Classification System For Fractures Research Articles

Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models.

BACKGROUNDAcetabular fractures pose diagnostic and surgical challenges. They are classified using the Judet-Letournel system, which is based solely on X-ray. However, computed tomography (CT) imaging is now more widely utilized in diagnosing these injuries. The emergence of 3-dimensional (3-D) printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan pre-operatively.AIMTo evaluate the reliability of the Judet-Letournel classification system of acetabular fractures, when using either CT imaging or 3-D printed models.METHODSSeven patients with acetabular fractures underwent pelvic CT imaging, which was then used to create solid, 3-D printed models. Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach. The same questionnaire was completed using only CT imaging, and two weeks later, using only 3-D printed models. The inter- and intra-observer agreement rates were then analyzed.RESULTSInter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification: κ = 0.44, κ = 0.55, respectively (P < 0.001) and fair for preferred surgical approach: κ = 0.34, κ = 0.29, respectively (P < 0.005). Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate: κ = 0.48, κ = 0.41, respectively. No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists.CONCLUSIONThe Judet-Letournel classification demonstrated only moderate rates of agreement. The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification, but decreased it with respect to the preferred surgical approach. This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries, thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.

An independent inter- and intraobserver agreement assessment of the AOSpine sacral fracture classification system

BACKGROUND CONTEXTThe AOSpine sacral classification scheme was recently described. It demonstrated substantial interobserver and excellent intraobserver agreement in the study describing it; however, an independent assessment has not been performed. PURPOSETo perform an independent inter- and intraobserver agreement evaluation of the AOSpine sacral fracture classification system. STUDY DESIGNAgreement study. METHODSComplete computerized tomography (CT) scans, including axial images, with coronal and sagittal reconstructions of 80 patients with sacral fractures were selected and classified using the morphologic grading of the AOSpine sacral classification system by six evaluators (from three different countries). Neurological modifiers and case-specific modifiers were not assessed. After a four-week interval, the 80 cases were presented to the same raters in a random sequence for repeat assessment. We used the Kappa coefficient (κ) to establish the inter- and intraobserver agreement. RESULTSThe interobserver agreement was substantial when considering the fracture severity types (A, B, or C), with κ=0.68 (0.63–0.72), but moderate when considering the subtypes: κ=0.52 (0.49–0.54). The intraobserver agreement was substantial considering the fracture types, with κ=0.69 (0.63–0.75), and considering subtypes, κ=0.61 (0.56–0.67). CONCLUSIONThe sacral classification system allows adequate interobserver agreement at the type level, but only moderate at the subtypes level. Future prospective studies should evaluate whether this classification system allows surgeons to decide the best treatment and to establish prognosis in patients with sacral fractures.

Second-look arthroscopic findings and clinical outcomes after management of intra-articular lesions in acute ankle fractures with arthroscopy

BackgroundAnatomically surgical reduction of ankle fractures does not always result in a clinically favorable outcome. Arthroscopic examination combined with treatment of intra-articular lesion may related to clinical outcomes ObjectivesThe purpose of the present study was to review initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes. ResultsLauge-Hansen classification system of ankle fractures included supination-external rotation type (n = 24), supination-adduction type (n = 3), pronation-external rotation type (n = 7), and pronation-abduction type (n = 6), total 40 ankles. Osteochondral lesions were found in 25 ankles (62%) with an initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in secondary arthroscopy were found in 17 cases. According to the Ferkel and Cheng staging at secondary arthroscopy, 4 of 25 ankles with osteochondral lesions of the talus were deteriorating (more than stage D). In terms of ICRS overall repair grades, 5 ankles (20%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles, respectively, in secondary arthroscopy, and correlations were found between AOFAS scores, VAS and intra-articular lesions. ConclusionSecond-look arthroscopic examination combined with treatment of intra-articular lesion such as arthrofibrosis and osteochondral lesion arising from ankle fracture surgery may consider to improve clinical outcomes.

Medial Hoffa Fracture: Description of a Novel Classification System and Rationale for Treatment Based on Fragment-Specific Fixation Strategy.

