Comparative analyses of diagnostic methods in knee injuries

Solitary liver lesions in children: interobserver agreement and accuracy of MRI diagnosis

KeywordsAnterior cruciate ligament; Tear; Meniscus; Rupture; PatternsIntroductionAnterior cruciate ligament (ACL), as a primary stabilizing structure of knee is the most common disrupted ligament in acute trauma in the US every year [1,2]. On the other hand, the menisci play a crucial role in the dynamics of the knee. Their shape, attachment, and material properties contribute substantially to joint alignment and load transmission by distributing both tensile and compressive forces. Damage to the menisci can influence proprioception, stability, and mobility of the knee [3,4]. Risk factors for meniscal tears include prolonged or repeated deep knee bending, obesity, and sports [5]. Acute injury, as seen in alpine sports, involves complex dynamics, which can damage singular or multiple tissue structures of the knee [5,6]. Meniscal tears are typically thought to be initiated by coupled compression and twisting movements [7,8] which can accompany high-energy maneuvers such as cutting, jumping, and landing during sporting events [9].Meniscal injuries commonly occur in conjunction with ACL tears. A numerous studies have examined the occurrence of these injuries, with their presence being reported as 16% to 82% in knees with acute ligament tears and as high as 96% in knees with chronic ligament tears [10-14]. Magnetic resonance imaging (MRI) is valuable tool, preferred than diagnostic arthroscopy in most patients with ligamentous and meniscal tears because it avoids the surgical risks of arthroscopy, with better accuracy in medial and lateral meniscus and ACL [15].Lateral meniscal tears (LMTs) occur slightly more frequently than medial meniscal tears (MMTs) in knees with acute ACL injuries, 56% lateral versus 44% medial. [10,12]. MMTs however, are more common in chronic ACL deficiency [10,12,14]. This difference in tear occurrence is usually attributed to the anatomic and functional differences that exist between the two menisci, especially in the ACL deficient knee, the lateral meniscus relatively loosely attached to the tibial plateau which allows it to be quite mobile, whereas the medial meniscus, is firmly attached to the tibia, especially at the posterior horn [12,16,17]. This firm attachment allows the medial meniscus to act as a knee stabilizer, a significant restraint to anterior tibial translation in the ACL deficient knee [18-21]. The loss of ACL function increases tibial translation, allowing the meniscus to “engage” the femoral condyle and act as a wedge against the tibia [22,23], while others have suggested that mechanical trauma causes the MMTs in this setting [12,18,20]. Several studies have explored the relationship between ACL injury and meniscal tear [24-30]. Some showed preponderance of the LMTs in the acute setting and in osteoarthritis [24,25], others suggested the MMTs especially in acute reconstructions [26-29].This study was conducted to determine the patterns of meniscus damage associated with ACL rupture and identify the commonest type of meniscus damage in our population that is associated with ACL tear.MethodsMedical records of patients with ACL rupture covering a period of 16 years (January 1996 to December 2012) seen at the author’s institute were retrospectively reviewed. The collected data included the presence or absence of meniscal tear, the type of meniscal tear diagnosed by MRI or arthroscopy, the time of the initial ACL injury and the time of meniscal tear, the duration between ACL rupture and reconstruction surgery, age, gender, mode of injury and level of sports activity performed, height, weight.BMI is calculated according to the Patient’s height and weight, patient is considered obese if the BMI is above 30 according to the World Health Organization [31].Sports level was classified as: professional athletes: (practicing a sport activity as a job, e.g. member of a team), recreational Athlete (considered a person, who is practicing a sport activity that is involving running and pivotal movements at least once in a week not professionally), non athlete (a person who is not practicing any kind of sport), patients with no clear statement regarding their level of sport are considered as missing data.Mode of Injury is classified as direct (Injury was caused be a direct trauma to the patent, e.g. hit by another player, felt on his knees or road traffic accident) or non direct (Injury was caused without trauma, e.g. over rotating the knee while exercising).Patients who were diagnosed with ACL rupture using MRI within 3 months of the injury, underwent primary arthroscopic ACL reconstruction at our institution and found to have meniscal damage diagnosed by MRI or arthroscopy were included in the study. Patients who had a chronic ACL tear or had undergone prior ipsilateral knee arthroscopy or surgery, those with osteoarthritis, with rheumatoid arthritis and patients who had undergone ACL rupture revision were excluded from the study. All images were obtained by routine knee MRI.Types of Meniscal Tears were obtained from the reports of the MRI and Arthroscopy and were classified as (longitudinal, Degenerative, flap, radial, complex) as according to Tandogan et al. [32], De Smet [33].Data collected were entered and coded systematically into a Microsoft Excel worksheet and were imported to a Predictive analysis software (PASW) program version 18 (SPSS, IBM, Chicago, Illinois, USA). Oneway analysis of variation (ANOVA) was used to compare means between the three groups (LMTs, MMTs and both). Pearson correlation was conducted to determine the relationship between the outcome variables (age, gender and sport levels). Independent sample t -test was done to identify differences between the mean values of continuous variables. Chi square test was done to determine associations between categorical variables. A test result considered statistically significant if p< 0.05.ResultsA total of 294 patients satisfied the inclusion criteria of the current study from 1996 to 2012. Of these patients, 175 (59.5%) had MMTs, 91 (31%) had LMTs and 28 patients (9.5%) with both MMT and LMT (Table 1).Table 1: Demographic characteristics of all patients with ACL rupture with meniscus injury. Variables Age in years, mean (SD)27.98 (6.8)Weight in kg, mean (SD)80.80 (17.1)Height in cm, mean (SD)170.73 (7.7)BMI in kg/cm2, mean (SD)27.68 (5.6)Mode of injury Direct injury, n (%)125 (42.5)Non-direct injury, n (%)169 (57.4)Sports level Professional athletes, n (%)5 (1.7)Recreational athletes, n (%)196 (66.7)Non-athlete, n (%)28 (9.5)No available data, n (%)65 (22.1) Patients who had MMTs were significantly older (29.10 ± 7.0 years) compared to lateral (26.24 ± 5.9 years) and both (26.61 ± 6.7 years), p=0.002. There were no significant differences in the height, weight, and BMI, level of sport and mode of injury in between the three groups (MMTs, LMTs and both) (Table 2). Types of meniscal tears are shown in Table 3.Table 2: Comparison between MMT, LMT and both in 294 patients who hadACL tear. VariablesMMTn=175LMTn=91Bothn=28 p valuesAge in years, mean (SD)29.10 (7.0)26.24 (5.9)26.61 (6.7)0.002^Weight in kg. mean (SD)82.38 (17.5)79.14 (16.4)76.87 (16.3)0.165^Height in cm, mean (SD)170.40 (8.1)171.42 (6.6)170.49 (8.1)0.602^BMI, mean (SD)28.34 (5.6)26.83 (5.6)26.43 (5.2)0.062^Obesity, n (%)56 (32.0)22 (24.2)7 (25.0)0.294*Type of ACL tear Direct ACL tear, n (%)68 (38.9)32 (35.2)9 (32.1)0.425*Indirect ACL tear, n (%)65 (37.1)30 (33.0)8 (28.6)Level of sports Recreational athlete, n (%)105 (60.0)67 (73.6)22 (78.6)0.144*Professional athlete, n (%)3 (1.7)2 (2.2)1 (3.6)Note: ^ by ANOVA, * by Chi-square test Table 3: Types of meniscal tears by MRI & Arthroscopy. Types of Meniscal TearsMedialLateralTotalLongitudinal Tears152(75%)86(72%)238(74%)Degenerative Tears16(8%)10(8%)26(26%)Radical Tears8(4%)9(7%)17(5%)Complex Tears6(3%)2(2%)8(2.5%)FLAP6(3%)5(4%)11(3.5%)N/A15(7%)7(7%)22(7%)Total203119322DiscussionIn our study, the patients who had medial meniscal tearing were significantly older than those who had only lateral meniscal tear, and those who had both medial and lateral meniscal tears. No such relationship was significant between age and lateral meniscal tear. Our findings are in concordance with the findings of the study that was conducted in Turkey by Tandogan et al. [32], which showed preponderant injury to the medial meniscus than the lateral meniscus, they also found that the mean age of the patients with medial meniscal tears was 27.0 ± 7.6 years, significantly older than those who had no medial meniscal tearing (25.4 ± 6.7 years). Our patient’s mean age who had medial meniscal tearing was 29.10 ± 7.0 years, significantly older than 26.61 ± 6.7 years in those who did not have medial meniscal tearing. Sports level was not significantly correlated to the parameters we have studied or to the site of meniscal tear. This is probably because most of our patients (66.8%) were just recreational athletes.Our study was in contrast to the findings of Bellabarba et al. [10] ,Thompson et al. [12], Melissa [34] wherein they found that LMTs are more frequently encountered than MMTs, and that MMTs on the other hand are more common in chronic injuries. Our study showed more frequent MMTs than LMTs, of patients with acute ACL injuries. Again, this is probably due to the older age of our patients, which was significantly correlated with MMTs.Obesity, Mechanism of injury, Sport level as a risk factors of meniscal tear didn’t show any significance in determining a common pattern, which goes with the same results that was found in Kluczynski