|Year : 2022 | Volume
| Issue : 3 | Page : 137-141
Comparison between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and cruciate ligament injuries: A cross-sectional study
VM Predeep Kumar1, Raju Karuppal2
1 Department of Orthopaedics, Kerala Health Services, Kannur, Kerala, India
2 Department of Orthopaedics, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||08-May-2022|
|Date of Decision||11-May-2022|
|Date of Acceptance||13-May-2022|
|Date of Web Publication||05-Aug-2022|
Karuppal House, Post Mukkam, Kozhikode - 673 602, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Complete evaluation of knee injury includes detailed clinical examination, radiological evaluation, and arthroscopy. Objective: The objective of this study was to compare the effectiveness of clinical, magnetic resonance imaging (MRI), and arthroscopic findings in meniscal and cruciate ligament injuries. Patients and Methods: A cross-sectional study of 40 post knee injury symptomatic patients aged 20–40 years. Clinical and MR imaging findings were compared with arthroscopic findings (considering arthroscopy as the gold standard diagnostic test). The specificity, sensitivity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated and compared. Results: The specificity, sensitivity, PPV, NPV, accuracy of clinical examination, and MRI were similar for anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. The diagnostic accuracy of clinical examination and MRI were 82.5% and 90%, respectively, and 95% and 92.5% for medial meniscal and lateral meniscal injuries, respectively, and 97.5% and 100% for ACL and PCL injuries, respectively. Conclusion: The diagnostic accuracy of clinical examination is similar to MRI for ligament injuries and marginally lower for meniscal injuries. MRI is useful to clarify clinical diagnosis in clinical cases of meniscal and cruciate ligament injuries that are doubtful.
Keywords: Arthroscopy, cruciate ligaments, knee clinical examination, magnetic resonance imaging, meniscus
|How to cite this article:|
Predeep Kumar V M, Karuppal R. Comparison between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and cruciate ligament injuries: A cross-sectional study. Apollo Med 2022;19:137-41
|How to cite this URL:|
Predeep Kumar V M, Karuppal R. Comparison between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and cruciate ligament injuries: A cross-sectional study. Apollo Med [serial online] 2022 [cited 2022 Nov 28];19:137-41. Available from: https://apollomedicine.org/text.asp?2022/19/3/137/351227
| Introduction|| |
The anatomic situation, the complexity of structures, biomechanical and kinematic peculiarities, and frequent exposure to external forces make the knee joint most vulnerable to traumatic injury., Knee injuries vary from simple sprains to complex injuries such as a meniscal tear, disruption of ligaments, bony injuries, and cartilage damage. Complete evaluation of knee injury includes a detailed history, thorough clinical examination, radiological evaluation, and arthroscopic examination. Magnetic resonance imaging (MRI) is a highly sensitive test to detect meniscal, ligament injuries, and other soft-tissue injuries including chondral injuries., Arthroscopy is the current gold standard assessment for ligament and meniscal injuries but is invasive and has many associated risks.
For the specialist knee surgeon, MRI is a diagnostic test that is reserved for complicated and confusing cases. A thorough clinical examination can help to diagnose meniscal and ligament injuries and can reduce the number of investigations. The use of routine preoperative MRI is controversial in cases of clinically definite knee injuries. Arthroscopy has a very important role in the treatment of internal derangement of the knee (IDK).
There are variations in the reported accuracy and efficacy of clinical methods, MRI, and arthroscopy to assess IDK. The variations may be explained by the advancement of radiological investigations to detect the location, structural analyses, and complexity of the knee injury. We compared the diagnostic effectiveness and accuracy of clinical, MRI, and arthroscopic findings in meniscal and cruciate ligament injuries in traumatic disorders of the knee joint and to look for the need for MRI before every arthroscopy.
| Patients and Methods|| |
A cross-sectional study was conducted from September 2016 to September 2017, in 40 patients (sample size was calculated with the formula of z2sd2/d2) who were referred from peripheral centers with post knee injury symptoms. The institutional ethics committee approval was obtained before the enrollment of participants.
