Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway.
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
J Bone Joint Surg Am. 2023 Sep 20;105(18):1435-1441. doi: 10.2106/JBJS.23.00195. Epub 2023 Jul 28.
Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures.
We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events.
The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome.
In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making.
Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.
用负重 X 光片代替重力应力测试来评估 Weber B（也称为 Lauge-Hansen 旋前-外旋 [SER]）踝关节骨折的稳定性可降低手术率，从而避免相关风险和并发症。尽管如此，对于承重稳定型骨折的非手术治疗仍存在争议，因为缺乏强有力的证据。我们研究了承重稳定型骨折在非手术治疗中，不稳定的重力应力测试与稳定的重力应力测试相比，对结果的影响。
我们对 149 例 Weber B 型踝关节骨折和负重 X 光片稳定的患者进行了前瞻性、非劣效性研究。重力应力 X 光片将骨折分为稳定型（SER2 [n = 88]）或部分不稳定型（SER4a [n = 61]）。所有患者均采用功能支具治疗并允许承重，随访 2 年。主要结局是 Manchester-Oxford 足部和踝关节问卷（MOXFQ），范围为 0 到 100，得分越低表示症状越少。前瞻性定义非劣效性边界为 7.5 分。次要结局包括 Olerud-Molander 踝关节评分、踝关节吻合度评估和与治疗相关的不良事件。
149 名参与者中有 144 名（96.6%）在 2 年时获得了主要结局数据。SER2 组的 MOXFQ 评分差值为 1.0 分（95%置信区间，-1.4 至 3.4 分；p = 0.397），与非劣效性一致。我们未发现任何其他结局存在显著的组间差异。
在负重 X 光片显示承重稳定、采用可移动矫形器治疗且允许承重的 Weber B/SER 踝关节骨折中，与稳定的重力应力测试（SER2）相比，同时存在不稳定的重力应力测试（SER4a）并不与患者报告或影像学结局较差相关，在 2 年随访时。因此，确定应力不稳似乎是多余的，这对基于应力不稳进行手术决策的适用性提出了质疑。
诊断 II 级。请参阅作者指南，以获取完整的证据等级描述。
