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3D-Printed Models versus CT Scan and X-Rays Imaging in the Diagnostic Evaluation of Proximal Humerus Fractures: A Triple-Blind Interobserver Reliability Comparison Study. Adv Orthop 2022; 2022:5863813. [PMID: 35733650 PMCID: PMC9208975 DOI: 10.1155/2022/5863813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/04/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
Background Proximal humerus fractures (PHFs) are one of the most frequent fractures in the elderly and are the third most fractures after those of the hip and wrist. PHFs are assessed clinically through conventionally standard imaging (X-ray and computed tomography (CT) scans). The present study aims to conduct the diagnostic evaluation and therapeutic efficacy of the 3D-printed models (3DPMs) for the PHFs, compared with the standard imaging. Objectives In terms of fracture classification and surgical indication, PHFs have poor interobserver agreement between orthopedic surgeons using traditional imaging such as X-rays and CT scan. Our objective is to compare interobserver reliability in diagnostic evaluation of PHFs using 3DPMs compared to traditional imaging. Methods The inclusion criteria were elders aged >65 years, fracture classification AO/OTA 11 B and 11 C, and no pathological fractures or polytrauma. In addition, 9 PHFs were assessed by 6 evaluators through a questionnaire and double-blinded administered for each imaging (X-ray and CT scan) and 3DPMs for each fracture. The questionnaire for each method regarded Neer classification, Hertel classification, treatment indication (IT), and surgical technique (ST). Interobserver reliability was calculated through the intraclass correlation coefficient (ICC). Results Nine patients with PHF were included in the study (66% female). The Neer and Hertel classifications between imaging types had similar ICC values between raters with no statistical differences. IT reliability using CT scan and 3DPMs (ICC = 1; (p=0.116)) assessed better agreement compared with X-rays IT. The ST reliability using 3DPMs (ICC = 0.755; p=0.002) was statistically superior to traditional imaging (ST-RX ICC = -0.004 (p=0.454); ST-CT ICC = 0.429 (p=0.116)). Conclusion Classification systems like Neer and Hertel offer poor reliability between operators. The 3DPMs for evaluating diagnostics are comparable to CT images but superior to the surgical technique agreement. The application of 3DPMs is effective for preoperative fracture planning and the modeling of patient-specific hardware.
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Martínez-Sola R, León-Muñoz VJ, Najem-Rizk AN, Soler-Vasco B, Arrieta-Martínez CJ, López-Sorroche E, Cárdenas-Grande E, Salmerón-Vélez G, Ruiz-Molina JÁ, Martínez-Martínez F, Santonja-Medina F. 'Absolute' inter-observer classifications agreement for proximal humeral fractures with a single shoulder anteroposterior X-ray. J Orthop Surg (Hong Kong) 2021; 29:23094990211010520. [PMID: 33896261 DOI: 10.1177/23094990211010520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Several studies have been carried out, and there is no classification for proximal humeral fractures (PHF) exempted from variability in interpretation and with questioned reliability. In the present study, we investigated the 'absolute diagnostic reliability' of the most currently used classifications for PHFs on a single anterior-posterior X-ray shoulder image. METHODS Six orthopaedic surgeons, with varying levels of experience in shoulder pathology, evaluated radiographs from 30 proximal humeral fractures, according to the 'absolute reliability' criteria. Each of the observers rated each fracture according to Neer, Müller/AO and Codman-Hertel's classification systems. RESULTS The overall inter-observer agreement (κ) has been 0.297 (CI95% 0.280 to 0.314) for the Neer's classification system, 0.206 (CI95% 0.193 to 0.218) for the Müller/AO classification system, and 0.315 (CI95% 0.334 to 0.368) for the Codman-Hertel classification system. We found loss of agreement in Neer's classification as the study progressed, low agreement in the AO classification, and stable values in the different evaluations with the best degree of agreement for Codman-Hertel classification, with a moderate agreement in the second evaluation among the six evaluators. CONCLUSION The Neer, AO, and Hertel-Codman classification systems for PHF with a single radiographic projection have a difficult interpretation for orthopaedic surgeons of varying levels of experience, and therefore substantial agreements are not obtained.
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Affiliation(s)
- Rocío Martínez-Sola
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Vicente J León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Antoine Nicolas Najem-Rizk
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Beatriz Soler-Vasco
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Carlos J Arrieta-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Eva López-Sorroche
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Guillermo Salmerón-Vélez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - José Ángel Ruiz-Molina
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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Matsumura N, Furuhata R, Seto T, Takada Y, Shirasawa H, Oki S, Kawano Y, Shiono S. Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures. J Orthop Surg Res 2020; 15:438. [PMID: 32967709 PMCID: PMC7509915 DOI: 10.1186/s13018-020-01966-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. Methods The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. Results The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). Conclusions The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients’ prognosis than the conventional Neer classification.
