Interobserver Reliability Analysis Research Articles

Qualitative analysis of the supraspinatus muscle fatty infiltration on MRI: correlation of the tangent sign with Goutallier grade at the Y view and medial scapular border in large retracted rotator cuff tears

BackgroundSurgically repairing rotator cuff tears with a higher extent of fatty infiltration is controversial. Current evidence supports performing rotator cuff repair in patients exhibiting Goutallier stage 3-4 fatty infiltration. However, the presence of retraction complicates accurate assessment using the Goutallier Classification, particularly on the lateral Y-view. A shift towards classifying fatty infiltration in more medial regions may enhance the precision of tissue quality quantification. The objective of this study was to analyze the uniformity of fatty infiltration within the entire supraspinatus muscle using the Goutallier Classification across three scapular Y-view sections and to examine the association between Goutallier grade, tangent sign, and modified Patte stage. MethodsA retrospective evaluation was conducted on preoperative magnetic resonance imaging (MRI) scans from a consecutive series of 97 patients who had previously undergone arthroscopic rotator cuff repairs. Three supraspinatus sections on the MRI sagittal plane were identified: the lateral Y-view (section one), a medial section at the suprascapular notch anatomical landmark (section two), and a section 3 cm medial from the suprascapular notch Medial Scapular Body (section three). Goutallier grade, tangent sign, and modified Patte stage were used to evaluate fatty infiltration, muscle atrophy, and tendon retraction, respectively. ResultsSection one had the highest Goutallier grade, while section three had the lowest. Intra-observer rest retest reliability analysis showed excellent consistency in all sections with section one (ICC=0.920, 95% CI), section two (ICC=0.917, 95% CI), and section three (ICC=0.923, 95% CI) for Goutallier grade. Inter-observer reliability analysis also revealed excellent consistency in sections one (ICC=0.951, 95% CI), section two (ICC=0.949, 95% CI), and section three (ICC=0.922, 95% CI) for Goutallier grade. A strong correlation was observed between Goutallier grade and modified Patte stage (τb=0.43-0.56, p=0.001), and between Goutallier grade and tangent sign (τb=0.43-0.54, p=0.001) across all sections. ConclusionThe severity of fatty infiltration within the supraspinatus muscle belly is inconsistent, with the lateral portion being the most severe and the medial portion the least severe. Goutallier grade demonstrates a strong correlation with tangent sign and modified Patte stage. This suggests that tendon retraction results in a potential overestimation in the amount of fatty infiltration defining some tears unjustly irreparable when measuring at the traditionally described lateral Y-view position compared with 3cm medial.

Is the Diagnosis of fifth Metatarsal Fracture Type Consistent? An Interobserver Reliability Study.

Treatment pathways of fifth metatarsal fractures are commonly directed based on fracture classification, with particular proximal fractures typically requiring closer observation and possibly more aggressive management. Our aim is to investigate the interobserver reliability of assessment of subtypes of fifth metatarsal fractures. We included all patients referred to our virtual fracture clinic with a suspected or confirmed fifth metatarsal fracture. Plain anteroposterior radiographs were reviewed by 2 novice observers, initially trained on the fifth metatarsal classification identification. Eight different zones were defined based on anatomical location. Patients were excluded from analysis if neither observer could identify a fracture. An interobserver reliability analysis using Cohen κ coefficient was carried out, and degree of observer agreement described using Landis and Koch's description. All data were analyzed using IBM SPSS, version 27. A total of 1360 patients who met the inclusion criteria were identified. The 2 observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and distal metaphysis (DM) fractures, which only achieved fair agreement (κ = 0.308 and 0.381 respectively). Zone 3 has slight agreement with zone 2 proximally, and there is an apparent difficulty with distal diaphyseal shaft (DS) fractures, resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; κ = .398, P < .001). Reliability of subcategorizing fifth metatarsal fractures using standardized instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow-up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration. Level III, retrospective cohort study.

Strategies for Minimizing the Effects of Observer Variability on Sagittal Parameter Measurements of the Spine.

