRI) in patients waiting for knee arthroscopy could reduce arthroscopy rates and improve patient outcome.

METHODS

A prospective randomized controlled trial was conducted in a teaching hospital setting. All participating patients had knee MRI before arthroscopy. In the intervention group the MRI report was seen by surgeons, and in the control group it was not. The primary outcome measure was the proportion of patients who did not have an arthroscopy. Secondary outcome measures included the Short Form 36, EuroQol EQ-5D, Knee Injury and Osteoarthritis Score, and Knee Society Score.

RESULTS

Surgeons changed both their diagnosis and management plan in 47% of patients in the intervention group compared with 1% in the control group, with no difference between groups in the proportion of patients who underwent an arthroscopy. In the intervention group 7 of 125 patients (5.6%) did not have an arthroscopy compared with 8 of 127 patients (6.3%) in the control group. In one instance a surgeon decided against arthroscopy based on the MRI report. There was no significant difference between groups in other outcome measures.

CONCLUSIONS

We found no effect of MRI on the decision to perform arthroscopy or patient outcome. Performing MRI in patients already on the waiting list for arthroscopy may not be effective in reducing utilization of surgery.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial with no statistically significant difference but with narrow confidence intervals.

MR imaging of acute anterior cruciate ligament injuries

MRI of the knee has become an indispensable clinical tool in the management of chronic knee conditions. MRI for acute knee injuries is less well established but is becoming increasingly prevalent. MRI in acute ACL injuries is particularly useful for identifying associated injuries that will influence the early management of the patient. The aim of this paper is to describe the MRI findings of acute ACL tears, their commonly associated, and less common but serious associated injuries. Where available, the evidence for the sensitivity and specificity of these MRI features is presented. The contribution of these MRI findings to the management of the patient is discussed.

MR imaging of the posterolateral corner of the knee

The posterolateral corner (PLC) is a complex functional unit, consisting of several structures, which is responsible for posterolateral stabilization. The PLC is not consistently defined in the literature. However, most descriptions include the popliteal tendon (PT), the lateral collateral ligament (LCL), the popliteofibular ligament (PFL) and the posterolateral capsule, which is reinforced by the arcuate ligament (AL) and the fabellofibular ligament (FFL). Knowledge of PLC anatomy, including its variations, and understanding of the biomechanics is important for correct diagnosis of PLC injuries. An overlooked PLC injury can result in chronic instability, chronic pain, and, eventually, in secondary osteoarthritis. Damage to the PLC also has an adverse effect on the outcome of cruciate ligament repair. Isolated lesions of the PLC are rare. PLC lesions are typically associated with injuries of the cruciate ligaments, the menisci, bone and soft tissue. In the acute phase, clinical findings can be difficult to interpret due to pain and swelling. Magnetic resonance (MR) imaging potentially demonstrates the entire spectrum of PLC injuries and associated lesions of the knee, including those that may be overlooked during clinical examination or arthroscopy.

Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

To define the accuracy of clinical tests for assessing anterior cruciate ligament (ACL) ruptures.

BACKGROUND

The cruciate ligaments, and especially the ACL, are among the most commonly injured structures of the knee. Given the increasing injury prevalence, there is undoubtedly a growing need for clinical decision making of health care providers. We reviewed the literature to analyze the diagnostic accuracy of the clinical examination for assessing ACL ruptures.

METHODS AND MEASURES

MEDLINE (1966 to April 2005), EMBASE (1989 to April 2005), and CINAHL (1982 to April 2005) searches were performed. Also reference lists of the included studies were reviewed. Studies selected for data extraction were those that addressed the accuracy of at least 1 physical diagnostic test for ACL rupture and compared the performance of the clinical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or MRI. Searching was limited to English, German, and Dutch languages.

RESULTS

Twenty-eight studies that assessed the accuracy of clinical tests for diagnosing ACL ruptures met the inclusion criteria. Study results were, however, heterogeneous. The Lachman test is the most valid test to determine ACL tears, showing a pooled sensitivity of 85% (95% confidence interval [CI], 83-87) and a pooled specificity of 94% (95% CI, 92-95). The pivot shift test is very specific, namely 98% (95% CI, 96-99), but has a poor sensitivity of 24% (95% CI, 21-27). The anterior drawer test shows good sensitivity and specificity in chronic conditions, respectively 92% (95% CI, 88-95) and 91% (95% CI, 87-94), but not in acute conditions.

