Reliability of hip range of motion using goniometry in pediatric femur shaft fractures

INTRODUCTION: The purpose of this study was to determine the interrater reliability of the assessment of range of motion of the hip joint through goniometry. METHODS: We included children aged 4 to 10 years with a femoral shaft fracture, from 4 study sites, who had had either an early hip spica cast or an external fixator. An assessor blind to treatment received at each site measured range of hip joints motion, using a standardized goniometric technique at 15 and 24 months postfracture. RESULTS: The intraclass correlation coefficient (ICC) was used to quantify concordance or agreement. Most ICCs for the different aspects of hip range were between 0.2 and 0.5, indicating only slight agreement. The most reliable measure was hip flexion, with an ICC of 0.48 (95% confidence interval 0.29-0.63). CONCLUSION: Goniometric measurement, using standardized protocols for the hip, has low reliability. Only when differences in rotation exceed at least 30 degrees and in flexion-extension exceed 50 degrees should clinicians conclude that true change has occurred.     

Measurement of lumbar lordosis: inter-rater reliability, minimum detectable change and longitudinal variation

STUDY DESIGN: Repeated measures design to examine reliability and longitudinal variation of lumbar lordosis measurement. OBJECTIVES: To determine the interrater reliability, minimum detectable change (MDC) and longitudinal variation of the Cobb method for measuring lumbar lordosis using standardized rules. SUMMARY OF BACKGROUND DATA: The reliability of the 4-line Cobb method for measuring lumbar lordosis was not examined when standardized rules were instituted for drawing the lines. METHODS: A random sample of participants was selected from the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures for radiographic measurement of lumbar lordosis reliability (n=48) and stability (n=109). A standardized version of the 4-line Cobb method was used for all measurements of lordosis. The Intraclass Correlation Coefficient (ICC) was used to calculate interrater reliability for lordosis and to measure the stability of this measure over an approximate 2-year-time period. The standard error of measurement and MDC were calculated for lordosis measurement based on the ICC value. RESULTS: The interrater reliability coefficient for lumbar lordosis was in the excellent range (ICC=0.98; 95% CI: 0.95, 0.99). The MDC based on measurements between raters was 3.90 degrees. The ICC value for the stability, or reliability from time 1 to time 2, of lordosis measurement over time was 0.81 (95% CI: 0.74, 0.87). CONCLUSION: This study demonstrates that the 4-line Cobb method can be a highly reliable and precise method for measuring lumbar lordosis if standardized procedures are used. The Cobb method has an MDC that is appropriate for clinical use. Also, there is minimal longitudinal variation in lordosis measurements over a 2-year period.     

Intrarater and interrater reliability of assessment of lumbar multifidus muscle thickness using rehabilitative ultrasound imaging

STUDY DESIGN: Within-session intrarater and interrater reliability study. OBJECTIVE: To establish the intrarater and interrater reliability of thickness measurements of the multifidus muscle in a parasagittal plane, conducted by an experienced ultrasound operator and a novice assessor. BACKGROUND: There is considerable evidence for the important role of the multifidus muscle in segmental stabilization of the lumbar spine. The cross-sectional area of the multifidus muscle has been assessed in healthy subjects and patients with low back pain using real-time ultrasound imaging. However, few studies have measured the thickness of the multifidus muscle using a parasagittal view. METHODS AND MEASURES: The thickness of the multifidus muscle was measured at rest, using real-time ultrasound imaging, in 10 subjects without a history of low back pain, at the levels of the L2-3 and L4-5 zygapophyseal joints. The measure was carried out 3 times at each level by 2 assessors (1 experienced, 1 novice). Intrarater (model 3) and interrater (model 2) reliability was assessed by calculation of an F statistic (analysis of variance), the intraclass correlation coefficient (ICC), and the standard error of measurement (SEM). RESULTS: On the basis of an average of 3 trials, the 2 operators showed very high interrater agreement on the measurement of thicknesses at the L2-3 level (ICC2,3 = 0.96; 95% CI: 0.84 to 0.99) and the L4-5 vertebral level (ICC2,3 = 0.97; 95% CI: 0.87 to 0.99), with no systematic differences in muscle size across operators (P > .05). Interrater reliability was relatively lower for the L2-3 level (ICC2,1 = 0.85; 95% CI: 0.51 to 0.96) than the L4-5 level (ICC2,1 = 0.87; 95% CI: 0.52 to 0.97) when a single trial per rater was used, but these values still indicated a high level of agreement. In addition, the novice and experienced operator produced reliable intrarater measurements at L2-3 (ICC3,1 = 0.89; 95% CI: 0.72 to 0.97 and 0.94; 95% CI: 0.86 to 0.99) and at L4-5 (ICC3,1 = 0.88; 95% CI: 0.68 to 0.97 and 0.95; 95% CI: 0.86 to 0.99), with no systematic differences in muscle size across trials (P > .05). The consistently low SEM values also indicate low measurement error. CONCLUSION: A novice and an experienced assessor were both able to reliably perform this measure at rest for 2 vertebral levels using real-time ultrasound imaging. An average of 3 trials produced higher interrater reliability scores, though using a single trial per rater was also reliable.     

