Dutch Guideline on Knee Arthroscopy Part 1, the meniscus: a multidisciplinary review by the Dutch Orthopaedic Association.

Background and purpose - A guideline committee of medical specialists and a physiotherapist was formed on the initiative of the Dutch Orthopedic Association (NOV) to update the guideline Arthroscopy of the Knee: Indications and Treatment 2010. This next guideline was developed between June 2017 and December 2019. In this Part 1 we focus on the meniscus, in Part 2 on all other aspects of knee arthroscopy.Methods - The guideline was developed in accordance with the criteria of the AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II) with support of a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. The scientific literature was searched and systematically analyzed. Conclusions and recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs.

Finding the origin of pulmonary emboli with a total-body magnetic resonance direct thrombus imaging technique.

Pulmonary embolism is considered to originate from embolization of a deep-vein thrombosis, resulting in two manifestations of one disease: venous thrombosis. However, in up to 50% of patients with pulmonary embolism no deep-vein thrombosis is found with ultrasonography. An explanation for this low proportion is currently lacking. Other imaging modalities may increase the yield of detection of deep-vein thrombosis in the calf or in the abdominal region. Alternatively, not all pulmonary emboli may originate from deep-vein thromboses in the extremities. We searched for the origin of pulmonary emboli, by performing total-body magnetic resonance imaging-scans to visualize thrombi. Ninety-nine patients with a first pulmonary embolism confirmed by computed tomography underwent a magnetic resonance direct thrombus imaging-scan, a validated technique using endogenous contrast. Additionally, acquired and genetic risk factors were assessed. No thrombus was found in 55 patients, whereas a thrombus was identified in 44 patients. The commonest thrombus location was the lower leg; 12 patients had isolated calf vein thrombosis and five had isolated superficial vein thrombosis. A peripheral thrombus was found by magnetic resonance imaging in less than half of patients with pulmonary embolism. We propose several hypotheses to explain the absence of thrombi, such as a cardiac thrombus origin or embolization of the whole deep-vein thrombus. The possibility that pulmonary embolism arises de novo in the lungs, due to local inflammation-driven coagulation, needs to be considered.

Only MR can safely exclude patients from arthroscopy.

OBJECTIVE: The aim of this study was to determine in patients with subacute knee complaints and normal standardized physical examination the fraction of magnetic resonance imaging (MRI) studies showing arthroscopically treatable intra-articular pathology. MATERIAL AND METHODS: There were 290 consecutive patients (between 16 and 45 years) with at least 4 weeks of knee complaints and low clinical suspicion of intra-articular pathology based on physical exam. Two hundred seventy-four patients were included. Sixteen patients with prior knee surgery, rheumatic arthritis, or severe osteoarthritis were excluded. MRI was used to assign patients to group 1 (treatable abnormalities) or group 2 (normal or no treatable findings), depending on whether MR demonstrated treatable pathology. Arthroscopy was performed in group 1 patients. If symptoms persisted for 3 months in group 2 patients, cross over to arthroscopy was allowed. RESULTS: MR showed treatable pathology in 73 patients (26.6%). Arthroscopy was performed in 64 patients of 73 patients (group 1). In 52 patients (81.3%, 95% confidence interval (CI) 71.4-91.1%), arthroscopy was therapeutic. Of the 13 arthroscopies (6.5%) in group 2, four were therapeutic (30.8%, 95% CI 1.7-59.8). The highest fraction of MR studies showing treatable pathology was found in males, aged over 30 years, with a history of effusion (54.5%, six of 11 patients). CONCLUSION: Authors believe that the negative predictive value of clinical assessment in patients with subacute knee complaints is too low to exclude these patients from MR. MR should at least be considered in male patients aged 30 years and over with a history of effusion.

Detecting Meniscal Tears in Primary Care: Reproducibility and Accuracy of 2 Weight-Bearing Tests and 1 Non-Weight-Bearing Test.

