Scapholunate Interosseous Ligament Tears

Rationale and Objectives

The study aimed to perform a systematic review and meta-analysis for evaluating the diagnostic accuracy of 1.5 Tesla and 3.0 Tesla magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA), in the detection of scapholunate interosseous ligament (SLIL) injury.

Materials and Methods

A literature search was performed (until July 2015) using the PubMed (MEDLINE), Embase, ISI Web of Science, Scopus, and conference proceedings. Original studies evaluating the diagnostic accuracy of MRI or MRA in the detection of SLIL injuries using arthroscopy or open surgery as the reference standard were included.

Results

Of the initial 930 published records and 103 conference proceedings, 24 studies (1902 MRI examinations) were included (median SLIL injury prevalence: 33% [interquartile range: 25–42]). Heterogeneity was detected for 1.5 T MRI (chi-square: 47.93, P < 0.001) but not for 3.0 T MRI (chi-square: 8.00, P value: 0.09) and MRA (chi-square: 14.54, P value: 0.34) studies. The sensitivities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 45.7% (95% confidence interval: 40.1–51.4), 75.7% (66.8–83.2), and 82.1% (76.1–87.2), respectively. The specificities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 80.5% (77.3–83.4), 97.1% (89.8–99.6), and 92.8% (90.2–94.9), respectively. The diagnostic odds ratios of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 5.56 (2.71–11.39), 23.23 (3.16–171.00), and 65.04 (32.89–128.62) ( P value < 0.001), respectively. The results were consistent after addressing publication bias and sensitivity analyses.

Conclusions

MRA is superior to 3.0 T MRI, and 3.0 T MRI is superior to 1.5 T MRI in terms of diagnostic performance. 3.0 T MRI has the highest specificity for the detection of SLIL injuries.

Introduction

The scapholunate interosseous ligament (SLIL) is a small, intrinsic structure with an essential role in the stability of the proximal carpal row . The SLIL is a frequently injured interosseous ligament, and SLIL tear is the most common cause of chronic wrist ligamentous instability . Compromised function, chronic wrist pain, and ultimately secondary osteoarthritis are some of the most important complications of SLIL injury .

In some patients, diagnosis of wrist instability can be made using clinical examination and plain radiographs . However, noninvasive magnetic resonance imaging (MRI) or minimally invasive magnetic resonance arthrography (MRA) plays a major role in the detection of specific intrinsic ligaments’ injuries and decision-making for surgical management .

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Methods

Literature Search

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Search Strategy

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Study Selection—Eligibility

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Study Selection—Final Inclusion

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Data Collection

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Quality Assessment

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Statistical Analysis

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Results

Study Selection

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Study Characteristics and Risk of Bias

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Table 1

Summary of the Included Studies Evaluating the Diagnostic Accuracy of 1.5 T (and Lower Field Strength), 3.0 T, and MRA in Detecting SLIL Injury

