Predicted probability of meniscus tears: comparing history and physical examination with MRI

The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Background

Meniscal pathologies are common knee injuries and arthroscopic surgery is the current accepted gold standard for treatment. However, there is evidence to support the use of the Mulligan Concept (MC) Mobilization with Movement (MWM) for meniscal pathologies including the 'Squeeze' technique, tibial internal rotation (IR), and tibial external rotation (ER).

Hypothesis/Purpose

The purpose of this systematic review was to critically appraise the literature to investigate the effectiveness of MC MWMs for meniscal lesions on patient reported pain, function, and multi-dimensional health status in patients with clinically diagnosed meniscal pathologies.

Study Design

Systematic Review.

Methods

A literature search was completed across multiple databases using combinations of the words "knee, function, mobilization with movement, MWM, mulligan concept, MC, meniscal pathology, meniscal derangement, and meniscal tear." Studies written within the prior 10 years that examined MC MWM techniques to treat knee meniscal injury were included. Articles that met the inclusion criteria (used MC MWM 'Squeeze' technique, tibial IR, or tibial ER for treatment of clinically diagnosed meniscal pathologies; Patient reported outcome [PRO] measures had to be used in the assessment of knee pain or function) were analyzed for quality. Randomized control trials were analyzed using the PEDro scale and the Downs & Black (D&B) checklist, case series were analyzed using the Joanna Briggs Institute (JBI) checklist, and case reports were analyzed using the CARES checklist.

Results

Six articles met the inclusion criteria and were included in this review, two randomized controlled studies, two case series, and two case reports consisting of 72 subjects. All six papers included reports of improvements in pain and function that were either statistically significant or met the minimal clinically important difference (MCID). Five studies reported the Disablement in the Physically Active (DPA) scale that also demonstrated statistically significant differences or met the MCID. The MC MWM 'Squeeze' technique, tibial IR, or tibial ER demonstrated the ability to reduce pain, improve function, and improve patient perceived disability following treatment of a clinically diagnosed meniscal pathology. These studies demonstrated short term results lasting from one week to 21 weeks.

Conclusion

Treatment interventions incorporating MC MWM techniques demonstrated reduction of pain and improvement in function in the short term in patients with clinically diagnosed meniscal pathologies.

Level of Evidence

2a.

Comparison of Accuracy in Expert Clinical Examination versus Magnetic Resonance Imaging and Arthroscopic Exam in Diagnosis of Meniscal Tear

Background

Many clinical tests and diagnostic studies have been developed to increase the clinician's ability to accurately diagnose disorders of the knee. Torn menisci or ligamentous structures within the knee cause significant pain and disability and thus require expeditious management. This study was conducted to evaluate the accuracy of clinical examination in comparison with MRI examination and with the help of arthroscopic examination as the gold standard in the diagnosis of meniscal tears.

Method

All of the arthroscopic surgery candidates, presenting symptoms of meniscal or cruciate ligament lesions, referring to Namazi and Chamran hospitals, Shiraz, Iran, were included in this study. Clinical examination (including McMurray test, Apley test, and 20 Thessaly test) was performed before the arthroscopy, and the results were recorded in special forms. Magnetic resonance imaging (MRI) results were also added. Then, arthroscopy was performed, declaring the definite diagnosis, and the results were compared to the results obtained from both tests and MRI. Statistical analysis was performed using SPSS software.

Results

86 patients with a mean age of 27 years old, including 63 (73%) male and 23 (27%) female, were studied. 57 (66%), 19 (22%), and 10 (12%) injuries were caused by sports, twisting, or trauma, respectively. Arthroscopic results showed 32 meniscal tears, of which 28 (87%) and 4 (13%) were in medial and lateral menisci, respectively, including 10 bucket handle, 17 longitudinal, and 5 of other types (transverse, oblique, radial) of injuries. Comparing MRI results to arthroscopic results, we had 2 false-positive and 2 false-negative cases. 62 cases of McMurray test results were accurate; 15 and 9 cases were reported false positive and false negative, respectively. 60 cases of Apley test results were accurate; 16 and 10 cases were reported false positive and false negative, respectively. 78 cases of Thessaly test results were accurate; 5 and 3 cases were reported false positive and false negative, respectively. Comparing Thessaly test results to McMurray and Apley showed statistical significance (P < 0.05). Comparing Thessaly test results to MRI showed no statistical significance (P = 0.151), while comparing McMurray and Apley test results to MRI showed statistical significance (P < 0.01).

