University of California San Francisco, San Francisco, California.
Stanford University, Stanford, California.
J Bone Joint Surg Am. 2019 Feb 20;101(4):353-359. doi: 10.2106/JBJS.18.00387.
There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test.
The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed.
Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78).
The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S.
The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.
在资源匮乏的环境中，很少有经过验证的工具可以作为下肢创伤后骨折愈合的替代指标。SIGN（外科植入物生成网络）骨折护理国际组织的“S&S 测试（ squat-and-smile test ）”一直在开发中，用于监测髓内钉治疗下肢长骨骨折后的结果。本研究的目的是开发和确定 S&S 测试的领域。
S&S 领域是通过迭代过程开发的，关于深蹲深度、深蹲所需的支撑以及面部表情这 3 个方面达成了共识。本回顾性研究纳入了 OTA/AO 32 型股骨干骨折的成年患者，并在术后 6 周以及 3、6 和 12 个月进行 S&S 测试。两位作者独立评估了患者进行 S&S 的照片。S&S 领域与 EuroQol 5-Dimensions（EQ-5D）指数评分相关，比较了 S&S 领域与再次手术的情况。使用κ统计量评估了组内和重测信度。进行了敏感性和特异性分析。
共评估了 231 名患者的 609 张 S&S 图像。每个领域都随着时间的推移而改善，并与 EQ-5D 评分呈正相关（p<0.05）。深蹲深度和深蹲所需的支撑与再次手术的需求相关（p≤0.01），两者在 1 年内排除再次手术需求的特异性均较高（分别为 0.95 和 0.97）。所有 3 个领域的重测信度均较高（κ=0.95、0.92 和 0.96）。深蹲深度和支撑需求的组内信度也很强（κ=0.75 和 0.78）。
S&S 是一种监测低资源环境下股骨干骨折临床和功能结果的潜在工具。我们的数据支持将深蹲深度和支撑需求的二元评估作为骨折愈合的替代指标，但不包括面部表情。需要在外部人群中进行前瞻性研究，以评估 S&S 的有效性、可靠性和反应性。
S&S 为中低收入国家的股骨干骨折评估提供了一个有价值的替代方法，因为它是基于深蹲的，易于管理，并且可以通过移动电话或短信进行远程评估。
