Nashville-led Committee Clarifies International Standards

Language has borders. Science does not.

An article published this spring in the American Journal of Sports Medicine (www.ajs.sagepub.com) revealed the results of a pilot study involving orthopaedic physicians from eight countries who worked to define a language of clear international scientific standards that could be used consistently to measure and classify information about meniscal tears in patients.

Meniscal tears are among the most common knee injuries seen by physicians noted Allen F. Anderson, MD, of Tennessee Orthopaedic Alliance, who serves as chairman of the knee committee of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). The surgical society was established to create a worldwide exchange of information on education, research and patient care in arthroscopy, knee surgery and orthopaedic sports medicine.

In working to develop the classification system, the committee evaluated the consistency in arthroscopic evaluation and documentation in meniscal tears among investigators, which was deemed to be essential to the validity of multicenter studies. Anderson pointed out in this age of evidence-based medicine, it is critical for investigative centers to work together to amass sufficient data.

 “To get more rigorous scientific data, we need more numbers. To get reliable numbers, we have to be sure we have terms that enable us to understand the evidence in the same scientific language,” he said. 

Other committee members were Nashville orthopaedic physicians Warren Dunn, MD, MPH of the Center for Health Services Research at Vanderbilt University Medical Center; R. Edward Glenn Jr., MD, also of Tennessee Orthopaedic Alliance; and Kurt P. Spindler, MD, of the Department of Orthopaedic Surgery and Rehabilitation and Vanderbilt Sport Medicine and Orthopaedic Patient Care Center.

The larger group included American physicians from Illinois, Massachusetts, Pennsylvania and Vermont, as well as international orthopaedic physicians from Australia, Belgium, Brazil, France, Germany, Italy and Japan. The committee initially met together to agree on the terminology to be used and then communicated thereafter electronically.

The AJSM article, “Interobserver Reliability of the ISAKOS Classification of Meniscal Tears” reported the group of experts developed and validated a classification system designed to evaluate outcomes of treatment for meniscal tears in international clinical trials. The article is seen as a valuable resource … not only for physicians, but also for physical therapists and coaches.

The pilot study was performed by eight members of the committee who graded 10 arthroscopic videos for classification of tear depth, rim width, location, tear pattern and quality of the tissue.

Interobserver reliability was determined by having these orthopaedic surgeons, who practice in different countries, evaluate 37 arthroscopic videos selected to represent different meniscal tear characteristics. The Spearman correlation coefficient was used to compare the area of the meniscus excised, as drawn on the diagram, with the numeric percentage of meniscus excised.

The committee came to the conclusion that the ISAKOS classification of meniscal tears provides sufficient interobserver reliability for the pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears.

Anderson noted, “We wanted to develop classifications that could be used worldwide. This was very important because of the potential for more statistical information.”

He continued, “With the demands of evidence-based medicine requiring information from very large numbers of cases — more than can be seen in one office — this is a way to communicate between multiple centers around the world by developing and clarifying a multicenter language.”

The committee agreed on terminology to define the tears and took descriptions and results from 50 patients with arthroscopic views. Those tears, based on class, were graded by eight different physicians on four continents.

Anderson observed, “This was a very important first step. We had to determine that the information was reliable and valid and establish consistent communication.”

The study showed that there was an 87 percent agreement for anterior-posterior location of the tear, 79 percent agreement for tear pattern, 88 percent agreement for tear depth, 68 percent agreement for anterior, middle and posterior location of the tear, and 72 percent agreement for tissue quality. There was 54 percent agreement for the rim width and 67 percent agreement if the tear was central to the popliteal hiatus.

Based on Landis and Koch criteria, there was substantial agreement for anterior-posterior location of the tear and tear pattern; moderate agreement for tear depth, anterior, middle and posterior location of the tear, and tissue quality; and fair agreement for rim width and if the tear was central to the popliteal tear.

Anderson added, “Now, because we know more, and know we are communicating consistently, we can gather more scientifically rigorous clinical evidence. We need more numbers to add to the power of the study — we may need 500 centers to get adequate information.”

Since the study was published in March and the article is “out there” to be read worldwide, Anderson expects the more clearly defined language will result in even better communication and more consistent results in the treatment of meniscal tears.

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