et al. [34] where different risk factors have been examined prospectively to see their effect on meniscal tears and chondral changes.The sensitivity of MRI in detecting meniscal pathology has been proven in several studies [10]. However, Oei in 2003 [35] pointed out the low sensitivity of MRI in detecting lateral meniscal pathology compared to detecting medial meniscal pathology with a sensitivity difference by as much as 14% (93.3% versus 79.3%), in an adult population, more so in the presence of ACL tears [36]. This window would probably explain the differences between the frequencies of LMTs and MMTs, more so in our findings, another point which could also explain our findings; is the common presentation of knee varus malalignment in Saudi population. In a comparison study between Saudi Arabian and Canadian cohorts by the same group, it was clearly found that in knee osteoarthritis patients Saudis had more varus alignment, showed by the Hip-Knee-Ankle angle parameter used to diagnose knee alignment disorders [37].A study addressing the Knee alignment in the Saudi Population Comparing the means of Tibiofemoral angle (TFA) of different age groups in Saudi population to those of corresponding age groups in Japanese and Australian Caucasians showed a statistically significant lower TFA difference in all age groups. Comparison of the means of TFA of different age groups in Saudi population to those of corresponding age groups in Japanese and Australian Caucasians showed a statistically significant difference in all age groups, also Comparison of the means of TFA of Saudi males and females to those of Europeans, Chinese and American Caucasians showed a significant difference from all of them [38].Genuvarus can result in added contact stresses on the medial compartment of the knee and possibly lead to accelerated wear and damage to the articular cartilage.Another explanation for the significant association of older age to MMTs is the association of the medial meniscus posterior horn with severity of the chondral lesion and arthritic changes according to the K-L radiographic score. There is usually accompanied chondral damage in MMTs [39].Secondary medial meniscal tears are considered as the main reason of osteoarthritis followed by ACL deficiency [40]. The aim of this study is to alert the surgeons about the existence of this common finding in order to decrease future osteoarthritis. There were a few limitations in the study mainly because of its retrospective nature; a lot of the Patient’s X-rays were not found in order to study the alignment of the knees. In addition we were not able to obtain detailed information about the chondral lesions in the MRI reports to augment our significant findings of MMTs among our older-aged population.ConclusionThe higher occurrence of medial meniscal tear in acute anterior cruciate tears could be attributed to the age related arthritic changes as well as to the common varus deformity in our population; this finding should be considered by the surgeons in order to decrease future osteoarthritis.ReferencesGriffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, et al. (2000) Noncontact anterior cruciate ligament injuries: Risk factors and prevention strategies. J Am Acad Orthop Surg 8: 141-150. Grindstaff TL, Hammill RR, Tuzson AE, Hertel J (2006) Neuromuscular control training programs and noncontact anterior cruciate ligament injury rates in female athletes: A numbers-needed to treat analysis. J Athl Train 41: 450-456. Aagaard H, Verdonk R (1999) Function of the normal meniscus and consequences of meniscal resection. Scand J Med Sci Sports 9: 134-140.Jerosch J, Prymka M, Castro W (1996) Proprioception of knee joints with a lesion of the medial meniscus. Acta Orthop Belg 62: 41-45.Baker P, Coggon D, Reading I, Barrett D, McLaren M, et al. (2002) Sports injury, occupational physical activity, joint laxity, and meniscal damage. J Rheumatol 29: 557-563.Renstrom P (1994) Clinical practice of sports injury prevention and care. Olympic encyclopedia of sports medicine. Oxford, London, Edinburgh, Boston, Melbourne, Berlin, Paris, Vienna: Blackwell Scientific Publications, LTD.Muellner T, Nikolic A, Vecsei V (1999) Recommendations for the diagnosis of traumatic meniscal injuries in athletes. Sports Med 27: 337-345. Slocum DB, Larson RL (1968) Rotatory instability of the knee: Its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg Am 50: 211-225.Muellner T, Weinstabl R, Schabus R, Vécsei V, Kainberger F, et al. (1997) The diagnosis of meniscal tears in athletes: A comparison of clinical and magnetic resonance imaging investigations. Am J Sports Med 25: 7-12. Bellabarba C, Bush-Joseph CA, Bach BR Jr (1997) Patterns of meniscal injury in the anterior cruciate-deficient knee: A review of the literature. Am J Orthop 26: 18-23.Yoon KH, Yoo JH, Kim KI (2011) Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. J Bone Joint Surg Am 93: 1510-1518.Thompson WO, Fu FH (1993) The meniscus in the cruciate-deficient knee. Clin Sports Med 12: 771-796. Panisset JC, Duraffour H, Vasconcelos W, Colombet P, Javois C, et al. (2008) Clinical, radiological and arthroscopic analysis of the ACL tear. A prospective study of 418 cases. Rev Chir Orthop Reparatrice Appar Mot 94: 362-368.Wickiewicz TL (1990) Meniscal injuries in the cruciate-deficient knee. Clin Sports Med 9: 681-694. Crawford R, Walley G, Bridgman S, Maffulli N (2007) Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 84: 5-23.Villegas DF, Hansen TA, Liu DF, Donahue TL (2008) A quantitative study of the microstructure and biochemistry of the medial meniscal horn attachments. Ann Biomed Eng 36: 123-131.Kan A, Oshida M, Oshida S, Imada M, Nakagawa T, et al. (2010) Anatomical significance of a posterior horn of medial meniscus: The relationship between its radial tear and cartilage degradation of joint surface. Sports Med Arthrosc Rehabil Ther Technol 2:1.Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, et al. (2000) Importance of the medial meniscus in the anterior cruciate ligament-deficient knee. J Orthop Res 18: 109-115. Hsieh H-H, Walker PS (1976) Stabilizing mechanisms of the loaded and unloaded knee joint. J Bone Joint Surg Am 58: 87-93. Indelicato PA, Bittar ES (1985) A perspective of lesions associated with ACL insufficiency of the knee: A review of 100 cases. Clin Orthop Relat Res 198: 77-80.Markolf KL, Kochan A, Amstutz HC (1984) Measurement of knee stiffness and laxity in patients with documented absence of the anterior cruciate ligament. J Bone Joint Surg Am 66: 242-252. Levy IM, Torzilli PA, Warren RF (1982) The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am 64: 883-888. Sullivan D, Levy IM, Sheskier S, Torzilli PA, Warren RF, et al. (1984) Medial restraints to anteriorposterior motion of the knee. J Bone Joint Surg Am 66: 930-936. Cipolla M, Scala A, Gianni E, Puddu G (1995) Different patterns of meniscal tears in acute anterior cruciate ligament (ACL) ruptures and in chronic ACL-deficient knees. Classification, staging and timing of treatment. Knee Surg Sports Traumatol Arthrosc 3: 130-134.Nikolic DK (1998) Lateral meniscal tears and their evolution in acute injuries of the anterior cruciate ligament of the knee. Arthroscopic analysis. Knee Surg Sports Traumatol Arthrosc 6: 26-30. Cerabona F, Sherman MF, Bonamo JR, Sklar J (1988) Patterns of meniscal injury with acute anterior cruciate ligament tears. Am J Sports Med 16:603-609. Keene GC, Bickerstaff D, Rae PJ, Paterson RS (1993) The natural history of meniscal tears in anterior cruciate insufficiency. Am J Sports Med 21:672-679.Paletta GA, Levine DS, O’Brien SJ, Wickiewicz TL, Warren RF (1992) Patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers. Am J Sports Med 20: 542-547.Smith JP III, Barrett GR (2001) Medial and lateral meniscal tear patterns in anterior cruciate ligament deficient knees. Am J Sports Med 29: 415-419. Kaeding CC, Pedroza AD, Parker RD, Spindler KP, McCarty EC, et al. (2005) Intra-articular findings in the reconstructed multiligament injured knee. Arthroscopy 21: 424-430. WHO (2000) Obesity: Preventing and Managing the Global Epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. Tandogan RN, Taşer O, Kayaalp A, Taşkiran E, Pinar H, et al. (2004) Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time form injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 12: 262-270.De Smet AA (2012) How I diagnose meniscal tears on knee MRI. AJR Am J Roentgenol 199: 481-499. Kluczynski MA, Marzo JM, Bisson LJ (2013) Factors Associated With Meniscal Tears and Chondral Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Prospective Study Am J Sports Med 41: 2759-2765.Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Myriam Hunink MG (2003) MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 226: 837-848.De Smet AA, Mukherjee R (2008) Clinical, MRI, and arthroscopic findings associated with failure to diagnose a lateral meniscal tear on knee MRI. AJR Am J Roentgenol 190: 22-26.Cooke TD, Harrison L, Khan B, Scudamore A, Chaudhary MA (2002) Analysis of limb alignment in the pathogenesis of osteoarthritis: a comparison of Saudi Arabian and Canadian cases. Rheumatol Int 22: 160-164.El Fouhil AF, Khoshhal KI, Al-Nakshabandi NA, Al-Boukai AA, Atteya M (2011) Normal knee angles in the adult Saudi population. Saudi Med J 32: 1143-1148.Ozkoc G, Circi E, Gonc U, Irgit K, Pourbagher A, et al. (2008) Radial tears in the root of the posterior horn of the medial meniscus. Knee Surg Sports Traumatol Arthrosc 16: 849-854.Lohmander LS, Englund PM, Dahl LL, Roos EM (2007) The long-term consequence of anterior cruciate ligament and meniscus injuries: Osteoarthritis. Am J Sports Med 35: 1756-1769.