STUDY DESIGN: Diagnostic accuracy study using a cross-sectional design. OBJECTIVES: To determine the interexaminer reliability and the diagnostic accuracy in primary care of 1 existing weight-bearing meniscal test, the Thessaly test, 1 new weight-bearing test, the deep squat test, and 1 non-weight-bearing test, the joint-line tenderness test. BACKGROUND: Meniscal tears are difficult to detect in primary care. Although valuable in secondary care, weight-bearing physical examination tests require validation in primary care in unselected patients. METHODS: Between October 2009 and December 2013, 121 patients (age range, 18-65 years) seen in primary care and suspected of having internal derangement of the knee of less than 6 months in duration were included in the study. Diagnostic accuracy of the 3 meniscal tests was determined based on assessment with magnetic resonance imaging. The meniscal tests were performed by 3 trained physical therapists, who were not informed about the patient history and magnetic resonance imaging results. Each test was performed independently by 2 of the 3 trained physical therapists in alternating pairs. RESULTS: The Thessaly test and the deep squat test had a moderate level of interexaminer reliability, with kappas of 0.54 and 0.46, respectively. The joint-line tenderness test had poor interexaminer reliability and was therefore not assessed for diagnostic accuracy. The following results are reported separately for both examiners. The Thessaly test had a sensitivity of 66.7% (95% confidence interval [CI]: 53.0%, 78.0%) and 51.2% (95% CI: 36.8%, 65.4%), a specificity of 37.9% (95% CI: 27.2%, 50.0%) and 43.5% (95% CI: 30.2%, 57.8%), a positive likelihood ratio of 1.07 (95% CI: 0.82, 1.41) and 0.91 (95% CI: 0.62, 1.33), and a negative likelihood ratio of 0.88 (95% CI: 0.54, 1.45) and 1.12 (95% CI: 0.72, 1.76). Similarly, the deep squat test had a sensitivity of 74.5% (95% CI: 61.1%, 84.5%) and 76.7% (95% CI: 62.3%, 86.9%), a specificity of 42.4% (95% CI: 31.2%, 54.4%) and 36.2% (95% CI: 24.0%, 50.5%), a positive likelihood ratio of 1.29 (95% CI: 0.97, 1.68) and 1.20 (95% CI: 0.92, 1.58), and a negative likelihood ratio of 0.60 (95% CI: 0.35, 1.04) and 0.64 (95% CI: 0.33, 1.25). CONCLUSION: Although the Thessaly and deep squat tests have a moderate level of reliability, neither test is sufficiently accurate to help in the diagnosis of meniscal tears in primary care. Future research should focus on other relevant patient variables instead of on physical examination tests in the detection of meniscal tears. LEVEL OF EVIDENCE: Diagnosis, level 3b.

[A woman with a large tumor in the lower neck]. / Een vrouw met een grote zwelling laag in de hals.

A patient with a tumor in the lower neck regions, originated in days, was seen at the emergency department. Initial investigations showed a non-ill patient with increased infection parameters. Further investigations showed a septic arthritis of the left sternoclavicular joint.

Reliability and validity of diagnosing acetabular labral lesions with magnetic resonance arthrography.

