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A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine the diagnostic accuracy of magnetic resonance imaging (MRI) and ultrasound (US) in the diagnosis of anterior cruciate ligament (ACL), medial meniscus and lateral meniscus tears in people with suspected ACL and/or meniscal tears.

Methods

MEDLINE, Web of Science and the Cochrane library were searched from inception to March 2014. All prospective studies of the diagnostic accuracy of MRI or US against arthroscopy as the reference standard were included in the systematic review. Studies with a retrospective design and those with evidence of verification bias were excluded. Methodological quality of included studies was assessed using the QUADAS-2 tool. A meta-analysis of studies evaluating MRI to calculate the pooled sensitivity and specificity for each target condition was performed using a bivariate model with random effects. Sub-group and sensitivity analysis were used to examine the effect of methodological and other study variables.

Results

There were 14 studies included in the meta-analysis of the accuracy of MRI for ACL tears, 19 studies included for medial meniscal tears and 19 studies for lateral meniscal tears. The summary estimates of sensitivity and specificity of MRI were 87 % (95 % CI 77–94 %) and 93 % (95 % CI 91–96 %), respectively, for ACL tears; 89 % (95 % CI 83–94 %) and 88 % (95 % CI 82–93 %), respectively, for medial meniscal tears; and 78 % (95 % CI 66–87 %) and 95 % (95 % CI 91–97 %), respectively, for lateral meniscal tears. Magnetic field strength had no significant effect on accuracy. Most studies had a high or unclear risk of bias. There were an insufficient number of studies that evaluated US to perform a meta-analysis.

Conclusion

This study provides a systematic review and meta-analysis of diagnostic accuracy studies of MRI and applies strict exclusion criteria in relation to the risk of verification bias. The risk of bias in most studies is high or unclear in relation to the reference standard. Concerns regarding the applicability of patient selection are also present in most studies.

Level of evidence

III.

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Author information

Authors and Affiliations

  1. Department of Orthopaedics, Royal College of Surgeons in Ireland, Dublin, Ireland

    Nigel Phelan & Patrick Rowland

  2. Department of Clinical Therapies, University of Limerick, Limerick, Ireland

    Rose Galvin

  3. Professorial Unit, Cappagh National Orthopaedic Hospital, Dublin, Ireland

    John M. O’Byrne

Authors
  1. Nigel Phelan
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Corresponding author

Correspondence to Nigel Phelan.

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Appendices

Appendix 1: Search strategies

MEDLINE (PubMed)

((Ultrasonography [mh] OR ultrasound [56] OR ultrasonograph* [56]) OR (Magnetic Resonance Imaging [mh]

Index tests set

OR MR imag*[56] OR magnetic resonance imag* [56] OR MRI [56])) OR

(Arthroscopy [mh] OR arthroscop* [56]) AND

Reference standard set

(Menisci, Tibial [mh] OR Medial Meniscus [mh] OR medial menisc* [56] OR Lateral Meniscus [mh] OR lateral menisc* [56] OR meniscal [56] OR Anterior Cruciate Ligament [mh] OR anterior cruciate ligament* [56] OR ‘ACL’ [56]) AND (Knee injuries [mh] OR Cartilage, articular/injuries [mh] OR Cartilage, articular/surgery [mh] OR Rupture [mh:noexp] OR tear [56] OR tears [56] OR torn [56] OR thickness [56] OR repair [56] OR lesion [56] OR lesions [56] OR rupture [56] OR acute knee [56] OR abnormal*[56] OR pain[56] OR painful[56])

Target conditions set

EMBASE (Elsevier)

1 ‘echography’/de AND [embase]/lim (157490)

Index tests set

2 ultrasound:ab,ti OR ultrasonograph*:ab,ti OR sonograp*:ab,ti AND [embase]/lim (264425)

3 #1 OR #2 (327246)

4 ‘nuclear magnetic resonance imaging’/de AND [embase]/lim (398985)

5 ((‘magnetic resonance’ OR mr) NEAR/3 imag*):ab,ti AND [embase]/lim (182022)

6 mri:ab,ti AND [embase]/lim (179599)

7 #4 OR #5 OR #6 (453055)

8 #7 OR #3 (739416)

9 arthroscopy/de OR arthroscop*:ab,ti AND [embase]/lim

Reference standard set

10 #8 OR #9

11 Knee AND meniscus/de AND [embase]/lim

Target condition set

12 medial menis* AND [embase]/lim (3819)

13 lateral menis* AND [embase]/lim (3819)

14 meniscal [embase]/lim

15 ‘Anterior Cruciate Ligament’ (15713)

16 ((anterior adj2 cruciate$ adj2 ligament$) OR ACL) (11589)

17 #11 OR #12 OR #13 OR #14 OR #15 OR #16 (22229)

18 ‘knee injury’/de AND [embase]/lim

19 (acute NEAR/4 knee):ab,ti AND [embase]/lim

20 ‘anterior cruciate ligament rupture’/de AND [embase]/lim

21 ‘Cartilage injury’/de OR ‘knee meniscus rupture’/de AND [embase]/lim

22 tear:ab,ti OR tears:ab,ti OR torn:ab,ti OR thickness:ab,ti OR lesion:ab,ti OR rupture:ab,ti OR ruptured:ab,ti OR ruptures:ab,ti OR injur*:ab,ti OR repair:ab,ti OR abnormal*:ab,ti OR pain:ab,ti OR painful:ab,ti AND [embase]/lim (1316333)

Appendix 2: QUADAS-2

Modifications underlined.