This study aims to present a novel classification system and a rationale for treatment of medial Hoffa fractures. We developed a simple comprehensive classification system for medial Hoffa fractures based on the fragment size and presence of fracture comminution. Furthermore, we propose a treatment algorithm based on two pillars: our case series of nine patients presenting medial Hoffa fractures and the best evidence-based pertinent literature. Fracture healing, range of motion, function, and complications were evaluated after a minimum of 6 months follow-up. All fractures healed with no loss of reduction. Knee flexion ranged from 90 - 130° (mean 110°, standard deviation 15.2). Knee extension ranged from 0 - 10° (mean 1°, standard deviation 3.3). Knee function according to the Lysholm score ranged from 74 - 96 points (mean 85, standard deviation 6.3). There were no complications such as infection, fixation failure, or medial femoral condyle osteonecrosis. One patient required hardware removal due to soft tissue irritation and one patient underwent knee mobilization under anesthesia after 8 weeks of fracture fixation due to knee stiffness. The presented rationale for treatment based on the new classification system is a simple and effective strategy on the decision-making process for adequate management of medial Hoffa fractures.

Three-Column Classification System for Tibial Plateau Fractures: What the Orthopedic Surgeon Wants to Know.

Recent orthopedic surgical literature emphasizes a three-column approach to understand and guide the treatment of tibial plateau fractures. This three-column classification system published in 2010 relies on preoperative CT images to depict injuries to the medial, lateral, and posterior columns of the tibial plateau and improves surgical outcomes in complex tibial plateau fractures with coronal fracture planes and posterior plateau fracture fragments requiring dorsal plating. Tibial plateau fracture classification systems traditionally used by radiologists and orthopedic surgeons, including the Schatzker and the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) classification systems, rely on findings at anteroposterior radiography and lack the terminology to accurately characterize fractures in the coronal plane involving the posterior tibial plateau. Incorporating elements from the contemporary three-column classification system into radiology reports will enhance radiologists' descriptions of these injuries. It is essential for radiologists to understand the role of clinical assessment and the pertinent imaging findings taken into consideration by orthopedic surgeons in their management of these injuries. This understanding includes familiarity with injury patterns and how they relate to mechanism of injury, patient demographics, and underlying pertinent comorbidities. Evaluating findings on initial radiographs is the basis of tibial plateau fracture diagnosis. Additional information provided by preoperative cross-sectional imaging, including two-dimensional and three-dimensional CT and MRI in specific circumstances, aids in the identification of specific soft-tissue injuries and fracture morphologies that influence surgical management. These specific fracture morphologies and soft-tissue injuries should be identified and communicated to orthopedic surgeons for optimal patient management. Online DICOM image stacks are available for this article. ©RSNA, 2020.

Classification of femur trochanteric fracture: Evaluating the reliability of Tang classification.

Given the drawbacks of a femoral intertrochanteric fracture classification based on 2-dimensional radiographic imaging, an artificial intelligence-based classification system- the Tang classification system-which uses 3-dimensional image analysis, has previously been developed. This study explored the reliability of the Tang classification by comparing the consistency of this classification with the conventional 2-dimensional femoral intertrochanteric fracture classification systems. X-ray and computed tomography (CT) data of 258 patients with femoral intertrochanteric fractures were classified by 6 orthopedic surgeons using the Evans, Jensen, AO/OTA, and Tang classification systems on 2 separate occasions, 1 month apart. Kappa statistics were used to evaluate the inter- and intraobserver differences in classifications. When the interobserver reliability was based on X-ray image analysis, the Kappa values for the Evans, Jensen, AO/OTA, and Tang classifications were 0.54±0.03 (moderate agreement), 0.53±0.02 (moderate agreement), 0.46±0.02 (moderate agreement), and 0.63±0.02 (substantial agreement), respectively. When the interobserver reliability was based on CT images, the Kappa values of the Evans, Jensen, AO/OTA, and Tang classifications were 0.49±0.03 (moderate agreement), 0.49±0.03 (moderate agreement), 0.44±0.03 (moderate agreement), 0.64±0.02 (substantial agreement), respectively. For X-ray images, the intraobserver Kappa values for the Evans, Jensen, AO/OTA, and Tang classification were 0.53±0.02 (moderate agreement), 0.54±0.03 (moderate agreement), 0.45±0.03 (moderate agreement), and 0.65±0.03 (substantial agreement), respectively. When intraobserver reliability was based on CT images, the Kappa values for the Evans, Jensen, AO/OTA, and Tang classification were 0.52±0.03 (moderate agreement), 0.52±0.02 (moderate agreement), 0.41±0.02 (moderate agreement), and 0.63±0.03(substantial agreement), respectively. The current study suggests that the Tang classification system is more reliable than the Evans, Jensen, and AO/OTA classification systems for measuring intertrochanteric fractures of the proximal femur.