Reliability and validity of plain radiographs to assess angulation of small finger metacarpal neck fractures: human cadaveric study.

To quantify reliability and validity of plain radiographs for assessing the degree of small finger metacarpal neck fracture angulation, we created typical two-fragments fractures in 30 adult cadaveric specimens. Reliability and validity of different radiographic measurement methods were determined by the intraclass correlation coefficient (ICC) and the Bland and Altman graphical approach. Intraobserver and interobserver reliability was high with any radiographic measurement method. Mean ICCs values (95% confidence intervals) varied from 0.76 (0.56-0.88) to 1.00 (0.99-1.00). The graphical approach confirmed good agreement. Validity was substantial when the fracture angle was measured between the line along the longitudinal axis of the metacarpal shaft and the line from the center of the metacarpal head to the fracture site on lateral radiographs. Mean ICCs values varied from 0.70 (0.36-0.86) to 0.79 (0.5-0.90). The graphical analysis also indicated good agreement. In contrast, considerable lack of validity was observed when the angle was measured on oblique radiographs. Although the mean ICCs values varied from 0.68 (0.12-0.88) to 0.74 (0.05-0.90), suggesting substantial correlation, the graphical analysis provided evidence for poor validity. There was systematic bias with oblique radiographs consistently producing higher readings (up to 35 degrees ). In summary, reliability and validity are good only when the degree of small finger metacarpal neck fracture angulation is measured after drawing lines on lateral radiographs. Oblique radiograph measurements consistently produce higher readings.     

Radiographic assessment of pediatric proximal radius fractures: interrater and intrarater reliability

Three methods of measuring pediatric proximal radius fracture radiographs were compared using injury films of 32 patients. Angulation and displacement were independently measured by four physicians. One physician measured the films by each method a second time 2 months later. Values for interrater and intrarater reliability were determined using inter- and intra-class coefficients (ICC). Interrater reliability was poor for methods using the axis of the proximal radial fragment or the proximal radial physis as a reference (ICC = 0.47 and 0.42, respectively). Measurement of the angle between a line parallel to the proximal radius articular surface and the radial shaft had the highest interrater reliability (0.76); measurement of displacement had the lowest interrater reliability (0.09). The intrarater reliability was excellent for all methods (0.93-0.99) and was also highest when the proximal articular surface reference was used. Of described methods, use of the proximal radius articular surface and the radial shaft as references had the highest interrater and intrarater reliability.     

Radiological outcome after external fixation of 97 femoral shaft fractures in children

The aim of this prospective, consecutive study was to assess overgrowth and malunion after anatomical reduction and external fixation of displaced femoral shaft fractures in children. Ninety-seven closed femoral fractures in 95 children aged 3-15 were fixed with a unilateral external fixator and followed with conventional radiographs and standardized orthograms for 1 year. To evaluate further overgrowth and remodelling a subgroup of 45 patients was also seen at 2 years. Parameters known to influence overgrowth and remodeling were recorded.Eighty-six percent of the femora had an angulation less than 10 degrees in varus/valgus or recurvatum at the time of healing. The remaining fractures remodeled nearly completely. Leg length discrepancy was on average 0.1cm at 1 year. The mean overgrowth was 0.3 cm at 1 year and 0.5 cm at 2 years. Overgrowth and remodeling was not correlated to whether the leg healed in a shortened or lengthened position, nor was it correlated to pin site infection or re-reduction.The overgrowth was far less than expected when compared with previous studies using traction. When external fixation is used in femoral fractures in children, we therefore, recommend fixing the fracture without shortening regardless of the age of the child, type of fracture, fracture level or injury.     

