|Year : 2013 | Volume
| Issue : 3 | Page : 263-266
Study of correlation between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and anterior cruciate ligament injuries
Subhash R Puri, Samar K Biswas, Anil Salgia, Sahil Sanghi, Tushar Aggarwal, Pranav Patel
Department of Orthopedics, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, India
|Date of Web Publication||5-Jul-2013|
Subhash R Puri
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Approx. 28% of patients presents to orthopedic OPD with complaints of knee pain. Common medical complications include an unstable knee, chronic knee pain, and post traumatic arthritis. Aim: To study the correlation between clinical, magnetic resonance imaging (MRI), and arthroscopic findings in knee injuries. Materials and Methods: About 30 cases with history of rotational injury having knee pain and recurrent swelling were subjected to study. Results: MRI had better sensitivity (0.95 vs. 0.85) and specificity (1.0 vs. 0.5) in comparison with clinical examination for medial meniscus. In lateral meniscus injury (sensitivity 0.65 vs. 0.61 and specificity 0.95 vs. 0.92) and in ACL injury (Sensitivity 0.77 vs. 0.8 and specificity 1.0 vs. 0.96) the sensitivity and specificity of MRI versus clinical examination showed minimal difference. Conclusion: Our conclusion is that carefully performed clinical examination can give equal or better diagnosis of meniscal and ACL injuries in comparison with MRI scan. MRI may be used as an additional tool for diagnosis.
Keywords: Anterior cruciate ligament, arthroscopy, clinical, lateral meniscus, medial meniscus, magnetic resonance imaging
|How to cite this article:|
Puri SR, Biswas SK, Salgia A, Sanghi S, Aggarwal T, Patel P. Study of correlation between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and anterior cruciate ligament injuries. Med J DY Patil Univ 2013;6:263-6
|How to cite this URL:|
Puri SR, Biswas SK, Salgia A, Sanghi S, Aggarwal T, Patel P. Study of correlation between clinical, magnetic resonance imaging, and arthroscopic findings in meniscal and anterior cruciate ligament injuries. Med J DY Patil Univ [serial online] 2013 [cited 2020 Sep 18];6:263-6. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/263/114653
| Introduction|| |
Approximately 28% of patients were present in orthopedic OPD with complaints of knee pain. , The cause ranges from trauma, degenerative joint conditions, infections, inflammatory conditions, and congenital lesions.  In the diagnosis of the lesion in the knee, the surgeon has to obtain a thorough clinical history, examine the patient, and do investigations as may be required. Arthroscopy is regarded as the gold standard among the investigative modalities. ,,,
The commonly missed diagnoses in the knee are osteochondral fractures, partial anterior cruciate ligament (ACL) tears, and loose bodies.  Failure to recognize these has both medical and socioeconomic complications. The common medical complications include an unstable knee, chronic knee pain, and post traumatic arthritis. , The socioeconomic complications include loss of working hours during the treatment, high cost of medical care for procedures such as total knee arthroplasties and a perception of general poor health. 
In a tertiary care hospital, up to 2% of the patients presenting to the orthopedic out-patients clinic have knee pain without a definite clinical diagnosis and require diagnostic arthroscopy to define the pathology. This study therefore intended to compare the correlation of clinical impressions and arthroscopic findings and therefore asses the sensitivity of clinical assessment.
| Materials and Methods|| |
Thirty cases of knee pain with suspicion of meniscal or ACL injuries were identified clinically and subjected to MRI and arthroscopy. Patients having degenerative changes or evidence of loose bodies in plain radiographs, any prior surgery for the index diagnosis, and patients treated non-operatively were excluded from the study.
Clinical criteria used were history, tender joint line, and positive McMurray's test for meniscal injury. Lachman test and anterior drawer test were considered essential for diagnosis of ACL injury and these patients were subjected to MRI and arthroscopy. Arthroscopic examinations were carried out under general anesthesia. Clinical, MRI, and arthroscopic findings were kept and compared. Arthroscopic findings were regarded as the gold standard.
| Results|| |
Medial Meniscus Injuries
There were 24 cases where clinical diagnosis of medial meniscal tear was suspected. Out of these 24 cases there were 23 cases where both MRI and arthroscopy were positive in confirming the diagnosis [Figure 1] (95%). There were five cases of bucket handle tear. MRI had better sensitivity (0.95 vs. 0.85) and specificity (1 vs. 0.5) in comparison to clinical examination in diagnosis of medial meniscal tears. Similarly, +ve predictive values (95 vs. 0.5) and -ve predictive values (0.5 vs. 0.2) were found to be higher for MRI diagnosis than in clinical diagnosis for these injuries. Diagnostic accuracy of MRI scan diagnosis was considerably higher in comparison to clinical diagnosis (0.96 vs. 0.82). [Table 1], [Table 2] and [Figure 2].
