Roger Zhao, MS, DPTc Spring Symposium 2012

PT 910

Transmit weight bearing forces Joint stability and protection Increases congruity and contact area Shock absorption Nutrition, and lubrication for the

articular cartilage Proprioception *Limitation of extremes of flexion

and extension * Load sharing, stress distribution

(Chivers 2009, Greis 2002)

http://www.mendmeshop.com

Twisting injury or hyper-flexion Rotation + Compression Forces: +50-70% more load when in extension

and +85% with 90 of knee flexion

(Chivers 2009; Greis 2002)

Tearing sensation Delayed effusion History of catching or locking Pain with forced hyperextension or maximum flexion Pain or audible click with special tests Joint Line Tenderness (JLT)

(Lorenz 2011)

2nd most common injury to the knee (Logerstedt 2010) Incidence: 60-70 per 100,000 individuals/year

(Poulsen 2011)

10-20% of all orthopedic injuries (Logerstedt 2010) 50% of knee surgeries (Harrison 2009)

Injured knee playing Volleyball Symptoms:

Knee stuck or locked Pain weight bearing

Immediately tested: (-) McMurray (-) Apley (-) Joint Line Tenderness (JLT) www.creativerehab.com

Orthopod: Performed tests (-) McMurray, Apley, JLT (+) Thessaly

Magnetic Resonance Imaging (MRI): Complex tear

Oblique + flap ~50% lateral mensicus

(Arthroscopy)

What are the current most common meniscus special tests?

Meta-analysis of Current Tests - Low specificity, sensitivity - Clinical examination alone limited (Konan 2009)

Methodological Quality: Poor to Fair (Meserve 2008) Large conflicting differences in diagnostic accuracy

(Chivers 2009)

Varying criteria for diagnosing meniscus tear. (Chivers 2009)

History alone is insufficient as a diagnostic tool for meniscus tears (Hegedus 2007) Symptoms are often vague and non-specific

Current literature shows that knee meniscal tests are not diagnostic and there is heterogeneity between similar studies. (Hegedus 2007)

No current accurate tests to assess and diagnose meniscal tears

Most current clinicians and recent studies base the Thessaly test accuracy off of only one study, Karachalios 2005, by the creator of the test.

No current systematic reviews or meta-analysis combining all current original studies on Thessaly test

Arthroscopy: 90-95% accuracy Gold Standard (Konan 2009)

20% tears found on arthroscopy not diagnosed on original MRI (De Smet 2008)

MRI: 59-97% accuracy (Lorenz 2011, Jee 2003) No difference between MRI and exam (Korcabey 2004) Exam by clinician has shown greater accuracy (Lorenz

2011)

High cost and incidence of false positives (Konan 2009)

Dynamic reproduction of load transmission in the knee joint performed at 5 and 20 of flexion.

(+) Positive: Medial or lateral joint-line discomfort and may have a sense of locking or catching

(Karachalios 2005)

Examiner supports patient by holding his or her outstretched hands while the patient stands flat footed on the floor. The patient then rotates his or her knee and body, internally and externally 3X, keeping the same amount of flexion.

(Karachalios 2005)

Rotation and Compression with Flexion

Re-created by Thessaly Test Ellicit Symptoms

High Diagnostic Accuracy

Frequently treat patients with vague knee pain and variety of symptoms that could indicate meniscal pathology. Accurate diagnosis of underlying injury Rehabilitation and Plan of Care Decrease cost and time saved without need for imaging

(conservative treatment/direct access) Referral to MD for further imaging

1. Evaluate the evidence of a relatively NEW, but well accepted special test to rule in the diagnosis of meniscal tears in the knee. 2. Provide a reliable, clinical first-line screening tool that is accurate and easily performed.

Background: Diagnostic

Is the Thessaly Test a specific and sensitive examination tool for confirming the diagnosis of a meniscus tear?

Is the Thessaly test more accurate at 5 or 20?

Detecting lateral or medial meniscus tears?

Null H0:

For confirming the diagnosis of a meniscal tear the Thessaly test is not a

a) sensitive b) specific or c) both sensitive and specific examination test.

Alternative Ha:

For confirming the diagnosis of a meniscal tear the Thessaly test is a a) sensitive b) specific or c) both sensitive

and specific examination test.

Limited to 1-5 studies High sensitivity and specificity Useful examination tool to be used in the clinic

PubMed, PEDro, CINAHL, Cochrane Database, Google Scholar

Checked reference lists and related articles Search Terms: Thessaly Test

Diagnos* Accuracy Menisc* Knee

Inclusion Criteria: English 2005 to current (creation of test date) Adults with diagnosis of meniscal tear based off history and

MOI Original validation study of Thessaly test

Exclusion Criteria: Other Knee Injuries Articles Excluded: 1 Non-English, 1 with concurrent ACL tears, 6 non original study (meta-analysis in larger meniscus test study or clinical commentary)

Sensitivity, Specificity, Diagnostic Accuracy, Likelihood ratios, Receiver Operating Characteristic (ROC) Curve At 5 degrees (Karachalios

and Konan studies)

At 20 degrees (all 3 studies)

(Hing 2009)

*Secondary reviewer confirmed that the studies met the inclusion criteria

Study Reference Standard

Outcomes #Tests (n=subjects)

Karachalios et, al. 2005

Arthroscopy and MRI

-Thessaly 5 & 20 -Medial vs Lateral tear -McMurray, Apley, JLT

Tested: 1640 (n=410)

