Giordano Vincenzo, Gomes Arthur Fs, Amaral Ney P, Albuquerque Rodrigo P, Pires Robinson Es
Serviço de Ortopedia e Traumatologia Prof, Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brasil.
Patient Saf Surg. 2011 Oct 4;5:24. doi: 10.1186/1754-9493-5-24.
Intra-articular hardware penetration can occur during osteosynthesis of ankle fractures, jeopardizing patients' outcomes. The intraoperative recognition of misplaced screws may be difficult due to the challenge of adequate interpretation of specific radiographic views. The present study was designed to investigate the diagnostic accuracy of standardized radiographic ankle views to determine the accuracy of diagnosis for intra-articular hardware placement of medial malleolar screws in a cadaveric model.
Nine preserved human cadaveric lower extremity specimens were used. Under direct visualization, two 4.0 mm cancellous screws were inserted into the medial malleolus. Each specimen was analyzed radiographically using antero-posterior (AP) and mortise views. The X-rays were randomly uploaded on a CD-ROM and included in a survey submitted to ten selected orthopaedic surgeons. The "Standards for Reporting of Diagnostic Accuracy" (STARD) questionnaire was used to determine the surgeons' perception of accuracy of screw placement in the medial malleolus. The selection of items was based on evidence whenever possible, therefore the "inconclusive" category was added. Inter and intraobserver variations were analyzed by kappa statistics to measure the amount of agreement.
There was a poor level of agreement (kappa 0.4) both in the AP and in the mortise view among all the examiners. Associating the two x-rays, the agreement remained poor (kappa 0.4). In the cases in which there was a diagnosis of articular penetration, there was a poor agreement related to which of the screws was intra-articular. The number of "inconclusive" responses was low and constant, without a statistically significant difference between the subspecialists
The routine intraoperative radiographic imaging of the ankle is difficult to interpret and unreliable for detection of intra-articular hardware penetration. We therefore recommend to reposition medial malleolar screws intraoperatively if there is any doubt regarding inadequate screw placement.
踝关节骨折骨固定过程中可能发生关节内硬件穿透，危及患者预后。由于对特定影像学视图进行充分解读存在挑战，术中识别螺钉位置不当可能较为困难。本研究旨在调查标准化踝关节影像学视图的诊断准确性，以确定在尸体模型中内踝螺钉关节内放置的诊断准确性。
使用九个保存的人类尸体下肢标本。在直接可视化下，将两枚4.0毫米的松质骨螺钉插入内踝。每个标本均使用前后位（AP）和榫眼视图进行影像学分析。X线随机上传至光盘，并纳入提交给十位选定骨科医生的调查中。使用“诊断准确性报告标准”（STARD）问卷来确定外科医生对内踝螺钉放置准确性的看法。项目选择尽可能基于证据，因此增加了“不确定”类别。通过kappa统计分析观察者间和观察者内的差异，以测量一致性程度。
所有检查者在AP视图和榫眼视图中的一致性水平均较差（kappa值为0.4）。将两张X线片结合起来，一致性仍然较差（kappa值为0.4）。在诊断为关节穿透的病例中，对于哪枚螺钉位于关节内的一致性较差。“不确定”反应的数量较少且恒定，各亚专科之间无统计学显著差异。
踝关节常规术中影像学成像难以解读，对于检测关节内硬件穿透不可靠。因此，我们建议如果对螺钉放置不当存在任何疑问，术中应重新定位内踝螺钉。
