1. Evidence-based knee and ankle examination (Part 1)
Robbie Foy

2. Evidence based medicine
“… the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of patients… means integrating individual clinical expertise with the best available external evidence evidence”
Sackett et al. BMJ 1996;312:70-71

3. What do we want out of a diagnosis?
Greater margin of certainty or safety
Rationale for clinical management
Better clinical outcomes
More efficient use of limited resources

4. Problems with diagnostic ‘tests’
Lack of evidence
Quality of evidence
Timeliness of evaluations
Understanding of concepts and application
Getting evidence into practice

5. A review of diagnostic test evaluations
184 studies evaluating 218 diagnostic tests
Only 7% of reviewed studies met all quality criteria
Accuracy of poorer quality evaluations over-estimated
Accuracy of poorer quality evaluations was over-estimated (in worst case) by up to three times
Lijmer et al. JAMA 1999;282:1061-6

6. Back to school… Disease present Disease absent Total Test positive a b
Test negative c d
c+d
a+c
b+d
a+b+c+d
Sensitivity: the probability of testing positive if the disease is truly present
Specificity: the probability of testing negative if the disease is truly absent

7. SpIN SnOUT The dummy’s guide
High specificity helps rule a diagnosis IN
SnOUT
High sensitivity helps rule a diagnosis OUT

8. Fear of the McMurray Test

9. The McMurray Test
To perform the test, the knee is held by one hand, which is placed along the joint line, and flexed to ninety degrees while the foot is held by the sole with the other hand. The examiner then places one hand on the lateral side of the knee to stabilize the joint and provide a valgus stress. The other hand rotates the leg externally while extending the knee. If pain or a "click" is felt, this constitutes a "positive McMurray test" for a tear in the medial meniscus. Likewise the medial knee can be stablized and the leg internally rotated as the leg is extended. A tag, caused by a tear will cause a palpable or even audible click on extension of the knee. A positive test indicates a tear of the lateral meniscus
Wikipedia

11. Performance of the McMurray Test
Sensitivity 53%
Specificity 59%
(Versus gold standard of arthroscopy)

12. Causes of variations in performance
Patient selection
Examiner specialty
Examiner skills and experience
All orthopaedics in review

13. The performance of composite examination
Sensitivity 77%
Specificity 91%

14. What do I want out of today?
To learn the best performing and most efficient combination of techniques to examine the knee
Including history taking
Specifically for meniscal injuries?
To increase my skills and confidence in applying these techniques

15. The Chinese Banquet Menu Syndrome

16. What do you want out of today?
Take a minute to write down 2-3 key learning objectives

17. What do you want out of today?
Take a minute to write down 2-3 key learning objectives
Take a minute to compare these with your neighbour

18. What do you want out of today?
Take a minute to write down 2-3 key learning objectives
Take a minute to compare these with your neighbour
Share some examples

19. Evidence-based knee and ankle examination (Part 2)
Robbie Foy

20. Bad doctors?
“In almost all studies the process of care did not reach the standards set out in national guidelines or set by the researchers themselves.”
Seddon ME, Marshall MN, Campbell SM, Roland MO. Qual Health Care 2001, 10:
Clinical research, such as the earlier exemplars, continually produces new findings that can improve population health. These findings will not change population health outcomes unless health care systems and professionals adopt them in practice. We know that the transfer of research findings into practice is unpredictable and can be a slow and haphazard process. A systematic review of quality of care studies from UK primary care and elsewhere concluded that “in almost all studies the process of care did not reach the standards set out in national guidelines or set by the researchers themselves.” This is a critical problem for research funders, healthcare systems and, of course, patients.

21. A psychological framework to think through changing practice
Behavioural theory offers a basis for understanding clinical practice and thereby a rationale for strategies to change behaviour
Consensus process identified main constructs from 33 psychological theories and grouped them into 12 domains
Subsequent semi-structured interview schedule
Michie S, et al. Qual Saf Health Care 2005;14:26-33
Bewildering array of existing theories

22. A psychological framework to think through changing practice
Domain
Illustrative questions
Knowledge
Do you know why you are doing X?
Skills
Do you know how to do X?
Professional role
Should you be doing X?
Self-efficacy
How confident are you about doing X?
Beliefs about consequences
What will happen if you do X?
Motivation and goals
How much do you want to do X?
Memory and attention
Will you remember how to do X?
Environment and context
Are there competing tasks and constraints?
Social influences
Do your colleagues / patients expect you to do X?
Emotion
How do you feel about doing X?
Behavioural regulation
What preparatory steps are needed to do X?
Nature of the behaviour
What is X?
Ask for examples

23. What did you get out of today?
Were you able to meet your learning objectives?
Did you change any of your learning objectives?
Discuss with your neighbour

24. What did you get out of today?
Were you able to meet your learning objectives?
Did you change any of your learning objectives?
Discuss with your neighbour
How do you plan to put your learning into practice?
Discuss with neighbour
Share your suggestions