Exploratory-descriptive study. Evaluate the influence of observer variability on the measurements of both thoracic kyphosis (TK) and lumbar lordosis (LL) obtained with anatomic and functional spinal segmentation methods. Parametric analysis for spinal surgery planning typically relies on anatomic parameters. However, incorporating functional parameters that consider the vertebrae orientation is important to minimizing surgical calculation errors. The authors developed parametric analysis software that integrates traditional and functional methodologies. The proposed method included functional thoracic kyphosis and functional lumbar lordosis calculated from the lines normal to the inflection points of the spine model. Using a synthetic lateral X-ray, the observer variability was computer-simulated generating 20 landmark sets that replicate the annotations of 20 observers. The analysis also included 10 clinical X-rays, annotated twice by 3 judges with a minimum 1-week interval. The spinal curvature angles were derived using the anatomic and functional methods. Statistical analysis were performed for comparison. For the synthetic X-ray, the proposed method presented significantly less variability: TK (<±2.5 degrees, P=0.00023) and LL (<±5 degrees, P=0.00012). For the clinical X-rays, the interobserver reliability analysis yielded higher intraclass correlation coefficients (ICC) for functional TK (ICC>0.97) and functional LL (ICC>0.87) than for TK (ICC<0.91) and LL (ICC<0.89). Statistically significant differences were observed for both TK (P=0.001) and LL (P=0.030). Under the traditional method, observer variability led to measurement differences surpassing ±19 degrees, whereas differences with the proposed method were within ±10 degrees for both parameters. The vertebral endplate is not the most suitable place to measure spinal sagittal curvatures. Small changes in landmark position significantly alter the measured Cobb angle. The proposed method offers a substantial advantage regarding the influence of observer variability, in addition to the more individualized analysis.

IS THE DIAGNOSIS OF FIFTH METATARSAL FRACTURE SUBTYPE CONSISTENT? AN INTEROBSERVER RELIABILITY STUDY

IntroductionTreatment pathways of 5th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management.Primary objectiveTo investigate the reliability of assessment of subtypes of 5th metatarsal fractures by different observers.MethodsPatients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5th metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5th metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis &amp; Koch's description. All data was analysed using IBM SPSS v.27.Results878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively).ConclusionsReliability of sub-categorising 5th metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration.

Interobserver Reliability and Sensitivity to Change of a Composite Ocular Inflammatory Activity Index: UVEDAI©.

This was a multicenter, prospective, longitudinal, observational study involving eight Spanish tertiary hospitals to determine the interobserver reliability of an uveitis disease activity index, (UVEDAI) and assess its sensitivity to change in patients with receiving pharmacologic treatment. Patients aged ≥ 18years diagnosed with active noninfectious uveitis were included. A complete baseline assessment was performed by two ophthalmologists who determined ocular inflammatory activity using the UVEDAI index independently of each other. The principal ophthalmologist made a new visit at 4weeks to determine the change in inflammatory activity. The interobserver reliability analysis was performed by calculating the intraclass correlation coefficient (ICC), with the values of the variables and the UVEDAI obtained by both ophthalmologists in the more active eye at the baseline visit. Sensitivity to change in the UVEDAI index was assessed at 4weeks from the start of pharmacologic treatment by determining the clinically relevant change, defined as a change in UVEDAI of ≥ 0.8 points over baseline. The mean change between both measures was compared using the repeated-measures t-test. A total of 111 patients were included. In the interobserver reliability analysis, the ICC for the UVEDAI value was 0.9, and, when compared with the mean UVEDAI values obtained by the ophthalmologists, no statistically significant differences were found (p value > 0.05). As for the sensitivity to change in UVEDAI, statistically significant differences (p value = 0.00) were found for the mean values of the index compared with baseline. In all cases, the index value decreased by > 1 point at the 4-week visit. The interobserver reliability of the UVEDAI was high in the total sample. Furthermore, the index was sensitive in determining the change in inflammatory activity after treatment. We believe that UVEDAI is a disease activity index that enables objective comparison of results in clinical practice and trials.