Conclusion

Clinical examination, performed by an experienced examiner, can have equal or even more diagnostic accuracy compared to MRI to evaluate meniscal lesions. In this study, the Thessaly test has been approved as a reliable clinical test in the diagnosis of meniscal tears.

Magnetic resonance imaging can increase the diagnostic accuracy in symptomatic meniscal repair patients

PURPOSE

The purpose of this study was to evaluate meniscal repair healing in symptomatic patients through combined clinical assessment, magnetic resonance imaging (MRI) and re-arthroscopy. This study investigated the diagnostic accuracy of MRI and clinical assessment in determining failed meniscal repair in symptomatic meniscal repair patients, as verified by re-arthroscopy.

METHODS

Eighty patients were included. All had undergone a primary meniscal repair followed by an MRI and re-arthroscopy due to clinical symptoms of a meniscal lesion. A validated semi-quantitative scoring system was employed for identifying MRI-diagnosed healing failure. The clinical assessment was divided into joint swelling, joint-line tenderness, locking and a positive McMurray's test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI and positive clinical findings were calculated using second-look arthroscopy as a standard.

RESULTS

The MRI results showed healing of 22 (27.5%) of the menisci and 58 (72.5%) unhealed menisci, whereas second-look arthroscopy identified 15 (19%) healed menisci and 65 (81%) unhealed menisci. The isolated MRI findings were 0.85, 0.8, 0.95 and 0.55 for sensitivity, specificity, PPV and NPV, respectively. The PPVs of the clinical assessments were 0.78, 0.85 and 0.94, with one, two and three clinical findings, respectively. A grade 3 MRI combined with joint-line tenderness presented a PPV of 0.98.

CONCLUSION

A supplementary MRI will increase diagnostic accuracy when fewer than three clinical findings are present in a symptomatic meniscal repair patient. The clinical relevance of this finding is that MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology.

LEVEL OF EVIDENCE

III.

Assessment of 3-T MRI using susceptibility-weighted imaging to detect and evaluate intra- or periarticular blood metabolites and meniscal tears of the knee

Purpose

The purpose of this study was to assess the suitability of susceptibility-weighted imaging (SWI) sequences using the 3T MRI-unit for assessment of potential intraarticular pathologies in patients with acute and chronic torsion trauma of the knee joint.

Material and methods

Sixty-three patients with subacute and chronic rotary knee joint trauma of either the left or right knee were studied using an Achieva MRI 3T device (Philips, Amsterdam, Netherlands). Ground truth was set by two expert radiologists with seven and 10 years of experience in musculoskeletal imaging. Readings were performed separately for meniscus and joint space including synovia, ligaments, and periarticular soft tissue. Haemorrhage was defined as any lesion that was either T1 or SWI positive, without proton density (PD)-hypointensity (calcification). A lesion was defined as any pathology/variant with any signal positivity of either T1, PD, or SWI.

Results

A total of 63 patients were included (F : M = 22 : 41). The median age of the cohort was 29 years (range 13 to 71 years). Thirty-nine patients showed a meniscal tear, and only three of them (7.7%) demonstrated a meniscal haemorrhage. A total of 18 patients suffered from a periarticular injury, and 16 patients (88.9%) demonstrated a concomitant periarticular haemorrhage.

Conclusions

These data suggest that SWI can be used for the diagnosis of intra- or periarticular blood metabolites because their potential have an impact on mechanical conflict with the surface of the knee joints, in particular the cartilage and their effect on malacic lesions, but it performs poorly in the detection of meniscal pathologies.

Patient-reported symptoms and changes up to 1 year after meniscal surgery

Background and purpose - Detailed information on the symptoms and limitations that patients with meniscal tears experience is lacking. This study was undertaken to map the most prevalent self-reported symptoms and functional limitations among patients undergoing arthroscopic meniscal surgery and investigate which symptoms and limitations had improved most at 1 year after surgery. Patients and methods - Patients aged 18-76 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic meniscal surgery were included in this analysis of individual subscale items from the Knee Injury and Osteoarthritis Outcome Score and 1 question on knee stability. Severity of each item was scored as none, mild, moderate, severe, or extreme. Improvements were evaluated using Wilcoxon's signed-rank test and effect size (ES). Results - The most common symptoms were knee grinding and clicking, knee pain in general, pain when twisting and bending the knee and climbing stairs (88-98%), while the most common functional limitations were difficulty bending to the floor, squatting, twisting, kneeling, and knee awareness (97-99%). Knee pain in general and knee awareness improved most 1 year after meniscal surgery (ES -0.47 and -0.45; p < 0.001), while knee instability and general knee difficulties improved least (ES 0.10 and -0.08; p < 0.006). Interpretation - Adults undergoing surgery for a meniscal tear commonly report clinical symptoms and functional limitations related to their daily activities. Moderate improvements were observed in some symptoms and functional limitations and small to no improvement in others at 1 year after surgery. These findings can assist the clinical discussion of symptoms, treatments, and patients' expectations.

