Abstract
BackgroundOrthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus. However, the clinical implications of low observer agreement remain unclear. The purpose of the study was to compare the agreement on Neer classification with the agreement on treatment recommendations.MethodsWe conducted a multi-centre observer-study. Five experienced shoulder surgeons independently assessed a consecutive series of 193 radiographs at two occasions three months apart. All pairs of radiographs were classified according to Neer. Subsequently, the observers were asked to recommend one of three treatment modalities for each case: non-operative treatment, locking plate osteosynthesis, or hemiarthroplasty.ResultsAt both classification rounds mean kappa-values for inter-observer agreement on treatment recommendations (0.48 and 0.52) were significantly higher than the agreement on Neer classification (0.33 and 0.36) (p < 0.001 at both rounds). The highest mean kappa-values were found for inter-observer agreement on non-surgical treatment (0.59 and 0.55). In 36% (345 out of 965) of observations an observer changed Neer category between first and second classification round. However, in only 34% of these cases (116 out of 345) the observers changed their treatment recommendations.ConclusionsWe found a significantly higher agreement on treatment recommendations compared to agreement on fracture classification. The low observer agreement on the Neer classification reported in several observer studies may have less clinical importance than previously assumed. However, inter-observer agreement did not exceed moderate levels.
Highlights
Orthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus
Kappa-values were interpreted qualitatively according to Landis and Koch [3]: kappa-values less than 0 indicate poor agreement, 0.00-0.20 slight agreement, 0.21-0.40 fair agreement, 0.41-0.60 moderate agreement, 0.61-0.80 substantial agreement, and 0.81-1.00 excellent agreement. For both classification rounds mean kappa-values and ninety-five percent confidence intervals were calculated for inter-observer agreement on 1) adequacy of radiographs for classification and treatment purposes, 2) classification according to the 16-category Neer classification, and 3) treatment recommendations: non-operative, locking plate osteosynthesis, or hemiarthroplasty
The highest kappa values were found for inter-observer agreement on non-surgical treatment on both classification rounds, mean kappa 0.59 and 0.55
Summary
Orthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus. The clinical implications of low observer agreement remain unclear. The purpose of the study was to compare the agreement on Neer classification with the agreement on treatment recommendations. Orthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus according to the Neer classification [1]. The clinical implications of low observer agreement on fracture classification remain unclear. Inter-observer agreement on binary treatment decision has been reported [2] but to our knowledge, no study has compared the agreement on classification with the agreement on treatment recommendations. The purpose of the study was to compare the agreement on Neer classification with the agreement on. We conducted a multi-centre observer-study among experienced shoulder surgeons assessing a large consecutive series of unselected radiographs of proximal humeral fractures
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
