Inter-observer reliability of radiographic classifications and measurements in the assessment of Perthes' disease

We evaluated the inter-observer agreement of radiographic methods when evaluating patients with Perthes' disease. The radiographs were assessed at the time of diagnosis and at the 1-year follow-up by local orthopaedic surgeons (O) and 2 experienced pediatric orthopedic surgeons (TT and SS). The Catterall, Salter-Thompson, and Herring lateral pillar classifications were compared, and the femoral head coverage (FHC), center-edge angle (CE-angle), and articulo-trochanteric distance (ATD) were measured in the affected and normal hips. On the primary evaluation, the lateral pillar and Salter-Thompson classifications had a higher level of agreement among the observers than the Catterall classification, but none of the classifications showed good agreement (weighted kappa values between O and SS 0.56, 0.54, 0.49, respectively). Combining Catterall groups 1 and 2 into one group, and groups 3 and 4 into another resulted in better agreement (kappa 0.55) than with the original 4-group system. The agreement was also better (kappa 0.62-0.70) between experienced than between less experienced examiners for all classifications. The femoral head coverage was a more reliable and accurate measure than the CE-angle for quantifying the acetabular covering of the femoral head, as indicated by higher intraclass correlation coefficients (ICC) and smaller inter-observer differences. The ATD showed good agreement in all comparisons and had low interobserver differences. We conclude that all classifications of femoral head involvement are adequate in clinical work if the radiographic assessment is done by experienced examiners. When they are less experienced examiners, a 2-group classification or the lateral pillar classification is more reliable. For evaluation of containment of the femoral head, FHC is more appropriate than the CE-angle.     

Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures

Our aim was to assess the reproducibility and the reliability of the Weber classification system for fractures of the ankle based on anteroposterior and lateral radiographs. Five observers with varying clinical experience reviewed 50 sets of blinded radiographs. The same observers reviewed the same radiographs again after an interval of four weeks. Inter- and intra-observer agreement was assessed based on the proportion of agreement and the values of the kappa coefficient. For inter-observer agreement, the mean kappa value was 0.61 (0.59 to 0.63) and the proportion of agreement was 78% (76% to 79%) and for intra-observer agreement the mean kappa value was 0.74 (0.39 to 0.86) with an 85% (60% to 93%) observed agreement. These results show that the Weber classification of fractures of the ankle based on two radiological views has substantial inter-observer reliability and intra-observer reproducibility.     

Inter-observer and intra-observer reliability in the radiographic diagnosis of avascular necrosis of the femoral head following reconstructive hip surgery in children with cerebral palsy

Purpose

The incidence of avascular necrosis (AVN) following reconstructive hip surgery in cerebral palsy (CP) ranges from 0 to 69 % in the current literature. The purpose of this study was to determine the inter- and intra-observer reliability of radiographically diagnosing AVN in children with CP after hip surgery.

Methods

A retrospective review of 65 children with CP who had reconstructive hip surgery between 2009 and 2012 at BC Children’s Hospital was completed. Anterior–posterior and lateral radiographs were presented to four pediatric orthopaedic surgeons over two rounds. Surgeons were asked to review the set of unidentified radiographs and comment ‘yes’ or ‘no’ for the presence of AVN. Two weeks later the same set of radiographs was sent in a different order and the surgeons were again asked to comment on AVN. Inter- and intra-observer reliability was determined using kappa statistics.

Results

The intra-observer reliability ranged from 0.65 to 0.88 with an average score of 0.76. Inter-observer reliability showed greater variability, ranging from 0.41 to 0.77 with an average score of 0.56 across all surgeons.

Conclusions

Although the intra-rater reliability produced a strength of “good” and the inter-rater reliability a strength of “moderate” agreement, the variability within these scores is clinically important as it demonstrates the difficulty in identifying AVN. This may explain the variability in AVN that is reported in the literature. The need for further education and research in the diagnosis of AVN in children with CP who have undergone reconstructive hip surgery is clinically necessary.