The study included patients of both sexes aged 20–40 years who were referred with a history of a knee injury and who had symptoms of pain, instability, giving way, locking, or frequent fall. The study excluded patients with a previous history of knee arthroscopy or any other knee surgery, who did not give consent to participate in the study, with contraindications for an MRI assessment, history of previous episodes of knee locking, nontraumatic cause of meniscal and ligamentous pathology, degenerative knee joint arthritis, infection, and neoplasm, with a previous open knee injury, intra-articular fractures and patients who were unfit for anesthesia.
A single well-experienced orthopedician examined the knee joints of all 40 study participants. Clinical examination was performed after obtaining a detailed history. Clinical tests to detect meniscal injuries included McMurray's test and eliciting point tenderness. Anterior cruciate ligament (ACL) injuries were tested with Lachman and anterior drawer tests. Posterior cruciate ligament (PCL) injuries were tested with the posterior drawer test and posterior sagging of the tibia. Patients that presented with trauma-related symptoms such as knee pain, instability, giving way, locking, and history of frequent falls, and who were positive for any of the clinical tests were considered clinically positive. All 40 patients underwent MRI evaluation with a 1.5 Tesla MRI scanner in the same week of clinical examination. The MRI evaluation included T1 and proton-density-weighted sequences in sagittal and in coronal planes, T2-weighted sequences in axial, coronal, and sagittal planes. The fat-suppressed T2 and short-tau inversion recovery sequences were also done whenever indicated.
Scoring of meniscal injuries on MRI was done according to Lotysch et al. grading system. All MRI images were reported by a single senior radiologist. All patients underwent arthroscopic examination within a period of 10 days from clinical examination, using 30° arthroscope with HD cameras. Standard anteromedial and anterolateral portals were used. Examination of the knee under anesthesia was again performed to look for signs of instability. Recordings of clinical, MRI, and arthroscopic findings were documented in an MS Excel spreadsheet. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), the accuracy and positive and negative likelihood ratios (LR+ and LR-) of clinical examination findings, and MRI were estimated. Arthroscopy was considered the gold standard test for comparisons. The point estimates of the diagnostic effectiveness parameters and 95% confidence intervals (CI) around the point estimates were estimated.
The true positive was considered as a tear diagnosed by clinical tests/MRI and confirmed by arthroscopy. The true negative was considered as a nontear or nonlesion on clinical tests/MRI and confirmed by arthroscopy. False positive was considered as a tear or lesion identified on clinical tests/MRI that was not confirmed by arthroscopy. False negative was considered as a nontear identified on clinical tests/MRI that was found to be a tear by arthroscopy. Accuracy is the ability to differentiate the injured case and uninjured cases correctly. Accuracy was assessed by the calculation of the proportion of true positive and true negative in all evaluated cases.
| Results|| |
The study group consisted of 40 patients (35 males and 5 females) from 20 to 40 years of age (mean age, 28.4 years). Most of them had a left-sided knee injury (n = 24, 60%). The most common modes of injury were indirect injured (85%), like sports injuries, particularly in football. Of the 40 cases, 19 cases of medial meniscal tear, 9 cases of lateral meniscal tear, 35 cases of ACL injury, and 2 cases of PCL injury were confirmed by arthroscopic examination.
Medial meniscus tears
Twenty patients of medial meniscal tears were detected by clinical examination, and 16 of these 20 (80%) cases were confirmed by arthroscopy. Three patients (15%) were positive on arthroscopy in the 20 patients without medial meniscal tears on clinical examination. A comparison of findings of clinical examination with those of arthroscopy revealed 16 true positives, 17 true negatives, 4 false positives, and 3 false-negative results.
Among the 20 MRI-proven cases of medial meniscal injury, 16 cases were confirmed by arthroscopy. The MRI was negative for medial meniscus tear in 20 patients, and arthroscopy was also negative in these 20 cases. A comparison of findings of MRI with those of arthroscopy, revealed 16 true positives, 20 true negatives, 4 false positives, and zero false-negative results.
