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Harbrecht A, Hackl M, Ott N, Uschok S, Wegmann K, Müller LP, Leschinger T. Mayo classification of olecranon fractures revisited - Assessment of intra- and interobserver reliability based on CT scans. J Orthop 2024; 52:102-106. [PMID: 38440410 PMCID: PMC10909575 DOI: 10.1016/j.jor.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Purpose Olecranon fractures are classified using the commonly accepted Mayo classification. Its reliability has been analyzed by means of radiographs. A CT scan is often obtained due to joint involvement. Purpose of this study was to evaluate the intra- and interobserver reliability of the Mayo classification based on CT examination. Methods Radiographic and CT images of 20 olecranon fractures were classified by four surgeons at two time points 30 days apart. Intra- and interobserver reliability were assessed using kappa coefficients. Results Mean intraobserver reliability between X-rays was substantial and between CTs almost perfect (0.76 and 0.82, respectively). Mean interobserver reliability was fair for X-rays and moderate for CTs (0.32 and 0.44, respectively). Conclusion Despite the more detailed imaging compared with radiography only moderate interobserver reliability was found for the classification of olecranon fractures based on CT imaging. This might lead to inconsistent fracture classification in both scientific and clinical setting.
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Affiliation(s)
- Andreas Harbrecht
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Michael Hackl
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Nadine Ott
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Stephan Uschok
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
- Orthopädische Chirurgie München, Munich, Germany
| | - Lars P. Müller
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tim Leschinger
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
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Essa A, Levi A, Ron TG, Ner EB, Finestone AS, Tamir E. The role of three dimension computed tomography in Lisfranc injury diagnosis. Injury 2022; 53:3530-3534. [PMID: 35927069 DOI: 10.1016/j.injury.2022.07.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 05/10/2022] [Accepted: 07/18/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the intra/inter observer and diagnostic reliability of 3-dimensional (3D) model reconstruction computed tomography (CT) compared to the traditional two-dimensional (2D) CT when evaluating Lisfranc (LF) injuries. METHODS A retrospective study was performed on CT studies of patients with clinically suspected LF injuries examined in the emergency department at medium size medical center. Each CT study was evaluated for metatarsal fractures and subluxations employing both standard 2D and 3D CT model reconstruction. Four orthopaedists, 2 senior and 2 residents, were assigned to review and evaluate each CT. Each CT study was reviewed twice by each reader in a randomized order. Descriptive statistics were calculated for all measured variables. The intra-observer and inter-observer agreement Kappa coefficients were calculated to evaluate reliability and reproducibility between and within readers for each modality. RESULTS The study included 44 patients. Median age was 41.4 years (interquartile range, 23-58). The intra-observer and inter-observer reliability was good (intra-observer; 3D Kappa; 0.76 and 2D Kappa 0.73 p<0.001, inter-observer; 3D Kappa 0.68, 2D Kappa 0.63 and combined 2D and 3D kappa 0.68, p<0.001). Three dimensional CT was found to be more sensitive than 2D CT, specifically when evaluating for second metatarsal dislocation (sensitivity: 70% vs 47%). Combined evaluation of 2D and 3D CT, greatly improved sensitivity rate to 85.7%. In terms of fracture diagnosis, combined evaluation of 2D and 3D CT showed higher sensitivity and specificity rates as compared to 2D or 3D alone. CONCLUSION The employment of 3D CT in LF injury diagnosis, in isolation and in combination with 2D CT, seems to improve the diagnostic accuracy and reliability between and within observers compared to 2D CT alone.
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Affiliation(s)
- Ahmad Essa
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel.
| | - Almog Levi
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel
| | - Tzvi Guy Ron
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel
| | - Eran Beit Ner
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel
| | - Aharon S Finestone
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Ramat Aviv 6997801, Israel
| | - Eran Tamir
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center, Zerifin, Kfar-Qassim 7033001, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Ramat Aviv 6997801, Israel
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Chelli M, Gasbarro G, Lavoué V, Gauci MO, Raynier JL, Trojani C, Boileau P. The reliability of the Neer classification for proximal humerus fractures: A survey of orthopedic shoulder surgeons. JSES Int 2022; 6:331-337. [PMID: 35572425 PMCID: PMC9091924 DOI: 10.1016/j.jseint.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals. Methods All articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard. Results Survey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders (P = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors. Discussion In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized.
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Affiliation(s)
- Mikaël Chelli
- ICR Nice - Institute for Reconstructive Bone and Joint Surgery and Sport Surgery, Groupe Kantys, Nice, Provence-Alpes-Côte d'Azur, France
- Université Côte d'Azur, Inria, Epione Research Team, Nice, Provence-Alpes-Côte d'Azur, France
- Corresponding author: Mikaël Chelli, MD, MSc, ICR - 7 avenue Durante, 06000 Nice, Provence-Alpes-Côte d'Azur, France.