CONCLUSION

In case of suspected ACL injury it is recommended to perform the Lachman test. Because the pivot shift test is very specific both in acute as well as in chronic conditions, it is recommended to perform the pivot shift test as well.

Articular cartilage defects in 1,000 knee arthroscopies

PURPOSE

Focal chondral or osteochondral defects can be painful and disabling, have a poor capacity for repair, and may predispose patients for osteoarthritis. New surgical procedures that aim to reestablish hyaline cartilage have been introduced and the results seem promising. The purpose of this study is to provide reliable data on chondral and osteochondral defects in patients with symptomatic knees requiring arthroscopy and to calculate the prevalence of patients who might benefit from cartilage repair surgery.

TYPE OF STUDY

Prospective study.

METHODS

One thousand consecutive knee arthroscopies were included in this study. Immediately after each arthroscopy, the surgeon completed a questionnaire providing detailed information about the findings. Chondral and osteochondral lesions were classified in accordance with the system recommended by the International Cartilage Repair Society (ICRS).

RESULTS

Chondral or osteochondral lesions (of any type) were found in 61% of the patients. Focal chondral or osteochondral defects were found in 19% of the patients. In these patients, 61% related their current knee problem to a previous trauma, and a concomitant meniscal or anterior cruciate ligament injury was found in 42% (n = 81) and 26% (n = 50), respectively. The mean chondral or osteochondral total defect area was 2.1 cm(2) (range, 0.5 to 12; standard deviation [SD], 1.5). The main focal chondral or osteochondral defect was found on the medial femoral condyle in 58%, patella in 11%, lateral tibia in 11%, lateral femoral condyle in 9%, trochlea in 6%, and medial tibia in 5%. It has been suggested that cartilage repair surgery may be most suitable in patients younger than 40 to 50 years old. A single, well-defined ICRS grade III or IV defect with an area of at least 1 cm(2) in a patient younger than 40, 45, or 50 years accounted for 5.3%, 6.1%, and 7.1% of all arthroscopies, respectively.

CONCLUSIONS

Our study supports the contention that articular cartilage defects are common. It has the advantages of a prospective design and use of a new classification system recommended by the ICRS. This modern system focuses on objectively measurable parameters of the lesion's extent and not its surface appearance.

Clinical examination of the knee following trauma: an evidence-based perspective

The knee is a common site of injury. The increasing number of clinical tests and greater understanding of the joints biomechanics, lead to difficulties in both the interpretation of the clinical examination and in the reliance that should be placed on specific signs or tests. This article helps review the present evidence surrounding examination of the knee. This will enable clarification of which tests are most appropriate to be applied for specific injuries, and how they should be interpreted by the clinician. The most accurate test currently is that for anterior cruciate ligament deficiency as described by Lachman. Other classically taught tests, such as that of McMurray for meniscal tears, have been demonstrated to be of poor sensitivity and specificity.

A modeling study of partial ACL injury: simulated KT-2000 arthrometer tests

A partial ACL injury may involve different levels of fiber disruption, orfibers may sustain microscopic changes in their structure without gross disruption, resulting in a change in ligament function. The effect of partial ACL tears on the mechanical and functional stability of the knee has not been well documented, in part because of diagnostic difficulties. A computer model of the knee in the sagittal plane was used in this study to simulate tests using the KT-2000 Knee Arthrometer, which quantifies Lachman's test for ACL injury. A variety of partial ACL anterior and posterior bundle injuries were simulated. Anterior and posterior bundle injuries were subdivided into four different simulated injury levels: mild (one-half tear of the bundle), moderate (complete tear of the bundle), severe (complete tear of the bundle and tear of one-half of the other bundle), and more severe (severe injury plus an additional elongation of the other bundle represented by 5% increases of its initial strain). Force-displacement results obtained from simulated KT-2000 knee arthrometer tests depended on the level of injury. Mild and moderate injuries produced only small change in the anterior tibial translation--at different force levels. Severe injury produced increased anterior tibial translation depending on which bundle was completely ruptured. The compliance index defined as the ratio of the displacement and the force within 68 N and 90 N anterior drawer forces, the stiffness, and the rate of change of stiffness of the anterior force-displacement were found to be better at predicting partial ACL ruptures than simple differences in anterior tibial translation. It was possible in the model results to discriminate knees with various levels of partial ACL injuries using the first and second derivatives of the force-displacement curve.