The knee joint assessment to detect anterior cruciate ligament (ACL) injury after trauma involves clinical examination and radiography. The gold standard method is doing arthroscopy. We did this study seeking to evaluate the effectiveness of other non-invasive diagnostic methods, including the Anterior Drawer test, Lachman testand magnetic resonance imaging (MRI) in detectingACLtears after trauma, compared to the reference standard method (the arthroscopy). This descriptive cross-sectional study was conducted in the Orthopaedic Department of the Khyber Teaching Hospital, Peshawar, for six months. A total of 86 participants with knee injuries fulfilling the inclusion criteria were recruited for the study. Mechanism of injury, side of injury and body weight were recorded. The Anterior Drawer test and Lachman test for ACL injury were performed by orthopaedic surgeons with at least five years of post-fellowship experience in orthopaedic surgery. Sensitivities, specificities and accuracy of the clinical tests and MRI were calculated. The statistical analysis revealed that the mean age of participants was 35.73 (SD12.7) years, with a range from 18 to 55 years. Among the participants, 67 (77.91%) were maleand 19 (22.09%) were female. The side of injury was predominantly right in 50 (58.14%) and left in 36 (41.86%) participants. Road traffic accidents (RTAs) were the leading cause of knee injury, accounting for 63.95% (55) of cases, followed by sports injuries at 23.26% (20). Regarding diagnostic accuracy, MRI showed a sensitivity of 98.57%, specificity of 87.50%and diagnostic accuracy of 96.51% in detecting ACL tears. The Lachman test demonstrated a sensitivity of 90%, specificity of 87.5%and diagnostic accuracy of 89.53% compared to arthroscopy. Similarly, the anterior Drawer test exhibited a sensitivity of 88.57%, specificity of 87.50%and diagnostic accuracy of 88.37% against the gold standard of arthroscopy. These findings underscore the effectiveness of these diagnostic modalities in identifying ACL injuries. All three tests (MRI, Lachman test and anterior Drawer test) can be used for the diagnosis of anterior cruciate ligament injury with optimal results.