| | - Gregory Gasbarro
- Orthopaedic Specialty Hospital, Mercy Medical Center, Baltimore, MD, USA
| | - Vincent Lavoué
- ICR Nice - Institute for Reconstructive Bone and Joint Surgery and Sport Surgery, Groupe Kantys, Nice, Provence-Alpes-Côte d'Azur, France
| | - Marc-Olivier Gauci
- University Institute for Locomotion and Sports (iULS), University Côte d'Azur, Nice, Provence-Alpes-Côte d'Azur, France
| | - Jean-Luc Raynier
- ICR Nice - Institute for Reconstructive Bone and Joint Surgery and Sport Surgery, Groupe Kantys, Nice, Provence-Alpes-Côte d'Azur, France
| | - Christophe Trojani
- ICR Nice - Institute for Reconstructive Bone and Joint Surgery and Sport Surgery, Groupe Kantys, Nice, Provence-Alpes-Côte d'Azur, France
| | - Pascal Boileau
- ICR Nice - Institute for Reconstructive Bone and Joint Surgery and Sport Surgery, Groupe Kantys, Nice, Provence-Alpes-Côte d'Azur, France
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Cocco LF, Aihara AY, Lopes FPPL, Werner H, Franciozi CE, dos Reis FB, Luzo MVM. Three-dimensional printing models increase inter-rater agreement for classification and treatment of proximal humerus fractures. Patient Saf Surg 2022; 16:5. [PMID: 35057844 PMCID: PMC8772160 DOI: 10.1186/s13037-021-00312-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Proximal humerus fractures (PHF) are frequent, however, several studies show low inter-rater agreement in the diagnosis and treatment of these injuries. Differences are usually related to the experience of the evaluators and/or the diagnostic methods used. This study was designed to investigate the hypothesis that shoulder surgeons and diagnostic imaging specialists using 3D printing models and shoulder CT scans in assessing proximal humerus fractures. METHODS We obtained 75 tomographic exams of PHF to print three-dimensional models. After, two shoulder surgeons and two specialists in musculoskeletal imaging diagnostics analyzed CT scans and 3D models according to the Neer and AO/OTA group classification and suggested a treatment recommendation for each fracture based on the two diagnostic methods. RESULTS The classification agreement for PHF using 3D printing models among the 4 specialists was moderate (global k = 0.470 and 0.544, respectively for AO/OTA and Neer classification) and higher than the CT classification agreement (global k = 0.436 and 0.464, respectively for AO/OTA and Neer). The inter-rater agreement between the two shoulder surgeons were substantial. For the AO/OTA classification, the inter-rater agreement using 3D printing models was higher (k = 0.700) than observed for CT (k = 0.631). For Neer classification, inter-rater agreement with 3D models was similarly higher (k = 0.784) than CT images (k = 0.620). On the other hand, the inter-rater agreement between the two specialists in diagnostic imaging was moderate. In the AO/OTA classification, the agreement using CT was higher (k = 0.532) than using 3D printing models (k = 0.443), while for Neer classification, the agreement was similar for both 3D models (k = 0.478) and CT images (k = 0.421). Finally, the inter-rater agreement in the treatment of PHF by the 2 surgeons was higher for both classifications using 3D printing models (AO/OTA-k = 0.818 for 3D models and k = 0.537 for CT images). For Neer classification, we saw k = 0.727 for 3D printing models and k = 0.651 for CT images. CONCLUSION The insights from this diagnostic pilot study imply that for shoulder surgeons, 3D printing models improved the diagnostic agreement, especially the treatment indication for PHF compared to CT for both AO/OTA and Neer classifications On the other hand, for specialists in diagnostic imaging, the use of 3D printing models was similar to CT scans for diagnostic agreement using both classifications. TRIAL REGISTRATION Brazil Platform under no. CAAE 12273519.7.0000.5505.
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Affiliation(s)
- Luiz Fernando Cocco
- Department of Orthopedic, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital Samaritano Higienópolis Américas Serviços Médicos, São Paulo, Brasil
| | - André Yui Aihara
- Department of Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | - Carlos Eduardo Franciozi
- Department of Orthopedic, Orthopaedic Surgeon, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Fernando Baldy dos Reis
- Department of Orthopedic, Orthopaedic Surgeon, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Marcus Vinicius Malheiros Luzo
- Department of Orthopedic, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital Samaritano Higienópolis Américas Serviços Médicos, São Paulo, Brasil
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Liu G, Guo X, Zhao Q, Qin B, Lu J, Bao D, Fu S. A new biomechanical classification system for split fractures of the humeral greater tuberosity: guidelines for surgical treatment. J Orthop Surg Res 2021; 16:692. [PMID: 34819107 PMCID: PMC8614056 DOI: 10.1186/s13018-021-02839-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Split fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method. Methods We created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCT) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed. Results The mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicate that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment. Conclusions Biomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.
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Affiliation(s)
- Gang Liu
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Center for Orthopedic Diseases Research, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Expert Workstation in Luzhou, Luzhou, Sichuan, China.,Clinical Base of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Guangdong Province Medical 3D Printing Application Transformation Engineering Technology Research Center, Luzhou, Sichuan, China
| | - Xiaoguang Guo
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Center for Orthopedic Diseases Research, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Expert Workstation in Luzhou, Luzhou, Sichuan, China.,Clinical Base of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Guangdong Province Medical 3D Printing Application Transformation Engineering Technology Research Center, Luzhou, Sichuan, China
| | - Qian Zhao
- Department of Breast Surgery, Luzhou Hospital of Traditional Chinese Medicine, Luzhou, Sichuan, China
| | - Bo Qin
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Center for Orthopedic Diseases Research, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Expert Workstation in Luzhou, Luzhou, Sichuan, China.,Clinical Base of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Guangdong Province Medical 3D Printing Application Transformation Engineering Technology Research Center, Luzhou, Sichuan, China
| | - Junjie Lu
- Department of Orthopedics, YiXing Traditional Chinese Medicine Hospital, Yixing, Jiangsu, China
| | - Dingsu Bao
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Center for Orthopedic Diseases Research, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China.,Expert Workstation in Luzhou, Luzhou, Sichuan, China.,Clinical Base of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Guangdong Province Medical 3D Printing Application Transformation Engineering Technology Research Center, Luzhou, Sichuan, China
| | - Shijie Fu
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China. .,Center for Orthopedic Diseases Research, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China. .,Expert Workstation in Luzhou, Luzhou, Sichuan, China. .,Clinical Base of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Guangdong Province Medical 3D Printing Application Transformation Engineering Technology Research Center, Luzhou, Sichuan, China.
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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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Principles of Locking Plate Fixation of Proximal Humerus Fractures. J Am Acad Orthop Surg 2021; 29:e523-e535. [PMID: 33539058 DOI: 10.5435/jaaos-d-20-00558] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/24/2020] [Indexed: 02/01/2023] Open
Abstract
Proximal humerus fractures are common, particularly in elderly patients and those with osteopenia or osteoporosis. Although nonsurgical management results in satisfactory outcomes for most patients, surgical treatment is indicated in select cases. Despite an increasing trend toward arthroplasty, open reduction and internal fixation of proximal humerus fractures can still provide excellent clinical outcomes. Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy. In particular, understanding reliable regions of biomechanically superior bone can help prevent failure of fixation. Biomechanical studies have shown that locked plating of proximal humerus fractures provides stable fixation. Cadaveric and finite element models underscore the importance of screw placement in the posteromedial metaphysis. When medial column support is challenging to obtain, or when bone quality is poor, augmentation with bone autograft, allograft, and/or synthetic composites can improve the biomechanics of internal fixation constructs. The purpose of this review is to outline the anatomic, biologic, and biomechanical principles of plate fixation for proximal humerus fractures to provide evidence-based recommendations for optimizing fixation and preventing fixation failure.