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Affiliation(s)
- Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Ryogo Furuhata
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takayuki Seto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuhei Takada
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hideyuki Shirasawa
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoshi Oki
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yusuke Kawano
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shohei Shiono
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Soler-Peiro M, García-Martínez L, Aguilella L, Perez-Bermejo M. Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. J Orthop Surg Res 2020; 15:347. [PMID: 32831119 PMCID: PMC7444241 DOI: 10.1186/s13018-020-01880-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Although there are numerous publications about surgical treatment of proximal humeral fractures (PHFs), few assess conservative treatment, which is the most common approach. The aim of this systematic literature review was to assess criteria for indications, treatment protocols, and outcomes obtained with the conservative treatment of 3-part and 4-part PHF. METHODS We searched the PubMed and Cochrane databases for clinical studies published between 2000 and 2019 on conservative treatment for 3-part and 4-part PHF that included patients older than 18 years, a minimum follow-up of 1 year, fracture classification, and description of outcomes with assessment scales. RESULTS The search yielded 26,660 records. We reviewed 44 of them in full, and finally 6 studies were included. We obtained a population of 133 patients (79% women), with a mean age of 74.3 years (range 25 to 98) and mean follow-up of 32 months (range 12 to 68.8). According to the Neer classification system, there were 41% (55) three-part fractures and 59% (78) four-part fractures; 5.81% of the patients were lost to follow-up. The mean Constant score was 64.5 for three-part fractures and 54.9 patients with four-part fractures. Consolidation was achieved in 95% of the three-part fractures and 91% of the four-part fractures. Loss of mobility varied according to the type of fracture. Regarding complications, the most frequent was malunion (21%), followed by avascular necrosis (9%). CONCLUSIONS Our data show that most three-part PHFs treated conservatively achieve fracture consolidation even noting a negligible rate of malunion got fair-good functional results with few complications, while the orthopedic four-part PHF treatment presents high rate of consolidation with less rate of malunion than the three-part PHF but achieve poor functional results with few complications. LEVEL OF EVIDENCE Level IV, Systematic Review.
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Affiliation(s)
- Manuel Soler-Peiro
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain.
| | - Lorena García-Martínez
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Luis Aguilella
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
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Marongiu G, Leinardi L, Congia S, Frigau L, Mola F, Capone A. Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems. J Orthop Traumatol 2020; 21:4. [PMID: 32166457 PMCID: PMC7067934 DOI: 10.1186/s10195-020-0543-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The 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 METHODS A 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. RESULTS The 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. CONCLUSIONS The 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.
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Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy.
| | - Lorenzo Leinardi
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
| | - Stefano Congia
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
| | - Luca Frigau
- Department Economics and Business Science, Cagliari State University, Cagliari, Italy
| | - Francesco Mola
- Department Economics and Business Science, Cagliari State University, Cagliari, Italy
| | - Antonio Capone
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
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Imaging to improve agreement for proximal humeral fracture classification in adult patient: A systematic review of quantitative studies. J Clin Orthop Trauma 2020; 11:S16-S24. [PMID: 31992911 PMCID: PMC6977161 DOI: 10.1016/j.jcot.2019.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 11/20/2022] Open
Abstract
Proximal humeral fracture classification has low reproducibility. Many studies have tried to increase inter- and intra-observer agreement with more sophisticated imaging. The aim of this review was to determine which imaging modality produces the best inter- and intra-observer agreement for proximal humeral fracture classification in adults and to determine if this varies with observer experience or fracture complexity. OvidMEDLINE, The Cochrane Library, EBSCO CINAHL and Elsevier Scopus were searched on July 22nd, 2018. Quantitative studies comparing at least two imaging modalities for inter- or intra-observer agreement of proximal humeral fracture classification in adults were eligible for inclusion in this systematic literature review. Two reviewers independently screened and extracted data. Study quality was appraised using a modified Downs and Black checklist. The search strategy identified 1987 studies, of which 15 met the eligibility criteria. All included studies addressed inter-observer agreement and 8 provided results for intra-observer agreement. A narrative synthesis was performed. Trends were compared between studies as clinical heterogeneity and the statistical measures used by included studies prevented meta-analysis. Inter- and intra-observer agreement was found to increase from radiographs (x-ray) to two-dimensional (2D) computed tomography (CT) to three-dimensional (3D) CT. 2D and 3D CT may improve inter-observer agreement to a greater extent in less experienced observers and in more complex fractures. Future studies should compare 2D and 3D CT with subgroups categorising surgeon experience and fracture complexity. X-ray should be used for initial assessment; however doctors should have a low threshold for ordering CT. PROSPERO number: CRD42018094307.
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Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg 2018; 27:470-477. [PMID: 29433645 DOI: 10.1016/j.jse.2017.09.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/22/2017] [Accepted: 09/30/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment. METHODS Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction-internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed. RESULTS ORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002). CONCLUSION Successful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group.
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Fisher ND, Barger JM, Driesman AS, Belayneh R, Konda SR, Egol KA. Fracture Severity Based on Classification Does Not Predict Outcome Following Proximal Humerus Fracture. Orthopedics 2017; 40:368-374. [PMID: 28968473 DOI: 10.3928/01477447-20170925-04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
This study was conducted to determine whether proximal humerus fracture patterns as defined by the Orthopaedic Trauma Association (AO/OTA) classification and the Neer 4-part system predicted functional outcomes for patients treated with open reduction and internal fixation with locked plates and, if so, which system correlated better with outcomes. During a 12-year period, 213 patients with a displaced proximal humerus fracture who underwent surgical treatment with a locking plate at 1 academic institution were prospectively followed. All patients were treated in a similar way and were followed by the operating surgeon at routine intervals. Functional outcomes were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Of these patients, 164 were available for analysis. Functional outcomes based on DASH scores did not differ significantly by Neer system, AO/OTA classification, or varus/valgus humeral head alignment at more than 12 months postoperatively. However, patients with Neer 4-part fracture and AO/OTA type 11-C fracture had worse shoulder range of motion in terms of forward elevation and external rotation. Time to healing and complication rates also were not significantly different based on either classification system. Fracture classification can predict shoulder range of motion 12 months after surgical fixation, but its use is limited in predicting functional outcome scores, time to healing, and complication rates. Patients who undergo surgical repair of a proximal humerus fracture can expect good functional results independent of the initial injury pattern, but more severe fracture patterns may lead to decreased shoulder range of motion. [Orthopedics. 2017; 40(6):368-374.].
