Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis

Objectives: To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture. Data Sources: A systemic literature search was conducted in the MEDLINE, Embase, and Cochrane Library databases to identify studies published from January 1990 to August 2022. Study Selection: Studies that evaluated external rotation or gravity stress tests or hook or tap tests for the diagnosis of deltoid ligament or syndesmosis injury were included. Data Extraction: Authors, publication years, study design, index tests, reference standards, demographic features of participants, reliability, and the numbers of true-positive, true-negative, false-positive, and false-negative subjects were extracted from 14 included studies. Article quality was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool. Data Synthesis: The pooled sensitivity and specificity of each index test for each structure were calculated with a random-effects model using the extracted data of true-positive, true-negative, false-positive, and false-negative outcomes in all relevant studies. The overall diagnostic performance of the different index tests for different structures was determined with the estimation of the area under the curve using the summary receiver operating characteristics curve. Conclusions: The gravity stress test and the tap test exhibited high sensitivity and specificity in diagnosing deltoid ligament injury. The hook test has relatively high accuracy in diagnosing syndesmosis injury. Further studies with large sample sizes are warranted to confirm the results of this review. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.