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Bougher H, Buttner P, Smith J, Banks J, Na HS, Forrestal D, Heal C. Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures. JSES Int 2021; 5:198-204. [PMID: 33681838 PMCID: PMC7910723 DOI: 10.1016/j.jseint.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Hypothesis This study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants. Methods Thirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (κ), percentage agreement, and 95% confidence intervals (CIs). Results Seven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (κ = 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and κ = 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (κ = 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (κ = 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants. Conclusion Three-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching.
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Affiliation(s)
- Hannah Bougher
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
| | | | | | - Jennifer Banks
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
| | - Hyun Su Na
- Mackay Base Hospital, Mackay, QLD, Australia
| | - David Forrestal
- Queensland University of Technology, Brisbane City, QLD, Australia
| | - Clare Heal
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
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Do 3-D Printed Handheld Models Improve Surgeon Reliability for Recognition of Intraarticular Distal Radius Fracture Characteristics? Clin Orthop Relat Res 2020; 478:2901-2908. [PMID: 32667759 PMCID: PMC7899383 DOI: 10.1097/corr.0000000000001356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined. QUESTIONS/PURPOSES (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model? METHODS We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test. RESULTS We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09). CONCLUSIONS Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius. LEVEL OF EVIDENCE Level II, diagnostic study.
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Stoddart M, Pearce O, Smith J, McCann P, Sheridan B, Al-Hourani K. Proximal Humerus Fractures: Reliability of Neer Versus AO Classification on Plain Radiographs and Computed Tomography. Cureus 2020; 12:e8520. [PMID: 32656034 PMCID: PMC7346293 DOI: 10.7759/cureus.8520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone. Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient. Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005). Conclusion: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO.
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Affiliation(s)
- Michael Stoddart
- Trauma and Orthopaedics, Royal National Orthopaedic Hospital, London, GBR
| | - Oliver Pearce
- Trauma and Orthopaedics, Southmead Hospital, Bristol, GBR
| | - James Smith
- Orthopaedics, Southmead Hospital, Bristol, GBR
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Three-dimensional computed tomography reconstruction improves the reliability of tibial pilon fracture classification and preoperative surgical planning. Arch Orthop Trauma Surg 2020; 140:187-195. [PMID: 31529150 DOI: 10.1007/s00402-019-03259-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Indexed: 02/09/2023]
Abstract
PURPOSE In the present study, we aimed to evaluate the impact of two-dimensional multi-planar computed tomography (2D-MP-CT) scans and three-dimensional surface rendering computed tomography reconstruction (3D-SR-CT) on the inter- and intra-observer reliability of four commonly used classification systems for tibial pilon fractures, and on the reliability and validity of surgical treatment planning for fracture fixation. METHODS Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for bone graft augmentation. Fractures were first evaluated using 2D-MP-CT, followed by 3D-SR-CT. We calculated the Kappa values for the correlation between the fracture classifications, types of surgical approaches, implant positions, and bone graft recommendations by the observers. Furthermore, we assessed the correlation between the treatment plans recommended by the observers and the actual surgical procedure performed. RESULTS All classifications showed poor inter-observer reliability and moderate intra-observer reliability with 2D-MP-CT scans. The inter-observer reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications improved to moderate, whereas the intra-observer reliability of the AO/OTA classification improved to good with additional 3D-SR-CT. The correlation between the suggested and the actually performed surgical approaches was poor with 2D-MP-CT, but improved to moderate with 3D-SR-CT. The suggested plate positions showed a moderate correlation with the actually performed plating; although the correlation improved significantly, it remained moderate with 3D-SR-CT. CONCLUSION The use of 3D-SR-CT reconstruction can improve the reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications. Furthermore, three-dimensional imaging enables a more valid planning of the surgical approach and implant position.
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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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Intraobserver and Interobserver Reliability of Radiographic Analysis of Proximal Humerus Fractures in Adolescents. J Pediatr Orthop 2019; 39:e125-e129. [PMID: 28984686 DOI: 10.1097/bpo.0000000000001083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. METHODS Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. RESULTS Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. CONCLUSIONS Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. LEVEL OF EVIDENCE Level III-diagnostic.
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Cho Y, Lee P, Lee C, Chen C, Lin Y. Three-dimensional CT Improves the Reproducibility of Stability Evaluation for Intertrochanteric Fractures. Orthop Surg 2018; 10:212-217. [PMID: 30152606 PMCID: PMC6594481 DOI: 10.1111/os.12396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 04/03/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Femoral intertrochanteric fractures are among the most common fractures in the elderly. There are various classification systems in intertrochanteric fractures. The aim of these classification systems is to help surgeons choose an appropriate treatment. The treatment of femoral intertrochanteric fractures depends on the results of a stability evaluation using imaging studies. However, it is difficult to evaluate the true fracture line using plain X-ray films, especially on the sagittal plane and for intertrochanteric fractures with complex morphologies. The aim of the current study was to determine whether three-dimensional CT (3DCT) improves the reproducibility of stability evaluation for femoral intertrochanteric fractures. METHODS This was a single-center observational study of intertrochanteric fractures. We retrospectively collected patients in our hospital with intertrochanteric fractures that underwent plain X-ray (anteroposterior, lateral view) CT scans with axial images (2DCT) and 3DCT for an injured hip between 1 December 2011 and 30 November 2015. The exclusion criteria were pathological fractures (due to metastasis or primary bone tumors) and previous intertrochanteric surgery. During this period, 61 patients were enrolled. Two patients were excluded because lateral view X-rays were not available. A total of 59 patients (27 women, 32 men) with an average age of 77 years (range, 55-96 years) were included in our final analysis. The stability evaluation (i.e. stable or unstable) and implant choices (i.e. dynamic hip screws or Gamma nail) were recorded independently by four observers (two attending physicians and two residents). All images were reviewed and classified using the AO/OTA and Evans modified by Jensen (EVJE) classification systems. The session was repeated after a 3-month wash-out period. The inter-observer agreement was evaluated using the Kappa test. RESULTS The inter-observer agreements, measured by the mean weighted kappa values (expressed as X-ray vs 3DCT) were as follows: For stability evaluation, the mean kappa values for attending physicians and residents were 0.68 versus 0.76 and 0.55 versus 0.56. For implant choices, the mean kappa values for attending physicians and residents were 0.68 versus 0.76 and 0.57 versus 0.65. For AO/OTA classification, the values for attending physicians and residents were 0.67 versus 0.65 and 0.70 versus 0.81. For EVJE classification, the values for attending physicians and residents were 0.66 versus 0.63 and 0.56 versus 0.55. CONCLUSIONS Three-dimensional CT improved the reproducibility of stability evaluation for femoral intertrochanteric fractures. Preoperative CT scanning may provide a diagnostic benefit for evaluating the stability of intertrochanteric fractures.