To evaluate the effectiveness of a neuromuscular warm-up program in preventing acute knee injury in adolescent female football (soccer) players. Cluster randomized (by team) controlled trial, stratified by geographical district. Sample size was calculated (n = 8118) with 80% power to show a reduction of 50% in an estimated 1.15% annual incidence of anterior cruciate ligament (ACL) injury at P ≤ 0.05. Clubs in 8 regional districts of the Swedish Football Association, during the 2009 season (April through October). Female under-14 to under-18 football clubs (ages 12-17 years) were recruited. Reasons for the exclusion of clubs were lack of response, <2 training sessions per week, and the current use of an injury prevention program. The clubs were randomized to a neuromuscular warm-up intervention (Knäkontroll, SISU Idrottsböcker, Sweden, 2005) or to a control group, who were instructed to continue with their usual training and playing practices. The neuromuscular training program included 6 exercises that focused on knee control and core stability (1- and 2-legged knee squats, a pelvic lift, the bench, the lunge, and jump/landing). The exercises were to be done twice per week and were to take about 15 minutes, after a brief running warm-up. They progressed through 4 levels of difficulty. The team coaches supervised the program after instruction from study therapists. The primary outcome was the rate of ACL injuries. Diagnosis was confirmed, as appropriate, by a physician and by magnetic resonance imaging. Secondary outcomes were the rates of serious knee injury and any acute knee injury, defined as those with sudden onset during play that led to a player being unable to participate in training or competition. Severe injuries were those that caused absences of >4 weeks. Two study therapists evaluated the injuries. The coaches recorded data, including when the intervention was performed, any injuries, individual playing times, and periods of absence. Assessment of the primary outcome was done by physicians blinded to group assignment. During 278 298 hours of play, 96 knee injuries occurred in 92 players (intervention group 48, control group 44). The rate did not differ between groups. Of the 21 ACL injuries, 7 occurred in the intervention group and 14 in the control group, giving a rate ratio (RR) of 0.36 (95% confidence interval [CI] 0.15-0.85; P = 0.02). Severe injuries (intervention group 26, control group 31) did not differ between groups. They included 22 collateral or capsular sprains, 21 ACL injuries, 7 patella dislocations or subluxations, 6 meniscal or chondral lesions, and 1 tibial plateau fracture. Compliant players (those who performed ≥ 1 exercise session per week; 1303 players) had a lower rate of ACL injury (RR, 0.17; 95% CI, 0.05-0.57), of severe knee injury (RR, 0.18; 95% CI, 0.07-0.45), and of any acute knee injury (RR, 0.53; 95% CI, 0.30-0.94) than the control group. A short weekly neuromuscular exercise program reduced the rate of ACL injuries among adolescent female football (soccer) players. Those who were compliant with the intervention had fewer severe knee injuries and fewer injuries overall.

