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Orthopedic Extremity/Foot-Ankle Journal Club
Ed Mulligan, MS, PT, SCS, ATCGrapevine, [email protected]
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The diagnostic accuracy of a new clinical test (the Thessaly Test) for early detection of meniscal tears
Karachalios T, Hantes M, Aibis AH, Sachos V, Karantanas AH, Malizos, K. J Bone Joint Surg Am. 87:955-962, 2005
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15866956&query_hl=3
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Article Summary
Investigation of a new diagnostic procedure (Thessaly Test) in a series of consecutive patients and volunteers with comparison applied against a universally accepted “gold standard” (MRI).
INTRODUCTION
The Question the Study Proposes
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The Question
What is the diagnostic accuracy of a new dynamic clinical test for the detection of meniscal pathology– This may be important because the current gold
standard (MRI) is expensive and not always readily available.
– Current testing methods inaccurate? Clinical tests are inadequate compared to MRI?
Introduction seemed contradictory; very brief (essentially non-existent) literature review
– A research hypothesis was not offered
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Let me do a quick literature review
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How do we currently diagnose a meniscal injury?
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Diagnosis of Meniscal Injury
Mechanism of Injury– Youth: Twisting Trauma– Elderly: Degeneration
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Diagnosis of Meniscal Injury
Classic Signs/Symptoms– Joint line tenderness– True locking or catching
complaint– Mild, delayed effusion– Quad atrophy
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What does the literature say about the accuracy of common meniscal special tests?
First, let’s review what sensitivity and specificity imply
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Clinical Decision-making Mnemonics
SPINUse a specific test to rule in a hypothesisSpecific tests have very few false positivesHigh specificity means that if you get a positive test, you can count on it being a true positive
SNOUT– Use a sensitive test to rule out a hypothesis– Sensitive tests have very few false negatives– High sensitivity means that if you get a negative test,
you can count on it being a true negative
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So, how sensitive and specific are meniscal tests?
Statistical Truth
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McMurray’s Test
High specificity; Low sensitivity– Malanga GA, et al. Arch Phys Med Rehabil 2003– Corea JR, et al. Knee Surg Sports Traumato Arthrosc 1994
High positive predicative validity– Scholten, et al. J Fam Pract. 2001
+ and - Likelihood ratios inconclusive – Solomon DH, et al. JAMA, 2002
Limited emphasis – only a “thud” on the medial joint line was specific (not sensitive)
– Evans PJ. Am J Sports Med. 1993
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Joint Line Tenderness
Good sensitivity, poor specificityMalanga GA, et al. Arch Phys Med Rehabil 2003
+ and - Likelihood ratios inconclusiveSolomon DH, et al. JAMA, 2002
High sensitivity and specificity (particularly when an isolated lesion and on lateral side)
Eren, OT. Arthroscopy. 2003
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“Dynamic Test”- similar to Thessaly?
For Lateral Meniscal Tears– 85% sensitivity– 90% specificity– 89% accuracy
Mariani PP, et al. A prospective evaluation of a test for lateral meniscus. Knee Surg Sports Traumatol Arthrosc, 1996; 4(1):22-26.
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Ege’s Test
Higher accuracy (84%), sensitivity (64%), and specificity (90%) than McMurray’s or joint line tenderness
Akseki D, et al. Arthroscopy. 2004
Deep squat in full LE ER for medial and LE IR for lateral meniscus
Positive test with pain or click – typically around 90°
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Systematic Review Summary
Diagnostic accuracy of clinical tests is poor– McMurray’s
Sensitivity ranged from .20 - .66Specificity ranged from .57 - .96
– Joint Line TendernessSensitivity ranged from .58 - .95Specificity ranged from .05 - .74
Scholten RJ, et al. J Fam Pract. 2001
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Agrees with FowlerPredictive Value of 5 Clinical Signs in the Evaluation of Meniscal Pathology
Fowler PJ, Lubliner JA. Arthroscopy. 198986%44%Blocked Extension70%51%Pain on Forced Flexion
30%85%Joint Line Tenderness80%16%Apley96%29%McMurray
SpecificitySensitivityTEST
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Evidenced-Based Answer
Ellis ME, et al. J Family Prac. Nov 2004. – No physical exam (joint effusion,
McMurray test, Joint line tender-ness, or Apley compression) yielded clinically significant likelihood ratios for a meniscal tear
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Likelihood Ratios
represent the change in the odds of a diagnosis, based on the outcome of the test.
