Rev. bras. ortop. vol.50 número6

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w w w . r b o . o r g . b r

Original

Article

Diagnosis

of

knee

injuries:

comparison

of

the

physical

examination

and

magnetic

resonance

imaging

with

the

findings

from

arthroscopy

夽

Nilton

Orlando

Júnior,

Marcos

George

de

Souza

Leão

∗

_,

Nelson

Henrique

Carvalho

de

Oliveira

Fundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received23September2014 Accepted5November2014 Availableonline19October2015

Keywords:

Kneetrauma/diagnosis Kneetrauma/therapy Tibialmenisci

a

b

s

t

r

a

c

t

Objectives:Toascertainthesensitivity,specificity,accuracyandconcordanceofthephysical examination(PE)andmagneticresonanceimaging(MRI)incomparisonwitharthroscopy, indiagnosingkneeinjuries.

Methods:Prospectivestudyon72patients,withevaluationandcomparisonofPE,MRIand arthroscopicfindings,todeterminetheconcordance,accuracy,sensitivityandspecificity. Results:PEshowedsensitivityof75.00%,specificityof62.50%andaccuracyof69.44%for medialmeniscal(MM)lesions,whileitshowedsensitivityof47.82%,specificityof93.87% andaccuracyof79.16%forlateralmeniscal(LM)lesions.Foranteriorcruciateligament(ACL) injuries,PEshowedsensitivityof88.67%,specificityof94.73%andaccuracyof90.27%.For MMlesions,MRIshowedsensitivityof92.50%,specificityof62.50%andaccuracyof69.44%, whileforLMinjuries,itshowedsensitivityof65.00%,specificityof88.46%andaccuracyof 81.94%.ForACLinjuries,MRIshowedsensitivityof86.79%,specificityof73.68%andaccuracy of83.33%.ForACLinjuries,thebestconcordancewaswithPE,whileforMMandLMlesions, itwaswithMRI(p<0.001).

Conclusions:Meniscal and ligamentinjuries can be diagnosed through carefulphysical examination,whilerequestsforMRIarereservedforcomplexordoubtfulcases.PEand MRIusedtogetherhavehighsensitivityforACLandMMlesions,whileforLMlesionsthe specificityishigher.

LevelofevidenceII–Developmentofdiagnosticcriteriaonconsecutivepatients(with universallyappliedreference“gold”standard).

夽

WorkperformedattheOrthopedicsandTraumatologyService,Fundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil. ∗ _{Corresponding}_author.

E-mail:mgsleao@uol.com.br(M.G.deSouzaLeão). http://dx.doi.org/10.1016/j.rboe.2015.10.007

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Diagnóstico

das

lesões

do

joelho:

comparac¸ão

entre

o

exame

físico

e

a

ressonância

magnética

com

os

achados

da

artroscopia

Palavras-chave: Traumatismosdo joelho/diagnóstico

Traumatismosdojoelho/terapia Meniscostibiais

r

e

s

u

m

o

Objetivos: Verificarasensibilidade,especificidade,acuráciaeconcordânciaentreoexame físico(EF)earessonânciamagnética(RM)emcomparac¸ãocomaartroscopia,nodiagnóstico daslesõesdojoelho.

Métodos: Estudoprospectivocom72pacientesavaliadosquantoaoEF,àRMeaos acha-dosartroscópicos.Foramcomparadososachadosentresieobservaram-seaconcordância, acurácia,sensibilidadeeespecificidade.

Resultados: OEFdemonstrousensibilidadede75%,especificidadede62,50%eacuráciade 69,44%paraaslesõesmeniscaismediais(MM).Paraomeniscolateral(ML)encontraram-se sensibilidadede47,82%,especificidadede93,87%eacuráciade79,16%.OEFdemonstrou, paralesõesdoligamentocruzadoanterior(LCA),sensibilidadede88,67%,especificidadede 94,73%eacuráciade90,27%.AslesõesdoMM,àsimagensdeRM,apresentaram sensibili-dadede92,50%,especificidadede62,50%eacuráciade69,44%.AslesõesdoMLapresentaram sensibilidadede65%,especificidadede88,46%eacuráciade81,94%.ARMevidencioupara asrupturasdoLCAsensibilidadede86,79%,especificidadede73,68%eacuráciade83,33%. ParaoLCA,amelhorconcordânciafoicomoEF;eparaMMeML,comaRM(p<0,001). Conclusões:Oexamefísicocuidadosodiagnosticaaslesõesmeniscaiseligamentares.ARMé reservadaparacasoscomplexosouduvidosos.Associados,EFeaRMtêmaltasensibilidade paraaslesõesdoLCAedoMM,porémparaoMLéaespecificidadequeémaior.