Error estimates in novice and expert raters for the KT-1000 arthrometer

STUDY DESIGN: Single group repeated measures with multiple raters. OBJECTIVES: To determine the inter-rater reliability of KT-1000 measurements of novice and experienced raters and to provide error estimates for these raters. BACKGROUND: The KT-1000 arthrometer is often used clinically to quantify anterior tibial displacement. Few data have been documented, however, about the relative reliability of KT-1000 measurements obtained by novice compared with experienced users. METHODS AND MEASURES: Two novice and two experienced KT-1000 users performed measurements on 29 knees of 25 patients after anterior cruciate ligament (ACL) reconstruction or with a diagnosis of ACL deficiency. Measurements were performed at 131 N. Interrater and intertrial reliability coefficients (interclass correlation coefficient; ICC) and the standard error of measurement were calculated for expert and novice raters. RESULTS: The interrater ICC for novices was 0.65 and the interrate error was +/- 3.52 mm (90% confidence interval [CI]). The interrater ICC for experts was 0.79 and the interrater error was +/- 2.94 mm (90% CI). CONCLUSIONS: These results suggest that experience in using the KT-1000 is related to the interrater error of measurements and that training is an important consideration when using the KT-1000 arthrometer.     

Detection of abdominal aortic calcification with lateral spine imaging using DXA.

Radiographic abdominal aortic calcification (AAC) is associated with incident cardiovascular disease and mortality independent of other risk factors. Lateral spine imaging using dual-energy X-ray absorptiometry (DXA) is now available to detect prevalent vertebral fracture (called vertebral fracture assessment), but its potential utility to detect radiographic AAC has not been investigated. Fifty-seven of 205 women age 65 or older who had participated in a prior study of the detection of prevalent vertebral fracture with lateral DXA had technically adequate radiographs and lateral DXA images to assess AAC. Two readers scored both the radiographic and lateral DXA images for AAC using a previously validated 24-point scale, blinded to both of each other's readings and also to their own readings on the other technology. The agreement between radiograph and lateral DXA AAC scores was very good (intra-class correlation coefficient [ICC] of 0.81 (95% confidence interval [CI]: 0.66-0.90) for reader 1 and 0.82 (95% CI: 0.69-0.90) for reader 2). The ICC between the two reader's AAC scores on radiographs was 0.92 (95% CI: 0.88-0.95) and on lateral DXA images was 0.89 (95% CI: 0.80-0.94). Lateral spine imaging with DXA shows very good agreement with standard radiography in the detection of AAC. Lateral imaging of the spine with DXA intended to detect vertebral fracture is a promising technology for the simultaneous assessment of a risk factor for cardiovascular disease incidence and death.     

Addition of 3D-CT evaluation to radiographic images and effect on diagnostic reliability of current 2018 AO/OTA classification of femoral trochanteric fractures

IntroductionThe AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability.MethodsA retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior–posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability.ResultsIn the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239–0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305–0.428; low-experience group: κ = 0.304, 95% CI 0.246–0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428–0.539 and κ = 0.409, 95% CI 0.352–0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322–0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups.ConclusionThe current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.     

Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing

Background

Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively.

Purpose

The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing.

Methods

A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen’s kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed.

Results

ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979).

Conclusions

This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.

     

Interrater reliability of subtalar neutral, calcaneal inversion and eversion

The purposes of this study were to determine the interrater reliability of the measurements of calcaneal inversion/eversion and subtalar joint neutral (STJN) in a patient population; to compare STJN using the mathematical and palpatory methods; and to compare the amount of calcaneal eversion in prone, bilateral stance, and unilateral stance. Three examiners measured 20 patients with recent ankle pathology according to a standardized protocol. Intraclass correlation coefficients (ICC) were used to determine interrater reliability. Analysis of variance (ANOVA) was used to determine if a difference in motion existed between test positions. The results demonstrated that prone measurements of calcaneal inversion/eversion and STJN had low to moderate interrater reliability (ICC ranged from 0.25 to 0.60). Weight bearing measurements of calcaneal position demonstrated high interrater reliability (r = 0.91 in bilateral stance, r = 0.75 in unilateral stance). These findings suggest that nonweightbearing measurements may be of limited value in assessing subtalar joint range of motion. J Orthop Sports Phys Ther 1990;12(1):10-15.     