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Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res 2017; 12:137. [PMID: 28946902 PMCID: PMC5613450 DOI: 10.1186/s13018-017-0639-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
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Affiliation(s)
- Christoph J Laux
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Florian Grubhofer
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Abstract
INTRODUCTION The purpose of this study was to assess whether training observers and simplifying proximal humeral fracture classifications improve interobserver reliability among a large number of orthopaedic surgeons. METHODS One hundred eighty-five observers were randomized to receive training or no training in a simple classification for proximal humeral fractures before evaluating preoperative radiographs of a consecutive series of 30 patients who were treated with open reduction and internal fixation. RESULTS The overall interobserver reliability of the simple proximal humeral fracture classification system was low and not significantly different between the training and the no training group (κ = 0.20 and κ = 0.18, respectively; P = 0.10). Subgroup analyses showed that training improved the agreement among surgeons who have been in independent practice ≤5 years (κ = 0.23 versus κ = 0.14; P < 0.001), surgeons from the United States (κ = 0.23 versus κ = 0.16; P = 0.002), and general orthopaedic surgeons (κ = 0.42 versus κ = 0.15; P = 0.021). DISCUSSION Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures. However, training observers improved interobserver reliability of a simple proximal humeral fracture classification system among surgeons from the United States and, in particular, younger and less specialized surgeons. This finding may suggest that our interpretations of radiographic information might become more fixed and immutable with experience.
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Kumar V, Singh A. Fracture Supracondylar Humerus: A Review. J Clin Diagn Res 2016; 10:RE01-RE06. [PMID: 28208961 DOI: 10.7860/jcdr/2016/21647.8942] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/27/2016] [Indexed: 11/24/2022]
Abstract
Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.
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Affiliation(s)
- Vineet Kumar
- Assistant Professor, Department of Orthopaedic Surgery, K. G. Medical University , Lucknow, Uttar Pradesh, India
| | - Ajai Singh
- Professor, Department of Orthopaedic Surgery, K. G. Medical University , Lucknow, Uttar Pradesh, India
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Gracitelli MEC, Malavolta EA, Assunção JH, Kojima KE, dos Reis PR, Silva JS, Ferreira Neto AA, Hernandez AJ. Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg 2016; 25:695-703. [PMID: 27085296 DOI: 10.1016/j.jse.2016.02.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/01/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. METHODS In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. RESULTS There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). CONCLUSION Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.
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Affiliation(s)
- Mauro E C Gracitelli
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil.
| | - Eduardo A Malavolta
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Jorge H Assunção
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Kodi E Kojima
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Paulo R dos Reis
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Jorge S Silva
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Arnaldo A Ferreira Neto
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Arnaldo J Hernandez
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
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CORR Insights(®): Greater Tuberosity Fractures: Does Fracture Assessment and Treatment Recommendation Vary Based on Imaging Modality? Clin Orthop Relat Res 2016; 474:1266-8. [PMID: 26883650 PMCID: PMC4814408 DOI: 10.1007/s11999-016-4737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 01/31/2023]
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Papakonstantinou MK, Hart MJ, Farrugia R, Gabbe BJ, Kamali Moaveni A, van Bavel D, Page RS, Richardson MD. Interobserver agreement of Neer and AO classifications for proximal humeral fractures. ANZ J Surg 2016; 86:280-4. [DOI: 10.1111/ans.13451] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - Melissa J. Hart
- Victorian Orthopaedic Trauma Outcomes Registry (VOTOR); Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Richard Farrugia
- Department of Orthopaedics; The Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Belinda J. Gabbe
- Department of Epidemiology and Preventative Medicine; Monash University; Melbourne Victoria Australia
| | | | - Dirk van Bavel
- Department of Orthopaedics; St Vincent's Hospital; Melbourne Victoria Australia
- Department of Orthopaedics; The Epworth Hospital; Melbourne Victoria Australia
| | - Richard S. Page
- Department of Orthopaedics; University Hospital; Geelong Victoria Australia
- School of Medicine; Deakin University; Geelong Victoria Australia
| | - Martin D. Richardson
- Department of Orthopaedics; The Epworth Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
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Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography: Validation of a Method on Plain Radiography to Guide Surgical Treatment. J Orthop Trauma 2014; 28:445-51. [PMID: 24270356 DOI: 10.1097/bot.0000000000000038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Residual displacement of greater tuberosity (GT) fractures has been shown to negatively affect shoulder function. However, accurate measurement of GT displacement remains a problem with errors up to 13 mm on plain radiography (XR). A new GT ratio for measuring fracture displacement on XR is described, validated, and correlated with computed tomography (CT) and surgical decision making. METHODS A retrospective review of shoulder radiographs was performed from 2007 to 2010 to identify all cases of isolated GT fractures with both XR and CT. The GT ratio was performed on all XR and correlated with superior GT displacement measured on CT. The GT ratio was then tested for accuracy of surgical decision using 5-mm superior displacement on CT as the cutoff. Finally, the inter- and intraobserver reliabilities of the GT ratio were calculated and compared with the Neer and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classifications. RESULTS Forty cases of acute GT fractures with XR and CT were identified. The GT ratio correlated very well with superior displacement on CT (Pearson correlation = 0.852, P < 0.01) and accurately classified GT fractures as "surgical" (n = 9, 23%) or "nonsurgical" (n = 31, 77%). GT ratios ≤0.00 were nonsurgical, ≥0.50 were surgical, and 0.00-0.50 warranted further imaging (P < 0.01). The GT ratio performed as well as or better than the AO and Neer classifications for inter- and intraobserver reliabilities. CONCLUSIONS The GT ratio described in this study correlates very well with CT for superior GT fracture displacement. It involves significantly less radiation and accurately classifies GT fractures as nonsurgical (ratio < 0.00), surgical (ratio > 0.50), or as benefiting from further imaging (0.00-0.50). It performs as well or better than the Neer or AO classification. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Buckwalter JA, Anderson DD, Brown TD, Tochigi Y, Martin JA. The Roles of Mechanical Stresses in the Pathogenesis of Osteoarthritis: Implications for Treatment of Joint Injuries. Cartilage 2013; 4:286-294. [PMID: 25067995 PMCID: PMC4109888 DOI: 10.1177/1947603513495889] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Excessive joint surface loadings, either single (acute impact event) or repetitive (cumulative contact stress), can cause the clinical syndrome of osteoarthritis (OA). Despite advances in treatment of injured joints, the risk of OA following joint injuries has not decreased in the last 50 years. Cumulative excessive articular surface contact stress that leads to OA results from post-traumatic joint incongruity and instability, and joint dysplasia, but also may cause OA in patients without known joint abnormalities. In vitro investigations show that excessive articular cartilage loading triggers release of reactive oxygen species (ROS) from mitochondria, and that these ROS cause chondrocyte death and matrix degradation. Preventing release of ROS or inhibiting their effects preserves chondrocytes and their matrix. Fibronectin fragments released from articular cartilage subjected to excessive loads also stimulate matrix degradation; inhibition of molecular pathways initiated by these fragments prevents this effect. Additionally, injured chondrocytes release alarmins that activate chondroprogentior cells in vitro that propogate and migrate to regions of damaged cartilage. These cells also release chemokines and cytokines that may contribute to inflammation that causes progressive cartilage loss. Distraction and motion of osteoarthritic human ankles can promote joint remodeling, decrease pain and improve joint function in patients with end-stage post-traumatic OA. These advances in understanding of how altering mechanical stresses can lead to remodeling of osteoarthritic joints and how excessive stress causes loss of articular cartilage, including identification of mechanically induced mediators of cartilage loss, provide the basis for new biologic and mechanical approaches to the prevention and treatment of OA.
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Affiliation(s)
- Joseph A. Buckwalter
- Department of Orthopaedics and Rehabilitation and Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
- Iowa City Veterans Administration Medical Center, Iowa City, IA, USA
| | - Donald D. Anderson
- Department of Orthopaedics and Rehabilitation and Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - Thomas D. Brown
- Department of Orthopaedics and Rehabilitation and Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - Yuki Tochigi
- Department of Orthopaedics and Rehabilitation and Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
- Department of Orthopaedics, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - James A. Martin
- Department of Orthopaedics and Rehabilitation and Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
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Bruinsma WE, Guitton TG, Warner JJP, Ring D. Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT. J Bone Joint Surg Am 2013; 95:1600-4. [PMID: 24005201 DOI: 10.2106/jbjs.l.00586] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). METHODS Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. RESULTS Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. CONCLUSIONS Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports.
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Affiliation(s)
- Wendy E Bruinsma
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Hillbricht S, Stürzebecher K, Suhren J, Kasch R, Herzog J, Schulz AP. Plattenosteosynthese oder Marknagelung bei proximaler Humerusfraktur – Retrospektive Analyse von 156 Fällen über 3 Jahre mit einem 2-Jahres-Follow-up. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s11678-013-0208-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Cuny C, Baumann C, Mayer J, Guignand D, Irrazi M, Berrichi A, Ionescu N, Guillemin F. AST classification of proximal humeral fractures: introduction and interobserver reliability assessment. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 23:35-40. [PMID: 23412405 DOI: 10.1007/s00590-011-0916-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/19/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND This article introduces an alphanumeric AST (Articular, Surgical neck, Tuberosities) classification of proximal humeral fractures, based on the number, localization, and displacement of articular and extra-articular fragments. All possible cases of proximal humeral fractures can be assessed from a single figure using this classification. The aim of the study was thus to describe the AST classification and to assess interobserver reliability. METHODS This classification is based on a single figure, allowing an easy description of the anatomic variants of different proximal humeral fractures. The severity of the fracture is determined by the fragment displacement in angular degrees and the major linear displacement in millimeters. AST reproducibility was assessed and compared with Neer, AO, and Duparc classifications, commonly used in clinical practice. The interobserver agreement was measured with Cohen's kappa coefficients and their 95% confidence intervals. RESULTS Thirteen independent observers analyzed a total of 64 X-rays. Overall kappa coefficients were 0.34, 0.29, 0.24, and 0.25 for AST, Neer, AO, and Duparc classifications, respectively. CONCLUSION The AST classification, which is easier to use because it is based on only one figure, is at least as reproducible as other proximal humeral fracture classifications.
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Affiliation(s)
- Christian Cuny
- Department of Orthopaedics and Traumatology, CHR Metz Bon-Secours, 57038, Metz Cedex, France.
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Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C. Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. J Shoulder Elbow Surg 2013; 22:e8-14. [PMID: 22818893 DOI: 10.1016/j.jse.2012.04.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 03/25/2012] [Accepted: 04/01/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND The therapeutic spectrum for the treatment of displaced proximal humeral fractures ranges from conservative therapy to head-preserving surgical interventions and joint replacement. This study initiated a survey on the current treatment options with regard to diagnostics, choice of therapy, and complications that are encountered at trauma surgeries and orthopedic hospitals in Germany, Austria, and Switzerland. MATERIALS AND METHODS The survey included 743 hospitals. The questionnaire covered information on demographics, diagnostics, classification, therapy, and complications of proximal humeral fractures. RESULTS The questionnaire was completed by 348 hospitals. Five of 6 hospitals treat more than 40% of the fractures surgically. The percentage distribution of the available implants is at 63.4% for angular stable plates, 30.9% for intramedullary nails, and 10.1% for fracture prostheses. The 5 complications reported most frequently were nonanatomic reduction (83%), implant perforation (73%), secondary displacement of the fracture (71%), avascular necrosis (67%), and implant-related impingement (59%). CONCLUSIONS A preference for surgical treatment of proximal humeral fractures was found, with stabilization predominantly being attempted by the use of angle-stable implants. The 2 most common complications were "nonanatomic reduction of fractures" and the more specific problem of "implant perforation" when fixed-angle implants were used for treatment.