A retrospective study of pathology reports of melanomas excised by general practitioners (GPs) was undertaken in the course of a population-based study of melanoma, with a telephone survey of the current practice of those GPs who had excised melanomas. The objectives of this study were to identify all cases of cutaneous melanoma excised by GPs in the North-East Thames Region between 1989 and 1993, and to review the management of those patients. The main outcome measures of the study were: (i) the patterns of distribution of GP excisions within the region; (ii) the histological subtypes of melanomas excised, the accuracy of the pre-excision clinical diagnosis and the adequacy of treatment of the GP-treated tumours compared with the control group; and (iii) the reported current practice in the management of pigmented skin lesions by the GPs who had excised melanomas. Eight hundred and nineteen melanomas were excised in the region during the study period, of which 59 were excised by GPs. The Breslow thickness of tumours was similar in both GP-excised and non-GP-excised groups. Tumours were more likely to be amelanotic in the GP-excised group (P < 0.001). Incomplete excision was significantly more likely in the GP group (P < 0.001). The GPs made a confident clinical diagnosis of melanoma in only 17% of patients prior to surgery. The reported referral rate to specialists by this subset of GPs of patients with pigmented lesions was low, and at interview half of the GPs reported that they felt confident enough to manage patients with suspected skin cancers on their own. The majority of the GPs did not routinely obtain histological examination of skin lesions they believed to be benign. In conclusion, there are problems with the accuracy of clinical diagnosis and inadequacy of excision of melanomas removed in primary care. In the majority of cases, however, patients were subsequently appropriately treated by referral to specialist units. There was an under-usage of pathological examination of samples by the GPs interviewed.

