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Orthopedic Extremity/Foot-Ankle Journal Club

Ed Mulligan, MS, PT, SCS, ATCGrapevine, [email protected]

continuing EDcontinuing EDcopyright© epm 2001


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


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


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


How do we currently diagnose a meniscal injury?


Diagnosis of Meniscal Injury

Mechanism of Injury– Youth: Twisting Trauma– Elderly: Degeneration


Diagnosis of Meniscal Injury

Classic Signs/Symptoms– Joint line tenderness– True locking or catching

complaint– Mild, delayed effusion– Quad atrophy


What does the literature say about the accuracy of common meniscal special tests?

First, let’s review what sensitivity and specificity imply


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


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


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


“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.


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°


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


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


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


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


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


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


Generalization

Decent specificity with entrapment examsDecent sensitivity with palpatory findings


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



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



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



Bragard’s Sign– Reproduction of

symptoms medially with ER and Ext

– Alleviation of symptoms medially with IR and Flex

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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



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



Passler Rotational Grind Test– Circumduction movement of knee in combinations

of flex/extension, rotation, and varus-valgus



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


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


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°


Joint Line Tenderness

Assuming a positive test was reproduction of symptomatic complaint with palpation


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


Apley Compression-Distraction Test

Reproduction of symptoms withcompression and rotation;alleviation of symptoms withdistraction


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


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


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


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


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


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


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


Discussion

Meniscal MOI – S/SMeniscal Provocative ManeuversTraditional Testing Accuracy

Clinical interpretation and utility of the Thessaly Test


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


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


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


Clinical Calculator

http://faculty.vassar.edu/lowry/clin1.html


Thessaly Test FindingsMedial Meniscal


Findings with Confidence Intervals

89 (82-94)

97 (94-98)


Findings with Confidence Intervals

2 (1-7)

3 (1-6)


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?


Issue

Early detection (that’s what the title says)– Yet an exclusion criteria was acute knee injuries

(less than 4 weeks old)


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


Overall Impression

Unique study investigating a new techniquePaper written in a clear, concise wayInadequate reflection on results as compared to earlier studies


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?


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



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

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