University of Chicago Medicine, Department of Orthopedic Surgery, Chicago, Illinois.
Stanford University, Department of Orthopedic Surgery, Palo Alto, California.
West J Emerg Med. 2022 Oct 24;23(6):939-946. doi: 10.5811/westjem.2022.8.56453.
The purpose of this study was to assess the added clinical value of oblique knee radiographs four-view (4V) compared to orthogonal anteroposterior (AP) and lateral radiographs in a two-view (2V) series.
We obtained 200 adult, 4V knee radiographs in 200 patients in the ED and randomly divided them into two groups with 100 series in each group. Ten reviewers - three musculoskeletal radiologists and seven orthopedic surgeons - performed radiograph analyses. These reviewers were randomly divided evenly into group one and group two. Reviewers were blinded to patient data and first reviewed 2V radiographs (AP/lateral) only, and then reviewed 4V radiographs, including AP/lateral, and two additional oblique views for the same patients at least four weeks later. Acute pathology identification and the need for further imaging was assessed for all reviewers, and clinical decision-making (operative vs nonoperative treatment, need for admission, need for additional imaging) was assessed only by the seven orthopaedic surgeon reviewers.
Mean sensitivity for pathology identification was 79% with 2V and 81% with 4V (P =0.25). Intra-observer kappa value was 0.81 (range 0.54-1.00). Additional oblique radiographs led orthopaedic reviewers to change their treatment recommendations in 62/329 patients (18.84%) (P <0.001). Eight of 329 radiographic series were identified as "critical misses." (2.43%) (P =0.004), when pathology was reported as normal or reviewers recommended nonoperative treatment on 2V radiographs but changed their recommendation to operative management after the addition of oblique radiographs. The number needed to treat (NNT) for any treatment change and for "critical misses" was 83 and 643, respectively.
Although the addition of oblique radiographs may improve a clinician's ability to identify subtle pathologic findings not identified on 2V, it rarely leads to significant changes in treatment recommendations. Given the high NNT, limiting the usage of these oblique radiographs in the general patient population may reduce costs without significantly affecting patient care.
本研究旨在评估与传统的前后位（AP）和侧位（LAT）两视图（2V）相比，斜位膝关节四视图（4V）在 2V 系列中的附加临床价值。
我们在急诊科收集了 200 名成年患者的 200 例 4V 膝关节 X 线片，并将其随机分为两组，每组 100 例。10 名评估者 - 3 名肌肉骨骼放射科医生和 7 名骨科医生 - 进行了 X 线片分析。这些评估者被平均分为两组一和组二。评估者对患者数据不知情，仅先查看 2V 射线（AP/LAT），然后至少四周后查看包括 AP/LAT 在内的 4V 射线，以及另外两个针对同一患者的斜位视图。所有评估者评估急性病理学识别和进一步影像学检查的需要，仅 7 名骨科医生评估者评估临床决策（手术与非手术治疗、住院需求、额外影像学检查需求）。
2V 时病理学识别的平均敏感性为 79%，4V 时为 81%（P=0.25）。观察者内kappa 值为 0.81（范围 0.54-1.00）。斜位射线导致骨科评估者改变了 329 名患者中的 62 名（18.84%）的治疗建议（P<0.001）。在 329 个射线系列中，有 8 个被认为是“关键漏诊”（2.43%）（P=0.004），当病理学报告正常或评估者在 2V 射线片上建议非手术治疗，但在添加斜位射线片后改变建议为手术治疗时。任何治疗改变和“关键漏诊”的需要治疗数（NNT）分别为 83 和 643。
虽然添加斜位射线可能会提高临床医生识别 2V 无法识别的细微病理发现的能力，但很少导致治疗建议的重大改变。鉴于高 NNT，限制这些斜位射线在一般患者人群中的使用可能会降低成本，而不会对患者护理产生重大影响。