Is neuromuscular and proprioceptive training effective in preventing knee and anterior cruciate ligament (ACL) injuries? The authors searched CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE/EMBASE, PubMed, and Web of Science databases from 1996 through December 2014 and limited the results to peer-reviewed manuscripts published in English. Search terms for all databases were knee injury OR knee injuries; OR anterior cruciate ligament injury OR anterior cruciate ligament injuries; OR ACL injury OR ACL injuries; OR lower limb injury OR lower limb injuries AND prevention. Inclusion criteria were (1) English language, (2) published from 1996 through 2014, (3) the intervention used neuromuscular or proprioceptive training to prevent knee or ACL injuries, (4) human participants, (5) the incidence of knee or ACL injury was provided. For the articles that met the inclusion criteria, 2 authors worked independently using the Jadad scale to extract the first author, year of publication, title, sport type, participant sex, participant age, country in which the study was conducted, number of participants in the control and intervention groups, intervention characteristics or components, and knee or ACL injury outcome. A total of 24 studies with 1093 participants were included in this review. Intervention efficacy was determined from weighted incidence rate ratios. After the intervention of neuromuscular and proprioceptive training exercises, the incidence ratio (frequency of a disease or injury occurrence in a population over a specific time frame) was calculated at 0.731 (95% confidence interval = 0.614, 0.871) for knee injury and at 0.493 (95% confidence interval = 0.285, 0.854) for ACL injury. This indicated a link between neuromuscular and proprioceptive training programs and injury reduction. No significant correlation was present between more components added to training and a greater decrease in injury to either the knee or ACL. Neuromuscular and proprioceptive training appeared to decrease the incidence of injury to the knee and specifically the ACL. However, no evidence suggested that a specific group of exercises was better than others.