NíveldeEvidênciaII–Desenvolvimentodecritériosdiagnósticosempacientesconsecutivos (compadrãodereferencia“ouro”aplicado).

Introduction

Accuratediagnosingofkneeinjuriesisdirectlylinkedtotaking the clinical history and making a careful physical exami-nation.Meniscal andligament injuriesof thisjoint can be evaluated by means of magneticresonance imaging (MRI) examinations,whichprovideimagesshowingabnormalities ofthemorphologythatarecharacterized.Thesensitivityof thisexaminationcanberaisedaccordingtothemethodsused byradiologists.1 _MRI_is_usually_an_accurate_type_of

comple-mentaryexaminationforkneeassessment,but it hashigh cost.2

MRI hashigh applicability to the knees, in comparison withotherjoints,anditprovidesexcellentdiagnostic capac-ityforevaluatinglesionsofdifferenttypes,suchasligament, meniscal,tendon,boneandchondralinjuries.3_However,_no

evidenceto suggest that MRI mightreduce the number of negativearthroscopic procedures has been demonstrated.4

It has been shown that lesion of the anterior meniscal cornu seen on MRI may not any significant clinical pre-sentation,andcorrelationwiththephysicalexaminationis recommended.5_Heterogenous_results_regarding_the_accuracy

of physical examinations on meniscal injuries have been observedbecauseofdeficienciesofclinicalpractice.6

Qualifiedorthopedicsurgeonscan safely diagnose ante-riorcruciateligamentandmeniscalinjuriesthroughphysical examination,whilereservingMRIforcomplicatedand con-fusingcases.Thispracticeisnotrecommendedinitially,and itimpairsthesurgeon’straining.7

Theprogressofarthroscopicsurgeryoverrecentdecades, together with clinical and complementary examinations, in association with the low morbidity ofthe surgical pro-cedure, has encouraged its use for diagnosing, treating and making prognoses in relation to intra-articular knee injuries.8

Theobjectiveofthepresentstudy wastodeterminethe accuracy,sensitivity,specificityandconcordanceofthe find-ingsfromphysicalexaminationsandMRIontheknee,taking arthroscopyonthisjointtobethegoldstandard.

Materials

and

methods

BetweenJune2012andDecember2013,aprospectivecohort studywasconductedon72patients(72knees:44rightknees and28leftknees)ofmeanage33.54years,rangingfrom17 to59years(SD34±9),anddistributedaccordingtosexas61 males(84.72%)and11females(15.28%).Thesepatients pre-sentedmeniscalandligamentinjuriesofthekneeandwere evaluatedasoutpatientsandthroughintraoperative arthro-scopicfindings.

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acute injuries (less than four weeks since the injury); chondral injuries; femoropatellar pathological conditions; and refusal to sign the free and informed consent state-ment.

Eachpatient’sprevioushistoryofpathologicalconditions wastaken.Emphasis wasgiven tothe causeofthe injury. Thedifferentetiologiesoftheinjurieswere groupedas fol-lows: 58 related to sports (79.2%), 12 were due to trauma unrelated to sports (16.7%) and two were idiopathic (the patient could establish a causal link withthe injury). The patients were asked about their symptoms, such as pain, joint effusion, episodes ofinstability and episodes ofjoint locking. A detailed physical examination was undertaken by a surgeon with more than five years of experience of treating pathological conditions of the knee. In order to evaluate meniscal injuries, the McMurray test was used. For anterior cruciate ligament (ACL) injuries, the Lachman tests were used. Varus and valgus stress tests and poste-rior drawer tests were also performed. The patients’ MRI examinationswere then evaluated, always afterthe phys-ical examination. For the purposesof this study,only the report of the examinations and not the interpretations of the images was taken into consideration. The MRIs were produced infour different imagingcenters and the radiol-ogists didnot haveany contactwith the patientsand did not know about the present study. The MRI reports and physicalexaminationfindingswere noted accordingtothe anatomicalstructureinvolved,suchascruciateligamentsand menisci.