[Table 1] presents the sensitivity, specificity, PPV, NPV, and likelihood ratios, and accuracy of clinical and MRI findings compared with arthroscopy in medial meniscal tear.
|Table 1: Diagnostic effectiveness of clinical and magnetic resonance imaging assessments compared with arthroscopy in medial meniscal tears of the knee|
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Lateral meniscus tears
There were nine cases of clinically positive lateral meniscal tear of which eight were confirmed by arthroscopy. Arthroscopy could detect four positive cases in the 31 patients who had absent lateral meniscal tear in clinical examination. A comparison of findings of clinical examination with arthroscopy revealed 8 true positives, 27 true negatives, 1 false positive, and four false-negative results. Among the 7 MRI-proven lateral meniscal tear patients, only five cases were confirmed by arthroscopy. Arthroscopy could detect 1 positive case in the 33 patients who had an absence of lateral meniscal tear in MRI. There were 5 true positives, 32 true negatives, 2 false positives, and 1 false-negative results. [Table 2] presents the sensitivity, specificity, PPV, NPV, and accuracy of clinical and MRI findings in lateral meniscal tear.
|Table 2: Diagnostic effectiveness of clinical and magnetic resonance imaging assessments compared with arthroscopy in lateral meniscal tears of the knee|
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Anterior cruciate ligament injury
This study included 34 clinically positive ACL cases. Arthroscopy confirmed the ACL injury in all these 34 cases. Arthroscopy detected one case of partial tear in the 6 cases that were negative for ACL injury on clinical examination. Hence, true positives were found to be 34 and true negative to be 5. There was no false-positive result, but one false-negative result. Among the 40 patients, 34 cases were confirmed both by MRI and arthroscopy and 6 cases were MRI negative for ACL injury. Arthroscopy detected one case of partial ACL injury which was reported as normal in MRI. There were 34 true positives, 5 true negatives, and 1 false-negative result. No false-positive results were detected. [Table 3] presents the sensitivity, specificity, PPV, NPV, and accuracy of clinical and MRI findings in the ACL tear.
|Table 3: Diagnostic effectiveness of clinical and magnetic resonance imaging assessments compared with arthroscopy in anterior cruciate ligament injuries of the knee|
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Posterior cruciate ligament injury
We had only two cases of PCL injury, both were confirmed by clinical, MRI, and arthroscopic examination.
| Discussion|| |
Our study reveals that clinical assessments have slightly lower diagnostic accuracy than MRI for medial and lateral meniscus tears, but similar diagnostic accuracy for cruciate ligament injuries. A positive likelihood ratio >10 indicates that the diagnostic test has clinical utility and can be used in clinical practice. We found that the positive likelihood ratios were clinically significant for both clinical and MRI assessment in lateral meniscus tears. The positive likelihood ratio was slightly lower for clinical assessments compared to MRI for medial meniscus tears. The point estimates of the LR + were <10 for both clinical and MRI in medial meniscus tears, however, the upper margin of the 95% CI was >10 for both assessment techniques suggesting clinical utility for both assessments in medial meniscus tears. Our study was comparable with many similar studies.,,,, MRI can detect even minute meniscal lesions including the intrasubstance degeneration, which gives high signal intensity image in MRI.
Rayan et al. have reported nearly similar diagnostic effectiveness for specificity (95% vs. 92%), PPV (78% vs. 74%), NPV (87% vs. 88%), and diagnostic accuracy (85% vs. 85%), of clinical examination compared to MRI. These results are similar to our observations. The diagnostic accuracy of clinical assessments versus MRI was equal in both ACL injury and PCL injury. Previous studies have reported a strong relation between MRI and arthroscopic findings and confirmed the value of MRI in assessing IDK.,, Gupta et al. reported that MRI is an effective modality with high sensitivity, diagnostic accuracy, and NPV. Hence, it is a very reliable screening test for diagnosing meniscal and ligament injuries. These results are similar to our observations. Puri et al. reported that MRI has a significant role when clinical signs and symptoms are inconclusive, which will be more beneficial in avoiding unnecessary arthroscopic surgery. Esmaili Jah et al. concluded that a well-performed repeated physical examination can sometimes be as good as MRI. He also stated that there are possibilities of clinical errors in cases of combined injuries where modern imaging techniques have a great role. MRI scan has a better NPV in diagnosing both meniscal and ACL injury, which is similar to our results. When clinical signs and symptoms are inconclusive, it is beneficial to perform an MRI scan to avoid unnecessary arthroscopic surgery. However, skilled clinical examination findings have equality to MRI which we have seen in ACL and PCL injury in our study.