Lateral Meniscus Injuries
There were 18 cases where clinical diagnosis of lateral meniscal tear was suspected. Out of these 18 cases MRI was positive in all cases and in 15 cases arthroscopy was positive [Figure 3] (83%). Between clinical examination diagnosis and MRI scan diagnosis for lateral meniscal injuries [Table 1] and [Table 2], there was minimal difference in sensitivity (0.75 vs. 0.78, respectively) and specificity (0.66 vs. 0.50), +ve predictive value (0.93 vs. 0.95) and -ve predictive value (0.28 vs. 0.20). Diagnostic accuracy was the same for both the modalities (0.73 vs. 0.76). [Table 1], [Table 2] and [Figure 4].
Anterior Cruciate Ligament Injuries
There were nine cases where ACL injury was suspected clinically, whereby all of them had ACL injury evident on arthroscopy as well [Figure 5] (100%). Out of 20 cases where ACL was found damaged on MRI scan, 17 cases had arthroscopic evidence of ACL injury (85.0%). One case (4.76%) out of 21 cases where clinical ACL was found normal had evidence of injury on arthroscopy. Similar to the lateral meniscal tears, ACL injury diagnosis using clinical examination and MRI scan [Table 1] and [Table 2], there was minimal difference in sensitivity (0.77 vs. 0.81, respectively), specificity (1.0 vs. 0.96), + ve predictive value (1.0 vs. 0.81), −ve predictive value (0.95 vs. 0.95), and diagnostic accuracy (0.93 vs. 0.96) [Figure 6].
|Figure 6: MRI and arthroscopy probing showing a anterior horn tear in the meniscus|
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| Discussion|| |
We studied 30 patients who initially had clinical examination, MRI, and then arthroscopy was conducted. We also analyzed several papers comparing MRI scans with arthroscopy for the knee joint. Chang et al. studied findings of 148 patients with figures of 92% for sensitivity and 87% for specificity for meniscal tears.  The conclusion was that MRI is a reliable diagnostic tool for displaced meniscal tears. Aydingoz et al. found sensitivity and positive predictive values of 90% in a series of 45 meniscal injuries.  De Smet and Graf analyzed 400 records and concluded that sensitivity of MRI scans was reduced for meniscal tears in the presence of ACL injury.  Reduction of sensitivity was shown to be from 94 to 69% for medial meniscal tears. Munshi et al. studied 23 patients of hemarthrosis who had MRI scans followed by arthroscopy.  Higher sensitivity was found and the conclusion was made that prospective use of MRI could have prevented 22% of diagnostic arthroscopic procedures. Jee et al. concluded that MRI in the presence of ACL tears has lower sensitivity for detecting meniscal tears due to missed lateral meniscal tear.  Lundberg et al. found sensitivity and specificity of 74 and 66%, respectively, for medial and 50 and 84% for lateral meniscus. 
They found that MRI could not replace arthroscopy in diagnosis of acute knee injuries. Barronian et al. found 100% sensitivity for medial meniscal tears and 73% for lateral thus finding MRI to be a reliable tool.  For Mohan et al., in their retrospective series of 130 patients, diagnostic accuracy of clinical examination was 88% for medial meniscal tears and 92% for lateral meniscal tears; they concluded that clinical diagnosis of meniscal tears is as reliable as the magnetic resonance imaging (MRI) scan.  Rose et al. found better diagnostic accuracy clinically than with MRI scans in a series of 100 patients.  On the contrary, in a prospective series by Abdon et al., clinical examination had only 61% accuracy for meniscal tears.  Cheung et al. interpreted a series of 293 patients finding 89% sensitivity and 84% specificity for medial meniscus injuries.  For lateral meniscus, the sensitivity was 72% and specificity 93%. Kelly et al. found high negative predictive value in a series of 60 patients.  Rangger et al. studied 121 patients and concluded that MRI should be an essential diagnostic tool before arthroscopy.  Barronian et al. found 88% sensitivity and 72% specificity for meniscal injuries concluding that a selective role exists for MRI.  Kreitner et al. re-evaluated discrepancies in MRI reports and arthroscopic findings. Insufficient arthroscopic evaluation was identified as a further cause for discrepancy. 
| Conclusion|| |
By obtaining correlation between clinical examination, MRI scan, and arthroscopy for meniscal and ACL injuries, we conclude that carefully performed clinical examination can give equal or better diagnosis of meniscal and ACL injuries in comparison to MRI scan. MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has a much better negative predictive value than positive predictive value in both meniscal and ACL injury diagnosis. When clinical signs and symptoms are inconclusive, performing an MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery. When clinical diagnosis is in favor of either meniscal or ACL injuries, performing an MRI scan prior to arthroscopic examination is unlikely to be of significance. MRI scanning should not be used as a primary diagnostic tool in meniscal and ACL injuries. By passing MRI scans and performing arthroscopic examination in suspected cases will be helpful providing earlier treatment of the condition.