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Affiliation(s)
- Yi‐cheng Cho
- Department of OrthopaedicsTaichung Veterans General HospitalTaichungTaiwan
| | - Pei‐yuan Lee
- Department of OrthopaedicsShow‐Chwan Memorial HospitalChanghuaTaiwan
| | - Cheng‐hung Lee
- Department of OrthopaedicsTaichung Veterans General HospitalTaichungTaiwan
- Department of BiotechnologyHung Kuang UniversityTaichungTaiwan
| | - Chih‐hui Chen
- Department of OrthopaedicsTaichung Veterans General HospitalTaichungTaiwan
- School of MedicineNational Yang‐Ming UniversityTaichung CityTaiwan
| | - Yu‐min Lin
- Department of OrthopaedicsTaichung Veterans General HospitalTaichungTaiwan
- Department of MedicineChung Shan Medical UniversityTaichung CityTaiwan
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A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory. J Shoulder Elbow Surg 2018; 27:940-949. [PMID: 29415824 DOI: 10.1016/j.jse.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/29/2017] [Accepted: 12/03/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study regards a volumetric analysis of proximal humeral fractures. The main purpose was to investigate the head displacement in relation to the shaft and its link to volume reductions ("bone loss") of the anatomic segments interposed between the head and the shaft: the tuberosities and the calcar. We call this area "control volume." METHODS In 20 fractures, we used 3-dimensional virtual reconstruction to create a reference system that divides geometrically the control volume and allows the evaluation of displacement angles of the humeral head. We calculated the volumetric reduction of control volume segments for each fracture through a specific mathematical protocol. RESULTS The measurement of the head displacement angles in 20 fractures led to following results: in the coronal plane, 10 varus, 6 valgus, 4 neutral; in the sagittal plane, 6 anterior tilt, 9 posterior tilt, 5 neutral position. There was a reduction of control volume in 19 of 20 fractures. Only in 1 fracture was the control volume intact and the fracture was nonimpacted. In 19 impacted fractures, the volume reduction was variable (4% minimum loss, 98% maximum loss). In head varus position, loss was greater in the medial area than in the lateral area. There was generally a clear correspondence between the positions assumed by the head and the volumetric losses of the respective control volume segments. CONCLUSIONS The control volume is an important anatomic and functional area of the proximal humerus. A morphovolumetric 3-dimensional approach improves knowledge about pathomorphology of proximal humeral fractures.
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Tuberculum-majus-Frakturen und Rotatorenmanschettenläsion. ARTHROSKOPIE 2017. [DOI: 10.1007/s00142-017-0139-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Zusammenfassung. Zusammenfassung: Die Komplikationsrate nach Osteosynthese von proximalen Humerusfrakturen ist trotz neu entwickelten Implantaten hoch. Wir sind der Meinung, dass die hohe Individualität der Patienten auch einen möglichst individuellen Therapieansatz benötigt. Somit definierten wir einen evidenzbasierten Behandlungsalgorithmus, der die Patientenindividualität und das ganze Behandlungsspektrum beinhalten sollte. Wir suchten dabei nach einem optimalen Weg zwischen Risiko (Komplikationen) und Ertrag (Schulterfunktion). Vor allem die Lebensqualität sollte nach der Frakturbehandlung wieder möglichst gut sein. Die ersten Resultate unserer prospektiven Untersuchung sind vielversprechend. Die konservativen Wege im Algorithmus scheinen gut zu funktionieren, nur sehr selten musste davon abgewichen werden. Es zeigt sich jedoch, dass vor allem die Osteosynthesen noch immer komplikationsbelastet sind. Diesbezüglich gilt es, den Algorithmus und die chirurgische Technik in Zukunft noch zu verbessern.
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Affiliation(s)
| | - Bernhard Jost
- 1 Orthopädie und Traumatologie, Kantonsspital St. Gallen
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Wennergren D, Stjernström S, Möller M, Sundfeldt M, Ekholm C. Validity of humerus fracture classification in the Swedish fracture register. BMC Musculoskelet Disord 2017; 18:251. [PMID: 28601085 PMCID: PMC5466790 DOI: 10.1186/s12891-017-1612-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/02/2017] [Indexed: 01/15/2023] Open
Abstract
Background The ability to correctly classify fractures is of importance for choosing the appropriate treatment and for providing appropriate data for research and quality registers. In the Swedish Fracture Register (SFR) fractures of all types are registered by the attending physician, often a junior doctor. For the majority of fractures, a modified AO/OTA classification is used. This study aimed to validate the accuracy of classification of humerus fractures in the SFR and also at providing insight into inherent classification uncertainties. Methods One hundred and sixteen humerus fractures (among them 90 proximal) were retrieved by computer randomisation from the SFR and reassessed independently at two occasions, 6 weeks apart, by three senior orthopaedic surgeons blinded to patient information and a consensus “gold standard” classification was established. This was compared with the classifications that had been entered into the register. Results The agreement between gold standard classification and original classification in the SFR was kappa = 0.57 for all humerus fractures. For proximal humerus fractures kappa-coefficient for intra-observer agreement was 0.593, 0.599 and 0.752 for the three observers respectively. Taking into account the similarities between certain fracture groups, a modified calculation of agreement was performed. With this modification the intra-observer agreement was 0.910-0.974 and inter-observer agreement was 0.912. Conclusion The classification of humerus fractures in the Swedish Fracture Register was just as accurate as in previous studies, i.e. moderate as defined by Landis and Koch. However, when we introduced a modified analysis, that takes into account the similarities between certain fractures, the accuracy was “near perfect”.