Effect of Sequential Burr Passes on Minimally Invasive Akin and First Metatarsal Dorsiflexion Osteotomies

Introduction/Purpose: Minimally invasive surgical (MIS) techniques for are exponentially increasing as a surgical option for treating midfoot and forefoot conditions. However, performing percutaneous osteotomies using the burr prevents direct visualization to estimate the correct measurements for the resection. This study aimed to evaluate the impact of each burr pass on the degree of correction, gap size, and alignment in MIS Akin and first metatarsal dorsiflexion osteotomies (DFO). It is hoped that this will improve the surgeon's ability to correct the desired amount of deformity and assist in surgical planning. Methods: Minimally invasive Akin and first metatarsal DFO were performed on ten cadaveric specimens using a 2 mm Shannon burr. The lateral (for Akin) and plantar (for 1st DFO) cortices were left intact. A total of 5 passes with the Shannon burr were performed during each osteotomy. The osteotomy gap was manually closed after each pass and held closed while completing the subsequent passes. Fluoroscopy images were obtained before and after each of the five passes, on which two independent reviewers performed measurements and inter-observer reliability was evaluated with ICC analysis. Measurements included the metatarsal dorsiflexion angle (MDA) and dorsal cortical length (MDCL). Likewise, the phalangeal measurements included the first phalangeal medial cortical length (PCML) and proximal to distal phalangeal articular angle (PDPAA) (Figure 1). Results: The average decrease in PCML with each burr pass was as follows: 1.53 mm at the 1st pass, 1.33 mm at the 2nd pass, 1.27 mm at the 3rd pass, 1.23 mm at the 4th pass, and 1.13 mm at the 5th pass. The MDCL sequentially decreased by 1.80 mm, 1.59 mm, 1.35 mm, 0.75 mm, and 0.60 mm. The MDA consistently decreased, and the PDPAA incrementally became more valgus oriented following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters. Conclusion: The results revealed the length and alignment changes trends in the forefoot and midfoot osteotomies with each burr pass. On average, a first metatarsal dorsal wedge resection of 4.7 mm and first phalangeal medial wedge resection of 2.9 mm was achieved after 3 and 2 burr passes, respectively. The first burr pass provided a correction of 76% of the burr diameter, while it decreased to 66%, 63%, 61%, and 56% of the burr diameter with each subsequent pass. This data may aid surgeons determine the optimal number of burr passes required for the amount of resection needed. Overview of the radiographic measurements. A) first metatarsal dorsiflexion angle (MDA), B) first metatarsal dorsal cortical length (MDCL), C) first phalangeal medial cortical length (PCML) and D) proximal to distal phalangeal articular angle (PDPAA). The diameter of the sphere © The Author(s) 2024(Dsphere) was calculated automatically by the MATLAB script for calibration purposes.

Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool

BackgroundWhile the effectiveness of cardiotocography in reducing neonatal morbidity is still debated, it remains the primary method for assessing fetal well-being during labor. Evaluating how accurately professionals interpret cardiotocography signals is essential for its effective use. The objective was to evaluate the accuracy of fetal hypoxia prediction by practitioners through the interpretation of cardiotocography signals and clinical variables during labor.Material and methodsWe conducted a cross-sectional online survey, involving 120 obstetric healthcare providers from several countries. One hundred cases, including fifty cases of fetal hypoxia, were randomly assigned to participants who were invited to predict the fetal outcome (binary criterion of pH with a threshold of 7.15) based on the cardiotocography signals and clinical variables. After describing the participants, we calculated (with a 95% confidence interval) the success rate, sensitivity and specificity to predict the fetal outcome for the whole population and according to pH ranges, professional groups and number of years of experience. Interobserver agreement and reliability were evaluated using the proportion of agreement and Cohen’s kappa respectively.ResultsThe overall ability to predict a pH level below 7.15 yielded a success rate of 0.58 (95% CI 0.56-0.60), a sensitivity of 0.58 (95% CI 0.56-0.60) and a specificity of 0.63 (95% CI 0.61-0.65). No significant difference in the success rates was observed with respect to profession and number of years of experience. The success rate was higher for the cases with a pH level below 7.05 (0.69) and above 7.20 (0.66) compared to those falling between 7.05 and 7.20 (0.48). The proportion of agreement between participants was good (0.82), with an overall kappa coefficient indicating substantial reliability (0.63).ConclusionsThe use of an online tool enabled us to collect a large amount of data to analyze how practitioners interpret cardiotocography data during labor. Despite a good level of agreement and reliability among practitioners, the overall accuracy is poor, particularly for cases with a neonatal pH between 7.05 and 7.20. Factors such as profession and experience level do not present notable impact on the accuracy of the annotations. The implementation and use of a computerized cardiotocography analysis software has the potential to enhance the accuracy to detect fetal hypoxia, especially for ambiguous cardiotocography tracings.