| References|| |
|1.||McAlindon TE. The knee. Best Pract Res Clin Rheumatol 1999;13:329-44. |
|2.||Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: A review of community burden and current use of primary health care. Ann Rheum Dis 2001;60:91-7. |
|3.||Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential Diagnosis. Am Fam Phys 2003;68:917-22. |
|4.||Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthoscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: A systematic review. Br Med Bull 2007;84:1-4. |
|5.||Kim SJ, Shin SJ, Koo TY. Arch type pathologic suprapatellar plica. Arthroscopy 2001;17:536-8. |
|6.||Coumas JM, Palmer WE. Knee arthrography. Evolution and current status. Radiol Clin North Am 1998;36:703-28. |
|7.||Khan Z, Faruqui Z, Oguynbiyi O, Rosset G, Iqbal J. Ultrasound assessment of internal derangement of the knee. Acta Orthopaedics Belg 2006;72:72-6. |
|8.||Yoon YS, Rah JH, Park HJ. A prospective study of the accuracy of clinical examination evaluated by arthroscopy of the knee. Int Orthop 2004;21:223-7. |
|9.||McDaniel W, Dameron T. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am 1980;62:696-705. |
|10.||Jomha NM, Borton DC, Clingeleffer AJ, Pinczewski LA. Long-term osteoarthritic changes in anterior cruciate ligament reconstructed knees. Clin Orthop 1999;358:188-93. |
|11.||Oreilly SC, Muir KR, Doherty M. Knee pain and disability in the Nottingham community: Association with poor health status and psychological distress. Br J Rheumatol 1998;37:870-3. |
|12.||Chang CY, Wu HT, Huang TF, Ma HL, Hung SC. Imaging evaluation of meniscal injury of the knee joint: A comparative MR imaging and arthroscopic study. Clin Imaging 2004;28:372-6. |
|13.||Aydingoz U, Firat AK, Atay OA, Doral MN. MR imaging of meniscal bucket-handle tears: A review of signs and their relation to arthroscopic classification. Eur Radiol 2003;13:618-25 |
|14.||Smet AA, Graf BK. Meniscal tears missed on MR imaging: Relationship to meniscal tear patterns and anterior cruciate ligament tears. AJR Am J Roentgenol 1994;162:905-11. |
|15.||Munshi M, Davidson M, MacDonald PB, Froese W, Sutherland K. The efficacy of magnetic resonance imaging in acute knee injuries. Clin J Sport Med 2000;10:34-9. |
|16.||Jee WH, McCauley TR, Kim JM. Magnetic resonance diagnosis of meniscal tears in patients with acute anterior cruciate ligament tears. J Comput Assist Tomogr 2004;28:402-6. |
|17.||Lundberg M, Odensten M, Thuomas KA, Messner K. The diagnostic validity of magnetic resonance imaging in acute knee injuries with hemarthrosis. A single-blinded evaluation in 69 patients using high-field MRI before arthroscopy. Int J Sports Med 1996;17:218-22. |
|18.||Barronian AD, Zoltan JD, Bucon KA. Magnetic resonance imaging of the knee: Correlation with arthroscopy. Arthroscopy 1989;5:187-91. |
|19.||Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop 2007;31:57-60. |
|20.||Rose NE, Gold SM. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy 1996;12:398-405. |
|21.||Abdon P, Lindstrand A, Thorngren KG. Statistical evaluation of the diagnostic criteria for meniscal tears. Int Orthop 1990;14:341-5. |
|22.||Cheung LP, Li KC, Hollett MD, Bergman AG, Herfkens RJ. Meniscal tears of the knee: Accuracy of detection with fast spin-echo MR imaging and arthroscopic correlation in 293 patients. Radiology 1997;203:508-12. |
|23.||Kelly MA, Flock TJ, Kimmel JA, Kiernan HA, Singson RS, Starron RB, et al. MR imaging of the knee: Clarification of its role. Arthroscopy 1991;7:78-85. |
|24.||Rangger C, Klestil T, Kathrein A, Inderster A, Hamid L. Influence of magnetic resonance imaging on indications for arthroscopy of the knee. Clin Orthop Relat Res 1996;330:133-42. |
|25.||Barronian AD, Zoltan JD, Bucon KA. Magnetic resonance imaging of the knee: Correlation with arthroscopy. Arthroscopy 1989;5:187-91. |
|26.||Kreitner KF, Runkel M, Herrig A, Regentrop HJ, Grebe P. MRI of knee ligaments: Error analysis with reference to meniscus and anterior cruciate ligaments in an arthroscopic controlled patient cohort. Rofo 1998;169:157-62. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]