Thesurgery was performedby oneof the authors who had not participated in the initial attendance ofthe case. Theligament stability was again tested, under anesthesia. Arthroscopy was performed through the anterolateral and anteromedialportals.Duringtheoperation,theintra-articular injuriesofthekneefoundthrougharthroscopywerenoted. Anytypeofmeniscallesionencounteredduringthesurgery wasconsideredtobeapositivefinding,independentofthe type(radialorlongitudinal,simpleorcomplex,or degenera-tive)andthesidewasnoted(medialorlateral).Arthroscopy wasconsideredtobethegoldstandardinmakingthe diag-nosis of knee joint injuries. This study did not take into consideration the type of treatment for the joint injuries (meniscalandACL).

Theresultsfromcomparingthefindingsfromthe physi-calexamination,MRIandarthroscopywereobtainedthrough thisdatabase,andthesensitivity,specificity,accuracy,positive predictivevalue,negativepredictivevalueandconcordance wereevaluated.

Someoftheconceptsusedinthisstudyaredefinedbelow:

(1) Sensitivity–thisdemonstratedtheefficiencyofMRIand thephysicalexaminationfordiagnosinglesionsthrough arthroscopy.

TP/TP+TN

(2) Specificity – this demonstrated the efficiency of the parametersfordiagnosingtheabsenceoflesionsthrough arthroscopy.

TN/TN+_FP

(3) Accuracy–thisdemonstratedthecapacityofthe physi-calexaminationorMRItocorrectlydefinethepresenceor absenceoflesionsthrougharthroscopy.

TP+_TN/No._of_examinations

(4) Positivepredictivevalue(PPV)–thiswasthelikelihoodthat thelesiondiagnosedonMRIorinthephysicalexamination wouldbepresentthrougharthroscopy.

TP/TP+_FP

(5) Negativepredictivevalue(NPV)–thiswasthelikelihood that there would not beany lesion when the physical examinationorMRIwasnormal.

TN/TN+FN

(6) Truepositive(TP):physicalexaminationorMRIshowing lesion,andarthroscopyshowinglesion.

(7) Truenegative(TN):physicalexaminationorMRInormal, witharthroscopynormal.

(8) Falsepositive(FP):physicalexaminationorMRIshowing lesion,witharthroscopynormal.

(9) Falsenegative(FN):physicalexaminationorMRInegative, andarthroscopyshowinglesion.

Thedescriptiveanalysiswasperformedbymeansofthe Minitab statistical software, version 14.1. The kappa con-cordance analysis was performed through the website of the Epidemiology and StatisticsLaboratory (http://www.lee. dante.br/pesquisa/kappa/). Inthis analysis, thesignificance leveltakenfordecision-makingwas5%.

All the patients read and signedthe freeand informed consent statement and the study was submitted to and approved by the institution’s research ethics committee, under the ethics assessment certificate (CAAE) number 16051913.4.0000.0007.

Results

Throughthephysicalexamination,42kneeswerediagnosed with medialmeniscal injuries.From the arthroscopic find-ings,40 kneespresentedinjuries.Thus,thesensitivitywas 75%,specificity62.50%and accuracy69.44%. Forthe lateral meniscus,thetotalnumberofinjuriesencounteredwas14 and therewere positive arthroscopic findings in 23 knees, withsensitivityof47.82%,specificityof93.87%andaccuracyof 79.16%.

Anteriorcruciateligamentinjurieswerefoundin48knees from the clinical examinationand 53 through arthroscopy, withsensitivityof88.67%,specificityof94.73%andaccuracy of90.27%(Table1).

TheMRIshowedmedialmeniscalinjuriesin46kneesand arthroscopyshowedinjuriesin40menisci,thuspresenting sensitivity of92.50%, specificity of62.50% and accuracyof 69.44%.Forthelateralmeniscallesions,thefollowingresults werefound:19kneeswithinjuriesonMRIandpositive arthro-scopicfindingsin20knees,withsensitivityof65%,specificity of88.46%andaccuracyof81.94%.

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Table1–Correlationofphysicalexaminationwitharthroscopy.

Resultsfromcorrelatingphysicalexaminationwitharthroscopyinthecasesof72knees

Sensitivity(%) Specificity(%) Accuracy(%)

Medialmeniscus 75.00 62.50 69.44

Lateralmeniscus 47.82 93.87 79.16

ACL 88.67 94.73 90.27

ACL,anteriorcruciateligament.

Table2–CorrelationofMRIwitharthroscopy.