Morphology and novel classification of proximal humeral fractures.

Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs. Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft. Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5-10mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57-0.71) and 0.841, P < 0.01, respectively. Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.

Assessing the Inter-observer Agreement of Electrocardiography Interpretation in the Elderly Surgical Patients: A Cross-Sectional Study

Background: Electrocardiography (ECG) is an essential objective diagnosis tool, specifically for the elderly who are about to undergo surgery. From the examination results, it is possible to determine the presence of a heart condition that could impair the surgical outcome. Furthermore, the examination is slightly influenced by the subjectivity of observers. Purpose: To evaluate the inter-observer agreement on the reader of a 12-lead ECG on elderly patients subjected to elective surgery. Method: A consequential ECG examination was conducted on elderly patients who underwent elective surgery at Dr. Kariadi Hospital Semarang between July and November 2021. Two junior internist observers were independently involved in reading the ECG results in different places. The inter-observer reliability analysis used kappa statistics to determine consistency between observers. Result: Analysis was carried out on 193 patients aged 60-87 years old, with a prevalence of abnormal ECG was 33.7%. Kappa Conformity Value was 0.864 (95 % CI: 0.790-0.938, p&lt;0.001). Conclusion: The value of agreement between junior internists in ECG interpretation among elderly surgical patients is good (kappa value &gt;0.8). Even though the observers are junior internist, the result of the interpretation with a high kappa is considered to have reliable validity.

Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy

PurposeThis study aimed to evaluate the impact of each burr pass on degree of correction, gap size and calcaneal morphology in MIS Zadek osteotomy. MethodsMIS Zadek osteotomy was performed on ten cadaveric specimens using a 3.1 mm Shannon burr. After each burr pass, the osteotomy gap was manually closed, and the subsequent burr passes were carried out with the foot held in dorsiflexion, which was repeated five times. Lateral X-rays were taken before and after each burr pass. Two independent reviewers measured the dorsal calcaneal length after each burr passage, as well as changes in several calcaneal parameters including X/Y ratio, Fowler Philip angle, and Böhler angle. ResultsThe average decrease in dorsal calcaneal cortical length with each burr pass was as follows: 2.6 ± 0.9 mm at the 1st pass, 2.4 ± 1 mm at the 2nd pass, 2 ± 1 mm at the 3rd pass, 1.6 ± 1 mm at the 4th pass, and 1.4 ± 0.7 mm at the 5th pass. The Fowler Philip and Böhler angles consistently decreased while the X/Y ratio consistently increased following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters. ConclusionThe results revealed the trends of length and anatomical changes in the calcaneus with each burr pass. On average, a dorsal wedge resection of 10 mm was achieved after 5 burr passes. This data can aid surgeons in determining the optimal number of burr passes required for a particular amount of resection, ensuring the attainment of the desired patient-specific surgical outcome.

Shoulder extension impairment with residual neonatal brachial plexus injury.

