title: Diagnostic performance of magnetic resonance imaging and pre-surgical evaluation in the assessment of traumatic intra-articular knee disorders in children and adolescents: what conditions still pose diagnostic challenges?
abstract: BACKGROUND
  Diagnosis of intra-articular lesions in children based on clinical examination and MRI is particularly challenging.
  
  
  OBJECTIVE
  To evaluate the diagnostic performance of MRI and pre-surgical evaluation of the knee in pediatric patients relative to arthroscopic evaluation as the gold standard. We report diagnoses frequently missed or inaccurately diagnosed pre-operatively.
  
  
  METHODS
  We conducted a retrospective review of MRI and pre-surgical evaluation in children and adolescents ages 1-17 years who were treated by knee arthroscopy during a 2½-year period. All MRIs were reviewed by a pediatric radiologist blinded to clinical findings. Pediatric orthopedic clinic notes were reviewed for pre-surgical evaluation (based on physical exam, radiograph, MR images and radiologist's MRI report). Arthroscopic findings were used as the gold standard. We calculated the percentages of diagnoses at arthroscopy missed on both MRI and pre-surgical evaluation. Diagnostic accuracy between children and adolescents and in patients with one pathological lesion vs. those with >1 lesion was analyzed. We performed a second review of MR images of the missed or over-called MRI diagnoses with knowledge of arthroscopic findings.
  
  
  RESULTS
  We included 178 children and adolescents. The most common diagnoses missed on MRI or pre-surgical evaluation but found at arthroscopy were: discoid meniscus (8/30, or 26.7% of cases); lateral meniscal tears (15/80, or 18.8% of cases); intra-articular loose bodies (5/36, or 13.9% of cases), and osteochondral injuries (9/73, or 12.3% of cases). Overall diagnostic accuracy of MRI and pre-surgical evaluation was 92.7% and 95.3%, respectively. No significant difference in diagnostic accuracy between children and adolescents was observed. When multiple intra-articular lesions were present, lateral meniscal tears were more likely to be inaccurately diagnosed (missed or over-called) on both MRI (P = 0.009) and pre-surgical evaluation (P < 0.001).
  
  
  CONCLUSIONS
  Overall diagnostic accuracy of MRI and pre-surgical evaluation was quite high. The traumatic intra-articular knee lesions that still pose a diagnostic challenge for MRI and pre-surgical evaluation are lateral discoid meniscus, lateral meniscal tears, intra-articular loose bodies and osteochondral injuries. Special attention should be given to those diagnoses when evaluating a pediatric knee MRI. In children with multiple intra-articular injuries, there is significantly more inaccuracy in pre-arthroscopic diagnosis of lateral meniscal tears on both MRI and pre-surgical evaluation.
authors.affiliation: The Children's Hospital of Philadelphia, Division of Orthopaedics, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
authors.forename: Itai
authors.initials: I
authors.lastname: Gans
authors.forename: Maria A
authors.initials: MA
authors.lastname: Bedoya
authors.forename: Victor
authors.initials: V
authors.lastname: Ho-Fung
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Ganley
mesh_terms: D000293:Adolescent; D001182:Arthroscopy; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007223:Infant; D007718:Knee Injuries / Q000175:diagnosis* / Q000601:surgery; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D012189:Retrospective Studies