The management of cranial injuries in antiquity and beyond.

Cranial injuries were among the earliest neurosurgical problems faced by ancient physicians and surgeons. In this review, the authors trace the development of neurosurgical theory and practice for the treatment of cranial injuries beginning from the earliest ancient evidence available to the collapse of the Greco-Roman civilizations. The earliest neurosurgical procedure was trephination, which modern scientists believe was used to treat skull fractures in some civilizations. The Egyptian papyri of Edwin Smith provide a thorough description of 27 head injuries with astute observations of clinical signs and symptoms, but little information on the treatment of these injuries. Hippocrates offered the first classification of skull fractures and discussion of which types required trephining, in addition to refining this technique. Hippocrates was also the first to understand the basis of increased intracranial pressure. After Hippocrates, the physicians of the Alexandrian school provided further insight into the clinical evaluation of patients with head trauma, including the rudiments of a Glasgow Coma Scale. Finally, Galen of Pergamon, a physician to fallen gladiators, substantially contributed to the understanding of the neuroanatomy and physiology. He also described his own classification system for skull fractures and further refined the surgical technique of trephination. From the study of these important ancient figures, it is clearly evident that the knowledge and experience gained from the management of cranial injuries has laid the foundation not only for how these injuries are managed today, but also for the development of the field of neurosurgery.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

ObjectivesTo assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons.MethodsRetrospective data (1/2008–12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories.ResultsThe overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56–0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings.ConclusionsThe overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously.Key Points• The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate.• Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons.• Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

The new AO classification system for intertrochanteric fractures allows better agreement than the original AO classification. An inter- and intra-observer agreement evaluation

BackgroundA new AO classification for intertrochanteric fractures was recently published; no studies have evaluated its inter- and intra-observer agreement. MethodsSix evaluators (three hip subspecialists and three residents) assessed radiographs of 68 intertrochanteric fractures; fractures were classified using the original and the new AO classifications. The cases were displayed in a random sequence after a six-week interval for repeat evaluation. We used the Kappa coefficient (k) to determine inter- and intra-observer agreement. ResultsInter-observer agreement was slight (k = 0.128 [0.092–0.170]) using the original and fair (k = 0.250 [0.186–0.327]), with the new AO classification. Orthopedic residents exhibited better agreement than hip surgeons using the original classification (k = 0.302 [0.210–0.416] and k= -0.018 [-0.058–0.029], respectively) and the new classification (k = 0.388 [0.294–0.514] and k = 0.109 [0.031–0.192], respectively). Using both classifications as dichotomous variables (stable or unstable patterns), the agreement was slight (k = 0.158 [0.074–0.246]) using the original classification and moderate (k = 0.425 [0.308–0.550]) with the new AO classification. Intra-observerThe agreement was fair using the original (k = 0.350 [0.278–0.424]) and the new (k = 0.295 [0.239 to 0.353]) AO classifications, respectively. Residents had better agreement than hip specialists using the original (k = 0.405 [0.303–0.512]) versus (k = 0.292 [0.193–0.293]) and the new classification (k = 0.449 [0.370 to 0.528] versus k = 0.129 [0.064 to 0.208]). ConclusionThe inter-observer agreement using the new AO classification was significantly better than using its original version. Also, the new AO classification system allowed better agreement when distinguishing stable from unstable patterns.

A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model

This study aimed to classify the pathomorphology of impacted proximal humeral fracturesaccording to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making. In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated. From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree. The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.

Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.

