CT三维重建在股骨转子间骨折AO分型中的价值

目的探讨CT三维重建在股骨转子间骨折AO分型准确性、一致性以及稳定性评估中的优越性。方法由3名医生阅读术前X线片,并按AO分型方法进行骨折分型、稳定性评估并讨论获得一致结论;同样方法阅读术前CT三维重建图像,获得分型、稳定性评估及一致结论。对两者结论不同的病例由3名医生共同阅读X线片及CT三维重建图像,经讨论得出一致分型及稳定性评估结论,加上基于X线片和CT三维重建相同的结论作为金标准。结果 3名医生基于CT三维重建AO分型的一致性、分型准确性均高于X线片。3名医生稳定性评估准确率:基于X线片不稳定性骨折比例均明显低于金标准,差异均有统计学意义(P 0. 01);基于CT三维重建比例与金标准比较差异均无统计学意义(P 0. 05)。结论采用CT三维重建在股骨转子间骨折分型准确性、一致性以及稳定性评估明显优于X线片。     

三种胸腰段骨折分类法的可信度和可重复性研究

目的:探讨并比较AO分型、Denis分类、TLICS评分分类系统在胸腰段骨折诊断中的可信度和可重复性。方法:选择临床及影像学资料(X线片、CT、MRI)完整的31例胸腰段骨折患者,将该31例患者的资料提供给6名骨科医生,分别采用AO分型、Denis分类、TLICS评分分类三种方法进行脊柱骨折分类。3个月后进行重复分类。采用加权Cohen′s Kappa系数评价观察者间可信度和观察者内可重复性。结果:AO分型、Denis分类、TLICS评分分类的观察者间平均Kappa系数分别为0.517、0.639、0.713;三种分类方法的观察者内平均Kappa系数分别为0.766、0.832、0.804。结论:三种胸腰段骨折分类方法比较,TLICS评分分类方法的可信度和可重复性较高,Denis分类方法次之,AO分型方法较差,前者更具临床实用价值。     

股骨转子间骨折

股骨转子间骨折多生于老年人，放射影像学诊断要注意骨折线方向、小转子是否累及、骨折粉碎和移位程度，可用Evans分型、Jensen改良的Evans分型、AO分型等重点在于骨折稳定性的判断。手术治疗、牢固固定是目前基本治疗原则，常用的内固定材料分为滑动加压螺钉加侧方钢板(如DHS)、髓内固定(如Gamma钉、PFN)两大类。外固定支架仅用于严重多发创伤与老年体弱多病者，人工关节置换仅用于严重粉碎骨折伴严重骨质疏松者。     

股骨转子间骨折新综合分类法有效性验证

目的 验证股骨转子间骨折（intertrochanteric fracture,ITF）新综合分类法的有效性。方法 研究纳入616例ITF患者,男279例（45.29%）,女337例（54.71%）;年龄23～100岁,平均72.5岁。由2名骨科住院医师（研究者Ⅰ、Ⅱ）及2名高年资骨科医师（研究者Ⅲ、Ⅳ）各自间隔1个月,分别采用1996/2007版国际内固定协会/美国骨创伤协会（AO/OTA）分型、2018版AO/OTA分型及新综合分类法,按随机顺序对616例患者CT影像资料进行分型。采用Kappa一致性检验评估3种ITF分型方法在观察者内及观察者间一致性。结果 4名观察者两次评估3种分型方法的观察者间一致性分析结果示,3种分型方法均具有较强的观察者间一致性;其中,新综合分类法κ值高于1996/2007版及2018版AO/OTA分型,且观察者的经验对分型结果有一定影响,低年资较高年资骨科医师观察者间一致性稍好。4名观察者对3种分型方法两次评估的观察者内一致性分析结果示,除观察者Ⅳ在2018版AO/OTA分型中一致性略高于新综合分类法外,其他3名观察者新综合分类法一致性更好。说明新综合分...     