– Given a positive likelihood ratio of 2, if a test result is positive, the odds of the disease being present is doubled.
A positive likelihood ratio >10 provides strong evidence that the disorder is presentA negative likelihood ratio <0.1 provides strong evidence that the disorder is not presentScores between 0.5 and 2.0 are neutral
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Ellis Study in Journal of Family Practice, 2004
McMurray
11 (1.8 – 20.2)Aggregate Exam, Lat Meniscus
3.1 (0.54 – 5.7)Aggregate Exam, Med Meniscus
2.7 (1.4 – 5.1)Aggregate Exam
1.1 (0.7 – 1.6)0.8 – 14.90.9 (0.8 – 1.0)Joint Line Tenderness
17.3 (2.7 – 68)1.5 – 9.51.3 (0.9-1.7)
Positive Likelihood ratio (95% CI)4 studies – 424 patients13 studies – 2231 patients9 studies –1018 patients
Jackson 2003Scholten 2001Solomon 2001
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McMurray
0.13 (0 – 0.25)Aggregate Exam, Lat Meniscus
0.19 (0.11 – 0.77)Aggregate Exam, Med Meniscus
0.4 (0.2 – 0.7)Aggregate Exam
0.8 (0.3 – 3.5)0.2 – 2.11.1 (1.0 – 1.3)Joint Line Tenderness
0.5 (0.3 – 0.8)0.4 – 0.90.8 (0.6-1.1)
Negative Likelihood ratio (95% CI)4 studies – 424 patients13 studies – 2231 patients9 studies –1018 patients
Jackson 2003Scholten 2001Solomon 2001
Ellis Study in Journal of Family Practice, 2004
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Influence of Concurrent ACL Injury
Diagnostic Accuracy is decreased
– Akseki D, et al. Acta Orthop Traumatol. 2003
– Eren, OT. Arthroscopy. 2003– Fowler. Arthroscopy, 1989
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MRI Imaging for Meniscal Disorders
Diagnostic accuracy – 72%Sensitivity – 88% (medial - 94%; lateral 78%)Specificity – 57%+ Predicative Value – 66%- Predictive Value – 83%67% accurate for degenerative lesions78% accurate for traumatic lesions
Raunest J, et al. J Bone Joint Surg Am. 1991
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Generalization
Decent specificity with entrapment examsDecent sensitivity with palpatory findings
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Additional Special Tests referenced in Magee
Bounce Home– Springy block to full extension
Childress Sign– Duck walking causing pain or
snapping in posterior horn area
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Additional Special Tests referenced in Magee
O’Donahue’s– Pain with rotation at 0 or 90°
Modified Helfet– Lack of ER (lateralization of
tibial tubercle) in full extensionRetracting Meniscus– Medial meniscus does not disappear with ER and
reappear with IR at 90° of flexion
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Additional Special Tests referenced in Magee
Steinmann’s Tenderness Displacement Test– Tenderness at joint line moves posteriorly with
flexion, anteriorly with extension, medially with ER, and laterally with IR Flexion
Extension
ERIR
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Additional Special Tests referenced in Magee
Bragard’s Sign– Reproduction of
symptoms medially with ER and Ext
– Alleviation of symptoms medially with IR and Flex
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Additional Special Tests referenced in Magee
Payr’s Test– Medial joint line pain in the Figure 4 position
Cabot’s Popliteal Sign– Medial joint line pain while
isometrically extending the knee from the Figure 4 position
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Additional Special Tests referenced in Magee
Bohler’s Sign– Pain with varus/valgus in
compressed compartment
Kromer’s Test– same as Bohler’s Sign
but also incorporates flexion/extension motion
Lateral Pain Medial Pain
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Additional Special Tests referenced in Magee
Passler Rotational Grind Test– Circumduction movement of knee in combinations
of flex/extension, rotation, and varus-valgus
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Additional Special Tests referenced in Magee
Anderson Medial-Lateral Grind Test– Grinding caused by Valgus/Flexion from full
extension to 45° flexion; return in Varus/ExtensionMay also cause a pivot shift if ACL deficient
METHODOLOGY
How the Study was Conducted
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Materials and Methods
Sample of convenience from 780 patients referred to their department with a knee injury– Inclusion Criteria:
Knee complaint with suggestive history and appropriate MOI for meniscal pathology
– Exclusion Criteria:Multiple injuriesEvidence of OAPrevious SxAbnormal RadiographsAcute Injury (less than 4 weeks)
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Demographics
Experimental Group A (had MRI and scope)– 213 patients
29 years old (18-55)74% male; 26%female
Control Group B(had MRI only)– 197 volunteers
Age, sex, gender, size matched
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Clinical Examination
All patient (experimental and control group) were examined by 4 physicians
– Unsure what made two MDs experienced and two MDs inexperienced
Examination consisted of five specific tests or findings– Medial or Lateral Joint Line Tenderness– McMurray Test– Apley Compression/Distraction Test– Thessaly Test at 5°– Thessaly Test at 20°
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Joint Line Tenderness
Assuming a positive test was reproduction of symptomatic complaint with palpation
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McMurray Test
Application of varus or valgus stress while the knee is extended and rotated
– Varus stress compresses medial meniscus
– Valgus stress compresses lateral meniscus
– Flexion compresses posterior meniscus
– Rotation stretches meniscal attachments and distorts the tear
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Apley Compression-Distraction Test
Reproduction of symptoms withcompression and rotation;alleviation of symptoms withdistraction
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Thessaly Test
With balance assist, the patient internally and externally rotated their body while in unilateral stance with the knee in 5° and 20° of flexion
Positive test was present when patient reported joint line discomfort or a sense of locking or catching
Essentially a weight-bearing replication of the McMurray and Apley tests in a greater degree of extension
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MRI
Presence of Mensical Injury was judged against gold standard of T1 weighted MRI– Interpreted by an “experienced”
and “fellow” radiologistICC agreement not reported
Referenced MRI accuracy as 98% during introduction
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Blinding (in regard to “true” meniscal status according to the MRI Gold Standard or to the Thessaly Test findings)
Patients - noExaminers - yesInvestigators – Radiologists – yes– Group Allocators - no
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total population
a + b + c + d
total without condition
b + d
total with condition
a + c
TOTALS
total who test negative
c + d
true negatived
false negativec
Negative Test(-)
total who test positive
a + b
false positiveb
true positivea
Positive Test(+)
is not (-)is (+)
Statistical AnalysisSensitivity - Specificity
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Sensitivity – a/a+c
Specificity – d/b+d
% False Positive – b/a+b+c+d
% False Negative – c/a+b+c+d
Accuracy – a+d/a+b+c+d x 100
total population
a + b + c + d
total without conditionb + d
total with conditiona + c
TOTALS
total who test negative
c + dtrue negative
dfalse negative
cNegative Test(-)
total who test positivea + b
false positive
btrue positive
aPositive Test(+)
is not (-)is (+)
2 x 2 Table for Statistical Truth
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Accuracy Results
Test Accuracy
90%96%94%Thessaly 20°
82%90%86%Thessaly 5°80%89%81%Joint Line59%82%75%Apley’s72%84%78%McMurray’s
ACL + MeniscusLateral MeniscusMedial MeniscusExam
Also reported sensitivity, specificity, false positives and negatives for each test
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Thessaly 20° Raw Data
TotalNegativePositive
49 (a+b)15 (b)34 (a)Positive
361 (c+d)358 (d)3 (cNegative
410373 (b+d)37 (a+c)Total
Lateral Meniscal Injury
410271 (b+d)139 (a+c)Total277 (c+d)262 (d)15 (cNegative133 (a+b)9 (b)124 (a)Positive
Medial Meniscal Injury
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Thessaly 20° Test Results
ACL + Meniscus
Lateral Mensicus
Medial Meniscus
1%1%4%False Negative
90%96%94%Accuracy
9%4%2%False Positive91%96%97%Specificity80%92%89%Sensitivity
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Intra/Interexaminer Reliability
> 95%– How was intraexaminer reliability evaluated?– No difference based on experience?– What were the ICCs?
