To describe, evaluate and validate the diagnostic performance of a new clinical sign, the sleeper’s sign, for the diagnosis of a medial submeniscal flap tear (MSMFT).
This retrospective single-center series included patients aged 18–55 years old who underwent arthroscopic treatment in 2013–2015 for a medial meniscal tear. This study was performed according to STARD (standards for reporting of diagnostic accuracy) guidelines, and the reference test was a peroperative diagnosis of a MSMFT. The preoperative consultation reports were all analyzed to search for the sleeper’s sign, defined as night time medial tibiofemoral pain when the patient is in the fetal position with both knees in contact and no pain during daytime activities.
Three-hundred and ten patients responded to the study criteria, mean age 41.7 ± 9.7 years old. The sleeper’s sign was identified in 39 (12.6%) patients and a MSMFT was confirmed during arthroscopy in 47 (15.2%) cases, with significant agreement between this sign, arthroscopy (kappa = 0.78, p = 10–4) and MR-imaging (kappa = 0.72, p < 0.0001). The performance parameters of the sleeper’s sign were: sensitivity 74.5 ± 12.5%, specificity 98.5 ± 1.6%, Youden index 0.73 and accuracy 96.9%. MR imaging was found to be more sensitive (91.5 ± 8%). Multivariate analysis identified the sleeper’s sign as a risk factor of MSMFT during arthroscopy: OR 131.9 CI 95% [26.9–646.2], p < 0.0001 and a bone edema next to the flap tear on MR-imaging: OR 13, CI 95% [1.9–7.1], p = 0.008.
The “sleeper’s sign” is a new, valid, highly specific clinical sign for the diagnosis of a medial submeniscal flap tear. MRI was found to be more sensitive than the sleeper’s sign.
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Anderson AF, Lipscomb AB (1986) Clinical diagnosis of meniscal tears: description of a new manipulative test. Am J Sports Med 14:291–293
Anderson AF, Irrgang JJ, Dunn W et al (2011) Interobserver reliability of the International Society of Arthroscopic, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears. Am J Sports Med 39:926–932
Apley G (1947) The diagnosis of meniscus injuries. J Bone Joint Surg Am 29:78–84
Aydingoz U, Firat AK, Atay OA, Doral MN (2003) MR imaging of meniscal buckethandle tears: a review of signs and their relation to arthroscopic classification. Eur Radiol 13:618–625
Bossuyt PM, Cohen JF, Gatsonis CA, Korevaar DA, STARD group (2016) STARD 2015: updated reporting guidelines for all diagnostic accuracy studies. Ann Transl Med 4:85
Dandy DJ (1990) The arthroscopic anatomy of symptomatic meniscal lesions. J Bone Joint Surg Br 72:628–633
De Smet AA, Tuite MJ, Norris MA, Swan JS (1994) MR diagnosis of meniscal tears: analysis of causes of errors. AJR Am J Roentgenol 163:1419–1423
Dorsay TA, Helms CA (2003) Bucket-handle meniscal tears of the knee: sensitivity and specificity of MRI signs. Skeletal Radiol 32:266–272
Haramati N, Staron RB, Rubin S, Shreck EH, Feldman F, Kiernan H (1993) The flipped meniscus sign. Skeletal Radiol 22:273–277
Harrison BK, Abell BE, Gibson TW (2009) The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 19:9–12
Helms CA, Laorr A, Cannon WD Jr (1998) The absent bow tie sign in bucket-handle tears of the menisci in the knee. AJR Am J Roentgenol 170:57–61
Herman LJ, Beltran J (1988) Pitfalls in MR imaging of the knee. Radiology 167:775–781
Herschmiller TA, Anderson JA, Garrett WE, Taylor DC (2015) The trapped medial meniscus tear: an examination maneuver helps predict arthroscopic findings. Orthop J Sports Med 3:2325967115583954
Konan S, Rayan F, Haddad FS (2009) Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc 17:806–811
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174
Le Hir P, Charousset C, Duranthon LD et al (2007) Magnetic resonance imaging of medial meniscus tears with displaced fragment in the meniscal recesses. Rev Chir Orthop Reparatrice Appar Mot 93:357–363
Lecas LK, Helms CA, Kosarek FJ, Garret WE (2000) Inferiorly displaced flap tears of the medial meniscus: MR appearance and clinical significance. AJR Am J Roentgenol 174:161–164
Lefevre N, Naouri JF, Herman S, Gerometta A, Klouche S, Bohu Y (2016) A current review of the meniscus imaging: proposition of a useful tool for its radiologic analysis. Radiol Res Pract 2016:8329296
Mackenzie R, Dixon AK, Keene GS, Hollingworth W, Lomas DJ, Villar RN (1996) Magnetic imaging of the knee: assessment of effectiveness. Clin Radiol 51:245–250
McMurray TP (1942) The semilunar cartilages. Br J Surg 29:407–414
Miller GK (1996) A prospective study comparing the accuracy of the clinical diagnosis of meniscal tear with magnetic resonance imaging and its effect on clinical outcome. Arthroscopy 12:406–413
Newman AP, Daniels AU, Burks RT (1993) Principles and decision making in meniscal surgery. Arthroscopy 9:33–51
Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Hunink MGM (2003) MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 226:837–848
Rubin DA, Paletta GA Jr (2000) Current concepts and controversies in meniscal imaging. Magn Reson Imaging Clin N Am 8:243–270
Van de Berg BC, Malghem J, Poilvache P, Maldague B, Lecouvet FE (2005) Meniscal tears with fragments displaced in notch and recesses of knee: MR imaging with arthroscopic comparison. Radiology 234:842–850
Watanabe AT, Carter BC, Teitelbaum GP, Seeger LL, Bradley WG Jr (1989) Normal variations in MR imaging of the knee: appearance and frequency. AJR Am J Roentgenol 153:341–344
Study investigators: Olivier Grimaud: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France; Serge Herman: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France; Alain Meyer: Clinique du Sport Paris, 75005 Paris, France, Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France.
Fonds de Dotation pour la Recherche Clinique en Orthopédie et Pathologie du Sport, Paris, France (Grant No. 2019).
Conflict of interest
The authors have no conflict of interest to declare.
Ethics approval for this study was received from the Comité de Protection des Personnes Ile-de-France IV (CPP IDF IV), Hôpital Saint-Louis.
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Study investigators authors are listed in the Acknowledgements section.
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Lefevre, N., Klouche, S., Sezer, H.B. et al. The “sleeper’s sign” is valid and suggestive of a medial sub-meniscal flap tear. Knee Surg Sports Traumatol Arthrosc (2019). https://doi.org/10.1007/s00167-019-05655-4
- Medial submeniscal flap tear
- Knee arthroscopy
- Validity and diagnostic performance
- Sleeper's sign