新型胸腰椎骨折损伤AO分型系统的可信度和可重复性研究

目的:评价新型胸腰椎骨折损伤AO分型系统的可信度和可重复性,探讨影响分型一致性的主要原因。方法:选取5名医师,根据术前正侧位X线片、CT、MRI影像,用新型AO分型系统独立对收治的70例胸腰椎骨折损伤患者进行分型。对同一例患者,5名医师在一次分型中只要有1名医师分型不同即认定为不一致。6周后,打乱资料顺序再次分型。全部资料均不含与分型有关的任何标记,应用加权Cohen′s Kappa系数(unweighted Cohen Kappa coefficients)评价观察者间可信度和观察者内可重复性。结果:新型AO分型系统的可信度Kappa系数为0.602,可重复性平均Kappa系数为0.782。在3大骨折类型中,压缩型(A型)和分离移位型(C型)损伤的判定具有中、高度的可信度和极好的可重复性,可信度Kappa系数分别为0.604、0.662,可重复性平均Kappa系数分别为0.787、0.761;牵张型损伤(B型)判定的一致性相对较差,可信度Kappa系数为0.362,可重复性平均Kappa系数为0.657。损伤各亚型整体一致性,可信度Kappa系数为0.526,可重复性平均Kappa系数为0.701;其中B2型一致性最差,可信度Kappa系数为0.214,可重复性平均Kappa系数为0.633;其次为A4型,可信度Kappa系数为0.322,可重复性平均Kappa系数为0.685。结论:新型胸腰椎骨折损伤AO分型系统具有中、高度的一致性和极好的可重复性,但对A4和B2型骨折判定的可信度较差。     

CT与X线检查在股骨转子间骨折的诊断及治疗价值比较

目的探讨CT对比X线对于股骨转子间骨折分型及手术方式的作用价值。方法多中心回顾性分析北京大学第三医院及北医三院延庆医院2016年9月以前就诊的股骨转子间骨折患者,同时留存有X线及CT检查的病例共261例,6名骨科医生分别给出X线和CT对应的AO分型及手术方式选择,收集数据并分析。结果 CT检查并没有体现出明确的分型价值;对于高年资医师,在AO分型亚型方面,在阅读CT后倾向于将部分A2.1更改为其他亚型,差异有统计学意义(P0.05);在治疗方式上,高年资医师阅读CT后有32例患者因判断出外侧壁粉碎骨折而改为应用髓外板固定,差异有统计学意义(P0.05),同时CT减少了不同医师在治疗方式选择上的差异。结论 CT对比X线在诊治股骨转子间骨折上存在价值,主要体现在高年资医师对于外侧壁粉碎需要行外侧壁重建的股骨转子间骨折判断更加准确,从而选择更为合适的髓外锁定板固定方式。     

Hoffa骨折的CT分型

目的 介绍一种新的Hoffa骨折CT分型,并对Hoffa骨折的CT分型与Letenneur X线分型的组间一致性进行比较. 方法 随机选取2008年1月至2011年12月收治的20例Hoffa骨折患者的影像学资料(膝关节正、侧位X线片和股骨髁CT三维重建片),呈递给20位由高级、中级和初级临床医师组成的阅片者,以同样的流程分别根据Letenneur X线分型和新的CT分型对Hoffa骨折进行分类,采用加权Kappa系数进行组内一致性检验,比较多个阅片者之间的两种分型的一致性. 结果 20位阅片者对20例Hoffa骨折患者的CT分型:Ⅰ型占66.0％,Ⅱ型占30.5％,Ⅲ型占3.5％.Ⅰ型骨折中涉及b区域的Ⅰb型最多,占50.0％,Ⅰa型占19.0％,Ⅰc型占31.0％；Ⅱ型粉碎性骨折中粉碎骨折块也多出现在b区域；涉及b区域的骨折在CT分型中总的发生率是67.0％.X线分型:Ⅰ型占31.4％,Ⅱ型占14.3％,Ⅲ型占28.0％,Ⅳ型占26.3％.多个阅片者之间CT分型一致性(Kappa=0.681)较X线分型更高(Kappa=0.261).结论 对于Hoffa骨折,新的CT分型一致性优于X线分型,尤其对于粉碎性骨折患者.     