Importance: The nasal bone is one of the most commonly fractured bones of the midface. However, the frequency of coincident fractures of adjacent bones such as the frontal process of the maxillary bone, nasal septum, and medial or inferior orbital walls has not been fully evaluated. Objective: The purpose of this study was to investigate the incidence of fractures of adjacent structures in the setting of a nasal bone fracture. Second, we propose a new classification system of nasal bone fractures with involvement of adjacent bony structures. Design, Setting, and Participants: One thousand, one hundred ninety-three patients with midfacial fractures were retrospectively reviewed. The characteristics of fractures of the nasal bone and the incidence of coincident fractures of the frontal process of maxilla, bony nasal septum, medial, or inferior orbital walls were analyzed. Exposure: All patients included in the study presented with nasal trauma. Main Outcomes and Measures: The coincident fractures of adjacent midfacial structures were assessed, and a new classification of midfacial fractures based on computed tomography (CT) scan images was proposed. Results: Among the 1193 cases, bilateral fractures of the nasal bone were most common (69.24%), and coexistent fracture of the frontal process of the maxilla and bony nasal septum was 66.89% and 42.25%, respectively. Coincident fracture of the orbital walls was observed in 16.51% of cases. The major etiology of fracture for the younger and elderly groups was falls, compared with assault as the most common etiology in the adult group. A classification scheme was generated in which fractures of the nasal bone were divided into five types depending on coexisting fractures of adjacent structures. Conclusions and Relevance: External force applied to the nasal bone can also lead to coexistent fracture of adjacent bony structures including the frontal process of the maxilla, nasal septum, and orbital walls. The proposed classification of nasal fracture based on CT imaging helps to incorporate coincident disruption of adjacent structures.

The reliability and validity of the modified Unified Classification System for periprosthetic femoral fractures after hip arthroplasty

BackgroundThis study assessed the reliability and validity of the modified Unified Classification System for femur fractures after hip arthroplasty. MethodsFour hundred and two cases were evaluated by 6 observers, 3 experts and 3 trainee surgeons. Each observer read the radiographs on 2 separate occasions and classified each case as to its type. Reliability was assessed by looking at the intraobserver and interobserver agreement using the Kappa statistic. Validity was assessed within the B group by looking at the agreement between the radiographic classification and the intraoperative findings. Interobserver and intraobserver agreement and validity were analyzed, using weighted kappa statistics. ResultsThe mean k value for interobserver agreement was found to be 0.882 (0.833–0.929) for consultants (almost perfect agreement) and 0.776 (0.706–0.836) for the trainees (substantial agreement). Intraobserver k values ranged from 0.701 to 0.972, showing substantial to almost perfect agreement. Validity analysis of 299 type B cases revealed 89.854% agreement with a mean k value of 0.849 (0.770–0.946) (almost perfect agreement). ConclusionsThis study has shown that the modified Unified Classification System is reliable and valid. We believe it is useful to improve the judgment of the implant stability, and establish the therapeutic strategy for periprosthetic femoral fracture.

Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs

BackgroundA proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification.MethodsA retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely “postero-lateral,” “postero-medial,” or “postero-central,” according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system.ResultsThe mean trajectory angle was 21° lateral for “postero-lateral” fragments, 7° lateral for “postero-central” fragments, and 28° medial for “postero-medial” fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20° within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons).ConclusionsThere are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.

Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems

BackgroundThe classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications.Materials and methodsA total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen’s kappa coefficient analysis.ResultsThe new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups.ConclusionsThe results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system.Level of evidence: Level III, diagnostic studies

The Reliability and Validity of the Thoraco-Lumbar Injury Classification and Severity score