     

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。     

Inter-observer and intra-observer variation in bone histomorphometry

Summary Inter-observer variation has been examined for a number of histomorphometric indices in 20 normal human iliac crest biopsies. Quantitation was performed using an eye-piece graticule and eye-piece micrometer. The same sections were examined by two observers and the methodology was identical. Intra-observer variation was also assessed. Significant inter-observer differences were found for the measurement of total trabecular bone volume, osteoid volume and surface, double plus single and double tetracycline labeled surfaces, and the mean osteoid seam width. The percentage variance due to inter-observer variation was highest for osteoid surface and volume, total resorption surface, and mean osteoid seam width. Intra-observer variation in both observers was small. We conclude that a large inter-observer variation may occur in the measurement of a number of histomorphometric indices, even when section preparation and methodology are identical. Caution should be used in basing the diagnosis of metabolic bone disease on strictly defined control data from other observers, particularly when this has been obtained from centers where the effects of inter-observer variation may be magnified by differences in methodology.     

脊柱侧凸椎体旋转半脱位三种测量方法的可重复性和可信度研究

【摘要】 目的：分析MB法（midbody,MB）、EP法（endplate,EP）和C法（centroid,C）在椎体旋转半脱位（rotatory subluxation,RS）测量中的可重复性和可信度,探讨三种测量方法的影响因素。方法：回顾性分析2012年3月～2020年6月于南京大学医学院附属鼓楼医院行手术治疗的59例脊柱侧凸畸形患者,其中先天性脊柱侧凸15例,特发性脊柱侧凸9例,退变性脊柱侧凸16例,神经肌源性脊柱侧凸19例;男17例,女42例,平均年龄34.0±18.8岁。3名脊柱外科医师均使用MB法、EP法及C法分别间隔两周测量RS值,用组内相关系数（intraclass correlation coefficient,ICC）对三种测量方法结果进行一致性分析。结果：59例患者平均主弯Cobb角为64.2°±23.9°。RS节段分别为T4/5节段1例（1.7%）、T5/6节段2例（3.4%）、T6/7节段3例（5.1%）、T7/8节段3例（5.1%）、T9/10节段1例（1.7%）、T10/11节段1例（1.7%）、T12/L1节段6例（10.2%）、L1/2节段5例（8.5%）、L2/3节段9例（15.3%）、L3/4节段16例（27.1%）、L4/5节段12例（20.3%）。MB法、EP法、C法测量的RS值分别为16.5±7.1mm、8.5±4.2mm、14.2±6.3mm。三种方法的观察者内一致性分别为MB法0.77-0.91、EP法0.78-0.81、C法0.82-0.94;观察者间一致性分别为MB法0.87、EP法0.90、C法0.86。结论：MB法、EP法和C法在RS的测量中均有较高的可重复性及可信度,其中C法的组内一致性最高、EP法的组间一致性最高。     

Inter-observer and intra-observer agreement in the radiographic diagnosis of avascular necrosis of the femoral head following slipped capital femoral epiphysis

Introduction  

Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder. Avascular necrosis (AVN) of the femoral head is a devastating complication of SCFE. The frequency of this complication reported in the literature has been variable. It was the objective of this study to estimate the inter- and intra-observer agreement between two experienced pediatric orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.     

Inter and intra-observer reliability in assessment of the position of the lateral sesamoid in determining the severity of hallux valgus

BackgroundThe position of the lateral sesamoid on standard dorso-plantar weight bearing radiographs, with respect to the lateral cortex of the first metatarsal, has been shown to correlate well with the degree of the hallux valgus angle. This study aimed to assess the inter- and intra-observer error of this new classification system.MethodsFive orthopaedic consultants and five trainee orthopaedic surgeons were recruited to assess and document the degree of displacement of the lateral sesamoid on 144 weight-bearing dorso-plantar radiographs on two separate occasions. The severity of hallux valgus was defined as normal (0%), mild (≤50%), moderate (51–≤99%) or severe (≥100%) depending on the percentage displacement of the lateral sesamoid body from the lateral cortical border of the first metatarsal.ResultsConsultant intra-observer variability showed good agreement between repeated assessment of the radiographs (mean Kappa = 0.75). Intra-observer variability for trainee orthopaedic surgeons also showed good agreement with a mean Kappa = 0.73. Intraclass correlations for consultants and trainee surgeons was also high.ConclusionThe new classification system of assessing the severity of hallux valgus shows high inter- and intra-observer variability with good agreement and reproducibility between surgeons of consultant and trainee grades.     