Harrison et, al. 2009

Arthroscopy -Thessaly at 20 Tested: 116 (n=116)

Konan et, al. 2009

Arthroscopy and MRI

-Thessaly 5 & 20 -Medial vs. Lateral tear -McMurray, Apley, JLT

Tested: 320 (n=109)

All papers high methodological quality: 1b

Independent blind comparison of an appropriate spectrum of consecutive patients, all who have undergone the diagnostic test and the reference standard. - Sackett et, al. Diagnostic Criteria

Data True + True -

Thessaly Test + 413.00 93.00 506.00

Thessaly Test - 166.00 1,404.00 1,570.00

579.00 1,497.00 2,076.00

Study Sensitivity Specificity Diagnostic Accuracy

Karachalios 80% 95% 91%

Harrison 90% 98% 93%

Konan 44% 85% 65%

Meta-Analysis 71% 94% 88%

71% of individuals with a meniscus tear will have a (+)Positive Test 94% of individuals without a meniscus tear will have a (-)Negative test

Study PPV(%) NPV(%) LR+ LR-

Karachalios 80% 94% 15.07 0.22

Harrison 98% 86% 39.72 0.10

Konan 74% 62% 3.02 0.66

Meta-Analysis

82% 89% 11.48 0.31

82% of individuals with a (+)Positive Test will have a meniscus tear 89% of individuals with a (-)Negative test will not have a meniscus tear

Sensitivity Specificity LR+ LR-

Study 5 20 5 20 5 20 5 20

Karachalios 69% 90% 93% 96% 10.15 24.09 0.33 0.11

Harrison NA 86% NA 98% NA 39.72 NA 0.86

Konan 35% 53% 83% 88% 2.08 4.31 0.78 0.54

Meta-Analysis

59% 78% 92% 95% 7.38 16.73 0.43 0.23

Thessaly at 20 significantly more accurate at sensitivity, specificity, and likelihood ratios.

Sensitivity, specificity, and likelihood ratios (LR) of Thessaly test for detecting medial vs. lateral meniscus tears.

Study Sensitivity(%) Specificity (%) LR+ LR-

Medial Lateral Medial Lateral Medial Lateral Medial Lateral

Meta-Analysis (Karachalios

+ Konan)

70 65 94 93 11.98 9.75 0.32 0.37 *Confidence intervals incalculable due to absence of raw data.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Sens

itivi

ty (T

rue

Posi

tive

Rat

e)

1 - Specificity (False Positive Rate)

ROC Curve for Thessaly Test

20

5

Test Sensitivity Specificity

McMurray* 70% 71%

Apley* 60% 70%

JLT* 63% 77%

Thessaly at 20

78% 95%

*Meta-analysis by Hegedus et, al 2007; JOSPT

12 patients excluded in study by Konan et, al., could not complete test due to pain or were not confident.

Karachalios et, al. reported at 20 degrees,

3.3% of patients in the symptomatic group had an exacerbation of knee symptoms requiring analgesics. One patient had the knee lock requiring manipulation under anesthesia.

No additional cost to perform this test to the clinic Simple physical examination that can be quickly performed in

a few seconds. Reduce the need for magnetic resonance imaging (MRI) for

diagnostics.

Average Cost/Year Thessaly Test MRI

Operating $0 $165

Procedure NA $2000

Machine NA $2,000,000

Maintenance (annually) $0 $800,000 (Pogetti 2008)

REJECT Null H0: For confirming the diagnosis of a meniscal tear the Thessaly test is not a a) sensitive b) specific or c) both sensitive and specific examination test.

ACCEPT Alternate Ha: For confirming the

diagnosis of a meniscal tear the Thessaly test is a a) sensitive b) specific or c) both sensitive and specific examination test.

High Sensitivity and Specificity High Accuracy and Validity of studies High LR+, LR- Area under ROC curve: Excellent

Small number of studies (n=3) >75% weighting from paper by Karachalios (1640/2076

tests) Strict Exclusion Criteria:

Early clinical or radiographic signs of OA Excluding many differential diagnosis or pathologies

likely to result in a positive Thessaly test and decrease accuracy.

No acute patients, only 4-6 weeks post injury Difficult measure knee ROM 5 vs 20 Unclear Instructions

Rotation from spine versus from hip and knee

Recommendation for future studies: Include with other tests and symptoms to find combination with best diagnostic accuracy

Create a less aggressive test to decrease harm Larger scale studies in general population without strict knee exclusion criteria

Long-term follow up cost comparison

The Thessaly test is an accurate and valuable diagnostic tool in assessing meniscal tears in patients.

Easily performed examination maneuver that all physical therapists can learn quickly.

May be too aggressive for acute or irritable patients 5 - no harm reported 20 - harm, but more accurate

Use subjective history, symptoms, current function, and clinical judgment before deciding to use test due to reported harm.

Thessaly test is an accurate and valid valuable diagnostic tool in assessing meniscal tears.

High diagnostic accuracy in terms of sensitivity and specificity.

20 more accurate than at 5 Physical therapists should incorporate the Thessaly test

into their physical examination when a meniscus tear is suspected.

Jeanette Lee, PT, PhD Deepak Kumar, PT, PhD, OCS Diane Allen, PT, PhD Thomas Tsai, DPTc Tin Pham, DPTc Bryan Ausink, DPTc Dan Lorenz, PT, OCS, CSCS UCSF/SFSU Class of 2012

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