ResultsfromcorrelatingMRIwitharthroscopyinthecasesof72knees

Sensitivity(%) Specificity(%) Accuracy(%)

Medialmeniscus 92.50 74.19 83.33

Lateralmeniscus 65.00 88.46 81.94

ACL 86.79 73.68 83.33

ACL,anteriorcruciateligament.

Table3–CorrelationofphysicalexaminationandMRIwitharthroscopy.

Resultsfromcorrelatingphysicalexamination/MRIwitharthroscopyinthecasesof72knees

Sensitivity Specificity Accuracy

Physical(%) MRI(%) Physical(%) MRI(%) Physical(%) MRI(%)

Medialmeniscus 75.00 92.50 62.50 74.19 69.44 83.33 Lateralmeniscus 47.82 65.00 93.87 88.46 79.16 81.94

ACL 88.67 77.35 94.73 73.68 90.27 76.38

MRI,magneticresonanceimaging;Physical,physicalexamination;ACL,anteriorcruciateligament.

Table4–Cross-correlationofphysicalexaminationandMRIwitharthroscopy.

Sensitivity(%) Specificity(%) Accuracy(%) PPV(%) NPV(%)

ACL 97.0 86.7 75.0 95.3 92.9

MM 96.2 76.5 52.8 86.2 92.8

LM 55.6 97.7 66.7 83.3 91.5

Physical,physicalexamination;MRI,magneticresonanceimaging;ACL,anteriorcruciateligament;MM,medialmeniscus;LM,lateralmeniscus; PPV,positivepredictivevalue;NPV,negativepredictivevalue.

Table5–Evaluationofconcordancebetweenthe

diagnosticmethodsforACLinjuriesbymeansof

arthroscopy,MRIandphysicalexamination.

Diagnosticexaminations Kappa Concordance p-Value

ArtversusMRIversusphysicala _0.55 _Moderate _<0.001 ArtversusMRIb _0.51 _Moderate _<0.001 Artversusphysicalc _0.66 _Strong _<0.001

ACL,anteriorcruciateligament;Art,arthroscopy;MRI,magnetic resonanceimaging;Physical,physicalexamination.

a _Concordance_was_found_between_the_three_methods.

b _Concordance_was_found_between_arthroscopy_and_MRI.

c _Concordance_was_found_between_arthroscopy_and_MRI.

73.68% and accuracy of83.33% (Table 2). Table 3 shows a summaryofthedatapresentedabove.Table4showsthe phys-icalexaminationandMRIvaluescombined,witharthroscopy takentobethegoldstandardforthediagnosis.

Table6–Evaluationofconcordancebetweenthe

diagnosticmethodsformedialmeniscalinjuriesby

meansofarthroscopy,MRIandphysicalexamination.

ArtversusMRIversusphysicala _0.367 _Slight/fair _<0.001 ArtversusMRIb _0.630 _Strong _<0.001 Artversusphysicalc _0.322 _Slight/fair _<0.001

MM,medialmeniscus;Art,arthroscopy;MRI,magneticresonance imaging;Physical,physicalexamination.

a _Slight/fair_concordance_was_found_between_the_three_methods.

b _Strong_concordance_was_found_between_arthroscopy_and_MRI.

c _Slight/fair_concordance_was_found_between_arthroscopy_and_MRI.

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Table7–Evaluationofconcordancebetweenthe diagnosticmethodsforlateralmeniscalinjuriesby

meansofarthroscopy,MRIandphysicalexamination.

ArtversusMRIversusphysicala _0.358 _Slight/fair _<0.001 ArtversusMRIb _0.530 _Moderate _<0.001 Artversusphysicalc _0.375 _Slight/fair _<0.001

MM,lateralmeniscus;Art,arthroscopy;MRI,magneticresonance imaging;Physical,physicalexamination.

a _Slight/fair_concordance_was_found_between_the_three_methods.

b _Strong_concordance_was_found_between_arthroscopy_and_MRI.

c _Slight/fair_concordance_was_found_between_arthroscopy_and_MRI.

between arthroscopy and the physical examination, for which the kappa value was 0.665; this concordance was significant (p<0.001). For the medial meniscus, the best concordance observed was between arthroscopy and MRI (=0.630;p<0.001)andforthelateralmeniscus,thebest con-cordanceencounteredwasalsobetweenarthroscopyandMRI (=0.530;p<0.001)(Tables5–7).

