背景:Lisfranc损伤主要累及掌掌关节复合体,在临床上常被误诊或漏诊。大多数医疗机构更喜欢使用常规射线照相术。然而,现有的Lisfranc损伤常规射线照片研究缺乏大量基于人群的样本,影响结果的有效性。我们旨在确定常规X线摄影对Lisfranc损伤的诊断有效性和可靠性,以及计算机断层扫描是否可以改变临床决策。
方法:这项回顾性研究包括307例患者,和100个病人没有,Lisfranc从2017年1月到2019年12月受伤。使用计算机断层扫描证实了诊断。一名高级和初级外科医生至少相隔3个月独立完成了对同一组匿名常规X射线照片的两次评估。然后要求外科医生根据X射线照片和随后的CT图像为每种情况建议两种治疗选择之一(手术或保守治疗)。
结果:所有观察者之间和观察者内部的可靠性都中等到非常好(所有κ系数>0.4)。平均(范围)真阳性率为81.8%(73.9%-87.0%),真阴率为90.0%(85.0%-94.0%),假阳性率为10.0%(6.0%-15.0%),假阴性率为18.2%(13.0%-26.1%),阳性预测值为96.1%(93.8%-97.8%),阴性预测值为62.4%(51.5%-69.7%),分类准确率为83.8%(76.7%-88.2%),平衡错误率为14.1%(10.2%-20.5%)。三柱损伤最有可能被识别(平均发生率,92.1%),其次是中间侧柱损伤(平均发生率,81.5%)。内侧柱损伤相对难以识别(平均比率,60.7%)。非移位损伤的诊断率(平均率,76.7%)低于流离失所者受伤(平均比率,95.5%)。给出了典型的例子。在非移位损伤的识别率方面,两位外科医生之间存在显着差异(p=0.005)。平均改变率为21.9%;高级外科医生的比率(15.6%)低于初级外科医生(28.3%)(p<0.001)。
结论:敏感性,特异性,常规X光片对Lisfranc损伤的分类准确率为81.8%,90.0%,和83.8%,分别。最有可能认识到三柱或流离失所的伤害。在随后评估计算机断层扫描图像后更改初始治疗决定的可能性为21.9%。不同经验水平的外科医生的诊断和临床决策表现出一定程度的变异性。如果怀疑有Lisfranc损伤且常规射线照相术阴性,则应考虑进行保护性承重和进一步的CT扫描。
BACKGROUND: Lisfranc injuries mainly involve the tarsometatarsal joint complex and are commonly misdiagnosed or missed in clinical settings. Most medical institutions prefer to use conventional radiography. However, existing studies on conventional radiographs in Lisfranc injury lack a large population-based sample, influencing the validity of the results. We aimed to determine the diagnostic validity and reliability of conventional radiography for Lisfranc injury and whether computed tomography can alter clinical decision-making.
METHODS: This retrospective study included 307 patients with, and 100 patients without, Lisfranc injury from January 2017 to December 2019. Diagnosis was confirmed using computed tomography. A senior and junior surgeon independently completed two assessments of the same set of anonymised conventional radiographs at least 3 months apart. The surgeons were then asked to suggest one of two treatment options (surgery or conservative treatment) for each case based on the radiographs and subsequently on the CT images.
RESULTS: All inter- and intra-observer reliabilities were moderate to very good (all κ coefficients > 0.4). The mean (range) true positive rate was 81.8% (73.9%-87.0%), true negative rate was 90.0% (85.0%-94.0%), false positive rate was 10.0% (6.0%-15.0%), false negative rate was 18.2% (13.0%-26.1%), positive predictive value was 96.1% (93.8%-97.8%), negative predictive value was 62.4% (51.5%-69.7%), classification accuracy was 83.8% (76.7%-88.2%), and balanced error rate was 14.1% (10.2%-20.5%). Three-column injuries were most likely to be recognized (mean rate, 92.1%), followed by intermediate-lateral-column injuries (mean rate, 81.5%). Medial-column injuries were relatively difficult to identify (mean rate, 60.7%). The diagnostic rate for non-displaced injuries (mean rate, 76.7%) was lower than that for displaced injuries (mean rate, 95.5%). The typical examples are given. A significant difference between the two surgeons was found in the recognition rate of non-displaced injuries (p = 0.005). The mean alteration rate was 21.9%; the senior surgeon tended to a lower rate (15.6%) than the junior one (28.3%) (p < 0.001).
CONCLUSIONS: The sensitivity, specificity, and classification accuracy of conventional radiographs for Lisfranc injury were 81.8%, 90.0%, and 83.8%, respectively. Three-column or displaced injuries were most likely to be recognized. The possibility of changing the initial treatment decision after subsequently evaluating computed tomography images was 21.9%. The diagnostic and clinical decision-making of surgeons with different experience levels demonstrated some degree of variability. Protected weight-bearing and a further CT scan should be considered if a Lisfranc injury is suspected and conventional radiography is negative.