Phase 1: State the review question:

Patients

Index test(s)

Reference standard and target condition

Phase 2: Draw a flow diagram for the primary study

Phase 3: Risk of bias and applicability judgements

Quadas-2 is structured so that 4 key domains are each rated in terms of the risk of bias and the concern regarding applicability to the research question (as defined above). Each key domain as a set of signalling questions to help reach the judgements regarding bias and applicability.

Domain 1: patient selection

  1. (A)

    Risk of bias

    1. 1.

      Describe methods of patient selection

    2. 2.

      Was a consecutive or random sample of patients enrolled? (Yes/No/Unclear)

    3. 3.

      Was a case–control design avoided? (Yes/No/Unclear)

    4. 4.

      Did the study avoid inappropriate exclusions? (Yes/No/Unclear)

Could the selection of patients have introduced bias?

RISK: LOW/HIGH/UNCLEAR

  1. (B)

    Applicability

    1. 1.

      Describe included patients (prior testing, presentation, intended use of index test and setting)

    2. 2.

      Is there concern that the included patients do not match the review question?

CONCERN: LOW/HIGH/UNCLEAR

Domain 2: index test (MRI)

  1. (A)

    Risk of bias

    Additional signalling questions underlined in following section.

    1. 1.

      Describe the index test, and how it was conducted and interpreted

    2. 2.

      Were MRI scans performed in the same hospital/centre ? (Yes/No/Unclear)

    3. 3.

      Was the index test interpreted by a single radiologist without consensus opinion ? (Yes/No/Unclear)

    4. 4.

      Were the index test results interpreted without knowledge of the results of the reference standard ? (Yes/No/Unclear)

    5. 5.

      If a threshold was used, was it pre-specified? (Yes/No/Unclear)

    6. 6.

      Could the conduct or interpretation of the index test have introduced bias ?

RISK: LOW/HIGH/UNCLEAR

  1. (B)

    Applicability

    1. 1.

      Is there concern that the index test, its conduct, or interpretation differ from the review question? CONCERN LOW/HIGH/UNCLEAR

Domain 3: reference test (arthroscopy)

  1. (A)

    Risk of bias

    Additional signalling question underlined in following section

    Question 3. Omitted from assessment of bias

    1. 1.

      Describe the reference standard, and how it was conducted and interpreted:

    2. 2.

      Was the reference standard performed by a single surgeon? (Yes/No/Unclear)

    3. 3.

      Is the reference standard likely to correctly classify the target condition? (Yes/No/Unclear)

    4. 4.

      Were the reference standard results interpreted without knowledge of the results of the index test? (Yes/No/Unclear)

Could the reference standard, its conduct, or its interpretation have introduced bias?

RISK: LOW/HIGH/UNCLEAR

  1. (B)

    Applicability

    1. 1.

      Are there concerns that the target condition as defined by the reference standard does not match the review question? CONCERN LOW/HIGH/UNCLEAR

Domain 4: flow and timing

  1. (A)

    Risk of bias

    1. 1.

      Describe any patients who did not receive the index test(s) and/or reference standard or who were excluded from the 2 × 2 table (refer to flow diagram)

    2. 2.

      Describe the time interval and any interventions between index test(s) and reference standard:

    3. 3.

      Was there an appropriate interval between index test(s) and reference standard? (Yes/No/Unclear)

    4. 4.

      Did all patients receive a reference standard? (Yes/No/Unclear)

    5. 5.

      Did patients receive the same reference standard? (Yes/No/Unclear)

    6. 6.

      Were all patients included in the analysis? (Yes/No/Unclear)

Could the patient flow have introduced Bias? RISK: LOW/HIGH/UNCLEAR

Appendix 3

See Tables 6, 7 and 8.

Table 6 Post-test probability of and ACL tear following MRI
Full size table
Table 7 Post-test probability of a medial meniscus tear following MRI
Full size table
Table 8 Post-test probability of a lateral meniscus tear following MRI
Full size table

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Phelan, N., Rowland, P., Galvin, R. et al. A systematic review and meta-analysis of the diagnostic accuracy of MRI for suspected ACL and meniscal tears of the knee. Knee Surg Sports Traumatol Arthrosc 24, 1525–1539 (2016). https://doi.org/10.1007/s00167-015-3861-8

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