Abstract Background The TLICS/TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability and validity of the TLICS/TLISS must be studied. Aim of the Work To determine the interrater and intrarater reliability and the validity of the TLICS score and its predecessor the TLISS scoring system in the clinical practice. Patients and Methods A total of 7 articles with 10 datasets were used to test the inter- and intrarater reliability and validity of the TLICS/TLISS score for thoracolumbar spine trauma. Included studies presented Thoracolumbar trauma cases’ details (including clinical data, plain radiographs, CT scans and MRI) to spine surgeons allowing them to score them using the TLICS/TLISS score in each of its components (neurologic status, PLC integrity and fracture morphology/mechanism), the final score and surgeons’ agreement with the scores treatment recommendations; as well as comparing the treatment recommendations (surgical vs non-surgical management) with the treatment the patients actually received. At a later time the surgeons were assigned the task with the cases reordered. The interrater reliability, as well as the intrarater reliability of the score for each component and sum, were evaluated by Cohen’s unweighted k-value and Spearman’s rank order correlation. In addition, the sensitivity and specificity of the score (validity) were evaluated by the percent of correct treatment recommendations according to the sum of the TLICS/TLISS and the treatment actually received by the patients. Results Interrater reliability assessed by generalized kappa coefficients was 0.45 ±0.17 for injury morphology/mechanism, 0.91 ±0.03 for neurologic status, 0.42 ±0.13 for posterior ligamentous complex status, 0.36 ±0.14 for TLICS/TLISS total, and 0.59 ±0.10 for treatment recommendation. Respective results using the Spearman correlation were 0.52 ±0.18, 0.95 ±0.05, 0.57 ±0.13, 0.75 ±0.10, and 0.64 ±0.20. Intrarater kappa coefficients were 0.53 ±0.14 for injury morphology/mechanism, 0.89 ±0.07 for neurologic status, 0.53 ±0.15 for posterior ligamentous complex status, 0.46 ±0.16 for TLICS/TLISS total, and 0.61 ±0.02 for treatment recommendation. Respective results using the Spearman correlation were 0.63 ±0.08, 0.90 ±0.03, 0.64 ±0.10, 0.77 ±0.03, and 0.60 ±0.02. The percent of correct treatment recommendation by the score and the treatment actually received by the patients was 94.4% ±1.5, with sensitivity of 0.91 ±0.06, specificity of 0.94 ±0.01, PPV of 0.94 ±0.01, NPV of 0.93 ±0.02. Conclusions The TLICS/TLISS score has good reliability and validity and it compares favorably to other contemporary and old thoracolumbar fracture classification systems.

A New Classification System for Pilon Fractures Based on CT Scan: An Independent Interobserver and Intraobserver Agreement Evaluation.

A new pilon fracture classification system based on CT scan data was recently published, showing almost perfect interobserver and intraobserver agreement among the authors who developed it. However, an independent assessment has not been done. To do an independent agreement evaluation of the new pilon fracture classification system with physicians with different levels of expertise in the management of pilon fractures. Seventy-one cases of acute pilon fracture were retrospectively collected. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. The kappa coefficient (κ) was used to determine agreement among evaluators. The interobserver agreement was substantial regarding the main fracture type (I, II, III, or IV), with an overall κ value of 0.69 (0.65 to 0.72). When including the II and III subtypes, the overall agreement was still substantial, with a κ value of 0.61 (95% confidence interval: 0.58 to 0.64). The intraobserver agreement was substantial when considering the main fracture categories (I, II, III, or IV), with a κ value of 0.78 (confidence interval: 0.72 to 0.84), and full agreement at the type level was observed in 76% (324/426) of evaluations. There was no notable difference between the foot and ankle surgeons and orthopaedic surgery residents in the interobserver and intraobserver agreement. The new classification system demonstrated substantial interobserver and intraobserver agreement between evaluators with different levels of expertise in the management of pilon fractures. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

Anatomical and clinical study of a new mallet fracture classification method.