If true, certainly indicates reproducibility amongst practitioners
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Discussion
Meniscal MOI – S/SMeniscal Provocative ManeuversTraditional Testing Accuracy
Clinical interpretation and utility of the Thessaly Test
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Provocative Maneuvers
Paper divides meniscal provocation maneuvers into palpatory and rotational reproduction techniquesI would argue they differ based on degree of – Weight bearing compression vs. distraction– Medial vs. lateral compartment
compression (varus-valgus)– Rotational distortion– Flexion to extension movements
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Strength of Proposed Special Test
Reproduces MOI– “monopodal rotation in the position of function (20°
flexion) squeezes apart the meniscal fragments causing pain on the peripheral, innervated rim”
Identifies a potentially suitable screening tool for allied health professionals and general practitioners to accurately detect meniscal pathology
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Precaution
3% of patients had a significant exacerbation of symptoms (requiring an analgesic tablet or MUA to unlock)
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Issue
Evaluations of diagnostic accuracy should be prescribed with confidence intervals– 95% is typical– With CI, reader can not know the range within which
the true values of the indices are likely to lie
– http://faculty.vassar.edu/lowry/clin1.html
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Clinical Calculator
http://faculty.vassar.edu/lowry/clin1.html
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Thessaly Test FindingsMedial Meniscal
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Findings with Confidence Intervals
89 (82-94)
97 (94-98)
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Findings with Confidence Intervals
2 (1-7)
3 (1-6)
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A reason to tap the brakes
SLAP Test History– Active compression test had nearly perfect
sensitivity and specificity but has never been replicated
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Issue
Should an MRI only be used when the clinical history, MOI, and clinical findings contradict a positive test?– How many surgeons rely strictly on clinical exam
and do not confirm necessity of surgery with an MRI?
– How would they know to include the test if the history, MOI, and clinical findings do not suggest the problem?
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Issue
Early detection (that’s what the title says)– Yet an exclusion criteria was acute knee injuries
(less than 4 weeks old)
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Questions?
Was test order randomized?What specifically constituted a positive test?How were ACL injuries identified?Should a dynamic rotation test be performed on a subject with suspected ACL deficiency?– Isn’t the Thessaly Test is same as
Losee’s “disco test”?apprehension indicates rotary instabilityJoint line pain (Merke’s sign) implies meniscal pathology
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Overall Impression
Unique study investigating a new techniquePaper written in a clear, concise wayInadequate reflection on results as compared to earlier studies
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Practical Application
Will your clinical practice change as a result of this study? If so, how?
No follow-up research was suggested – do the conclusions merit additional investigation If so, what?; how?
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Research Appraisal Sites
no extraction posted
not posted as it is really not an “intervention” study
Scholten study referenced as a systematic review
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Questions - Discussion
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Comparison of Home vs. Physical Therapy Supervised Rehabilitation Programs after ACL Reconstruction: A Randomized Clinical Trial
Grant JA, Mohtadi NG, Maitland ME, Zernicke RF. Am J Sports Med. 2003 33:1288-1297.
Mark Beckett, PTThursday 2/2/06 11:00 AM CST