Impairment of both shoulder extension and behind-the-back function are common in patients with residual neonatal brachial plexus injury (NBPI), but have scarcely been studied or reported in the literature. Behind-the-back function is classically evaluated using the hand-to-spine task used for the Mallet score. Angular measurements of shoulder extension with residual NBPI have generally been studied utilizing kinematic motion laboratories. To date, no validated clinical examination method for this has been described. Intra-observer and inter-observer reliability analyses of two shoulder extension angles - passive glenohumeral extension (PGE) and active shoulder extension (ASE) - were performed. Afterwards, a retrospective clinical study was conducted on prospectively-collected data on 245 children with residual BPI treated from January 2019 through August 2022. Demographic characteristics, level of palsy, previous surgical procedures, modified Mallet score, and bilateral PGE and ASE data were analyzed. All inter- and intra-observer agreement was excellent, ranging from 0.82 to 0.86. Median patient age was 8.1 years (3.5-21). Among the 245 children, 57.6% had Erb´s palsy, 28,6% extended Erb's palsy, and 13,9% global palsy. One hundred sixty-eight (66%) of the children could not touch their lumbar spine, among whom 26,2% (n=44) had to swing the arm to reach it. Both the degrees of ASE and PGE achieved correlated significantly with the hand-to-spine score, the ASE strongly (r=0.705) and the PGE weakly (r=0.372; both p<0.0001). Significant correlations also were found between lesion level and the hand-to-spine Mallet score (r=-0.339, p<0.0001) and ASE (r=-0.299, p<0.0001) and between patient age and the PGE (p=0.0416, r=-0.130). A statistically significant decrease in PGE and incapacity to reach the spine were found in patients who underwent glenohumeral reduction, shoulder tendon transfer, or humeral osteotomy, relative to those who had microsurgery or no surgery. Receiver operating curves (ROC) showed that, for both PGE and ASE, the the minimum extension angle required to successfully perform the hand-to-spine task was 10 degrees, with sensitivity levels of 69.9 and 82.2, and specificity levels of 69.5 and 87.8 (both p<0.0001), respectively. Glenohumeral flexion contracture and lost active shoulder extension are extremely common in children with residual NBPI. Both the PGE and ASE angles can be measured reliably with a clinical exam, with at least 10 degrees of PGE and ASE necessary to perform the hand-to-spine Mallet task. Level IV; Case Series; Prognosis Study.

Analysis of the Intra- and Inter-observer Reliabilities of Delbet Classification: Is Simplification Required.

This study aims to investigate the intra- and inter-reliabilities of Delbet classification and whether simplifying the classification improves reliability. The Radiographs of 58 patients under 16years old diagnosed with pediatric hip fractures between January 2012 and January 2020 were evaluated. Two separate Microsoft® PowerPoint (PPT) presentations consisting of 58 slides for Delbet's classification and its simplified form were prepared in which the order of cases was randomized and blinded. Then five orthopedic surgeons with different years of experience (more than 15years of surgical experience were accepted experienced group) in pediatric trauma surgery evaluated the presentations two times one month apart. In the inter-observer reliability analysis, a moderate agreement for the classical Delbet classification and a substantial agreement for the simplified Delbet classification was found in both evaluations. As a result of the intra-observer reliability analysis, there was substantial agreement in four observers, moderate agreement in one observer for the classical Delbet classification and substantial agreement in two observers, very good agreement in three observers for the simplified Delbet classification. The experience was not effective on agreement levels in the intra-observer reliability analysis of the classical Delbet classification system. The inter-reliability values of the less experienced group in the simplified classification were much higher than the classical Delbet classification. The simplification of the Delbet classification provides a significant increase in inter-observer reliability levels, especially in less experienced orthopedics and traumatology specialists, and a significant increase in intra-observer reliability levels. Level III, diagnostic study.

A comparative analysis of interobserver reliability and intraobserver reproducibility of the Oswestry-Bristol Classification and the Dejour Classification for trochlear dysplasia of the knee.

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians' management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications. In all, six assessors (four consultants and two registrars) independently evaluated 100 axial MRIs of the patellofemoral joint (PFJ) for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after four weeks. The inter- and intraobserver reliability scores were calculated using Cohen's kappa and Cronbach's α. Both classifications showed good to excellent interobserver reliability with high α scores. The OBC classification showed a substantial intraobserver agreement (mean kappa 0.628; p < 0.005) whereas the DJC showed a moderate agreement (mean kappa 0.572; p < 0.005). There was no significant difference in the kappa values when comparing the assessments by consultants with those by registrars, in either classification system. This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on axial MRIs of the PFJ, with the simple-to-use OBC having a higher intraobserver reliability score than that of the DJC.