Clinical tests used for the detection of meniscal tears in the knee do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or magnetic resonance imaging studies. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears. Two hundred and thirteen symptomatic patients with knee injuries who were examined clinically, had magnetic resonance imaging studies performed, and underwent arthroscopic surgery and 197 asymptomatic volunteers who were examined clinically and had magnetic resonance imaging studies done of their normal knees were included in this study. For clinical examination, the medial and lateral joint-line tenderness test, the McMurray test, the Apley compression and distraction test, the Thessaly test at 5 degrees of knee flexion, and the Thessaly test at 20 degrees of knee flexion were used. For all clinical tests, the sensitivity, specificity, false-positive, false-negative, and diagnostic accuracy rates were calculated and compared with the arthroscopic and magnetic resonance imaging data for the test subjects and the magnetic resonance imaging data for the control population. The Thessaly test at 20 degrees of knee flexion had a high diagnostic accuracy rate of 94% in the detection of tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus, and it had a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of joint-line tenderness, which presented a diagnostic accuracy rate of 89% in the detection of lateral meniscal tears, showed inferior rates. The Thessaly test at 20 degrees of knee flexion can be used effectively as a first-line clinical screening test for meniscal tears, reducing the need for and the cost of modern magnetic resonance imaging methods.

This retrospective study was conducted to analyse the reliability of clinical diagnosis in meniscal tear injuries. All patients attending our clinic with knee pain from January 2003 to December 2004 underwent systematic and thorough clinical assessment. One hundred and fifty patients were clinically diagnosed to have meniscal tears. All these patients underwent therapeutic arthroscopic knee surgery. The clinical diagnosis was confirmed during this procedure. The accuracy, sensitivity and specificity were calculated based on these arthroscopic findings. The accuracy of clinical diagnosis in our study was 88% for medial meniscal tears and 92% for lateral meniscal tears. The results of this study demonstrate that clinical diagnosis of meniscal tears is as reliable as the results published by other authors for magnetic resonance imaging (MRI) scan. We recommend the use of MRI for more doubtful, difficult and complex knee injuries.

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis

PurposeTo evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries.MethodsData from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions.ResultsA total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32–4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01–1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61–8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40–13.68; P = 0.001).ConclusionThe overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons’ and radiologists’ suspicion of these tears.Level of evidenceIII.

Background To investigate the clinical significance of color ultrasound, magnetic resonance imaging (MRI), miR-21, and CA199 in the diagnosis of pancreatic cancer (PC). Methods A total of 160 patients with PC admitted to our hospital from April 2018 to February 2021 were included in the PC group, and another 100 patients with benign pancreatic disease during the same period were included in the pancreatic benign disease group. Color ultrasound and MRI were used for imaging examination of the two groups of PC patients, and the sensitivity, accuracy, and specificity of the two methods for preoperative diagnosis of PC were calculated, respectively. A total of 100 healthy people who underwent physical examination during the same period were included in the control group. Serum CA199 levels of the three groups were detected by ELISA assay. The level of serum miR-21 in the three groups was detected by qRT-PCR. A receiver operating curve (ROC) was drawn to analyze and calculate the sensitivity, specificity, and accuracy of the two serum markers and the combination of color ultrasound and MRI in the detection of PC. Results Serum CA199 and miR-21 levels in the PC group were significantly higher than those in the benign lesion group and control group. CA199 and miR-21 levels in the benign lesion group were higher than those in the control group. Both color ultrasound and MRI showed a higher detection rate for PC, and the sensitivity and accuracy were significantly higher than those of CA199 and miR-21. The sensitivity, specificity, and accuracy of combined detection were 91.88%, 96.00%, and 93.46%, respectively, which were significantly higher than those of single detection. Conclusion The combined detection of color ultrasound, MRI, miR-21, and CA199 have a high application value in the early diagnosis of PC, which can effectively improve the sensitivity and accuracy of clinical diagnosis, reduce the probability of missed diagnosis and misdiagnosis, and provide a reference for the rational clinical treatment plan and prognosis.