Evaluation of clinical tests and magnetic resonance imaging for knee meniscal injuries: correlation with video arthroscopy

Objective

To determine the specificity, sensitivity, accuracy, likelihood, and correlation of the findings of meniscal tests and magnetic resonance imaging (MRI) to knee video arthroscopy.

Methods

A cross-sectional study, conducted between June and December 2015, which evaluated 84 patients with meniscal tears (MT) selected for video arthroscopy. Two orthopedic trainees and a resident performed a physical examination with specific tests. The results and reports from MRI were compared with arthroscopy findings. The data were analyzed in the statistical program R.

Results

The Steinmann I test was the most specific, with specificity of 86% and 91% for medial meniscus tears (MMT) and lateral meniscus tears (LMT), respectively. With regard to accuracy, the pain test on palpation of the joint interline (PPJI) showed values of 67% and 73% for detection of MMT and LMT, respectively. The PPJI test showed higher sensitivity, with a 77% chance of detecting MMT. Analysis of the set of three tests (McMurray, PPJI, and Steinmann I) compared to arthroscopy showed 85% sensitivity for MMT and 70% sensitivity for LMT. MRI showed a greater specificity for the diagnosis of MMT and LMT; the values were 82% and 91%, respectively.

Conclusion

The combination of the three tests shows better results compared to the isolated tests and thus can be associated to the MRI to make an effective diagnosis. However, further studies assisting in the development of a protocol to standardize diagnostic evaluation are required.

McMurray's Test and Joint Line Tenderness for Medial Meniscus Tear: Are They Accurate?

Background

Meniscus tears are the most common injury of the knee. The McMurray's test and Joint line tenderness for diagnosing meniscus tear have been widely tested, but results reported by different authors vary. The wide variations reported have an impact on clinical decision concerning whether to go for other diagnostic tests before going for diagnostic arthroscopy, which is considered as the gold standard.The purpose of this study was to determine the diagnostic value of Joint line tenderness and McMurray's test, as clinical signs, to diagnose underlying medial meniscus tears.

Methods

This was a prospective observational study done in Tribhuwan University Teaching Hospital. Patients undergoing knee arthroscopy were included in the study period of one year (from February 2011 to January 2012). Each patient was clinically examined with McMurray's test and joint line tenderness. The findings were then matched by the arthroscopic findings. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were then calculated.

Results

The sensitivity, specificity, positive predictive value , negative predictive value and accuracy for medial joint line tenderness in diagnosing medial meniscus tear were 50%, 61.7%, 51.8%, 60% and 56.45% respectively. The result was insignificant (p value=0.352). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for McMurray's test for diagnosing medial meniscus tear were 54%, 79%, 68% , 67.50% and 67.74% respectively. The result was significant (p value=0.007).

Conclusion

Clinical tests like McMurray and joint line tenderness have low diagnostic value when applied individually. They may be useful when combined together with the background of clinical history. The decision to scope the knee should not be solely taken on the results of clinical tests.

Anamnestic prediction of bucket handle compared to other tear patterns of the medial meniscus in stable knees

Objective

The aim of this study was to analyze and compare the preoperative anamnestic details between patients with an arthroscopic diagnosis of bucket handle and other tear patterns of the medial meniscus in stable knees.

Methods

A total of 204 patients (mean age 49.3 ± 13 years) were included in the study. The mean age was 49.3 ± 13 years. The study group included 65 patients (63 males, 2 females) with an arthroscopic diagnosis of bucket handle tear and the control group included 139 patients (90 males, 49 females) with non-bucket handle tear patterns. The preoperative clinical assessments of the two groups were analyzed retrospectively. Anamnestic prediction for the diagnosis of a bucket handle tear was based upon various medical history parameters. Multivariate logistic regression was carried out to identify independent anamnestic factors for predicting isolated bucket handle tears of the medial meniscus compared to non-bucket handle tears.