Discussion

Ligament and meniscal injuries of the knee are generally diagnosedbyorthopedicsurgeonsbymeansofphysical exam-ination,withcomplementaryaidfromMRI.Inthisstudy,the concordancebetweenthesetwotypesofdiagnosticmethod wasinvestigatedincomparisonwiththearthroscopicfindings fromtheknee.

According to Magee et al.,1 _comparison _between

arthroscopy and MRI presented sensitivity for meniscal injuries of the knee of89% and demonstrated that signal abnormalitiesseenonMRIgaveinformationabout morpho-logicalalterationsofinjuries.Intheirstudy,thesensitivityand specificityvaluesforMRIandarthroscopywererespectively 70.4%and50%formeniscalinjuries.

Brooks et al.4 _demonstrated _that _MRI_did _not _have _the

capacitytodecreasethenumberofnegativearthroscopy pro-cedures,giventhatthephysicalexaminationhadconcordance of79%withthearthroscopicfindingsandMRIshowed con-cordanceof77%witharthroscopy.

StudiesconductedbyShepardetal.5_have_suggested_that

meniscal injuries of the anterior cornu, which are found throughanincreaseintheMRIsignal,commonlydonothave apparentclinicalsigns.Thissuggeststhatthereisa correla-tionofinterpretationsofMRIwiththephysicalexamination. Asdemonstrated byKocabey et al.7 _in_2004, _there_was _no

statistical significance(p>0.05) incomparing MRI withthe physicalexamination,indiagnosingmeniscalandligament injuriesofthekneeinrelationtothearthroscopicfindings. Thissuggeststhatwell-trainedorthopedicsurgeonscansafely diagnoseanteriorcruciateligamentinjuriesandthatthe rou-tineofindicatingMRIbeforethephysicalexaminationisnot recommended.

Analysesconducted byPolly et al.9 _concluded _that _MRI

hasadjuvant value in relationto physicalexamination, in preoperativeplanning for knee operations,with sensitivity andspecificityof66.7%and95.1%respectivelyformeniscal

injuries,and100%and96.9%forACLinjuriesevaluatedusing MRI.

MRI should be used as an auxiliary tool in diagnosing meniscalandligamentinjuries,accordingtoChangetal.,10

whodemonstratedsensitivityof92%andspecificityof87%for MRIincomparisonwitharthroscopy,forkneeswithmeniscal injuries.

In acuteinjuriesinwhichphysicalexaminationmaybe inconclusive,MRIhelpsinthediagnosisinthispopulationand mayguidethesurgicalindication,accordingtoMunshietal.11

However,itscorrelationwitharthroscopyinthispopulation hasnotyetbeendocumented.

Combinedmethodsfordiagnosingkneeinjuriesconsisting ofphysicalexaminationandMRIwerefoundtobecapableof diminishingthenumberofnegativearthroscopyprocedures by5%,asdemonstratedbyMunketal.12 _This_suggests_that

MRIhasdiagnosticvalueandhelpsinrelationtothetypeof anesthesiaandtreatment,andthatitmaysignificantlyreduce theneedforasecondarthroscopicintervention.

Inadouble-blindstudy,Rappeportetal.13_commented_that

knee arthroscopy was performed without priorknowledge oftheMRIdata. TheaccuracyoftheMRIwasgreater than arthroscopyasthegoldstandardfordiagnosis,andwhenMRI wasusedasthestandard,theaccuracyofthearthroscopywas lower,giventhatinacertainsmallnumberofpatients,some injuriesfoundonMRIwerenotshownduringarthroscopy.It wassuggestedthatMRIshouldbeusedinitiallyfor diagnos-ingkneeinjuries,whichwouldalsodiminishthenumberof negativearthroscopyprocedures.

Gelbetal.14_demonstrated_that_MRI_has_been_used

exces-sivelyincasesofkneedisordersanddoesnothaveafavorable cost–benefitrelationshipinrelationtophysicalexamination, in comparisons with arthroscopy. For physical examina-tion,theseauthorsfoundsensitivityandspecificityof100%, whereasincomparingMRIwitharthroscopy,theyfound val-uesof95%and88%.

In a Brazilian study, Schneider et al.15 _found _that _MRI

wasareliableexaminationfordiagnosingkneeinjuries,with sensitivityof53%andspecificityof95%forACLinjuries,in comparisonwitharthroscopy.

Inthepresentstudy,thesensitivityandspecificityvalues forMRIcomparedwitharthroscopywere86.79%and73.68% respectively,forACLinjuries.