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Affiliation(s)
- David Wennergren
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Mölndal, Sweden.
| | - Stina Stjernström
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Mölndal, Sweden
| | - Michael Möller
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Mölndal, Sweden
| | - Mikael Sundfeldt
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Mölndal, Sweden
| | - Carl Ekholm
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Mölndal, Sweden
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Meleán P, Munjin A, Pérez A, Rojas JT, Cook E, Fritis N. Coronal displacement in proximal humeral fractures: correlation between shoulder radiographic and computed tomography scan measurements. J Shoulder Elbow Surg 2017; 26:56-61. [PMID: 27521137 DOI: 10.1016/j.jse.2016.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to analyze if there is a correlation in displacement measurements in coronal projections between shoulder radiographs and computed tomography (CT) scans in patients with proximal humeral fractures (PHFs). METHODS A comparative, retrospective analysis of images from our database was performed. Ninety-seven cases with PHFs with radiographs and CT scans were included. Four evaluators measured PHF displacement using the following: metaphyseal extension (ME), medial calcar (MC) medialization, apex-tuberosity distance (ATD), and cervicodiaphyseal (CD) angle. Measurement reliability was evaluated with a pilot sample by performing intraclass coefficient correlation analysis. Surgery indication according to displacement (CD angle <105° or >155° and ATD <3 mm) and agreement analysis were assessed by κ tests. RESULTS All evaluated parameters presented correlations among methods for intrarater and inter-rater reliability. All measurements showed significant differences (ME of 1.2 ± 6 mm, P = .034; MC of 1 ± 5 mm, P = .041; ATD of 2.6 ± 5 mm, P = .001; and CD angle of 9° ± 16°, P = .001). Regarding indications for treatment type relating to ATD and CD angle, there was agreement between CT scans and radiographs in 66 of 97 cases (κ = 0.351, P < .001). Twelve cases with surgical indications by CT scans had conservative indications by radiographs, whereas in 19 cases with conservative indications by CT scans, radiographic measurements suggested surgical treatment. CONCLUSION This study documented regular concordance between radiographs and CT scans for coronal displacement measurements in PHFs. Statistical differences were documented for all measurements. Webelieve that ATD and CD angle differences are clinically relevant (mean, 3 mm and 9°, respectively) because these differences might change the type of treatment.
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Affiliation(s)
- Patricio Meleán
- Shoulder Surgery and Upper Extremity Arthroscopy Unit, Orthopedics Department, Hospital del Trabajador, Santiago, Chile.
| | | | - Alfonso Pérez
- Upper Extremity Unit, Orthopedics Department, Hospital del Trabajador, Santiago, Chile
| | - José Tomás Rojas
- Orthopedics Department, Hospital del Trabajador, Santiago, Chile
| | - Erik Cook
- Shoulder Surgery and Upper Extremity Arthroscopy Unit, Orthopedics Department, Hospital del Trabajador, Santiago, Chile
| | - Nelson Fritis
- Shoulder Surgery and Upper Extremity Arthroscopy Unit, Orthopedics Department, Hospital del Trabajador, Santiago, Chile
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The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification. J Orthop Sci 2016; 21:596-602. [PMID: 27324664 DOI: 10.1016/j.jos.2016.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 05/26/2016] [Accepted: 05/28/2016] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures. MATERIALS AND METHODS Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated. RESULTS Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23-0.62) and Neer (κ = 0.29; 0.09-0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56-0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29-0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53-0.72) and Neer (κ = 0.51; 0.39-0.58). Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27-0.59) and Neer (κ = 0.40; 0.15-0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38-0.66) and Neer (κ = 0.42; 0.35-0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45-0.64) and substantial for Neer (κ = 0.63; 0.48-0.79). CONCLUSIONS The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.
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Abstract
Greater tuberosity fractures of the humerus can be successfully treated nonsurgically in most patients. However, as little as 3 to 5 mm of superior greater tuberosity displacement may adversely affect rotator cuff biomechanics and lead to subacromial impingement in patients who are active. In these cases, surgical treatment is recommended. Multiple surgical techniques include open and arthroscopic options tailored to fracture morphology, and strategies for repair include the use of suture anchors, transosseous sutures, tension bands, and plates/screws. Three classification systems are commonly used to describe greater tuberosity fractures: the AO, Neer, and morphologic classifications. Several hypotheses have been discussed for the mechanism of greater tuberosity fractures and the deforming forces of the rotator cuff, and the use of advanced imaging is being explored.
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Spross C, Grueninger P, Gohil S, Dietrich M. Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus. JBJS Essent Surg Tech 2015; 5:e15. [PMID: 30473923 PMCID: PMC6221419 DOI: 10.2106/jbjs.st.n.00106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate. Step 1 Preoperative Planning To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes. Step 2 Patient Positioning Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier. Step 3 Approach The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury. Step 4 Reduction and Fixation of the Tuberosities the Key to Obtaining Marionette-Like Control The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like. Step 5 Fracture Reduction After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate. Step 6 Fixation Implant-Specific Considerations Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities. Step 7 Tenotomy or Tenodesis of the Long Biceps Tendon Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval. Step 8 Wound Closure Do not close the deltopectoral interval. Step 9 Rehabilitation As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol. Results In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- C Spross
- Department of Orthopaedic Trauma, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch (Western Australia) 6150, Australia. E-mail address:
| | - P Grueninger
- Department of Traumatology and Orthopaedics, Stadtspital Waid, Tieche Strasse 99, 8037 Zurich, Switzerland. E-mail address for M. Dietrich:
| | - S Gohil
- Department of Orthopaedic Trauma, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch (Western Australia) 6150, Australia. E-mail address:
| | - M Dietrich
- Department of Traumatology and Orthopaedics, Stadtspital Waid, Tieche Strasse 99, 8037 Zurich, Switzerland. E-mail address for M. Dietrich:
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The effect of three-dimensional computed tomography reconstructions on preoperative planning of tibial plateau fractures: a case-control series. BMC Musculoskelet Disord 2015; 16:144. [PMID: 26071394 PMCID: PMC4465331 DOI: 10.1186/s12891-015-0608-0] [Citation(s) in RCA: 10] [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: 02/05/2015] [Accepted: 05/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tibial plateau fractures are a common intra-articular injury for which computed tomography (CT) scans are routinely used for preoperative planning. Three-dimensional reconstructions of CT scans have been increasingly investigated in recent years, however their role has yet to be defined. We wish to investigate the role of three-dimensional computed tomography reconstructions (3D-CT) in the preoperative planning of tibial plateau fractures. METHODS Twelve cases of tibial plateau fractures including plain film radiographs and conventional CT scans were distributed to 21 observers (orthopaedic residents and consultants). The observers filled out a preoperative plan checklist created for this study. Three months later the same cases were distributed, in random order, this time including 3D-CT reconstructions. The same preoperative checklists were completed, and compared to the previous checklists. RESULTS The preoperative plan checklist was able to detect differences between cases and between observers. No significant differences were detected between the total plan scores when comparing conventional CT to 3D-CT. Sub-analysis of plan specifics (incisions, hardware, adjuncts) was also not significantly different. The level of training of the observer or the fracture complexity did not affect these results. CONCLUSIONS No significant changes were made to observer's preoperative plans with the addition of 3D-CT. 3D-CT reconstructions come at a cost to the system, and therefore their usefulness should be investigated prior to widespread use. Our study demonstrates that the addition of 3D-CT reconstructions to the preoperative workup of tibial plateau fractures did not change management plans when compared to plans made using traditional CT-scans.