Although many machine learning algorithms have been developed to detect anterior cruciate ligament (ACL) injury based on magnetic resonance imaging (MRI), the performance of different algorithms required further investigation. The objectives of this current systematic review are to evaluate the diagnostic accuracy of machine-learning-assisted detection for ACL injury based on MRI and find the current best algorithm. We will conduct a comprehensive database search for clinical diagnostic tests in PubMed, EMBASE, Cochrane Library, and Web of science without restrictions on publication status and language. The reference lists of the included articles will also be checked to identify additional studies for potential inclusion. Two reviewers will independently review all literature for inclusion and assess their methodological quality using Quality Assessment of Diagnostic Accuracy Studies version 2. Clinical diagnostic tests exploring the efficacy of machine-learning-assisted system for detecting ACL injury based on MRI will be considered for inclusion. Another 2 reviewers will independently extract data from eligible studies based on a pre-designed standardized form. Any disagreements will be resolved by consensus. RevMan 5.3 and Stata SE 12.0 software will be used for data synthesis. If appropriate, we will calculate the summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of machine-learning-assisted diagnosis system for ACL injury detection. A hierarchical summary receiver operating characteristic (HSROC) curve will also be plotted, and the area under the ROC curve (AUC) is going to calculated using the bivariate model. If the pooling of results is considered inappropriate, we will present and describe our findings in diagrams and tables and describe them narratively. This is the first systematic assessment of machine learning system for the detection of ACL injury based on MRI. We predict it will provide highquality synthesis of existing evidence for the diagnostic accuracy of machine-learning-assisted detection for ACL injury and a relatively comprehensive reference for clinical practice and development of interdisciplinary field of artificial intelligence and medicine. This protocol outlined the significance and methodologically details of a systematic review of machine-learning-assisted detection for ACL injury based on MRI. The ongoing systematic review will provide high-quality synthesis of current evidence of machine learning system for detecting ACL injury. The meta-analysis has been prospectively registered in PROSPERO (CRD42019136581).

Does Temporomandibular Joint Magnetic Resonance Imaging Diagnosis Support Clinical Examination Diagnosis Following Diagnostic Criteria for Temporomandibular Disorders?

The diagnosis of acute appendicitis (AA) in pregnant women is commonly challenging owing to the normal results of laboratory tests, organ displacement, and normal physiological inflammatory alterations. This meta-analysis aimed to investigate the accuracy of magnetic resonance imaging (MRI) in diagnosis of AA in pregnant women. Two investigators independently performed a comprehensive systematic literature search of electronic databases including MEDLINE, Cochrane Central, EMBASE, Web of Science, Scopus, and Google Scholar to identify studies that reported accuracy of MRI for diagnosis of AA in pregnant women from inception to April 1, 2022. Our systematic search identified a total of 525 published papers. Finally, a total of 26 papers were included in the meta-analysis. The pooled sensitivity and specificity of MRI in diagnosis of AA in pregnant women were 0.92 (95% CI: 0.88-0.95) and 0.98 (95% CI 0.97-0.98), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 29.52 (95% CI: 21.90-39.81) and 0.10 (95% CI: 0.04-0.25), respectively. The area under hierarchical summary receiver operating characteristic (HSROC) curve indicated that the accuracy of MRI for diagnosis of AA in pregnant women is 99%. This meta-analysis showed that MRI has high sensitivity, specificity, and accuracy for diagnosis of AA in pregnant women and can be used as a first-line imaging modality for suspected cases of AA during pregnancy. Furthermore, it should be noted that when the result of ultrasonography is inconclusive, the use of MRI can reduce unnecessary appendectomy in pregnant patients.

Background: Transvaginal sonography (TVS) is very useful to assess the abnormalities in the anatomical structure of the uterus as well as endometrium. Not only this, it is capable of finding out any abnormalities of ovary, fallopian tubes, cervical structures as well as myometrium. The objective of the study was the role of transvaginal sonography in gynecological diagnosis at a tertiary care hospital.Methods: Present hospital based prospective study was carried out among 31 randomly selected eligible patients as per inclusion and exclusion criteria of the study for a period of one year at Department of Obstetrics and Gynecology of S. V. Medical College, Tirupati. All ethical guidelines were followed. A pre-designed and semi structured pre-tested questionnaire was prepared for entry of patient data.Results: Transvaginal sonography was more accurate in terms of evaluation of both tubes. Overall diagnostic accuracy of transvaginal sonography was 90.9%. It was found that the accuracy of clinical diagnosis was 100% in comparison to diagnosis by scan. In five cases, the clinical diagnosis of infertility was made as ovarian cyst and in all those cases it was confirmed. In three cases, the clinical diagnosis of infertility was made as fibroids and in all those cases it was confirmed. It was found that in cases of ectopic pregnancy, copper T missing loop and missed abortion, the clinical diagnosis was 100% accurate in comparison to scan diagnosis. Only in case of pelvic inflammatory disease, the accuracy of clinical diagnosis was 66% in comparison to scan diagnosis.Conclusions: Despite the few disadvantages of transvaginal sonography in measuring large pelvic masses, the smallest details of the masses yield valuable preoperative information. The more accurate delineation of internal echo characteristics scores the benefit over transvaginal sonography has its rightful place in gynecological practice has diagnostic and minimally invasive therapeutic tool.