胫骨平台骨折AO、Schatzker和Hohl and Moore分型的可信度和可重复性比较及意义

目的比较研究胫骨平台骨折AO、Schatzker和Hohl and Moore分型的可信度和可重复性。方法 4名不同年资的观察者对60例胫骨平台骨折按这3种分型方法进行分型,8周后再对打乱顺序后同一组患者再次分型,通过Kappa值和分型一致平均百分比进行可信度和可重复性分析。结果不同观察者对AO、Schatzker和Hohl and Moore 3种分型可信度评估的Kappa值分别为0.502、0.675、0.391,最后分型判断一致平均百分比分别为70.6%、87.9%、56.3%。同一观察者前后两个阶段3种分型可重复性的Kappa值分别为0.807、0.926、0.739,最后分型判断一致平均百分比分别为89.1%、94.8%、82.1%。结论这3种分型方法均不是理想的分型系统,但Schatzker分型在可信度和可重复性上明显优于AO和Hohl and Moore分型,易于掌握,更适合指导胫骨平台骨折的治疗。但是目前需要创建更精确的评估方法对骨折分型进行综合、全面的评估。     

股骨转子部骨折髓内钉内固定手术失败的原因分析及预防

目的 探讨股骨转子部骨折髓内钉内固定手术失败的原因及其预防.方法 回顾性分析2008年5月至2011年12月采用髓内钉固定且出现医源性手术失败的4例股骨转子部骨折患者资料,均为女性;年龄65～81岁,平均72.0岁.股骨转子间骨折3例,按改良Evans分型:ⅡB2例,Ⅲ型1例;股骨转子下骨折1例,根据Russell-Taylor分型为IA型.入院至手术时间为3～5d,平均3.8d.结果 手术失败原因:骨折复位错误2例,髓内钉置入错误2例.4例患者术后获10～14个月(平均11.6个月)随访.1例股骨转子间骨折患者术中并发股骨干骨折,卧床4个月后开始部分负重,术后9个月X线片示骨折基本获愈合.1例股骨转子下骨折患者术中并发股骨近端骨折,卧床4个月后行全髋关节置换术治疗.2例股骨转子间骨折患者术后较术前骨折断端明显移位,卧床3个月后部分负重,术后6个月X线片示骨折基本获愈合,患者生活自理,但存在髋关节内翻畸形.结论 骨折复位错误和髓内钉置入错误是股骨转子部骨折手术失败的主要原因.手术失败严重影响患者的康复,术中良好的复位、内固定物正确的放置是手术成功的关键.     

髋部隐匿性骨折

隐匿性股骨转子间骨折属于特殊类型的低能量骨损伤,多发生于老年骨质疏松患者,是一种假阴性骨折。因常规X线片检查不易发现,如不进行其他影像学检查(如超声、CT、MRI、核素扫描等),常延误诊治或发展演变为明显移位的骨折,给患者带来本可避免的痛苦。本文介绍股骨转子间隐匿性骨折的特点、诊断方法、分型和处理的研究进展。     

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

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

Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons

INTRODUCTION: The aim of this study was to determine the reliability of currently used classification systems for intertrochanteric fractures of the proximal femur, and to determine the reliability of these systems in experienced orthopaedic surgeons. MATERIALS AND METHODS: Forty intertrochanteric fractures of the proximal femur were classified independently by five experienced observers using the AO, Evans, Kyle, and Boyd classification systems on two separate occasions 3 months apart. The interobserver and intraobserver variation was assessed using kappa statistics. RESULTS: The level of agreement for classification into AO groups was almost perfect or substantial, and higher than other classification systems. When the fractures were further classified using the AO classification with subgroups, reliability became worse. CONCLUSIONS: The current study suggests that the AO classification system with groups can be used more reliably to measure intertrochanteric fractures of the proximal femur than Evans, Kyle, and Boyd classification systems. However, the reliability of the AO classification with subgroups is not satisfactory.     