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Clinical investigation for displaced proximal humeral fractures in the elderly: a randomized study of two surgical treatments: reverse total prosthetic replacement versus angular stable plate Philos (The DELPHI-trial). BMC Musculoskelet Disord 2014; 15:323. [PMID: 25261913 PMCID: PMC4247153 DOI: 10.1186/1471-2474-15-323] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/16/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge. METHODS/DESIGN This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected. DISCUSSION This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01737060.
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Berkes MB, Dines JS, Little MTM, Garner MR, Shifflett GD, Lazaro LE, Wellman DS, Dines DM, Lorich DG. The Impact of Three-Dimensional CT Imaging on Intraobserver and Interobserver Reliability of Proximal Humeral Fracture Classifications and Treatment Recommendations. J Bone Joint Surg Am 2014; 96:1281-1286. [PMID: 25100775 DOI: 10.2106/jbjs.m.00199] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The classification systems for fractures of the proximal part of the humerus provide low interobserver and intraobserver reliability when radiographs or two-dimensional computed tomography scans are used. The purpose of this investigation was to determine whether the use of three-dimensional computed tomography scans could improve interobserver and intraobserver reliability of AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) and Neer classifications and treatment recommendations. METHODS Two trauma surgeons, one shoulder surgeon, two senior orthopaedic residents, and two junior orthopaedic residents reviewed the radiographs and two and three-dimensional computed tomography scans of forty fractures of the proximal part of the humerus. Each imaging modality was reviewed in isolation, and fractures were classified according to the Neer and AO/OTA classifications and treatment recommendations were provided. This process was repeated for intraobserver analysis. Interobserver agreement was calculated within and between levels of training for each classification and treatment recommendation with respect to radiographs and two and three-dimensional computed tomography scans. RESULTS Among attending orthopaedic surgeons and senior residents, the use of three-dimensional computed tomography did not improve agreement compared with the use of two-dimensional computed tomography for the Neer classification based on planes, the AO/OTA classification, or the treatment recommendation, but it did improve agreement among junior residents. Comparing between levels of training, three-dimensional computed tomography increased agreement only between junior residents and more experienced reviewers for the Neer classification based on planes and for the AO/OTA classification but not for the treatment recommendation. Intraobserver agreement for each reviewer for classification and treatment ranged from slight to fair and was not improved through the use of three-dimensional computed tomography. CONCLUSIONS In this investigation, the use of three-dimensional computed tomography imaging did not offer improved interobserver and intraobserver agreement compared with the use of two-dimensional computed tomography imaging with regard to classification and treatment of fractures of the proximal part of the humerus, except among reviewers with limited clinical experience. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marschall B Berkes
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Joshua S Dines
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Milton T M Little
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Matthew R Garner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Grant Daniel Shifflett
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Lionel E Lazaro
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - David S Wellman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - David M Dines
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
| | - Dean G Lorich
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Berkes:
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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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Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures. Orthop Traumatol Surg Res 2014; 100:275-80. [PMID: 24709303 DOI: 10.1016/j.otsr.2014.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 11/12/2013] [Accepted: 01/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal humerus fractures are difficult to characterise and to classify according to the AO system. In this multicentre study, our objectives were to assess the usefulness of computed tomography (CT) and to measure intra-observer and inter-observer reliability according to observer experience. MATERIALS AND METHODS An online survey of professional practice was performed using a questionnaire based on a clinical case. Participants were asked to determine the AO classification using radiographs then to reappraise their answers after the addition of CT images. For the reliability study, 16 observers in five centres evaluated radiographs and CT scans of 26 distal humerus fractures. They used the radiographs to determine the AO classification and assess the main fracture characteristics then reappraised their findings after adding the CT images. The radiographs and 2D CT images were read twice at an interval of 2 weeks, and during the second reading, 3D CT images were available also. At least 1 month later, the same observers performed similar readings 2 weeks apart (radiographs and 2D CT images at the first reading and addition of 3D CT images at the second reading). RESULTS Correct fracture classification was achieved in 95% of cases with the CT images compared to only 73% with the radiographs. CT led to diagnostic and therapeutic changes in 90% and 25% of cases, respectively. Inter-observer reliability was poor for both AO classification and fracture characteristics, not only with the radiographs and 2D CT images, but also with the added 3D CT images. In contrast, intra-observer reliability improved after the addition of 3D CT images. Assessment accuracy was influenced by image quality and geographic origin of the observer but not by observer experience. CONCLUSION CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation. LEVEL OF EVIDENCE Level III.
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Matsushigue T, Pagliaro Franco V, Pierami R, Jun Sugawara Tamaoki M, Archetti Netto N, Hide Matsumoto M. Do computed tomography and its 3D reconstruction increase the reproducibility of classifications of fractures of the proximal extremity of the humerus? Rev Bras Ortop 2014; 49:174-7. [PMID: 26229795 PMCID: PMC4511748 DOI: 10.1016/j.rboe.2014.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 08/01/2013] [Indexed: 11/04/2022] Open
Abstract
Objective to determine whether 3D reconstruction images from computed tomography (CT) increase the inter and intraobserver agreement of the Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification systems. Methods radiographic images and tomographic images with 3D reconstruction were obtained in three shoulder positions and were analyzed on two occasions by four independent observers. Results the radiographic evaluation demonstrated that using CT improved the inter and intraobserver agreement of the Neer classification. This was not seen with the AO classification, in which CT was only shown to increase the interobserver agreement. Conclusion use of 3D CT allows better evaluation of fractures with regard to their component parts and their displacements, but nevertheless the intraobserver agreement presented is less than ideal.