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Affiliation(s)
- Alexander Tepass
- Klinik für Unfall- und Wiederherstellungschirurgie, BG-Unfallklinik Tübingen, Eberhard-Karls-Universität Tübingen, Schnarrenbergstrasse 95,Tübingen, Germany
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Carrerra EDF, Wajnsztejn A, Lenza M, Archetti Netto N. Reproducibility of three classifications of proximal humeral fractures. EINSTEIN-SAO PAULO 2012; 10:473-9. [DOI: 10.1590/s1679-45082012000400014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 11/05/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra- and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study. METHODS: A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis. RESULTS: The mean intra-observer Kappa agreement index (k=0.687) of the new classification, was higher than both the Neer classification (k=0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k=0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.028). CONCLUSION: the new classification considering bone compression had higher results for intra- and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system.
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[Proximal humerus fracture: new aspects in epidemiology, fracture morphology, and diagnostics]. Unfallchirurg 2012; 114:1051-8. [PMID: 22108769 DOI: 10.1007/s00113-011-2052-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The incidence of proximal humerus fractures is rising and they constitute the third most frequent fracture in the elderly after femoral fractures in the hip area and radius fractures. They are caused by the age-related increase in osteoporosis. In contrast to young people, low-energy trauma involved in simple falls represents the mechanism that leads to the injury in older people. Numerous authors have introduced systems for the classification of proximal humerus fractures.After a thorough clinical examination of the affected extremity including assessment of circulation, motor function, and sensitivity, attention should be directed toward concomitant injuries, especially in the region of the shoulder girdle and thorax. Advocated imaging consists of anteroposterior and axial views of the affected shoulder. Disagreement over management of this fracture is quite considerable and treatment ranges from a conservative approach through to procedures for minimally invasive plate osteosynthesis, open fixed-angle locked plating, and nailing up to prosthetic replacement.
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Majed A, Macleod I, Bull AMJ, Zyto K, Resch H, Hertel R, Reilly P, Emery RJH. Proximal humeral fracture classification systems revisited. J Shoulder Elbow Surg 2011; 20:1125-32. [PMID: 21481611 DOI: 10.1016/j.jse.2011.01.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/16/2010] [Accepted: 01/01/2011] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS This study evaluated several classification systems and expert surgeons' anatomic understanding of these complex injuries based on a consecutive series of patients. We hypothesized that current proximal humeral fracture classification systems, regardless of imaging methods, are not sufficiently reliable to aid clinical management of these injuries. MATERIALS AND METHODS Complex fractures in 96 consecutive patients were investigated by generation of rapid sequence prototyping models from computed tomography Digital Imaging and Communications in Medicine (DICOM) imaging data. Four independent senior observers were asked to classify each model using 4 classification systems: Neer, AO, Codman-Hertel, and a prototype classification system by Resch. Interobserver and intraobserver κ coefficient values were calculated for the overall classification system and for selected classification items. RESULTS The κ coefficient values for the interobserver reliability were 0.33 for Neer, 0.11 for AO, 0.44 for Codman-Hertel, and 0.15 for Resch. Interobserver reliability κ coefficient values were 0.32 for the number of fragments and 0.30 for the anatomic segment involved using the Neer system, 0.30 for the AO type (A, B, C), and 0.53, 0.48, and 0.08 for the Resch impaction/distraction, varus/valgus and flexion/extension subgroups, respectively. Three-part fractures showed low reliability for the Neer and AO systems. DISCUSSION Currently available evidence suggests fracture classifications in use have poor intra- and inter-observer reliability despite the modality of imaging used thus making treating these injuries difficult as weak as affecting scientific research as well. This study was undertaken to evaluate the reliability of several systems using rapid sequence prototype models. CONCLUSION Overall interobserver κ values represented slight to moderate agreement. The most reliable interobserver scores were found with the Codman-Hertel classification, followed by elements of Resch's trial system. The AO system had the lowest values. The higher interobserver reliability values for the Codman-Hertel system showed that is the only comprehensive fracture description studied, whereas the novel classification by Resch showed clear definition in respect to varus/valgus and impaction/distraction angulation.
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Affiliation(s)
- Addie Majed
- Division of Surgery Oncology Reproductive Medicine and Anaesthetics, Imperial College London, UK.
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Foroohar A, Tosti R, Richmond JM, Gaughan JP, Ilyas AM. Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience. J Orthop Surg Res 2011; 6:38. [PMID: 21801370 PMCID: PMC3162565 DOI: 10.1186/1749-799x-6-38] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 07/29/2011] [Indexed: 11/10/2022] Open
Abstract
SUMMARY Proximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs. METHODS Inter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience. RESULTS All kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores. CONCLUSIONS Although 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.