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries

Introduction

Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful.

Materials and methods

A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries.

Results

The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients.Patients with initial amylase and lipase levels measured greater than 2 h post-injury were more consistently elevated compared to those patients who had levels measured at 2 h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p = 0.012). No significant association was found for lipase measurements (p = 0.178).

Discussion and conclusions

In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2 h post-injury compared to those measured at 2 h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.     

Validity and reliability of the Persian version of self-administered foot evaluation questionnaire (SAFE-Q) in people with foot orthopedic problems

IntroductionFoot problems are one of the main causes of seeing a doctor. According to the World Health Organization's definition of health, the healthcare system must consider patients’ quality of life as an important entity. In this regard, many tools have been developed to evaluate patients' opinions about their health status. The purpose of the present study is to evaluate the validity and reliability of the Persian version of the Foot Self-Assessment Questionnaire (SAFE-Q) in patients with foot orthopedic problems.Method215 people aged 17–60 years with orthopedic foot problems were included in this cross-sectional study. The Spearman correlation coefficient of SAFE-Q questionnaires versus Foot Function Index (FFI) questionnaire was evaluated for the convergent validity. Forty-three people randomly completed SAFE-Q again one week later. Intraclass correlation coefficient (ICC) and Cronbach’s alpha was calculated to evaluate the test-retest reliability and internal consistency of the SAFE-Q, respectively.ResultsA strong relationship was found between the SAFE-Q total score and other scales with FFI questionnaire (r = 0.52 to 0.87). ICC test-retest reliability and Cronbach’s alpha were 0.981 and 0.98 for SAFE-Q, respectively.ConclusionThe results indicate that the Persian version of the SAFE-Q questionnaire has acceptable validity and reliability and can be used to assess the health status and quality of life of Persian speakers with orthopedic foot problems.     

平山病患者颈椎矢状面形态及稳定性的X线影像学研究

【摘要】 目的：探索平山病患者颈椎X线征象,并分析平山病患者颈椎矢状面形态及稳定性。方法：2007年5月~2013年1月,我们对明确诊断的青少年上肢远端肌萎缩症患者28例（平山病组,均为男性,年龄15～24岁,平均19.5岁）及同年龄段健康志愿者28例（对照组,均为男性,年龄18～23岁,平均20.9岁）进行比对研究,行颈椎正侧位（21例平山病患者和所有志愿者）和主动过伸过屈位X线检查检查,分别测量平山病组和对照组颈椎过屈侧位X线片上的屈曲活动度及角度位移,采用Borden法测量弧弦距来评价颈椎曲度。应用SPSS 17.0行数据分析,两组比对,并对平山病患者颈椎屈曲活动度和颈椎曲度行相关性分析。结果：平山病组患者颈椎屈曲活动度（C2～C7）为37.52°±9.09°,相较于对照组（25.39°±8.66°）增大（P<0.05）。平山病组患者下颈椎过伸过屈角位移（C3/4～C6/7）分别为14.37°±5.22°、16.70°±3.44°、17.05°±3.66°及15.15°±4.25°,经过单因子方差分析,相比较对照组的11.03°±3.67°、11.69°±3.85°、13.29°±3.61°及12.19°±3.55°显著增大（P<0.05）。21例平山病组患者的弧弦距为5.42±7.35mm,28例对照组志愿者为9.10±2.60mm,两组存在显著性差异（P<0.05）。57.1%（12/21）的平山病患者弧弦距测量表现为颈椎曲度变浅、变直或颈椎反弓,弧弦距与颈椎屈曲活动度呈统计学负相关（r=-0.585,|r|>0.50）。结论：平山病患者颈椎存在屈曲活动度增大、颈椎不稳定和颈椎曲度改变,其颈椎屈曲活动度增大与颈椎曲度变直或反弓具有一定相关性。     