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Affiliation(s)
| | | | - Rafael Pierami
- Universidade Federal de São Paulo, São Paulo, SP, Brazil
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A tomografia computadorizada e sua reconstrução 3D aumentam a reprodutibilidade das classificações das fraturas da extremidade proximal do úmero? Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Harnoss T, Felkel B, Döbele S, Schreiber U, Lenich A. Virtual morphological comparison of three intramedullary nailing systems for the treatment of proximal humeral fractures. Injury 2014; 45 Suppl 1:S24-8. [PMID: 24268131 DOI: 10.1016/j.injury.2013.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 02/02/2023]
Abstract
Proximal humerus fractures treated with intramedullary nails show good results. However, the correct anatomical reconstruction of four-part fractures is demanding especially when using intramedullary nails. We therefore compared different intramedullary nail designs for the proximal humerus in a virtual morphological manner. Three commercially available nailing systems where virtually implanted in virtually generated reproducible four-part fractures of 25 digitised humeri. The objective of this study was to quantify and characterise the anatomical position of the proximal screws in the most vulnerable case of a four-part fracture. Taking into account a minimum distance of 5mm between the screw head and the fracture line, osteosynthesis was possible in 54 out of 75 cases. Difficulties placing the proximal screws could be observed at the localisation of the lower lesser tubercle or/and at the sulcus intertubercularis. This morphological analysis could be the basis for choosing the most sufficient implant intra operatively or even improving the nail design.
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Affiliation(s)
- Tobias Harnoss
- St. Vinzenz Clinic Pfronten, Department for Surgery and Orthopedics, Kirchenweg 15, 87459 Pfronten, Germany.
| | - Bernd Felkel
- Munich University of Applied Sciences, Lothstr. 34, 80335 Munich, Germany.
| | - Stefan Döbele
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik, Eberhard Karls Universität Tübingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany.
| | - Ulrich Schreiber
- Munich University of Applied Sciences, Lothstr. 34, 80335 Munich, Germany.
| | - Andreas Lenich
- Clinic of Orthopedics and Traumatology, Department for Sport Orthopedics, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675 Munich, Germany.
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Guitton TG, Kinaci A, Ring D. Diagnostic accuracy of 2- and 3-dimensional computed tomography and solid modeling of coronoid fractures. J Shoulder Elbow Surg 2013; 22:782-6. [PMID: 23594717 DOI: 10.1016/j.jse.2013.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/30/2013] [Accepted: 02/18/2013] [Indexed: 02/01/2023]
Abstract
PURPOSE This study measured the diagnostic performance characteristics and reliability of 2-dimensional (2DCT) and 3-dimensional (3DCT) computed tomography images and modeling of coronoid fractures. METHOD The treating surgeon and first assistant evaluated 28 fractures for fracture type, specific characteristics, and proposed treatment. The observers evaluated the fractures 4 times: first based upon 2DCT computed images and radiographs; second with the addition of 3DCT images; third with the addition of 3D models; and finally based upon intra-operative exposure, which was considered the reference standard. RESULTS The diagnostic performance characteristics did not improve with more sophisticate imaging and models. The addition of 3DCT reconstructions improved the inter-observer reliability for fracture classification, characteristics, and proposed treatment. CONCLUSION More sophisticated images and modeling improved reliability but not accuracy when characterizing coronoid fractures.
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Affiliation(s)
- Thierry G Guitton
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA 02114, USA
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Liu X, Jiang H, Lang Y, Wang H, Sun N. A novel stereoscopic projection display system for CT images of fractures. Exp Ther Med 2013; 5:1677-1682. [PMID: 23837053 PMCID: PMC3702712 DOI: 10.3892/etm.2013.1044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/22/2013] [Indexed: 11/09/2022] Open
Abstract
The present study proposed a novel projection display system based on a virtual reality enhancement environment. The proposed system displays stereoscopic images of fractures and enhances the computed tomography (CT) images. The diagnosis and treatment of fractures primarily depend on the post-processing of CT images. However, two-dimensional (2D) images do not show overlapping structures in fractures since they are displayed without visual depth and these structures are too small to be simultaneously observed by a group of clinicians. Stereoscopic displays may solve this problem and allow clinicians to obtain more information from CT images. Hardware with which to generate stereoscopic images was designed. This system utilized the conventional equipment found in meeting rooms. The off-axis algorithm was adopted to convert the CT images into stereo image pairs, which were used as the input for a stereo generator. The final stereoscopic images were displayed using a projection system. Several CT fracture images were imported into the system for comparison with traditional 2D CT images. The results showed that the proposed system aids clinicians in group discussions by producing large stereoscopic images. The results demonstrated that the enhanced stereoscopic CT images generated by the system appear clearer and smoother, such that the sizes, displacement and shapes of bone fragments are easier to assess. Certain fractures that were previously not visible on 2D CT images due to vision overlap became vividly evident in the stereo images. The proposed projection display system efficiently, economically and accurately displayed three-dimensional (3D) CT images. The system may help clinicians improve the diagnosis and treatment of fractures.
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Affiliation(s)
- Xiujuan Liu
- Department of CT Room, 1st Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001
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Berkes MB, Little MTM, Lorich DG. Open reduction internal fixation of proximal humerus fractures. Curr Rev Musculoskelet Med 2013; 6:47-56. [PMID: 23321803 DOI: 10.1007/s12178-012-9150-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.