Cortices of Fibula and Tibia Can Provide Landmarks for Accurate Syndesmosis Fixation Angle: Computed Tomography Validation of Angle Bisector Method

Anatomic syndesmosis reduction is necessary to restore ankle biomechanics and prevent poor clinical outcomes, but malreduction can be encountered frequently since the ideal fixation angle varies between patients and fixation levels. This study aimed to validate the angle bisector method to reveal whether it provides an accurate syndesmotic fixation angle that is patient- and level-specific. Lower extremity CT angiography of 50 consecutive patients (25 male, 25 female) without evident ankle pathology were evaluated. The average age was 52.8 (±18, range: 18-75). Lines tangent to anterior and posterior cortices of tibia and fibula were drawn in the axial plane at both 2 cm and 3.5 cm above the ankle joint line. Bisection of the angle formed between these lines was drawn and its relationship with the centroidal axis, which is proposed to be the ideal syndesmotic axis, was evaluated. The angle between the bisector line & the centroidal axis and the distance between their most lateral intersections with the fibula were calculated. The measurements were made by 3 blinded observers. Intra- and interobserver reliability analyses were conducted. The average centroidal axis-bisector angle was 2.1° ± 2.1° at 2 cm and 0.6° ± 1.3° at 3.5 cm level. The average distance to the actual syndesmosis entry point was 1.0 ± 0.9 mm at 2 cm and 0.4 ± 0.4 mm at 3.5 cm level. The values didn't show any significant difference according to gender. Intra- and interobserver reliability analysis showed excellent correlation in all parameters (interclass correlation coefficient > 0.90). Angle bisector method was found strongly reliable providing accurate direction for syndesmotic axis. It can provide a patient- and level-specific angle for the application of syndesmotic implants without increasing the fluoroscopy exposure. Its use can have a broad impact on functional outcomes of ankle injuries by decreasing the malreduction rates. Further cadaveric validation and safety studies should be conducted for possible clinical usage.

Restoration of glenoid joint line: a three-dimensional analysis of scapular landmarks

Restoration of the glenoid joint line in shoulder arthroplasty is important for implant positioning and function. Medialization of the glenohumeral joint line due to glenoid bone loss is commonly encountered in primary and revision of shoulder arthroplasty albeit the direction and location of bone loss varies with different pathology. Three-Dimensional (3D) planning software has assisted in preoperative planning of complex glenoid deformities. However, limited literature is available defining a reliable 3D method to evaluate the glenoid joint line preoperatively. The purpose of this study is to identify a set of reliable scapular landmarks to be used as reference points to measure the premorbid glenoid joint line using 3D segmented models of healthy scapulae. Bilateral computed tomography scans from 79 patients eligible for primary stabilization procedures were retrospectively selected from our institutional surgical database (mean age 35±10 years, 58 males and 21 females). 3D models of the contralateral healthy scapulae were created via computed tomography scan segmentation using Mimics 24.0 software (Materialise, Leuven, Belgium). Anatomical landmarks were identified using 3-Matic 16.0 software (Materialise, Leuven, Belgium). The distance between identified landmarks and a sagittal plane created on the deepest point of the glenoid was recorded for each scapula and reliability of each landmark was assessed. Inter- and intra-observer reliabilities were also evaluated using intraclass correlation coefficients (ICCs). Four landmarks showed statistically significant results: the scapular notch (SN), the centroid of the coracoid (CC), a point on the most medial border of the scapula in line with the scapular spine (TS), and the most lateral point of the acromion (AL). The mean (± standard deviation) joint line measured from the SN, CC, TS and AL were 28.36±2.97 mm, 11.66±2.07 mm, 107.52±8.1 mm, and 29.72±4.46 mm, respectively. Inter-observer reliability analysis for SN, TS, and AL showed excellent agreement with ICC values of 0.966, 0.997, and 0.944, respectively, and moderate agreement for CC with ICC of 0.728. The results from this study assist in estimating joint line medialization preoperatively and in planning its subsequent restoration. A set of reliable landmarks can be used as references to estimate the premorbid glenoid joint line preoperatively.