Results

Analysis of the multivariate logistic regression yielded 3 statistically significant independent anamnestic risk factors for predicting isolated bucket handle tears of the medial meniscus: male gender (OR, 9.7; 95% CI, 1.1–37.6), locking events (OR, 4.6; 95% CI, 1.8–11.3) and pain in extension (OR, 6.9; 95% CI, 2.5–23.7). Other preoperative variables such as age, BMI, activity level, comorbidities, duration of symptoms, pain location, preceding injury and its mechanism had no significant effect on tear pattern.

Conclusions

Preoperative strong clues for bucket handle tears of the medial meniscus in stable knees are male gender, locking events and limitation in extension.

Level of evidence: Level III, Diagnostic study.

Diagnosis of knee injuries: comparison of the physical examination and magnetic resonance imaging with the findings from arthroscopy

Objectives

To ascertain the sensitivity, specificity, accuracy and concordance of the physical examination (PE) and magnetic resonance imaging (MRI) in comparison with arthroscopy, in diagnosing knee injuries.

Methods

Prospective study on 72 patients, with evaluation and comparison of PE, MRI and arthroscopic findings, to determine the concordance, accuracy, sensitivity and specificity.

Results

PE showed sensitivity of 75.00%, specificity of 62.50% and accuracy of 69.44% for medial meniscal (MM) lesions, while it showed sensitivity of 47.82%, specificity of 93.87% and accuracy of 79.16% for lateral meniscal (LM) lesions. For anterior cruciate ligament (ACL) injuries, PE showed sensitivity of 88.67%, specificity of 94.73% and accuracy of 90.27%. For MM lesions, MRI showed sensitivity of 92.50%, specificity of 62.50% and accuracy of 69.44%, while for LM injuries, it showed sensitivity of 65.00%, specificity of 88.46% and accuracy of 81.94%. For ACL injuries, MRI showed sensitivity of 86.79%, specificity of 73.68% and accuracy of 83.33%. For ACL injuries, the best concordance was with PE, while for MM and LM lesions, it was with MRI (p < 0.001).

Conclusions

Meniscal and ligament injuries can be diagnosed through careful physical examination, while requests for MRI are reserved for complex or doubtful cases. PE and MRI used together have high sensitivity for ACL and MM lesions, while for LM lesions the specificity is higher.

Level of evidence II – Development of diagnostic criteria on consecutive patients (with universally applied reference “gold” standard).

KneeTex: an ontology-driven system for information extraction from MRI reports

BACKGROUND

In the realm of knee pathology, magnetic resonance imaging (MRI) has the advantage of visualising all structures within the knee joint, which makes it a valuable tool for increasing diagnostic accuracy and planning surgical treatments. Therefore, clinical narratives found in MRI reports convey valuable diagnostic information. A range of studies have proven the feasibility of natural language processing for information extraction from clinical narratives. However, no study focused specifically on MRI reports in relation to knee pathology, possibly due to the complexity of knee anatomy and a wide range of conditions that may be associated with different anatomical entities. In this paper we describe KneeTex, an information extraction system that operates in this domain.

METHODS

As an ontology-driven information extraction system, KneeTex makes active use of an ontology to strongly guide and constrain text analysis. We used automatic term recognition to facilitate the development of a domain-specific ontology with sufficient detail and coverage for text mining applications. In combination with the ontology, high regularity of the sublanguage used in knee MRI reports allowed us to model its processing by a set of sophisticated lexico-semantic rules with minimal syntactic analysis. The main processing steps involve named entity recognition combined with coordination, enumeration, ambiguity and co-reference resolution, followed by text segmentation. Ontology-based semantic typing is then used to drive the template filling process.

RESULTS

We adopted an existing ontology, TRAK (Taxonomy for RehAbilitation of Knee conditions), for use within KneeTex. The original TRAK ontology expanded from 1,292 concepts, 1,720 synonyms and 518 relationship instances to 1,621 concepts, 2,550 synonyms and 560 relationship instances. This provided KneeTex with a very fine-grained lexico-semantic knowledge base, which is highly attuned to the given sublanguage. Information extraction results were evaluated on a test set of 100 MRI reports. A gold standard consisted of 1,259 filled template records with the following slots: finding, finding qualifier, negation, certainty, anatomy and anatomy qualifier. KneeTex extracted information with precision of 98.00 %, recall of 97.63 % and F-measure of 97.81 %, the values of which are in line with human-like performance.