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Affiliation(s)
- Marschall B Berkes
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
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Carofino BC, Leopold SS. Classifications in brief: the Neer classification for proximal humerus fractures. Clin Orthop Relat Res 2013; 471:39-43. [PMID: 22752734 PMCID: PMC3528923 DOI: 10.1007/s11999-012-2454-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Bradley C. Carofino
- Department of Orthopaedics and Sports Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356500, Seattle, WA 98195 USA
| | - Seth S. Leopold
- Department of Orthopaedics and Sports Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356500, Seattle, WA 98195 USA
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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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Brunner A, Heeren N, Albrecht F, Hahn M, Ulmar B, Babst R. Effect of three-dimensional computed tomography reconstructions on reliability. Foot Ankle Int 2012; 33:727-33. [PMID: 22995259 DOI: 10.3113/fai.2012.0727] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study evaluated the impact of three-dimensional (3D) volume-rendering computed tomography (CT) reconstructions on the inter- and intraobserver reliability of six commonly used classification systems in the assessment of calcaneal fractures. METHODS Four independent observers with different levels of clinical training evaluated 64 fractures according to the classifications of the Orthopaedic Trauma Association (OTA), Essex-Lopresti, Sanders, Crosby, Zwipp, and Regazzoni, using two-dimensional (2D) CT scans with multiplanar reconstructions and 3D volume-rendering reconstructions. RESULTS Interobserver reliability was moderate for the OTA, Essex-Lopresti, Sanders, Crosby, and Regazzoni classifications with 2D CT scans and 3D CT reconstructions. The Zwipp classification was poor with 2D CT scans and improved to moderate with 3D reconstructions. Intraobserver reliability with 2D CT scans was good for the Essex-Lopresti classification and moderate for the OTA, Sanders, Crosby, Zwipp, and Regazzoni classifications. After the addition of 3D reconstructions, all classifications showed moderate intraobserver reliability. CONCLUSION According to the findings of this study, the additional use of 3D reconstructions is of minor value when used in conjunction with the classifications of the OTA, Sanders, Crosby, Regazzoni, and Essex-Lopresti. If calcaneal fractures are assessed with the Zwipp classification, 3D reconstructions could be used to achieve comparable reproducibility compared to other classifications. CLINICAL RELEVANCE 3D reconstructions may have other benefits not evaluated in the presented study and may give useful information not captured by current classification systems.
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Affiliation(s)
- Alexander Brunner
- Department of Trauma Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland.
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Williams T, Barba N, Noailles T, Steiger V, Pineau V, Carvalhana G, Le Jacques B, Clave A, Huten D. Total talar fracture - inter- and intra-observer reproducibility of two classification systems (Hawkins and AO) for central talar fractures. Orthop Traumatol Surg Res 2012; 98:S56-65. [PMID: 22613935 DOI: 10.1016/j.otsr.2012.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/13/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We evaluated the inter- and intra-observer reproducibility of two classification systems for central talar fractures (Hawkins, as modified by Canal and Kelly and then by us; AO/AOT). HYPOTHESIS The analysis and classification of these fractures will be better with CT scans than with X-rays. MATERIAL AND METHODS Four observers evaluated 39 X-ray and CT scan files twice in the span of six weeks; each evaluation entailed classifying the fractures and describing their main features. Cohen's Kappa coefficient for inter-rater agreement was calculated and analysed. RESULTS The inter- and intra-observer reproducibility with CT scans was better with X-rays for most of the parameters evaluated. The modified Hawkins classification provided better reproducibility than the AO/AOT one. However, this classification system was not perfect, even after modifications and use of CT scans. DISCUSSION CT scans are an essential tool for the analysis of all talar fractures. We modified the Hawkins classification (as modified by Canal and Kelly) to include a Type 0 (no displacement or less than 2mm), include frontal body fractures that are displaced like neck fractures and take into account comminuted fractures and other trauma in the area. LEVEL OF PROOF IV - retrospective clinical study.
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Affiliation(s)
- T Williams
- Service de chirurgie orthopédique, hôpital de Cavale-Blanche, CHU, boulevard Tanguy-Prigent, 29200 Brest cedex, France
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Brouwer KM, Lindenhovius AL, Dyer GS, Zurakowski D, Mudgal CS, Ring D. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg 2012; 21:772-6. [PMID: 22516572 DOI: 10.1016/j.jse.2012.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 12/22/2011] [Accepted: 01/01/2012] [Indexed: 02/01/2023]
Abstract
PURPOSE This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification. METHODS Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard. RESULTS The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification. CONCLUSION Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.
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Affiliation(s)
- Kim M Brouwer
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA 02114, USA
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Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 2012; 26:98-106. [PMID: 21804410 DOI: 10.1097/bot.0b013e31821c2e15] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate functional outcome, patient self-assessment, and radiographic outcome at 1 year in displaced three- and four-part proximal humeral fractures (OTA group 11-B2 and 11-C2). DESIGN Randomized controlled trial. SETTING Academic medical center. PATIENTS/PARTICIPANTS Fifty patients aged 60 years or older with displaced three- or four-part proximal humeral fractures and no previous shoulder injuries were randomized either to surgical treatment or to conservative closed treatment. Twenty-five patients were included in each group. Forty-eight patients completed 12-month follow-up. Two surgical patients died within 3 months. INTERVENTION The surgically treated group had a standardized surgical treatment with open reduction and internal fixation using an angular stable plate and cerclages. Instructed physical therapy started the third postoperative day. The conservative treatment group had a standardized nonoperative treatment that included closed reduction if displacement between the head and metaphyseal shaft fragment exceeded 50% of the diaphyseal diameter. Physical therapy started on the fifteenth postoperative day. MAIN OUTCOME MEASUREMENTS The main outcome was the mean difference in Constant score between the injured and noninjured shoulder at 12 months. The secondary outcomes were patient self-assessment (American Shoulder and Elbow Surgeons score) and radiographic ratings at 12 months. RESULTS At 12 months, mean Constant scores favored conservative treatment by 2.4 points (nonsignificant; P = 0.62). There was no significant difference in mean patient self-assessment. However, radiographic outcomes were significantly better for surgically treated patients. CONCLUSION There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients.
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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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Resch H. Proximal humeral fractures: current controversies. J Shoulder Elbow Surg 2011; 20:827-32. [PMID: 21454104 DOI: 10.1016/j.jse.2011.01.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 01/09/2011] [Indexed: 02/01/2023]
Affiliation(s)
- Herbert Resch
- Department of Traumatology and Sports Injuries, University Hospital Salzburg-Paracelsus Medical University Salzburg, Salzburg, Austria.
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Abstract
Technologic advances in imaging of the upper extremity have taken an immense leap in the last decade. So has the amount of research that has been published on this subject. Three-dimensional (3D) reconstructions, in particular, have improved identification of fracture characteristics, such as fragments, fracture edges, and articular surfaces. Three-dimensional physical models can even increase the advantages of the 3D reconstructions. Together, 3D reconstructions and physical modeling may outweigh the disadvantages of increased cost, resource usage, and additional time, as research has shown that it can benefit both the surgeon and the patient significantly.
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