The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

Is Midcarpal Arthroscopy for Suspected Scapholunate Pathology Associated With Greater Interobserver Agreement and More Frequent Offer of Surgery?

PURPOSE

This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied.

METHODS

Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure.

RESULTS

The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair.

CONCLUSIONS

Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement.

CLINICAL RELEVANCE

The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit.

Dorsal Subluxation of the Proximal Interphalangeal Joint After Volar Base Fracture of the Middle Phalanx

Background: Treatment decisions regarding volar base fractures of the middle phalanx depend on whether the proximal interphalangeal (PIP) joint is reduced. Our aim was to study the agreement among hand surgeons in determining whether the PIP joint fractures are subluxated and to study the factors associated with subluxation of these fractures. Methods: In this retrospective chart review, 413 volar base fractures of the middle phalanx were included. Demographic and injury-related factors were gathered from medical records and radiographs. Using a Web-based survey, interobserver agreement was determined among 105 hand surgeons on the assessment of PIP joint subluxation of a series of 26 cases. Using the cohort of 413 fractures, a threshold for percent articular involvement and relative fracture displacement that corresponds with subluxation of the PIP joint was analyzed. Results: We found moderate to substantial agreement between hand surgeons on subluxation (κ = 0.59, P < .0001) and an overall percent agreement of 85%. Percent articular involvement and relative fracture displacement were independently associated with subluxation of the PIP joint (P < .001). Percent articular involvement of 35% had a specificity of 90% and a negative predicting value (NPV) of 92% for joint subluxation. Relative fracture displacement of 35% had a specificity of 92% and an NPV of 94% for joint subluxation. Conclusions: Surgeons generally agree on whether a PIP joint is subluxated. Percent articular involvement and relative fragment displacement are objective measurements that can help characterize joint stability and assist with decision-making.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging

AIM

(1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups.

METHODS

Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient.

RESULTS

Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05).

CONCLUSION

One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

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

BACKGROUND

The classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications.

MATERIALS AND METHODS

A total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen's kappa coefficient analysis.

RESULTS

The new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups.

CONCLUSIONS

The results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system.

LEVEL OF EVIDENCE

Level III, diagnostic studies.