Classification of intertrochanteric fractures with computed tomography: a study of intraobserver and interobserver variability and prognostic value

The purpose of this prospective study was to determine the level of interobserver and intraobserver agreement among orthopedic surgeons and radiologists when computed tomography (CT) scans are used with plain radiographs to evaluate intertrochanteric fractures. In addition, the prognostic value of current classifications systems concerning quality of life was evaluated. Sixty-one patients who presented with intertrochanteric fractures received open reduction and internal fixation with compression hip screw. Three orthopedic surgeons and 2 radiologists independently classified the fractures according to 2 systems: Evans-Jensen and AO (Arbeitsgemeinschaft für Osteo-synthesefragen). Fractures were initially graded with plain radiographs and then again in conjunction with CT. Results were analyzed using the (kappa) kappa coefficient. The 36-item Short-Form Health Survey was administered at baseline, 3 months, and 1 year, and results were correlated with fracture grade. Mean kappa coefficients when comparing radiography alone with radiography and CT scan were 0.63 for the AO system and 0.59 for the Evans-Jensen system. Both represent "fair" agreements. Mean overall interobserver kappa coefficients were 0.67 for radiologists and 0.57 for orthopedic surgeons. Radiologists also had higher intraobserver kappa coefficients. No significant relationships were found between follow-up Short Form Health Survey results and intraoperative grading of fractures. When these classification schemes are compared, interobserver agreement does not appear to change dramatically when information from CT scans is added. This may suggest that (1) more data have been provided by CT with greater possibilities for misinterpretation and (2) these classification schemes may not be comprehensive in describing fracture pattern and displacement. Finally, both systems failed to provide any prognostic value.     

三维CT成像对胫骨平台骨折术前评价结果的信度与效度分析

目的 通过比较使用三维CT与二维CT影像时对胫骨平台骨折分型和骨折特征术前评定结果 的信度与效度,探讨三维CT的诊断优势.方法 4名骨科高年资医生回顾性分析2004年9月至2006年11月间收治的21例胫骨平台骨折患者的病历,分别使用二维CT和三维CT影像对骨折分型和骨折特征做出判断,使用一致性检验来分析骨折分型判断结果 的评定者间信度和评定者自身信度,和对骨折特征判断结果 的标准效度(术中观察结果 作为金标准),并用McNemar检验比较三维CT和二维CT判断结果 与金标准的一致性差异.结果 使用三维CT时,对骨折分型判断结果 的评定者间信度和评定者自身信度均改善为极度一致,对骨折特征判断结果 与金标准的一致性显著性高于二维CT(P=0.027).结论 使用三维CT影像能提高对胫骨平台骨折分型和特征术前评价的可靠性和准确性,三维CT对胫骨平台骨折术前评价有很高的应用价值.     

AO or Schatzker? How reliable is classification of tibial plateau fractures?

Introduction We compare the intra- and interobserver reproducibility of classifications of tibial plateau fractures most commonly used in our clinical practice. These were the AO and Schatzker classifications.Patients and methods Agreement was measured using kappa coefficients on the data obtained from three observers reviewing 30 fractures and these values were interpreted according to Landis and Koch.Results It was found that both classifications were substantially reliable with regards to intraobserver reliability but that the Schatzker system was only fairly reliable and the AO classification moderately reliable with regards to interobserver reliability. Breaking down the AO classification, with regards to intraobserver reliability, the AO group was substantially reliable and the type excellently reliable. For interobserver reliability, the AO group was moderately reliable while the AO type was substantially reliable.Conclusion For tibial plateau fractures seen on plain x-ray, the AO classification is more reliable between observers than the Schatzker classification.     

Interobserver and intraobserver variations in tibial pilon fracture classification systems

BackgroundTibial pilon injuries are a complex group of fractures, whose classification and radiological assessment has been under constant reform. Till date, there is no universally accepted classification system.ObjectiveTo determine the interobserver agreement and intraobserver reproducibility of Ruedi and Allgower, AO, and Topliss et al. classification systems for tibial pilon fractures, with CT scans.MethodForty-seven CT scans of tibial pilon fractures were evaluated independently by 5 orthopaedic surgeons. Fractures were classified according to Ruedi and Allgower, AO and Topliss et al. types. Assessment was done on two occasions, eight weeks apart.ResultsThe interobserver reliability and intraobserver reproducibility for Ruedi and Allgower, AO and Topliss et al. classifications showed only moderate agreement. The interobserver agreement was dependent on the familiarity and specificity of the classification system.ConclusionCurrently used classification systems for tibial pilon fracture have moderate interobserver and intraobserver agreements, even with the help of CT scans. Therefore Tibial pilon fracture classification still remains largely undetermined.     