Study Publication Year Study Years Modality Number Prospective Versus Retrospective Reference Standard Blinded Age, Mean (Range) Gender (F:M) Country Institution (Department) 1 Zlatkin et al. 1989 N/A 1.5 T (GE) 20 Retrospective Arthroscopy and open surgery Yes N/A N/A United States University of Pennsylvania (R) 2 Schweitzer et al. 1992 N/A 1.5 T MRA (GE) 15, 14 Retrospective Arthroscopy Yes N/A N/A United States University of California, San Diego (R) 3 Johnstone et al. 1997 N/A 0.5 T (GE) 43 Prospective Arthroscopy—in 3 months N/A 30 (14–62) 26:17 United Kingdom Royal Cornwall Hospitals (O) 4 Kovanlikaya et al. 1997 N/A 1.0 T MRA (Siemens) 25 Prospective Arthroscopy and open surgery Yes (18–55) 16:9 Turkey Dokuz Eylul University (R) 5 Potter et al. 1997 1993–1996 1.5 T (GE) 53 Prospective Arthroscopy—in average 7 weeks Yes 36 (13–70) 25:52 United States Hospital for Special Surgery (R) 6 Scheck et al. 1997 1994–1996 1.5 T dMRA (Siemens) 41 Prospective Arthroscopy N/A 34 18:23 Germany Ludwig-Maximilian-University (R) 7 Herold et al. 2001 N/A iMRA (Siemens) 45 Prospective Arthroscopy—6 weeks N/A 32 (16–77) 23:22 Germany University of Regensburg (R) 8 Manton et al. 2001 N/A 1.5 T (GE) 50 Retrospective Arthroscopy—in 3 months Yes 40 (20–62) 23:27 United States Thomas Jefferson University (R) 9 Morley et al. 2001 1996–1999 1.5 T (Siemens) 54 Prospective Arthroscopy Yes 31 (15–63) 29:25 United Kingdom Southern General Hospital (O) 10 Schadel-Hopfner et al. 2001 1996–1998 1.0 T iMRA (Siemens) 72, 31 Prospective Arthroscopy—in 48 hours N/A 38 (14–76) 48:55 Germany University Hospital, Marburg (T) 11 Meier et al. 2002 2000 dMRA (Siemens) 125 Prospective Arthroscopy—in 24 hours Yes 37 (±12) 45:80 Germany Klinik für Handchirurgie, Bad Neustadt an der Saale (H) 12 Braun et al. 2003 N/A dMRA 75 Retrospective Arthroscopy Yes 38 25:50 Germany Universität Würzburg (R) 13 Haim et al. 2003 6 years iMRA 1.5 T (GE) 41 Retrospective Arthroscopy—in 10 months Yes 37 (7–57) 20:21 United States Yale University (R) 45 39 (12–62) 19:26 14 Schmid et al. 2005 2003 1.5 T (GE) 9 Cadaver study Open surgery or gross pathology Yes 83 (65–99) 4:4 Switzerland Balgrist University Hospital (R) 15 Magee et al. 2009 2007 3.0 T dMRA (GE) 49, 35 Retrospective Arthroscopy—in 75 days Yes 32 (14–58) 18:31 United States Neuroskeletal Imaging Institutem, FL (R) 16 Redeker et al. 2009 1998–2002 1.5 T and lower 217 Retrospective Arthroscopy N/A 36 (13–63) 105:112 Germany Medizinische Hochschule Hannover (P) 17 Prosser et al. 2011 2005–2009 N/A (low res) 55 Prospective Arthroscopy—in 3 weeks Yes N/A N/A Australia Sydney Hand Therapy and Rehabilitation Centre 18 Mahmood et al. 2012 2006–2009 dMRA (Philips) 30 Retrospective Arthroscopy—in 7 months N/A 42 (20–70) 20:10 United Kingdom Macclesfield District General Hospital 19 Lee RKL et al. 2013 2012 3.0 T dMRA (Philips) 10 Cadaver study Arthroscopy—in 1 week Yes 50 (26–59) 0:10 Hong Kong The Chinese University of Hong Kong (R) 20 Lee YH et al. 2013 2009–2010 dMRA 3.0 T (Philips) 48 Retrospective Arthroscopy—in 30 days Yes 34 (14–58) 20:28 South Korea Yonsei University (R) 21 Ruston et al. 2013 N/A N/A (low res) 38 Retrospective Arthroscopy N/A 35 (10–68) N/A United Kingdom University College London Hospital 22 Spaans et al. 2013 2006–2010 3.0 T (Philips) 38 Retrospective Open surgery Yes N/A N/A The Netherlands Universital Medical Center, Utrecht (P) 23 Pahwa et al. 2014 2007–2009 1.5 T dMRA (Siemens) 16 Prospective Arthroscopy—in 3 weeks Yes 29 (18–60) 18:35 India All India Institute of Medical Sciences (O) 24 Strobel et al. 2014 2011–2012 dMRA (Philips) 8 Prospective Open surgery Yes 43 (22–66) N/A Switzerland Lucerne Cantonal Hospital (R)

dMRA, direct MRA; GE, General Electric; iMRA, indirect MRA; MRA, magnetic resonance arthrography; N/A, not available; SLIL, scapholunate interosseous ligament.