Is the Diagnosis of 5th Metatarsal Fracture Type Consistent? An Inter-Observer Reliability Study

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Treatment pathways of 5th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Our primary objective was to investigate the reliability of assessment of subtypes of 5th metatarsal fractures by different observers. Methods: Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5th metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5th metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. Patients were excluded from analysis if neither observer could identify a fracture or if one or more observers could not access the images. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis &amp; Koch's description. All data was analysed using IBM SPSS v.27. Results: 1360 patients who met the inclusion criteria were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and DM fractures, which only achieved 'fair' agreement (K=.308 and .381 respectively). Zones 1.1 (K=.538), 1.3 (K=.511), 2 (K=.515), 3 (K=.57), DS (K=.545) and Head (K=.558) all tended towards but did not achieve substantial agreement. Slight agreement with the next proximal and distal adjacent zones were found in Zones 1.1, 1.2 and 1.3. Slight agreement with the adjacent distal zone was found in Zone 2 and DM fractures. Zone 3 has slight agreement with Zone 2 proximally and there is an apparent difficulty with distal DS fractures resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; K=.398, p&lt;.001). Conclusion: Reliability of sub-categorising 5th metatarsal fractures using standardised instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration.

Inter- and intra-rater reliability of knee flexion angle measurements on X-ray and MRI.

Range of motion (ROM) is an important aspect of orthopaedic patient assessment. It can be measured at the knee joint by determining the knee flexion angle (KFA) a patient can achieve at extremes of flexion and extension. As with any measurement, the accuracy and reliability of the method used determine its validity. The consistency of magnetic resonance imaging (MRI) scans as compared to the current gold standard of X-ray remains unknown in terms of KFA evaluation. The aim of this study was to assess and compare the reliability of measuring KFA between X-ray and MRI scans. This study included 80 patients (94 knees) who had attended a specialist knee clinic due to varying knee pathologies and undergone both X-ray and MRI scans. Lateral and T1-weighted sagittal imaging views (respectively) were used to measure KFA by two trained observers independently at two separate time points, 8 weeks apart. The data was then statistically analysed and intra- and inter-observer reliability calculated using the intraclass correlation coefficient (ICC). The intra-observer reliability for X-ray was 0.96 (P<0.001) and that for MRI was 0.83 (P<0.001). The inter-observer reliability for X-ray was 0.99 (P<0.001) and that for MRI was 0.81 (P<0.001). All the intra-class correlation coefficients were graded as excellent in both the intra- and inter-observer reliability analysis. Overall, the mean KFA was notably higher on X-ray measurements than that on MRI scans. There was a statistically significant difference between Time 1 and Time 2 measurements (17.7° vs. 16.8°) for MRI data (P=0.022). No significant difference was found for X-ray measurements (46.4° vs. 45.6°) in this regard (P=0.182). Both X-ray and MRI allow KFA to be measured with an excellent degree of reliability. However, X-ray measurements were overall superior to that of MRI mainly due to the larger field of view of the visible on-screen image which more readily identifies the anatomical landmarks required to measure KFA.

Reliability and accuracy of telemedicine-based shoulder examinations.

Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the interobserver reliability of findings on virtual physical examination relative to in-person evaluation is unclear. The purpose of this study was to determine the reliability of prerecorded video telemedicine for the evaluation of shoulder pathology compared with traditional in-person physical examination. New patients with unilateral shoulder pain presenting to a single-surgeon shoulder clinic were recruited between July and November 2020. In 1 visit, patients were evaluated with standardized in-person and video-guided telemedicine physical examinations in randomized order. Patients were evaluated for range of motion (ROM) and symptoms including pain, weakness, and apprehension. The telemedicine examination was recorded and consisted of a video guide displaying self-directed shoulder examination maneuvers that patients performed during remote coaching by an independent non-physician observer. The in-person physical examination was performed by the treating physician. The telemedicine videos were evaluated by two independent observers for interobserver reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum two-month washout period for intraobserver reliability and intra-platform reliability. Interobserver and intraobserver reliability analyses were conducted using Kuder-Richardson formula 20 (KR-20). Specificity and likelihood ratios were calculated with P < .05 representing statistical significance. A total of 32 patients (17 male and 15 female patients; average age, 50.2±16.2 years) were included in the analysis. Overall Kuder-Richardson formula 20 (KR-20) reliability across 40 physical examination maneuvers was 0.391±0.332 (76.4%±15.4% agreement) between the in-person and telemedicine examinations. Telemedicine maneuvers examining ROM limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person examination (0.700±0.114, 66.5%, 81.0%, and 6.06, respectively). Telemedicine maneuvers identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person examination (0.170±0.440, 23.5%, and 0.518, respectively). All patients were satisfied with their telemedicine experience. The overall reliability of a non-physician-directed video-guided telemedicine examination ranged from unacceptable to good. Shoulder ROM limitations identified during the telemedicine examinations were found to be the most reliable, whereas evaluations of instability were found to be the least reliable. Although initial telemedicine evaluation by a non-physician may be appropriate for ROM evaluation, in-person physician evaluation is recommended to confirm suspected diagnoses, especially if clinical concern for shoulder instability exists. Alternative methods of telemedicine delivery should be explored to improve the reliability of self-directed physical examination maneuvers.