Severinoet al.16 _suggested_that_MRI_was_an_appropriate

methodforcomplementingthephysicalexaminationincases ofligament andmeniscal injuriesofthe kneeand demon-stratedsensitivityandspecificityvaluesforMRIforinjuriesof theACL,medialmeniscusandlateralmeniscusofrespectively 82%and96%,96%and66%,and87%and88%,incomparison witharthroscopy.

IntheanalysesofYousefetal.17_on_the_correlation_between

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Inthepresentstudy,physicalexaminationandMRIwere evaluatedand comparedwitharthroscopy.Thiswas differ-entfromthestudiescitedabove,inwhichotherparameters wereevaluated.Theaccuracyofthephysicalexaminationfor medialmeniscalinjurieswasfoundtobe69.44%andthe accu-racyofMRIwas83.33%.Forthelateralmeniscus,thevalues were79.16%forthephysicalexaminationand81.94%forMRI. ForACLinjuries,theaccuracyofthephysicalexaminationwas foundtobe90.27%andtheaccuracyofMRIwas83.33%.

TheaccuracyofMRIfordetectingkneeinjurieswasmore than 90%when it wasevaluated byspecialists, as demon-stratedbyBen-Galinetal.,18 _but_they_found_a_{false-positive}

rateof47%forACLinjuries,incomparisonwiththe intraoper-ativefindings.Theaccuracyratewas80%forligamentinjuries. Thus,37%ofthesurgicalproceduresindicatedbecauseof sig-nificantalterationsseenonMRIwereperformedunjustifiably. AccordingtoVinckenetal.,19_patients_who_require

arthro-scopictreatmentcanbeappropriatelyidentifiedbymeansof MRIexamination,because ofthesensitivityand specificity ratesof87%and 88%.Theirdatawere similartowhatwas foundinthepresentstudy.

Gobbo et al.20 _concluded _that _the _set _of_maneuvers _for

meniscal injurieshad good accuracyand significant value, compared with MRI, especially for ruling out other joint injuries.

In2013,Navaliet al.21 _stated _that_physical_examination

andMRIhadacceptablediagnosticpowerinrelationtoknee injuries,althoughphysicalexaminationwasslightlysuperior. Thus,becauseofthecost,MRIshouldbereservedforcasesin whichthereweredoubts,orforcomplexinjuries.

Differingfromtheabovecitations,Yanetal.22_stated_that

MRIhadgreateraccuracy,sensitivityandnegativepredictive valuethanclinicalmaneuversincasesofmeniscalinjuries. TheyrecommendedthatMRIshouldberoutinelyrequested fordetectingthistypeofinjury.Thesefindingswere corrobo-ratedinthe presentstudy,withsimilarresults,comprising accuracy,sensitivity and negativepredictive values greater than those from physicalexamination, respectively as fol-lows:medialmeniscus,83.33%versus6944%,92.50%versus 75%and88.46%versus66.66%;andlateralmeniscus,81.94% versus79.16%,65%versus47.82%and86.79%versus79.31% (MRIversusphysicalexamination).

TheefficacyofMRIinrelationtoacutekneetraumahasnot beenstudiedappropriately.Inadoubleblindstudy, Muham-mad etal.23 _evaluated_the _clinical _efficacy _of_MRI_in _cases

ofacuteknee trauma withinconclusivephysical examina-tions,andusedarthroscopyasthediagnosticgoldstandard. The sensitivity and specificity of MRI were 90% and 67%, respectively,fordetectinganyACLinjuries,50%and86%for medialmeniscal injuries and 88% and 73% forthe lateral meniscus.They thereforesuggestedthat evaluationsusing MRI should be used to guide the need for surgery when theclinicalexaminationwasinconclusive,asinacuteknee injuries.23

Theobjectiveofevaluatingtheaccuracyofphysical exami-nationincomparisonwitharthroscopyandMRIwasthetopic ofastudybyVenuetal.24_They_stated_that_physical

examina-tionalonewasunsatisfactoryfordiagnosingkneeinjuriesand reportedthatMRIandarthroscopywereconcordantin94%of thepatientsevaluated.

In our evaluation, the physical examination presented greateraccuracyinrelationtoarthroscopythandidMRIfor lig-amentinjuries.However,formeniscalinjuries,MRIpresented greateraccuracyinrelationtoarthroscopy.