Comparison of knee magnetic resonance imaging findings in patients referred by orthopaedic surgeons versus nonorthopaedic practitioners

PURPOSE

To compare the percentages of normal magnetic resonance imaging (MRI) examination results and clinically significant knee abnormalities in patients referred for MRI of the knee by orthopaedic surgery residents and staff with those of patients referred by nonorthopaedic practitioners.

TYPE OF STUDY

Retrospective review of MRI findings.

METHODS

MRI reports of 754 patients (454 men and 300 women) were retrospectively reviewed; 373 patients were referred from the Department of Orthopaedic Surgery and 381 patients were referred from nonorthopaedic practitioners. The number of normal examination results, meniscal and ligament tears, chondral abnormalities, and Baker's cysts was tabulated and analyzed using a X-square injury analysis.

RESULTS

The rate of normal results for nonorthopaedic practitioners was 33.9% (129 of 381) compared with 15.3% (57 of 373) for orthopaedic surgeons (P <.001). Nonorthopaedic surgeons referred 69.4% (129 of 186) of the patients who had normal examination results. The positive finding for a lateral meniscus tear was 29.2% (109 of 373) for orthopaedic surgeons compared with 19.1% (73 of 381) for nonorthopaedic practitioners, which was statistically significant (P =.002) in regard to the distribution of injuries. No difference was found in other abnormalities assessed.

CONCLUSIONS

Patients referred by nonorthopaedic practitioners had significantly more normal knee MRI examination results than did those referred by orthopaedic surgeons.

The menisci: basic science and advances in treatment

Once described as a muscle remnant, and therefore treated with disrespect, the meniscus is now known to be a vital structure within the knee. Minimal partial meniscectomy performed arthroscopically, or meniscal repair when practical, have become the standard treatments. In spite of the advancements in understanding meniscal function and its preservation, much remains to be studied. In the future, availability of better repair techniques and the option of meniscal replacement with allograft or prosthetic menisci are expected to improve outcomes.

Comparison of magnetic resonance imaging with operative findings in acute traumatic dislocations of the adult knee

OBJECTIVES

To compare magnetic resonance imaging (MRI) with examination under anesthesia and with surgical findings in evaluating soft tissue injuries in acute traumatic knee dislocations in adults.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center.

PATIENTS

For a single surgeon, all patients who underwent MRI before surgical treatment for knee dislocations (ten individuals).

INTERVENTION

Incompetent ligaments were repaired or reconstructed.

MAIN OUTCOME MEASUREMENTS

MRI of knee dislocations was compared with clinical examination under anesthesia and with intraoperative findings at arthrotomy in ten cases. Pertinent positive and negative findings were recorded, and accuracy, sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

Two mid-grade sprains of the anterior cruciate ligament were erroneously read as complete tears. One rupture or avulsion of each the biceps tendon, the lateral collateral ligament, and the posterolateral and posteromedial corners were considered intact on MRI. The MRI studies erroneously identified tears of the lateral collateral ligament and medial meniscus in one case each. Otherwise, the study was highly accurate.

CONCLUSIONS

MRI is useful for defining the presence of ligamentous injuries in knee dislocations; however, clinical examination under anesthesia is more accurate.

Correlation of arthroscopic and clinical examinations with magnetic resonance imaging findings of injured knees in children and adolescents

This study evaluated the correlation among clinical diagnosis, magnetic resonance imaging reports, and arthroscopic findings in 28 patients aged 8 to 17 years (average, 14.4) with knee injuries. Meniscal, anterior cruciate ligament, and articular surface injuries were evaluated. A highly positive correlation (78.5%) was found between clinical and arthroscopic findings. A highly negative correlation was found between arthroscopic and magnetic resonance imaging findings (78.5%) and between clinical and magnetic resonance imaging findings (75%). In this series, accuracy, positive predictive value, negative predictive value, sensitivity, and specificity data were much more favorable from clinical examination than from magnetic resonance imaging. Overall, magnetic resonance imaging diagnoses added little guidance to patient management and at times provided spurious information.