Reliability of pediobarographs for paediatric foot deformity

Purpose Dynamic pediobarograph measures foot–floor contact pressure during walking and provides a quantitative functional assessment. The goal of this study was to assess the reliability of pediobarograph measurements in normal children and in those with cerebral palsy (CP). Materials and methods During the first investigation, five non-disabled children and four with CP had three pediobarograph measurements taken of each foot, repeated five times. The pediobarographs were analysed by dividing the foot into five segments; the heel, the lateral midfoot, the medial midfoot, the lateral forefoot and the medial forefoot. A measure of valgus/varus foot posture was defined as the relative medial–lateral difference of combined mid- and forefoot impulse, named valgus/varus index. During the second investigation, 50 children (100 feet) with spastic diplegic CP were studied to calculate the standard error of measurements (SEM), to investigate the number of pediobarograph measurements necessary to obtain accurate results. The third investigation was an inter- and intraobserver study performed on one normal subject’s repeated measurements. Results In the first investigation, the group with CP had a significantly increased variability in the medial midfoot (P = 0.013). The variability of the valgus/varus index had a standard deviation of 13%, demonstrating that this measure is relatively stable. The SEM and 95% confidence interval from the second experiment showed that, even if the accuracy increased with the number of measurements, the greatest gain seemed to be contributed by increasing the number of measurements from 3 to 6. The inter- and intraobserver study showed good to mostly excellent agreement. Conclusion Pediobarograph measurements can be used to monitor and quantitatively assess the progressive changes of foot deformity over time. Pediobarograph is a reliable measurement that shows little variability between measurements at the same occasion and between measurements on different days. Three to six measurements seems practical and adequate to obtain. The technical aspect of measuring shows good repeatability and agreement between observers. All patients and subjects gave their consent to participate in the study.     

Non-radiographic validity and reliability measures for assessing foot types: A systematic review

BackgroundFoot type classification is well recognized in clinical practice and orthopedic literature, a universally accepted classification or standardized measures to determine foot types are lacking. The objective of this study was to identify which non-radiographic assessment methods are considered valid and/or reliable for the classification of foot types.MethodA systematic database search was performed. Only cross-sectional studies that performed reliability and/or validity analysis of non-radiographic methods were included. To evaluate the risk of bias, the Critical Appraisal Tool (CAT) was used to evaluate the measurement properties of objective clinical methods.ResultsTwenty-six studies were included. The results of reliability and validity, in general, demonstrated high scores, but, inconsistencies were related to the variability of the measurements, heterogeneity of the methods used to determine reliability and validity, and lack of parameters for classifying foot types, which resulted in few elements to determine which method of foot type evaluation is valid and reliable.ConclusionGiven the Intraclass Correlation Coefficient and CAT results and the presence of normative values, the static measurements of the “Arch Height Index”, “Foot Posture Index”, and “Staheli Arch Index” can be suggested to classify foot types.     

Assessment of inter- and intra-observer reliability in the determination of radiographic version and inclination of the cup in metal-on-metal hip resurfacing

Purpose  

Determination of the cup orientation after metal-on-metal hip resurfacing may provide important information in the postoperative follow-up. We present a mathematical method based on a previously described approach to assess the version and inclination of the cup in the metal-on-metal bearing without a separate software computation from plain radiographs. The aim of the study was to assess the intra- and inter-observer reliability of this method.     

Inter- and intraobserver variability of radiographic measurements of knee alignment.

To evaluate the variability of radiographic measurement of knee alignment by different observers, as well as repeated measurements by the same observer, standing anteroposterior radiographs of both knees of 36 patients presenting with knee pain were analyzed. Four physicians independently measured the anatomic tibiofemoral angle of both knees for a total of 72 measurements for each observer. These measurements were then repeated 1 month later in a random and blinded fashion. The same handheld goniometer was used for all measurements. The second measurement was within 3.1 degrees of the first measurement 95% of the time, and within 4 degrees 98% of the time. The maximum difference was 6 degrees. Among all four observers, measurements were within 3.7 degrees of each other 95% of the time with a maximum difference of 6 degrees. In addition to radiographic measurement, one physician also performed clinical measurement of knee alignment on these 36 patients using the same handheld goniometer. The clinical measurement was within 5 degrees of the same clinician's radiographic measurement 95% of the time with a maximum difference of 7 degrees. This variability in measuring radiographic alignment should be considered when making decisions on the need for surgical intervention or when evaluating results of procedures that relate to coronal plane alignment of the knee.     

