Article

The current approach to the clinical diagnosis of traumatic and
degenerative symptomatic meniscal tears (SMTs) proposes combining history
elements and physical examination tests without systematic prescription of
imaging investigations, yet the evidence to support this diagnostic approach is
scarce. OBJECTIVE: To assess the validity of diagnostic clusters combining
history elements and physical examination tests to diagnose or exclude traumatic
and degenerative SMT compared with other knee disorders. DESIGN: Prospective
diagnostic accuracy study. SETTINGS: Patients were recruited from 2 orthopedic
clinics, 2 family medicine clinics, and from a university community. PATIENTS: A
total of 279 consecutive patients who underwent consultation for a new knee
complaint. METHODS: Each patient was assessed independently by 2 evaluators.
History elements and standardized physical examination tests performed by a
physiotherapist were compared with the reference standard: an expert physicians'
composite diagnosis including a clinical examination and confirmatory magnetic
resonance imaging. Participating expert physicians were orthopedic surgeons (n =
3) or sport medicine physicians (n = 2). Penalized logistic regression (least
absolute shrinkage and selection operator) was used to identify history elements
and physical examination tests associated with the diagnosis of SMT and recursive
partitioning was used to develop diagnostic clusters. MAIN OUTCOME MEASURES:
Diagnostic accuracy measures were calculated including sensitivity, specificity,
positive and negative predictive values, and positive and negative likelihood
ratios (LR+/-) with associated 95% confidence intervals (CIs). RESULTS: Eighty
patients had a diagnosis of SMT (28.7%), including 35 traumatic tears and 45
degenerative tears. The combination a history of trauma during a pivot, medial
knee pain location, and a positive medial joint line tenderness test was able to
diagnose (LR+ = 8.9; 95% CI 6.1-13.1) or exclude (LR- = 0.10; 95% CI 0.03-0.28) a
traumatic SMT. Combining a history of progressive onset of pain, medial knee pain
location, pain while pivoting, absence of valgus or varus knee misalignment, or
full passive knee flexion was able to moderately diagnose (LR+ = 6.4; 95% CI
4.0-10.4) or exclude (LR- = 0.10; 95% CI 0.03-0.31) a degenerative SMT. Internal
validation estimates were slightly lower for all clusters but demonstrated
positive LR superior to 5 and negative LR inferior to 0.2 indicating moderate
shift in posttest probability. CONCLUSION: Diagnostic clusters combining history
elements and physical examination tests can support the differential diagnosis of
SMT. These results represent the initial derivation of the clusters and external
validation is mandatory.
LEVEL OF EVIDENCE: I.
CI - Copyright (c) 2018 American Academy of Physical Medicine and Rehabilitation.
Published by Elsevier Inc. All rights reserved.

Langue : ANGLAIS