CONCLUSIONS

KneeTex is an open-source, stand-alone application for information extraction from narrative reports that describe an MRI scan of the knee. Given an MRI report as input, the system outputs the corresponding clinical findings in the form of JavaScript Object Notation objects. The extracted information is mapped onto TRAK, an ontology that formally models knowledge relevant for the rehabilitation of knee conditions. As a result, formally structured and coded information allows for complex searches to be conducted efficiently over the original MRI reports, thereby effectively supporting epidemiologic studies of knee conditions.

Characteristic arthroscopic signs of cartilage injuries indicating concomitant occult medial meniscal peripheral tears of posterior horn

BACKGROUND

Medial posterior horn meniscal tear is difficult to visualise during arthroscopy and is occasionally undetected by preoperative magnetic resonance imaging (MRI). Consequently, attention should be paid to performing a thorough examination and to some characteristic signs that indicate occult meniscal tear. The purpose of this study was to assess an indicative correlation between arthroscopic features of cartilage injury and a concomitant occult meniscal tear.

METHODS

We performed a retrospective clinical and radiographic study of a consecutive series of patients between January 2013 and December 2014. Of 1,596 patients, all 78 with wave-like chondral injury of the medial femoral condyle diagnosed at arthroscopy were included in the study. The occurrence, pattern, location and concomitant pathology of medial meniscal injury were analysed.

RESULTS

The characteristic wave sign associated with chondral injury in the medial femoral condyle was detected by MRI preoperatively in two cases only; all others were discovered intraoperatively at arthroscopy. Cartilage injury was rated as Outerbridge type II in 53 patients, type III in 24, and type IV in one. Wave sign defects were all characterised by their transverse orientation in the load-bearing femoral condyle. The occult longitudinal peripheral meniscus tear of the posterior horn was seen in all patients with a positive wave sign visualised under arthroscopy. The wave sign was positively correlated with medial peripheral meniscal injury of the posterior horn (P < 0.01).

CONCLUSION

Wave sign chondral injury in the medial femoral condyle seen at arthroscopy is a characteristic indicator for concomitant occult medial longitudinal peripheral meniscus tears of the posterior horn.

LEVEL OF EVIDENCE

Case series, Level IV.

Diagnostic needle arthroscopy and the economics of improved diagnostic accuracy: a cost analysis

BACKGROUND

Hundreds of thousands of surgical arthroscopy procedures are performed annually in the United States (US) based on MRI findings. There are situations where these MRI findings are equivocal or indeterminate and because of this clinicians commonly perform the arthroscopy in order not to miss pathology. Recently, a less invasive needle arthroscopy system has been introduced that is commonly performed in the physician office setting and that may help improve the accuracy of diagnostic findings. This in turn may prevent unnecessary follow-on arthroscopy procedures from being performed.

OBJECTIVE

The purpose of this analysis is to determine whether the in-office diagnostic needle arthroscopy system can provide cost savings by reducing unnecessary follow on arthroscopy procedures.

METHODS

Data obtained from a recent trial and from a systematic review were used in comparing the accuracy of MRI and VisionScope needle arthroscopy (VSI) with standard arthroscopy (gold standard). The resultant false positive and false negative findings were then used to evaluate the costs of follow-on procedures. These differences were then modeled for the US patient population diagnosed and treated for meniscal knee pathology (most common disorder) to determine if a technology such as VSI could save the US healthcare system money. Data on surgical arthroscopy procedures in the US for meniscal knee pathology were used (calendar year [CY] 2010). The costs of performing diagnostic and surgical arthroscopy procedures (using CY 2013 Medicare reimbursement amounts), costs associated with false negative findings, and the costs for treating associated complications arising from diagnostic and therapeutic arthroscopy procedures were assessed.

RESULTS

In patients presenting with medial meniscal pathology (International Classification of Diseases, 9th edition, Clinical Modification [ICD9CM] diagnosis 836.0), VSI in place of MRI (standard of care) resulted in a net cost savings to the US system of US$115-US$177 million (CY 2013) (use of systematic review and study data, respectively). In patients presenting with lateral meniscus pathology (ICD9CM 836.1), VSI in place of MRI cost the healthcare system an additional US$14-US$97 million (CY 2013). Overall aggregate savings for meniscal (lateral plus medial) pathology were identified in representative care models along with more appropriate care as fewer patients were exposed to higher risk surgical procedures.

CONCLUSIONS

Since in-office arthroscopy is significantly more accurate, patients can be treated more appropriately and the US healthcare system can save money, most especially in medial meniscal pathology.