Department of the first author is indicated as: H, hand surgery; O, orthopedic surgery; P, plastic and reconstruction surgery; R, radiology; T, traumatology.

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Synthesis of Results

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Table 2

Summary of the Examinations Evaluating the Diagnostic Accuracy of 1.5 T (and Lower Field Strength), 3.0 T, and MRA in Detecting SLIL Injury

Study MRI Reader True Positives True Negatives False Positives False Negatives Prevalence (%) Sensitivity (%) Specificity (%) 1.5 Tesla (and lower) MRI 1 Haim et al. 1.5 T 1, 2, and 3 11 97 11 16 20 41 90 2 Johnstone et al. 0.5 T 1 3 35 0 5 19 37 100 3 Kovanlikaya et al. 1.0 T 1 4 14 0 7 44 36 100 4 Manton et al. 1.5 T 1 10 11 23 3 28 77 32 5 Manton et al. 1.5 T 2 6 25 6 6 28 50 81 6 Morley et al. 1.5 T 1 1 42 3 8 17 11 93 7 Pahwa et al. 1.5 T 1, 2, and 3 5 8 0 3 50 62 100 8 Potter et al. 1.5 T 1 15 36 0 2 32 88 100 9 Prosser et al. 1.5 T or lower 1 17 26 6 6 42 74 81 10 Ruston et al. 1.5 T or lower 1 2 23 3 10 32 17 88 11 Schadel-Hopfner et al. 1.0 T 1, 2, and 3 18 37 7 10 39 64 84 12 Scheck et al. 1.5 T 1 and 2 15 32 62 14 24 52 34 13 Schmid et al. 1.5 T 1 and 2 14 25 6 9 43 61 81 14 Schweitzer et al. 1.5 T 1 and 2 2 7 3 3 33 40 70 15 Redeker et al. 1.5 T or lower 1 15 130 6 66 37 19 96 16 Zlatkin et al. 1.5 T N/A 5 13 0 2 35 71 100 3.0 Tesla MRI 1 Lee RKL et al. 3.0 T 1 and 2 2 6 1 1 30 66 86 2 Lee YH et al. 3.0 T 1 13 28 0 7 42 65 100 3 Magee et al. 3.0 T 1 and 2 16 31 0 2 37 89 100 4 Spaans et al. 3.0 T 1 26 1 0 11 97 70 100 5 Spaans et al. 3.0 T 2 30 0 1 7 97 81 0 MRA 1 Braun et al. dMRA 1 and 2 18 52 2 3 28 86 96 2 Haim et al. iMRA 1, 2, and 3 11 98 13 1 10 92 88 3 Herold et al. iMRA N/A 7 35 2 1 18 87 95 4 Kovanlikaya et al. dMRA 1 9 12 2 2 44 82 86 5 Lee RKL et al. dMRA 1 and 2 3 6 1 0 30 100 86 6 Lee YH et al. dMRA 1 17 27 1 3 42 85 96 7 Mahmood et al. dMRA 1 10 16 2 2 40 83 89 8 Magee et a. dMRA 1 and 2 12 23 0 0 34 100 100 9 Meier et al. dMRA 1 21 96 0 8 23 72 100 10 Pahwa et al. dMRA 1, 2, and 3 8 8 0 0 50 100 100 11 Schadel-Hopfner et al. iMRA 1, 2, and 3 15 7 0 9 77 62 100 12 Scheck et al. dMRA 1 and 2 26 82 12 3 24 90 87 13 Schweitzer et al. dMRA 1 and 2 2 8 2 3 33 40 80 14 Strobel et al. dMRA 1 2 6 0 0 25 100 100

dMRA, direct MRA; iMRA, indirect MRA; MRA, magnetic resonance arthrography; MRI, magnetic resonance imaging; N/A, not available; SLIL, scapholunate interosseous ligament.