BackgroundMallet fracture is avulsion of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. This study was performed to evaluate the anatomical characteristics of mallet fractures, investigate a new mallet fracture classification system using anatomical and imaging methods, and discuss the treatment schemes for different types of mallet fracture.MethodsSixty-four fresh cadaveric fingers were divided into four groups, and models of different types of mallet fracture with distal interphalangeal joint instability were established by dissecting 25%, 50%, 75%, and 100% of the bilateral collateral ligaments. The effect of mallet fractures on the stability of the distal interphalangeal joint was then observed. The lateral radiographs of mallet fractures in 168 patients were analyzed and classified according to the involvement of the joint surface in the fracture, the thickness of fracture, the untreated time after injury, and the complication of distal interphalangeal joint palmar subluxation. Forty-seven patients were surgically treated by reconstruction of extensor tendon insertion, the Ishiguro method, or single Kirschner wire fixation.ResultsThe established mallet fracture model showed that the distal interphalangeal joint was stable when the bilateral collateral ligaments were cut off by 25% (t = –0.415, P = 0.684) and significantly unstable when this range was ≥50% (50% transection: t = –6.363, P < 0.001; 75% transection: t = –17.036, P < 0.001; 100% transection: t = –30.977, P < 0.001, respectively). The mallet fractures were divided into Types I, II, and III (fracture involving <20%, 20%–50%, and >50% of the joint surface, respectively). Type II was further divided into Types IIa and IIb according to whether the course of injury was < or ≥2 weeks, respectively. The mean post-operative flexion of the distal interphalangeal joint was 63.4° ± 7.9°, and the mean extension lag was 6.7° ± 4.6°.ConclusionsThe lateral collateral ligament is the main factor that maintains the stability of the distal interphalangeal joint. Classification that combines the involvement of the joint surface in the fracture, the thickness of the fracture, and the untreated time after injury is reasonable and will help to choose an appropriate operational method.

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures \u2013 reliability comparison between two specialist groups

BackgroundAlthough of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures.MethodsRadiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch.ResultsThe overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system.ConclusionsThe low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

Multiple rib fractures: A novel and prognostic CT-based classification system

Background The accepted classification for multiple rib fractures is binary: flail chest or not. There is a wide spectrum of morphology with subsequent variation in the impact on chest wall mechanics and clinical outcomes. As the practice of surgical stabilisation of rib fractures evolves, there is a need for a better taxonomy. The aim of this study was to create a data-driven radiological classification system for multiple rib fractures, prognostic of both complications and surgical stabilisation of rib fracture. Methods The radiological pattern of injury was assessed for cases undergoing surgical stabilisation of rib fracture (n = 48) over a five-year period and a consecutive sample of non-operative controls (n = 48). Every rib fracture (n = 1032) was assessed on CT scans for location, displacement and comminution. An iterative classification system was developed and tested for inter-observer agreement and outcome prediction. Results The fractures occurred in a ‘series’ (≥3 consecutive ribs at a similar location) in 72% of cases: these were more likely to be displaced (p &lt; 0.001). Variables included in the classification were the anatomical pattern (presence, length and overlap of series) and degree of displacement. The classification was prognostic for complications (p &lt; 0.001), discriminated for fixation (C = 0.907) and had acceptable inter-observer agreement (k = 0.50). Conclusions The Sheffield Multiple Rib Fracture Classification derived categories of short/long series, and short/long flail chest, with sub-division according to the presence of displacement. It was prognostic for clinical outcomes and of surgical fixation. It may facilitate communication, comparison of outcomes and selection for management protocols.

INTER- AND INTRA-OBSERVER RELIABILITY OF SCHATZKER, AO, AND LUO CLASSIFICATIONS FOR TIBIAL PLATEAU FRACTURES.

ABSTRACTObjective: To verify inter- and intra-observer agreement of three classification systems for tibial plateau fractures - Schatzker, AO/ASIF, and Luo’s - among orthopedic surgery residents. Methods: This cross-sectional study was conducted with 29 observers. Radiographic and tomographic imaging of the knee of 15 patients presenting with fractures were evaluated. After six weeks, the test was reapplied. The level of agreement was calculated by the Kappa index. Results: In test 1, inter-observer agreement of all residents, according to the Kappa index, for Schatzker classification was 0.226, for AO 0.431, and Luo’s 0.319. In test 2, values were 0.316, 0.333, and 0.347, respectively (p < 0.001). Regarding intra-observer analysis, the mean Kappa indexes of 1st-year residents were: Schatzker, 0.20; AO, 0.32; and Luo’s, 0.3. For 2nd-year residents, means were: 0.51, 0.58, and 0.38, respectively. As for 3rd-year, results were 0.42, 0.42, and 0.41, respectively (p < 0.001). Conclusion: AO/ASIF showed a better reproducibility than other classifications, with substantial inter- and intra-observer agreement. We also found a stronger agreement among 2nd- and 3rd-year residents. Level of Evidence III, Diagnostic Studies - Investigating a Diagnostic Test.