Klein Erin E, Weil Lowell, Weil Lowell Scott, Bowen Michael, Fleischer Adam E
Weil Foot and Ankle Institute, Des Plaines, Illinois, USA (EEK, LW, LSW, MB, AEF)
Weil Foot and Ankle Institute, Des Plaines, Illinois, USA (EEK, LW, LSW, MB, AEF).
Foot Ankle Spec. 2014 Dec;7(6):466-70. doi: 10.1177/1938640014539810. Epub 2014 Sep 18.
There is uncertainty regarding the most accurate and cost-effective method for diagnosing plantar plate injuries within the foot. The purpose of this study was to examine the combined value of using clinical and radiographic findings to diagnose high grade tears (> 50% disruption) within the second metatarsophalangeal (MTP) joint. Ninety-eight consecutive patients (117 feet) who underwent corrective surgery for plantar forefoot pain at a single foot and ankle specialty clinic were included in this retrospective analysis. All patients received a structured intraoperative assessment of the second MTP joint plantar plate by a single trained observer. Twenty-five clinical and plain film radiographic variables obtained prior to surgery were tested for their association with a high grade plantar plate tear using multiple logistic regression techniques. A positive drawer sign was the most informative individual test for differentiating high from low grade tears (odds ratio [OR] = 2.9; 95% confidence interval [CI], 0.92-9.5; sensitivity 91.5%; specificity 22%). Patients with longstanding forefoot symptoms (> 2 years) tended to be more likely to have low grade tears only (OR = 2.1; 95% CI, 0.98-4.5; sensitivity 61.7%; specificity 58.1%). Most radiographic measurements did little to distinguish high from low grade tears; however, the addition of ipsilateral third MTP joint transverse deviation angle showed a trend toward improving upon the diagnostic accuracy of strategies that used clinical findings alone (area under the curve [AUC] improved from 0.63 to 0.67; P = .11). A third MTP joint deviation angle greater than 15° in either direction combined with drawer testing and duration of symptoms achieved the highest specificities of any combination of variables examined in the study (specificities 82.4% [95% CI, 73.7%-91.1%] and 89.1 [95% CI, 82.1-96.3], respectively). The combination of a positive drawer test coupled with transverse deviation of the third MTP joint (> 15°) on plain films strongly suggests an underlying high grade plantar plate tear of the second MTP joint. However, this study highlights the need for using advanced imaging to distinguish between high and low grade tears in many instances (eg, positive drawer test and normal or near-normal alignment of the third MTP joint).
Diagnostic, Level II.
对于足部跖板损伤最准确且最具成本效益的诊断方法仍存在不确定性。本研究的目的是探讨结合临床和影像学检查结果来诊断第二跖趾关节内高级别撕裂（> 50% 断裂）的价值。本回顾性分析纳入了在一家足踝专科诊所接受前足疼痛矫正手术的98例连续患者（117只脚）。所有患者均由一名经过培训的观察者对第二跖趾关节跖板进行结构化术中评估。术前获得的25项临床和X线平片影像学变量，采用多元逻辑回归技术检验其与高级别跖板撕裂的相关性。阳性抽屉试验是区分高级别与低级别撕裂最具信息量的单项检查（优势比[OR]=2.9；95%置信区间[CI]，0.92 - 9.5；敏感度91.5%；特异度22%）。有长期前足症状（> 2年）的患者仅更有可能出现低级别撕裂（OR = 2.1；95% CI，0.98 - 4.5；敏感度61.7%；特异度58.1%）。大多数影像学测量对区分高级别与低级别撕裂作用不大；然而，加上同侧第三跖趾关节横向偏斜角度后，显示出比仅使用临床检查结果的诊断策略的准确性有提高的趋势（曲线下面积[AUC]从0.63提高到0.67；P = 0.11）。第三跖趾关节在任一方向上的偏斜角度大于15°，结合抽屉试验和症状持续时间，在所研究的变量组合中具有最高的特异度（特异度分别为82.4% [95% CI，73.7% - 91.1%]和89.1 [95% CI，82.1 - 96.3]）。平片上阳性抽屉试验与第三跖趾关节横向偏斜（> 15°）相结合，强烈提示第二跖趾关节存在潜在的高级别跖板撕裂。然而，本研究强调在许多情况下（例如，阳性抽屉试验且第三跖趾关节对线正常或接近正常）需要使用先进成像来区分高级别与低级别撕裂。
诊断性研究，二级。