Our findings also showed the medial meniscus had relatively more false-positive results (total 4 cases) than false-negative results (zero cases) in MRI and more false-negative results for lateral meniscus (total 1) compared to false-positive results (total 2 cases) in MRI. Our results are comparable with the results of Fischer et al. who found relatively more false-positive results than false-negative results in MRI for medial meniscus and vice versa for lateral meniscus. This was explained by the over/under reading theory, which states that medial meniscus injuries are overread due to its high incidence than lateral meniscal tears. Similarly, in carefully performed clinical examination, we had more false-positive results (total 4 cases) than false-negative results (total 3 cases) for medial meniscus and reverse for lateral meniscus (4 false-negative results and one false-positive result).
Rayan et al. observed minimal difference in sensitivity (77% vs. 81%), specificity (100% vs. 96%), PPV (100% vs. 81%), NPV (95% vs. 95%), and diagnostic accuracy (93% vs. 96%) between clinical examination and MRI scan for ACL injuries. We found similar diagnostic effectiveness for clinical and MRI assessments in ACL injuries in our study. We found one false-negative case of ACL injury, both in clinical examination and MRI that was confirmed as a partial ACL tear in arthroscopy. We believe the intact synovial envelop of ACL might sometimes lead to an interpretation of normal ACL in MRI. Arthroscopy is useful in such situations as it can detect true ACL integrity and laxity.
Previous prospective studies for the diagnosis of ACL injury by MRI have reported a sensitivity that ranged from 92% to 100%, and specificity that ranged from 93% to 100%.,, However, there is not much data on PCL injuries possibly because of their relative rarity. Mahibul et al. reported 8 cases of PCL injuries were detected, and MRI sensitivity, specificity, and PPV were 100%. In their study of 124 patients, we found only two cases of PCL in our study, and both were detected in clinical examination and MRI. The results of our study show that clinical examination is a useful modality for routine evaluation of meniscal and ligament injuries. MRI will be useful as it can locate the exact site and stretch of the lesion in the management of these injuries before arthroscopy. MRI helps us to make a better preoperative plan, for better objective documentation and is more beneficial in clinically doubtful cases of IDK before proceeding to arthroscopy. The diagnostic accuracy of clinical tests versus MRI is similar for ligament injuries and marginally lower for meniscal injuries. This could be due to the better detection ability of intrasubstance injury and even minute meniscal lesions by MRI, which will not be possible by clinical methods and arthroscopy. A single experienced radiologist reported on all MRI images and a single experienced orthopedic surgeon reported on the clinical examinations reducing possible errors due to variations in interpretations. Our study had a few limitations. The small sample size maybe considered a limitation although formal sample size estimation was done before the study. The results of clinical and MRI assessments are dependent on the experience and skill of the clinician and radiologist. We have not assessed if the diagnostic effectiveness will differ by experience of the orthopedic surgeons or radiologists. The clinical and MRI assessments are compared to the existing gold standard of arthroscopy. However, arthroscopy is not 100% accurate in the evaluation of ACL and meniscal tears.
| Conclusion|| |
Clinical and MRI assessments show similar diagnostic effectiveness for ligament injuries and clinical assessments are marginally less effective than MRI for meniscal injuries. The marginal differences in effectiveness may be due to the better ability of MRI to detect intrasubstance injury and even other minute meniscal lesions. MRI is a reliable and useful diagnostic tool in doubtful clinical cases of cruciate ligament and meniscal injuries. MRI is beneficial in clinically significant knee injuries for preoperative evaluation and better planning of surgical procedures and objective documentation of findings.
The authors thank senior radiologist, Professor E. Devarajan, MD for reading the images in this study and Dr Praveen Nirmalan for the statistical analysis in this research work.
Conflicts of interest
We the authors hereby declare that we do not have any financial and other conflicts of interest that might bias the work. All the authors are confirming our consent of the approval for publishing this article. We have not published or submitted this article elsewhere. We also declare that it is not under consideration for publication with any other journal.We also state that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met, and that each author believes that the man-uscript represents honest work.
Institutional Ethical Committee Approval (for all human studies)
Ref.No.GMCKKD RP 2016/IEC/182.
The author(s) received no financial support for the research, authorship, and/or publi-cation of this article.
Dr. Predeep Kumar VM Critical revision of the article and Final approval of the version to be published. Dr. Raju Karuppal conception of the idea, drafting the article, Critical revision of the article and Final approval of the version to be published.
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[Table 1], [Table 2], [Table 3]