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Affiliation(s)
- Abtin Foroohar
- Department of Orthopaedic Surgery and Sports Medicine, TempleUniversity School of Medicine, 3401 N. Broad Street, Philadelphia, PA 1914, USA
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Foroohar A, Tosti R, Richmond JM, Gaughan JP, Ilyas AM. Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience. J Orthop Surg Res 2011. [PMID: 21801370 DOI: 10.1186/1749-1799x-6-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
SUMMARY Proximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs. METHODS Inter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience. RESULTS All kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores. CONCLUSIONS Although 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.
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Affiliation(s)
- Abtin Foroohar
- Department of Orthopaedic Surgery and Sports Medicine, TempleUniversity School of Medicine, 3401 N. Broad Street, Philadelphia, PA 1914, USA
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Kachramanoglou C, Chidambaram R, Mok D. Four-part proximal humeral fractures: diagnosis with the 'sunset' sign on anteroposterior radiograph. Ann R Coll Surg Engl 2010; 92:599-604. [PMID: 20522308 DOI: 10.1308/003588410x12699663903638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Four-part proximal humeral fractures require surgical intervention. However, they can be difficult to diagnose in radiological images. We aim to define a new, easily recognisable, radiological sign as a predictor of four-part fracture of the proximal humerus in a plain anteroposterior radiograph of the shoulder. PATIENTS AND METHODS We describe our 'sunset' sign as 'articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture'. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proven otherwise. Between 2002 and 2006, 80 consecutive patients had surgical treatment of their proximal humeral fractures in our unit. Pre-operative radiographs and operative notes of 79 patients were evaluated independently by three blinded observers. The presence of 'sunset' sign was recorded. Findings were then correlated with the operative diagnoses to confirm whether they were four-part fractures or not. With 95% confidence interval, we calculated the sensitivity, specificity, positive and negative predictive values for our diagnostic sign. RESULTS Of 79 patients, 30 displayed 'sunset' sign in their pre-operative radiograph. Of these, 28 had confirmed four-part fractures operatively. The positive predictive value of 'sunset' sign was 93%. The specificity and sensitivity were 95% and 78%, respectively. The sensitivity was affected by eight patients with four-part fractures with displaced articular head fragment which had dropped either medially or posteriorly. CONCLUSIONS These results suggest that, in patients with proximal humeral fractures, the presence of 'sunset' sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.
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Affiliation(s)
- C Kachramanoglou
- Department of Trauma and Orthopaedic Surgery, Epsom General Hospital, Epsom, UK.
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Management of proximal humeral fractures: surgeons don't agree. J Shoulder Elbow Surg 2010; 19:446-51. [PMID: 19800259 DOI: 10.1016/j.jse.2009.06.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 06/24/2009] [Accepted: 06/29/2009] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training. METHOD Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted kappa coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed. RESULTS Overall interobserver agreement on management was moderate (weighted kappa=0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time. CONCLUSION Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome.
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Esen E, Doğramaci Y, Gültekin S, Deveci MA, Suluova F, Kanatli U, Bölükbaşi S. Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients. Injury 2009; 40:1336-41. [PMID: 19595326 DOI: 10.1016/j.injury.2009.06.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 06/11/2009] [Accepted: 06/15/2009] [Indexed: 02/02/2023]
Abstract
AIM Our study reports long-term results and factors related to patient satisfaction in the case of primary hemiarthroplasty for humeral proximal end fractures. PATIENTS AND METHODS We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9+/-5.57 years (age range: 59-81 years). The mean follow-up period was 78.8+/-26.6 months (range: 48-118 months). We evaluated the following parameters: fracture type according to the Neer classification, the time interval between the fracture and the operation, postoperative radiological examination, the Neer outcome assessment criteria for patient satisfaction and functions, according to the Constant and Murley Scoring (CMS) system. RESULTS We found good-to-excellent outcomes in 36 (85.7%) and poor outcome in six (14.3%) patients according to the Neer criteria. The average values for CMS score, anterior elevation and external rotation were 73.59+/-17.95 (25-94), 121.30+/-42.99 degrees (range: 30-170 degrees ) and 30 degrees (range: 0-80 degrees ), respectively. The patients who had been operated in the early period (within 2 weeks) had better functional outcomes (p<0.001) and had significant pain relief. There was a strong positive correlation between the humeral offset (distance between the head and the tuberosities) and the degree of elevation (r=0.872, p<0.001). There was a strong negative correlation between the height of the humeral head and the degree of elevation (r=-0.853, p<0.001). CONCLUSION In humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction.
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Affiliation(s)
- Erdinç Esen
- Gazi University, Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey
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Abstract
Proximal humeral fractures can restrict daily activities and, therefore, deserve efficient diagnoses that minimize complications and sequels. For good diagnosis and treatment, patient characteristics, variability in the forms of the fractures presented, and the technical difficulties in achieving fair results with surgical treatment should all be taken into account. Current classification systems for these fractures are based on anatomical and pathological principles, and not on systematic image reading. These fractures can appear in many different forms, with many characteristics that must be identified. However, many current classification systems lack good reliability, both inter-observer and intra-observer for different image types. A new approach to image reading, following a well-designed set and sequence of variables to check, is needed. We previously reported such an image reading system. In the present study, we report a classification system based on this image reading system. Here we define 21 fracture characteristics and apply them along with classical Codman approaches to classify fractures. We base this novel classification system for classifying proximal humeral fractures on a review of scientific literature and improvements to our image reading protocol. Patient status, fracture characteristics and surgeon circumstances have been important issues in developing this system.
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Affiliation(s)
- José M Mora Guix
- Orthopaedic Surgery and Traumatology Department (Shoulder Unit), Hospital of Terrassa, and Clinica Sagrada Familia of Barcelona, Barcelona, Spain.