The impact of magnetic resonance imaging of the knee on surgical decision making

Although magnetic resonance imaging (MRI) of the knee is known to be an accurate technique for diagnosing soft tissue disorders of the knee, the value of MRI in improving patient outcome is controversial. The purpose of this project was to study the value of MRI in a subgroup of patients with knee pain and disability whose diagnosis was uncertain after standard orthopaedic evaluation. An extensive database was recorded prospectively for each of 208 patients providing clinical data as well as diagnoses from clinical, MRI, and surgical observations. These data were analyzed to determine the effect of MRI on diagnosis and patient outcome regarding surgical decision making. The overall diagnostic accuracy of MRI was determined to be 97% in patients undergoing arthroscopy. MRI differed from the clinical diagnosis in 33% of cases, the most common variance being diagnosis of meniscal tear. After combining the MRI and clinical information, surgical decision making was altered in 27% of cases. In a group of patients with acute knee symptoms, the decision not to proceed with surgery was made in 64% of cases. The study shows that MRI of the knee is a valuable tool for augmenting the diagnostic process. The data further show that MRI is a cost-effective technique for avoiding unnecessary surgery and affects patient outcome by improving surgical decision making.

The diagnostic accuracy of history, physical examination, and radiographs in the evaluation of traumatic knee disorders

We prospectively looked at the diagnostic accuracy of clinical examination of the knee in patients with arthroscopically documented knee injuries. The study included 156 patients with 156 knee injuries (72 acute and 84 chronic) who were seen during 1 year at Martin Army Hospital at Fort Benning Georgia. All patients were given a primary diagnosis based on their history, physical examination, and routine radiographs. Fifty-seven patients were also given one or more secondary diagnoses. Magnetic resonance imaging scans and arthrograms were not used in the evaluation of these patients. The primary diagnosis was correct in 83% of the knees. Of 57 secondary diagnoses given, 54% were correct and 31% were incomplete. An incorrect diagnosis was made in 14% of knees for both primary and secondary diagnoses. There were four patients with no identifiable lesion other than synovitis. With the increasing cost of medical care, the need for expensive diagnostic studies such as magnetic resonance imaging needs to be evaluated. The cost of a magnetic resonance image scan ranges between $600 to $1200 depending on the institution. The use of magnetic resonance imaging as a routine diagnostic aid in the clinical examination of the knee is unnecessary. Arthroscopic surgery of the knee should be based on the patient's history, physical examination, and radiographs.

Magnetic resonance imaging of knee disorders. Clinical value and cost-effectiveness in a sports medicine practice

To prospectively evaluate the clinical value of magnetic resonance imaging of the knee in a referral sports medicine practice, we performed a three-part study. First, we asked 72 consecutive patients a series of clinically relevant questions regarding the ordering of their magnetic resonance imaging scans. Second, we asked the treating physicians at our center if the magnetic resonance imaging findings changed the diagnosis or treatment. Third, we compared the clinical evaluation with the findings on magnetic resonance imaging scans for 37 patients who had arthroscopic confirmation. From the physician's perspective, in only three cases would the results of the scan have changed the diagnosis. Information from the scans was judged to contribute to patient treatment in only 14 of 72 patients. Finally, comparison of clinical evaluation and magnetic resonance imaging findings with findings during arthroscopic procedures showed that clinical evaluation had a sensitivity and specificity of 100% for diagnosis of anterior cruciate ligament injuries, whereas magnetic resonance imaging was 95% sensitive and 88% specific. For isolated meniscal lesions, the clinical assessment had a sensitivity and specificity of 91% compared with 82% and 87%, respectively, for magnetic resonance imaging. For evaluation of articular surface damage, the predictive value of a positive test was 100% for clinical assessment and 33% for the magnetic resonance imaging. We conclude that magnetic resonance imaging is overused in the evaluation of knee disorders and not a cost-effective method for evaluating injuries when compared with a skilled examiner. Clinical assessment equals or surpasses the magnetic resonance imaging in accuracy.