Three‐dimensional CT Improves the Reproducibility of Stability Evaluation for Intertrochanteric Fractures

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.

     

Inter- and intra-observer reliability of the new AO/OTA classification of proximal femur fractures

IntroductionHip fractures are a global health burden, with an incidence that is projected to increase from 66,000/year currently in the United Kingdom to 100,000/year by 2033. The classification of intertrochanteric fractures is key to the treatment algorithms advising on their surgical management.The AO/OTA classification is the most commonly used system, initially published in 1990 and subsequently shown to have poor inter- and intra-observer reliability, it was revised in 2018 with the main aim of re-classifying and further defining the 31-A2 group.Methods150 plain film anteroposterior and lateral plain film radiographs of intertrochanteric fractures from three hospitals were classified using the 2018 AO/OTA classification of intertrochanteric fractures by six Orthopaedic Surgeons (2 Consultants, 4 Trainees), all were blinded to the definitive surgical treatment for patients. Radiographs were re-classified after a minimum of 3-months, Cohen's Kappa for inter-observer reliability was calculated from first round classifications and intra-observer reliability from first and second classifications.ResultsMean Kappa for inter-observer reliability for AO group classification (e.g. 31-A1) was 0.479 (0.220 - 0.771, for sub-group classification (e.g. 31-A1.1) reliability reduced to 0.376 (0.276 - 0.613). Intra-observer reliability was comparable for both group and sub-group classifications, 0.661 and 0.587 respectively.ConclusionsThe revised 2018 AO/OTA classification aimed to simply the classification of intertrochanteric fractures, however it remains unreliable with only a “moderate” inter-observer reliability at group level with this falling to “fair” when sub-group classifications are made. Identification of stable and unstable injuries using the new AO/OTA system remains fraught with difficulties and appears difficult to apply with consistent accuracy.     

Comparison between reliability of Schatzker's classification and CT based four quadrant classification for tibial plateau fractures

IntroductionConventionally used Schatzker and AO/OTA classification, do not identify posterior column injuries in tibial plateau fractures. CT based Four quadrant classification, has been proposed to identify fractures of tibial plateau and help in surgical planning of treatment. However, to assess its validity, there is scanty literature about its reliability (inter and intra-observer variation) and comparison of its reliability with that of the more popular Schatzker classification in classifying tibial plateau fracture.Material and methodsX-rays and CT scans of 35 patients (18–65 years) of closed tibial plateau fractures were assessed by 5 Orthopaedic surgeons and classified by both Schatzker's and Four Quadrant Classification. A similar observation was recorded after 2 months. All observers were blinded for the demographic and clinical details of the patients. Their responses were noted and interobserver and Intraobserver variation was calculated. Kappa Test of Cohen was used to determine the level of agreement, as per Landis and Koch's criteria. The reliability of four quadrant classification was also compared with that of Schatzker's classification.ResultsThere was a moderate agreement in interobserver variation in observations for Schatzker's classification (on X-rays) which improved to substantial agreement when the observations were recorded after showing both CT and X-rays. The intraobserver variation had substantial agreement. On the other hand, there was a perfect agreement in both intra- and interobserver variation for Four Quadrant Classification. This difference between the reliability of both classifications was statistically significant (p < 0.001).ConclusionsFour Quadrant classification is a more reliable classification having a better agreement on interobserver and intraobserver variation.     

The interobserver and intraobserver reliability of the cooney classification of distal radius fractures between experienced orthopaedic surgeons

Various classification systems have been proposed for fractures of the distal radius, but the reliability of these classifications are seldom addressed. The objective of this study was to determine the interobserver and intraobserver reliability of the Cooney classification. Five orthopaedic surgeons with more than 10 years' experience in orthopaedic trauma assessed 43 sets of radiographic files according to the Cooney classification separately. Kappa statistics were used to analyse the interobserver and intraobserver reliability. There was moderate and substantial interobserver and intraobserver reliability of the Cooney classification without subtype, but only slight reliability when the subgroups were considered. These results question the value of this classification system for treatment decision making.