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30
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Abstract
The decision to operate and the selection of the appropriate surgical modality for proximal humerus fractures are largely based on the fracture pattern. Understanding the particular fracture pattern in each case is complicated. Most well-accepted classification systems were developed based on radiographs complemented by intraoperative findings. Three-dimensional reconstructions based on CT currently available in most institutions allow a much better understanding of complex fractures. Modern thinking about fracture classification probably should be revisited in the light of improved imaging techniques.
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Bahrs C, Schmal H, Lingenfelter E, Rolauffs B, Weise K, Dietz K, Helwig P. Inter- and intraobserver reliability of the MTM-classification for proximal humeral fractures: a prospective study. BMC Musculoskelet Disord 2008; 9:21. [PMID: 18279527 PMCID: PMC2275241 DOI: 10.1186/1471-2474-9-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 02/17/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A precise modular topographic-morphological (MTM) classification for proximal humeral fractures may address current classification problems. The classification was developed to evaluate whether a very detailed classification exceeding the analysis of fractured parts may be a valuable tool. METHODS Three observers classified plain radiographs of 22 fractures using both a simple version (fracture displacement, number of parts) and an extensive version (individual topographic fracture type and morphology) of the MTM classification. Kappa-statistics were used to determine reliability. RESULTS An acceptable reliability was found for the simple version classifying fracture displacement and fractured main parts. Fair interobserver agreement was found for the extensive version with individual topographic fracture type and morphology. CONCLUSION Although the MTM-classification covers a wide spectrum of fracture types, our results indicate that the precise topographic and morphological description is not delivering reproducible results. Therefore, simplicity in fracture classification may be more useful than extensive approaches, which are not adequately reliable to address current classification problems.
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Affiliation(s)
- Christian Bahrs
- BG Trauma Center, Eberhard-Karls-University, Schnarrenbergstr, 95, D-72076 Tuebingen, Germany.
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Brorson S, Hróbjartsson A. Training improves agreement among doctors using the Neer system for proximal humeral fractures in a systematic review. J Clin Epidemiol 2008; 61:7-16. [PMID: 18083458 DOI: 10.1016/j.jclinepi.2007.04.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 02/14/2007] [Accepted: 04/13/2007] [Indexed: 11/16/2022]
Affiliation(s)
- Stig Brorson
- Amager University Hospital, Department of Orthopaedic Surgery, Italiensvej 1, Copenhagen S, Denmark.
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Abstract
Preoperative classification of proximal humeral fractures in addition to thorough knowledge of the specific anatomy and vascular blood supply is more important for successful treatment than the choice of implant. If reduction and fixation is necessary, aggressive reduction maneuvers can compromise humeral head perfusion with subsequent humeral head necrosis regardless of the implant used. Modern implants such as intramedullary proximal humeral nails and anatomically designed proximal humeral angular stable plates offer high primary stability even in osteoporotic bone with preservation of periosteal blood supply to the humeral head. These implants allow early functional exercises and showed good to excellent results in the majority of patients with an acceptable complication rate. Increasing experience with these relatively new implants and further technical development might improve clinical results and reduce complications. Minimally invasive, percutaneous techniques also demonstrate favorable results comparable to those mentioned above, although mean patient age tends to be younger in these studies and complications requiring reoperation tend to be more pronounced in elderly patients due to poor bone quality. Alternatively, nonoperative treatment of displaced two- and three-part fractures in elderly patients with severe morbidity and high perioperative risks should be considered. In elderly patients with selected displaced four-part fractures or fracture dislocations and head-split fractures, hemiarthroplasty offers high subjective patient satisfaction despite moderate function with most of the patients being pain free.
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Affiliation(s)
- Johannes K M Fakler
- Dept of Trauma and Reconstructive Surgery, Charité University Medical School, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
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Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg 2008; 17:42-54. [PMID: 18308203 DOI: 10.1016/j.jse.2007.03.016] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 03/12/2007] [Indexed: 02/01/2023]
Abstract
A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.
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Affiliation(s)
- Brent Lanting
- Hand And Upper Limb Centre, St Joseph's Health Care London, London, Ontario, Canada
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Mez JC, Dabareiner RM, Cole RC, Watkins JP. Fractures of the greater tubercle of the humerus in horses: 15 cases (1986-2004). J Am Vet Med Assoc 2007; 230:1350-5. [PMID: 17472563 DOI: 10.2460/javma.230.9.1350] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine clinical and radiographic abnormalities in and outcome of horses with fractures of the greater tubercle of the humerus and to develop a radiographic technique for obtaining a cranioproximal-craniodistal oblique projection of the proximal portion of the humerus in standing horses. DESIGN Retrospective case series. ANIMALS 15 horses. PROCEDURES Data collected from medical records included signalment, history, horse use, severity and duration of lameness, radiographic and ultrasonographic findings, treatment, and outcome. RESULTS All horses had a history of acute, unilateral lameness. Twelve of 15 had visual or palpable abnormalities in the shoulder region. In 6 of 8 horses, the fracture could be seen on a cranioproximal-craniodistal projection of the proximal portion of the humerus. In 2 horses, this was the only projection on which the fracture could be seen, and in an additional 2, this was the projection on which the fracture could be seen most reliably. Ten horses underwent surgery (fragment removal, 7; open reduction and internal fixation, 2; and exploration without fragment removal, 1), and 5 were treated with variable periods of stall rest and turnout. Eleven horses returned to athletic use, including 9 of the 10 treated surgically and 2 of the 5 treated without surgery. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that horses with fractures of the greater tubercle of the humerus can return to athletic soundness following treatment and emphasized the need for obtaining a cranioproximal-craniodistal radiographic projection of the proximal portion of the humerus in horses suspected to have an injury in this region.