Effect of elbow position on radiographic measurements of radio-capitellar alignment

AIM:To evaluate the effect of different elbow and forearm positions on radiocapitellar alignment.METHODS:Fifty-one healthy volunteers were recruited and bilateral elbow radiographs were taken to form a radiologic database.Lateral elbow radiographs were taken with the elbow in five different positions:Maximal extension and forearm in neutral,maximal flexion and forearm in neutral,elbow at 90° and forearm in neutral,elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation.A goniometer was used to verify the accuracy of the elbow's position for the radiographs at a 90° angle.The radiocapitellar ratio(RCR)measurements were then taken on the collected radiographs using the Slice Omatic software.An orthopedic resident performed the radiographic measurements on the 102 elbows,for a total of 510 lateral elbow radiographic measures.ANOVA paired t-tests and Pearson coefficients were used to assess the differences and correlations between the RCR in each position.RESULTS:Mean RCR values were-2% ± 7%(maximal extension),-5% ± 9%(maximal flexion),and for elbow at 90° and forearm in neutral-2% ± 5%,supination 1% ± 6% and pronation 1% ± 5%.ANOVA analyses demonstrated significant differences between the RCRin different elbow and forearm positions.Paired t-tests confirmed significant differences between the RCR at maximal flexion and flexion at 90°,and maximal extension and flexion.The Pearson coefficient showed significant correlations between the RCR with the elbow at 90°-maximal flexion;the forearm in neutralsupination;the forearm in neutral-pronation.CONCLUSION:Overall,95% of the RCR values are included in the normal range(obtained at 90° of flexion)and a value outside this range,in any position,should raise suspicion for instability.     

足前部组织缺损再造修复一些问题的探讨

目的探讨前足骨与软组织损伤及缺损修复与重建的意义、方法及所涉及的相关问题。方法根据前足损伤种类及伤情,采用不同方法修复重建,趾骨缺损仅修复软组织;跖骨缺损及跖趾关节缺损(多合并皮肤软组织缺损)应做同期重建修复,采用带血管骨与皮瓣串、并联吻接移植受区替代缺损跖骨及足部皮肤。结果自1994～2000年,47例前足损伤患者采用上述方法修复重建取得满意疗效,患足基本恢复行走负重功能及较理想外观。结论针对前足损伤伤情及部位进行分型,有助于指导治疗、精确描述和深入研究。采用带血管骨与带血管皮瓣组合移植是修复重建前足复合组织缺损的较理想方法。     

Inter- and intratester reliability of radiographic measurements of spondylolisthesis.

Thirteen radiographic methods to measure spondylolisthesis were assessed to determine: 1. whether or not the different methods were correlated with each other; 2. their precision in detecting vertebral displacements; 3. inter- and intra-measurer reliability among six orthopedic surgeons performing radiographic measurements. Several methods were found to be correlated with each other in detecting spondylolisthesis on radiographs. However, on simulated displacements only three of them showed good correlation (r greater than or equal to 0.95, p less than 0.01). Intra- and intergroup correlations among the orthopedic surgeons were equally good (r greater than 0.90; p less than 0.01).     

Surgical correction of the cavus forefoot

A cavus forefoot deformity can exist as a result of muscle imbalance, and, when identified, the patient shouldundergo appropriate neurological evaluation. The deformity can result in increased stresses on the metatarsal heads and push the hindfoot into a varus position. In more advanced cases, it can result in decreased motion of both the subtalar and ankle joints. Physical examination is of great importance in evaluating these patients and includes evaluation of the gait cycle, as well as the position of the heel and toes at rest. Evaluation of the muscle strength available is also important. The Coleman and Chestnut block test can be very helpful in determining hindfoot stiffness and the relationship of the forefoot cavus and the hindfoot varus. Surgical correction of the cavus forefoot often can be accomplished with a Jones procedure, sometimes with a closing wedge osteotomy of the first and possibly second and third metatarsals. This will sometimes be sufficient to allow the hindfoot to come out of varus.