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Table 3

Summary of the Pooled Statistics Evaluating the Diagnostic Accuracy of 1.5 T (and Lower Field Strength), 3.0 T, and MRA in Detecting SLIL Injury

1.5 T (or Lower Field Strength) 3.0 T dMRA and iMRA Pooled estimates Sensitivity (%) 45.7(40.1–51.4) 75.7(66.8–83.2) 82.1(76.1–87.2) Specificity (%) 80.5(77.3–83.4) 97.1(89.8–99.6) 92.8(90.2–94.9) Summary: Random effect (DerSimonian–Laird) Positive likelihood ratio 3.07(1.79–5.26) 6.84(0.65–72.16) 9.19(5.96–14.19) Negative likelihood ratio 0.65(0.52–0.87) 0.33(0.22–0.51) 0.21(0.14–0.34) Diagnostic odds ratio 5.56(2.71–11.39) 23.23(3.16–171.00) 65.04(32.89–128.62) \* I-square 68.7% † 50.0% 10.6% Heterogeneity chi-square ( P value) 47.93( P < 0.001) 8.00( P :0.092) 14.54( P :0.337) Publication bias: trim and fill Diagnostic odds ratio adjusted for publication bias 3.93(1.88–8.20) 23.28(3.22–168.15) 49.97(24.57–101.62)

dMRA, direct MRA; iMRA, indirect MRA; MRA, magnetic resonance arthrography; MRI, magnetic resonance imaging; SLIL, scapholunate interosseous ligament.

Diagnostic odds ratio (DOR) is a measure of test performance that is independent of the prevalence(unlike the accuracy).

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Risk of Publication Bias

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Sensitivity Analysis

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Table 4

Sensitivity Analysis: Estimating the Diagnostic Odds Ratios with the Exclusion of Specific Subgroups

Including Studies with: 1.5 T (or Lower Field Strength) 3.0 T MRA Relative DOR More than 10 examinations 5.56 23.23 65.43 4.15 (2.71–11.39) (3.16–171.00) (31.73–134.91) (2.45–7.05)P value < 0.001 Single readings \* 6.29 46.41 65.04 4.12 (2.74–14.42) (7.23–298.01) (32.89–128.62) (2.27–7.47)P value < 0.001 Human samples (excluding cadaver studies) 5.58 26.84 67.41 4.27 (2.56–12.15) (2.17–332.43) (32.71–138.92) (2.44–7.47)P value < 0.001 Blinding 6.87 23.23 75.64 3.55 (3.29–14.38) (3.16–171.00) (26.42–216.58) (1.93–6.55)P value < 0.001 Information on age/gender 5.64 83.31 82.64 5.19 (2.43–13.08) (11.53–601.80) (42.65–160.14) (3.11–8.68)P value < 0.001 1.5 T versus 3.0 T versus MRA (excluding lower field strength MRIs) 4.79 23.23 65.04 4.45 (1.70–13.50) (3.16–171.00) (32.89–128.62) (2.62–7.55)P value < 0.001 1.5 T versus 3.0 T versus indirect MRA 5.56 23.23 65.43 4.14 (2.71–11.39) (3.16–171.00) (27.29–156.87) (2.32–7.39)P value < 0.001 1.5 T versus 3.0 T versus direct MRA 5.56 23.23 70.84 4.54 (2.71–11.39) (3.16–171.00) (16.97–295.69) (1.82–11.37)P value < 0.001

DOR, diagnostic odds ratio; MRA, magnetic resonance arthrography; MRI, magnetic resonance imaging.

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Heterogeneity and Meta-regression

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Discussion

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Conclusions

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Supplementary Data

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Appendix S1

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Figure S1

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