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Affiliation(s)
- Jason C Mez
- Departments of Large Animal Medicine and Surgery, College of Veterinary Medicine, Texas A and M University, College Station, TX 77843-4475, USA
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Mora Guix JM, Gonzalez AS, Brugalla JV, Carril EC, Baños FG. Proposed protocol for reading images of humeral head fractures. Clin Orthop Relat Res 2006; 448:225-33. [PMID: 16826120 DOI: 10.1097/01.blo.0000205899.28856.98] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Fractures of the proximal humerus can be treated effectively but require proper characterization. None of the existing classifications intended to facilitate characterization have been satisfactory. We studied proximal humerus fractures using radiographs alone and radiographs plus computed tomography scans to ascertain which imaging studies were most useful to characterize these fractures. We designed an assessment protocol consisting of 17 parameters divided in four groups: cephalodiaphyseal relationship (six parameters), cephalotuberosity relationship (six parameters), humeral head (two parameters), and fracture fragment description (three parameters). The computed tomography scans were assessed using 11 parameters (the same parameters used for assessing radiographs except for the six cephalodiaphyseal parameters). Four observers analyzed the parameters in 30 selected fractures with biplanar radiographic projections (30 patients) and computed tomography scans (22 patients) on two occasions. We found good interobserver reliability and intraobserver reliability with radiographs alone for the cephalodiaphyseal parameters. The best interobserver reliabilities with radiographs plus computed tomography scans were with the number of fragments, displacement of the lesser tuberosity, and extraarticular or articular fractures. Computed tomography allows better assessment of some parameters in characterizing proximal humeral fractures. The use of a structured protocol in reading images seems useful and allows better reliability than reported for other approaches. LEVEL OF EVIDENCE Diagnostic study, Level III (study of nonconsecutive patients without consistently applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- José M Mora Guix
- Department of Orthopaedic and Traumatology Surgery, Hospital de Terrassa, Barcelona, Spain.
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Shrader MW, Sanchez-Sotelo J, Sperling JW, Rowland CM, Cofield RH. Understanding proximal humerus fractures: image analysis, classification, and treatment. J Shoulder Elbow Surg 2005; 14:497-505. [PMID: 16194741 DOI: 10.1016/j.jse.2005.02.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Accepted: 02/07/2005] [Indexed: 02/01/2023]
Abstract
Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.
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Affiliation(s)
- M Wade Shrader
- Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 2005; 16 Suppl 2:S65-72. [PMID: 15526090 DOI: 10.1007/s00198-004-1714-2] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2004] [Accepted: 07/05/2004] [Indexed: 10/25/2022]
Abstract
The purpose of this article was to review critically the current treatment options for fractures of the proximal humerus in patients with severe osteoporosis. The main difficulties lie in correctly diagnosing the fracture and hence selecting the most appropriate method of treatment. The reliability of the diagnosis can be increased by systematically appending additional information to a basic fracture classification. Classification is best carried out on a morphological basis, whereby a descriptor of bone quality can be added in order to introduce the degree of osteoporosis into the decision-making algorithm. Any classification system that claims to provide both treatment and prognosis is inappropriate, because prognosis will depend hopefully on the treatment. Approaches to treatment differ widely amongst centers and surgeons. It is still unclear as to what would be the optimal treatment. Factors such as the individual's functional requirements and ability to cooperate should be given careful consideration. At our institution, hemiarthroplasty is the method of choice for ischemic humeral heads and/or when anatomic reconstruction cannot be obtained. In all other displaced fractures, the main objective is preservation of the head since the best functional results can generally be obtained with internal fixation. Selection of a balanced osteosynthesis, adapted to the weak bone, is mandatory. Bulky, stiff implants are inadequate and may cause additional damage. Load sharing, not load bearing, compound constructions are the aim. Obtaining metaphyseal elastic buttressing is the key element in achieving the necessary load-sharing fixation. The system should allow controlled impaction and be forgiving towards occasional load peaks that will occur and are beyond patient control. Thin and flexible implants are required to realize this type of fixation. Given the polypragmatic approach that is current in clinical practice there is room for further improvement of techniques and implants.
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Affiliation(s)
- Ralph Hertel
- Department of Orthopedic Surgery, Lindenhofspital, Berne, Switzerland.
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Affiliation(s)
- Charles S Neer
- Department of Orthopaedic Surgery, Columbia University, New York, NY, USA
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Sjödén GO, Movin T, Aspelin P, Güntner P, Shalabi A. 3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures. ACTA ORTHOPAEDICA SCANDINAVICA 1999; 70:325-8. [PMID: 10569259 DOI: 10.3109/17453679908997818] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The Neer and AO fracture classifications for fractures of the proximal humerus have shown poor reproducibility based on plain radiography. We wanted to investigate whether the addition of 3-dimensional (3D) reconstructions would increase the reproducibility of classification. 7 observers independently classified 24 fractures of the proximal humerus using both plain radiographs, CT and 3D and the classification was repeated 2 months later. There was a moderate interobserver agreement when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a mean kappa value of 0.44 and the AO had a value of 0.32 for the first assessment. In the second assessment, the mean kappa values were 0.49 and 0.34, respectively. Intraobserver reproducibility was fair to substantial agreement for Neer (kappa range 0.27-0.73) and for AO (kappa range 0.29-0.74). In conclusion, the addition of CT and 3D to plain radiographs did not improve the reproducibility of the classifications of Neer and AO of the proximal humerus.
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Affiliation(s)
- G O Sjödén
- Department of Orthopedics, Karolinska Institute, Huddinge University Hospital, Sweden.
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