Evaluationsofkneeinjuriesweremadebymeansof phys-ical examination in this study. However, Solomon et al.25

concluded from analyzing the accuracyofphysical exami-nationformeniscalandligamentinjuriesthatthismightbe betterusedfordiagnosiswhenassociatedwiththepatient’s history and use of a set ofmaneuvers, instead ofspecific maneuversformeniscalandligament injuriesapplied sep-arately.

In2009,Ryanetal.26_also_came_to_the_conclusion_that

phys-icalexaminationperformedcarefullycouldprovidethesame orevenabetterdiagnosisofmeniscalandligamentinjuries, incomparisonwithMRI.

In2012,Ercinetal.27_reported_that_physical_examinations

thatwereperformedwell,byexperiencedsurgeonsusing mul-tiplemaneuvers,weresufficientformakingthediagnosisof meniscalinjuries.Theirfindingswere similartotheresults fromthepresentstudy.

Thestudy byValles-Figueroaetal.28_was_more_emphatic

incontraindicatingroutinerequestsforMRIexaminationsfor evaluatingkneeinjuries.Theseauthorsstatedthatphysical examinationwassufficientfordiagnosingmeniscaland liga-mentinjuriesofthisjoint.

For medialmeniscal injuries, physicalexamination has greatersensitivitythanMRI,althoughitsaccuracyand speci-ficityarelow,accordingtoSharmaet al.29_Their_data_differ

somewhatfromours,inwhichMRIwasmoresensitivethan physicalexamination,althoughtheaccuracyandspecificity ofphysicalexaminationwerelowinourstudytoo,inrelation toMRI.

Accordingtotheliterature,30_with_regard_to_arthroscopy,

thereisariskofapproximately8%inrelationtothesurgical procedure.Forthisreason,thepresentauthorsdonotuseit onlyasadiagnosticmethod,butalsoasatherapeuticmethod. Inaddition,arthroscopyusedonlyfordiagnosisisaninvasive tool,anditisslowerandmoreexpensivethanMRI.

Inordertoevaluatetheconcordanceamongthe parame-tersanalyzed,weusedthekappacoefficient(),asdescribed byVieiraandGarret,31_with_concordance_values_as_expressed

in Fig. 1. Through this, the best concordance was found to be between the physical examination and ACL injuries (=0.665),whichwassignificantconcordance(p<0.001).For medialmeniscalinjuries,thebestconcordancewasobserved betweenarthroscopyandMRI(=0.630;p<0.001);andfor lat-eralmeniscalinjuries,thebestconcordancewasalsofoundto bebetweenarthroscopyandMRI(=0.530;p<0.001).Wedid notfindanysimilarvaluesinthecurrentliterature.

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Poor Slight Fair Moderate Significant Almost perfect

Kappa 0.0 0.20 0.40 0.60 0.80 1.0

Concordance Kappa

Less than an association by coincidence <0

Slight association 0.01–0.20

Fair association 0.21–0.40

Moderate association 0.41–0.60

Significant association 0.61–0.80

Almost perfect association 0.81–0.99

Interpretation of kappa

Fig.1–Interpretationofthekappacoefficient;Vieiraand Garret,31_2005.

instability,onlythe Lachmanmaneuverswereapplied.The method appliedfor treating these injuries, along with the long-term follow-up of these patients, was outside of the scopeofthepresentstudy.

Conclusions

AlthoughMRIandarthroscopyareexcellentcomplementary methodsfordiagnosingintra-articularkneeinjuries,physical examinationcanstillprovideaprecisediagnosiswhendone carefullybyanexperiencedsurgeon,especiallyincasesofACL injury. Thisis evencapableofpromoting lower healthcare costs.MRIshouldonlybeusedtocomplementthefindings indoubtfulcasesorincomplexinjuriesinwhichthe clini-calexaminationisinconclusive,and arthroscopyshouldbe usedfortreatingthese injuries.MRIshould beanoptional examination,ratherthanaroutineexamination.When phys-icalexaminationandMRIwereusedtogether,theirsensitivity forACLandmedialmeniscalinjurieswashighandthe speci-ficityforthelateral meniscuswashigher.For ACLinjuries, therewasconcordancebetweentheexaminations.However, thebestconcordancewasbetweenarthroscopyandphysical examination.Forthemedialmeniscus,thebestconcordance wasobservedbetweenarthroscopyandMRIandforthelateral meniscusitwasalsobetweenarthroscopyandMRI.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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