Digital templating in hip hemiarthroplasty: Is it possible to accurately predict femoral head size from magnification alone?

BackgroundTemplating is an integral part of pre-operative planning in elective hip arthroplasty to achieve favourable long-term outcomes, but its applications in trauma surgery remain limited. When templating from radiographs without a calibration marker, there is always an element of magnification which must be accounted for. Our aim was to establish our institute-specific magnification and to determine whether using this to predict femoral head size in hemiarthroplasty was more accurate than using set magnifications previously reported in the literature. Materials & methodsFifty consecutive patients who underwent hip hemiarthroplasty were retrospectively identified, their pre-operative radiographs reviewed and femoral head measured with templating software. Intra- and inter-observer reliability analyses were performed. Using this value, and two set values of 15% and 21% magnification, we attempted to predict femoral head sizes of our original cohort. The results were compared using paired t-test to ascertain if there was any significant difference in accuracy. ResultsWe established our institute-specific magnification as 17%. Inter- and intra-observer reliability were excellent. However, using this magnification we were only able to correctly predict to within ± one femoral head size in 49% of patients. There was no significant difference in accuracy comparing our institute-specific magnification with other magnifications from the literature. ConclusionWe would not recommend using magnification factor in digital templating software as this could potentially lead to errors in predicting final femoral head size in hip hemiarthroplasty and adversely affect patient outcomes.

A stronger association of diabetes mellitus with impaired hyperaemia using a novel ECG-gated device compared with peripheral arterial tonometry

PurposeImpaired digital reactive hyperaemia and flicker-stimulated retinal vascular response are commonly reported risk markers of cardiovascular disease. This is the first study to determine the correlation of these risk markers with diabetes mellitus by comparing our novel flicker-modulated ECG-gated fundoscope with the EndoPAT2000 system.MethodsIn total, 119 controls and 120 participants with diabetes mellitus partook in this cross-sectional study. The EndoPAT2000 system assessed digital reactive hyperaemia under fasting conditions. A mydriatic ECG-gated fundoscope with a novel flicker module acquired digital retinal images of the left eye before, during and after flicker stimulation. An inhouse semi-automated software measured retinal vessel diameters using a validated protocol with two observers repeating measurements in a subset of 10 controls and 10 participants with diabetes mellitus. Intra- and inter-observer reliability analyses occurred by the interclass correlation coefficient. A receiver operating characteristic curve established associations of variables with diabetes mellitus.ResultsDiabetes mellitus was more strongly associated with flicker-stimulated retinal arteriolar calibre change from baseline (AUC 0.81, 95% CI 0.75–0.87, p < 0.0001) than reactive hyperaemia index. Median flicker-stimulated arteriolar calibre change from baseline (controls: 2.74%, IQR 1.07 vs diabetes mellitus: 1.64%, IQR 1.25, p < 0.0001) and reactive hyperaemia index (controls: 1.87, IQR 0.81 vs diabetes mellitus: 1.60, IQR 0.81, p = 0.003) were lower in diabetes mellitus than controls. Intra- and inter-observer reliability coefficients were high from 0.87 to 0.93.ConclusionsImpaired flicker-stimulated retinal arteriolar calibre change from baseline is more highly correlated with diabetes mellitus in this study than a reduced reactive hyperaemia index.