与 CT 相比，非负重足位 X 线片在跖跗关节损伤中的的测量者间和测量者内可靠性。
Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries.
机构信息
School of Medicine, University of Tampere, 33520, Tampere, Finland.
Department of Orthopaedics and Traumatology, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland.
出版信息
Arch Orthop Trauma Surg. 2020 Oct;140(10):1423-1429. doi: 10.1007/s00402-020-03391-w. Epub 2020 Mar 5.
BACKGROUND
Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury.
METHODS
One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents.
RESULTS
Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003).
CONCLUSIONS
Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle.
LEVEL OF EVIDENCE
III.
背景
跗跖关节复合体（TMT）损伤，即 Lisfranc 损伤，范围广泛，从轻微的韧带损伤到严重的粉碎性挤压伤都有。尽管人们知道这些损伤经常被漏诊，但关于诊断准确性的文献有限。然而，之前尚未评估过 Lisfranc 损伤患者的非负重位 X 线（观察者间或观察者内的可靠性）的诊断准确性。
方法
收集了 100 套因急性足部损伤而拍摄的足部 X 光片，并对其进行了匿名处理。这些患者的诊断通过 CT 扫描得到了确认。在三分之一的 X 光片中，没有 Lisfranc 损伤；三分之一为无移位（<2mm）损伤；三分之一为移位损伤。由三位资深骨科医生和三位骨科住院医生对 X 光片进行独立评估。
结果
观察者间可靠性的 Fleiss kappa（κ）系数显示出中度相关性κ=0.50（95%置信区间：0.45-0.55）（第一次评估）和κ=0.58（95%置信区间：0.52-0.63）（第二次评估）。三个月后，再次进行评估，观察者内可靠性的 Cohen's kappa（κ）系数显示出高度相关性κ=0.71（0.64-0.85）。平均（范围）敏感度为 76.1%（60.6-92.4），特异性为 85.3%（52.9-100）。轻微损伤的敏感度低于严重损伤（65.4%比 87.1%，p=0.003）。
结论
基于非负重位 X 光片诊断 Lisfranc 损伤，观察者之间的一致性为中度，同一观察者不同时间的一致性为高度。如果仅使用非负重位 X 光片，会遗漏相当数量（24%）的损伤。无移位损伤比移位损伤更常被漏诊，因此，当临床体征不明显时，应特别小心。
证据等级
III 级。
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