BACKGROUND: Arthroscopic surgery of the hip is being increasingly used to diagnose and treat various abnormalities, including acetabular labral tears. Magnetic resonance arthrography has been suggested as the imaging test of choice for the evaluation of the acetabular labrum. There is substantial variability in the previously reported accuracy of magnetic resonance arthrography for diagnosing labral lesions. Interobserver reliability has not been established previously. The purpose of this study was to establish the interobserver reliability and the validity of magnetic resonance arthrography for detecting lesions of the acetabular labrum in a retrospective case series. METHODS: Two radiologists independently assessed the acetabular labrum on magnetic resonance arthrograms of ninety-five hips in ninety-three patients who underwent hip arthroscopy for a suspected acetabular labral lesion. Magnetic resonance arthrography findings were compared with the gold standard, which was defined as the assessment of the labrum during the hip arthroscopy. RESULTS: At arthroscopy, ninety-one labral lesions were identified in the ninety-five hips. The interobserver reliability of detecting labral lesions with magnetic resonance arthrography was fair (kappa=0.268). Magnetic resonance arthrography, as interpreted by observers A and B, showed a sensitivity of 86% and 86%, specificity of 75% and 50%, negative predictive value of 19% and 13%, and positive predictive value of 99% and 98%, respectively. CONCLUSIONS: Because of its limited reliability and the high prevalence of labral lesions, magnetic resonance arthrography provides a limited complementary benefit in the detection of labral lesions in patients with a high clinical suspicion of labral pathology. When there is a high clinical suspicion of a labral lesion, magnetic resonance arthrography has a poor negative predictive value and cannot be used to rule out a labral lesion. Physicians should critically consider whether the findings on a magnetic resonance arthrogram will alter the treatment strategy for an individual patient with a clinical suspicion of labral pathology.

Are radiographs needed when MR imaging is performed for non-acute knee symptoms in patients younger than 45 years of age?

OBJECTIVE: The objective was to determine the value of radiographs in young adults with non-acute knee symptoms who are scheduled for magnetic resonance imaging (MRI). MATERIALS AND METHODS: Nine hundred and sixty-one consecutive patients aged between 16 and 45 years with knee symptoms of at least 4 weeks' duration were prospectively included in three participating hospitals. After applying exclusion criteria, 798 patients remained. Exclusion criteria were previous knee surgery (including arthroscopy) or MRI, history of rheumatoid arthritis, clinical diagnosis of retropatellar chondromalacia, contra-indication for MRI and recent trauma. We identified two groups: group A with no history of trauma (n = 332), and group B with an old (>4 weeks) history of trauma (n = 466). Patients had a standardized history taken, and underwent a physical exam, antero-posterior (AP) and lateral radiographs and MRI. We evaluated the radiographs and MRI for osseous lesions, articular surface lesions, fractures, osteoarthritis, loose bodies, bone marrow edema and incidental findings. Subsequently, patients with osseous abnormalities (Kellgren grade 1 and 2 excluded) on radiographs and a matched control group was evaluated again using MRI without radiographs. RESULTS: Median duration of symptoms was 20 weeks. In group A, radiographs showed 36 osseous abnormalities in 332 patients (10.8%). Only 13 of these, all Kellgren grade 1 osteoarthritis, were not confirmed on MRI. MRI showed 72 (21.7%) additional abnormalities not confirmed on radiographs. In group B, radiographs showed 40 osseous abnormalities (8.6%) in 466 patients. Only 15 of these, all Kellgren grade 1 osteoarthritis, were not confirmed on MRI. MRI showed 194 (41.6%) additional abnormalities not confirmed on radiographs. The second evaluation of MRI without radiographs in 34 patients was identical to the first MRI evaluation. Common lesions were significantly more often diagnosed with MRI than with radiographs. CONCLUSION: Radiographs should not be obtained routinely when MRI is being performed in young adults with non-acute knee complaints because the yield and added value to MRI are low.

MR imaging: effectiveness and costs at triage of patients with nonacute knee symptoms.

