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Intraoperative Assessment of the Stability of the Distal Tibiofibular Joint in Supination-External Rotation Injuries of the AnkleSensitivity, Specificity, and Reliability of Two Clinical Tests
Harri Pakarinen, MD; Tapio Flinkkilä, MD, PhD; Pasi Ohtonen, MSc; Pekka Hyvönen, MD, PhD; Martti Lakovaara, MD; Juhana Leppilahti, MD, PhD; Jukka Ristiniemi, MD, PhD
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

  • Disclosure statement for author(s): PDF

Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, P.O. Box 21, FI 90029 OYS, Oulu, Finland. E-mail address for H. Pakarinen: harri.pakarinen@ppshp.fi. E-mail address for T. Flinkkilä: tapio.flinkkila@@ppshp.fi. E-mail address for P. Ohtonen: pasi.ohtonen@oulu.fi. E-mail address for P. Hyvönen: pekka.hyvonen@ppshp.fi. E-mail address for M. Lakovaara: martti.lakovaara@coronaria.fi. E-mail address for J. Leppilahti: juhana.leppilahti@ppshp.fi. E-mail address for J. Ristiniemi: jukka.ristiniemi@ppshp.fi
Investigation performed at Oulu University Hospital, Oulu, Finland

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Nov 16;93(22):2057-2061. doi: 10.2106/JBJS.J.01287
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This study was designed to assess the sensitivity, specificity, and interobserver reliability of the hook test and the stress test for the intraoperative diagnosis of instability of the distal tibiofibular joint following fixation of ankle fractures resulting from supination-external rotation forces.


We conducted a prospective study of 140 patients with an unstable unilateral ankle fracture resulting from a supination-external rotation mechanism (Lauge-Hansen SE). After internal fixation of the malleolar fracture, a hook test and an external rotation stress test under fluoroscopy were performed independently by the lead surgeon and assisting surgeon, followed by a standardized 7.5-Nm external rotation stress test of each ankle under fluoroscopy. A positive stress test result was defined as a side-to-side difference of >2 mm in the tibiotalar or the tibiofibular clear space on mortise radiographs. The sensitivity and specificity of each test were calculated with use of the standardized 7.5-Nm external rotation stress test as a reference.


Twenty-four (17%) of the 140 patients had a positive standardized 7.5-Nm external rotation stress test after internal fixation of the malleolar fracture. The hook test had a sensitivity of 0.25 (95% confidence interval, 0.12 to 0.45) and a specificity of 0.98 (95% confidence interval, 0.94 to 1.0) for the detection of the same instabilities. The external rotation stress test had a sensitivity of 0.58 (95% confidence interval, 0.39 to 0.76) and a specificity of 0.96 (95% confidence interval, 0.90 to 0.98). Both tests had excellent interobserver reliability, with 99% agreement for the hook test and 98% for the stress test.


Interobserver agreement for the hook test and the clinical stress test was excellent, but the sensitivity of these tests was insufficient to adequately detect instability of the syndesmosis intraoperatively.

Level of Evidence: 

Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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