PURPOSE: To prospectively evaluate the cost and effectiveness of magnetic resonance (MR) imaging performed to exclude the need for arthroscopy in patients with nonacute knee symptoms who are highly suspected clinically of having intraarticular knee abnormality. MATERIALS AND METHODS: The study was approved by the institutional review boards of three hospitals; informed patient consent was obtained. All 584 included patients (406 male, 178 female; mean age, 31.1 years+/-8.0 [standard deviation]) underwent MR imaging. Patients with an MR result positive for the diagnosis of intraarticular knee abnormality underwent arthroscopy (group A). Patients with a negative MR result were randomly assigned to undergo either conservative (group B) or arthroscopic (group C) treatment. Treatment was considered effective if the Noyes function score had increased 10% or more at 6 months. A cost analysis was performed from a societal perspective to compare the treatment strategy involving MR imaging with the strategy not involving MR imaging. RESULTS: Of the 584 patients, 294 (50.3%) were assigned to group A; 149 (25.5%), to group B; and 141 (24.1%), to group C. At 6 months, the number of patients effectively treated in group B (conservative treatment) was a mean of 5.1%+/-10.0 larger than the number of patients effectively treated in group C (arthroscopy). Owing to savings in productivity costs, total societal costs were lower with use of the strategy involving MR imaging by a mean of $153+/-488 (P=.54). CONCLUSION: MR imaging can be used without additional costs or disadvantageous effects on function to obviate arthroscopy in patients with nonacute knee symptoms who are highly suspected of having intraarticular knee abnormality.

Clinical consequences of bone bruise around the knee.

The aim of this study is to evaluate the relation between bone bruise and (peri-)articular derangement and to assess the impact of bone bruise on presentation and short term course of knee complaints. We recorded MR abnormalities in 664 consecutive patients with sub-acute knee complaints. Patients were divided in four groups: patients with and without intra-articular knee pathology, subdivided in patients with and without bone bruise. We assessed function and symptoms at the time of MR and 6 months thereafter. Bone bruises were diagnosed in 124 of 664 patients (18.7%). Patients with bone bruise had significantly more complete ACL, lateral meniscal, MCL and LCL tears. Both with and without intra-articular pathology patients with bone bruise had a significantly poorer function at the time of MR (Noyes score of, respectively, 313.21 versus 344.81 and 306.98 versus 341.19). Patients with bone bruise and intra-articular pathology showed significantly more decrease in activity (decrease of Tegner score from 6.28 to 2.12 versus 5.70-2.55). At 6 months there were no significant differences in clinical parameters between the four groups. We concluded that bone bruise in combination with MCL tear is an important cause of initial clinical impairment in patients with sub-acute knee complaints. Clinical improvement within 6 months is more pronounced than in patients without bone bruise.

Effectiveness of MR imaging in selection of patients for arthroscopy of the knee.

PURPOSE: To determine the effectiveness of magnetic resonance (MR) imaging in the appropriate identification of those patients with a high clinical suspicion of internal derangements of the knee who require arthroscopic therapy. MATERIALS AND METHODS: In a prospective multicenter study, MR imaging was performed at 0.5 T in 430 consecutive patients. The sensitivity and specificity of MR imaging in the patients who underwent arthroscopy and the corrected sensitivity and specificity of MR in all the study patients were calculated. For this correction, patients with negative MR and arthroscopic results were considered representative of the patients with negative MR results who were conservatively treated, and the number of the former was doubled. The standard errors of the corrected values were adjusted with the delta method. RESULTS: At MR imaging, arthroscopy was indicated in 221 patients, 200 of whom underwent arthroscopy. Two hundred nine patients with negative MR imaging results were randomized for arthroscopic (105 patients) or for conservative treatment (104 patients). Of the 105 patients randomized for arthroscopy, 93 actually underwent arthroscopy. Arthroscopic treatment was necessary in 13 of 93 patients with a negative diagnosis at MR imaging. Arthroscopic treatment was necessary in 179 of 200 patients with a positive diagnosis at MR (sensitivity, 93.2%; specificity, 79.2%). Sensitivity and specificity corrected for randomization were 87.3% and 88.4%. Sensitivity and specificity corrected for randomization, respectively, were 84.1% and 94.2% for the diagnosis of medial meniscal tears and 69.5% and 94.5% for the diagnosis of lateral meniscal tears at MR. CONCLUSION: MR imaging is an effective tool in the selection of patients for arthroscopy from among a general population.