Radiographic assessment of small finger metacarpal neck fractures

Treatment recommendations for metacarpal neck fractures of the small finger are generally based on the degree of apex dorsal angulation at the fracture site. We evaluated the variability of measurement of fracture angulation and the effect this variability has on treatment recommendations for these injuries. A total of 96 radiographs (anteroposterior, lateral, oblique views) of 32 patients with fractures of the small finger metacarpal neck were evaluated independently by 3 fellowship-trained orthopedic hand surgeons. Treatment recommendations for each fracture were tabulated. This process was repeated 6 weeks later to evaluate intraobserver variability. Kappa coefficients of inter- and intraobserver reliability of fracture angulation measurement and treatment plans were generated. The mean reliability coefficient of the measurement of fracture angulation between the 3 different observers was slight. Similarly, the reproducibility of fracture angulation measurement within observers was fair. Agreement between observers for appropriate treatment recommendations for each fracture was fair and agreement within observers for treatment was only slightly better. The measurement of fracture angulation of small finger metacarpal neck fractures seems to be subject to a high degree of inter- and intraobserver variability.     

Assessing angulation on digital images of radiographs of fractures of the distal radius: visual estimation versus computer software measurement

We assessed the reliability of visual estimation of angles on computer images of radiographs, and compared their accuracy with the measurement of angles using computer software for ten distal radius fractures. We asked 73 clinicians to visually estimate the dorsal angulation on ten computerized radiographs of fractures of the distal radius. The reliability of these estimations was calculated. Their accuracy was compared to a 'gold standard' obtained by consensus agreement between three consultants measuring these angles using the software. Inter-observer reliability was calculated as ICC?=?0.51 and intra-observer reliability as r?=?0.76. The visual estimations were less accurate with a mean percentage error of 31% (range, 7-83%). As angulation increased the estimation accuracy improved. Although reliability and accuracy of such estimation was better for clinicians with greater experience, actual measurement was more reliable and accurate.     

The International Standards for Neurological Classification of Spinal Cord Injury: reliability of data when applied to children and youths

STUDY DESIGN: Intra-rater reliability study, cross-sectional design. OBJECTIVES: To determine reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory exam in children. SETTING: Nonprofit pediatric hospital. METHODS: In all, 74 subjects had two trials of the motor and sensory exams. Intraclass correlation coefficients (ICC), 95% confidence intervals (CI) were generated for total motor (TM), pin prick (PP) and light touch (LT) scores for the entire sample, four age groups, severity and type of injury. Coefficients >0.90=high reliability; 0.75-0.90=moderate reliability and <0.75=inadequate reliability. RESULTS: Children 0.90 except for TM in complete injuries (0.808).Conclusion:The ISCSCI exams may have poor utility in children under 4 years. While reliability values for the motor and sensory exams met or exceeded recommended values, wide CI suggest poor precision of the motor exam in children under 15 years of age and sensory exams in children under 5 years.     

Reliability analysis of CT torsion assessment after closed cephalomedullary nailing of trochanteric femoral fractures. A comparison study of six established methods

BackgroundPosttraumatic maltorsion and implant failure after closed reduction of proximal femoral fractures remain a cause of concern. Although the reproducibility of torsion measuring techniques on CT for femoral shaft fractures has been thoroughly analyzed, little is known about the trochanteric fractures. Apart from the well-known CT limitations, posttraumatic alteration of bony landmarks makes torsional assessment even more challenging. Main goal of this study was to examine the reliability of different CT techniques on trochanteric femoral fractures after closed nail fixation. Secondary goal was to see whether the measurements within the examined population were influenced by the fracture type and patient age or BMI.Methods20 cases (AO.31-A1 or -A2) were retrospectively examined. Six established CT techniques for torsional assessment were performed from three different investigators twice at different time points. The intraclass correlation coefficient (ICC for 95% CI) was used to analyze the interobserver and intraobserver reliability.ResultsThe Hernandez method (0.986) followed by the Jend method (0.982) by a mean difference of <1° showed the highest reliability. Although increasing fracture complexity from A1 to A2 led to an overall worsening of the measurement precision, the Hernandez and Jend techniques revealed a very good consistency. Within the examined population, age and BMI had no impact on the precision of the measurements.ConclusionsThe Hernandez and Jend methods represent reliable alternatives for torsional assessment of trochanteric femur fractures treated with closed nail fixation when compared to the other measurement techniques here involved. Documentation of the torsion measuring method used in each case constitutes an essential element of the radiological reports.     

Good inter- and intraobserver reliability for assessment of the slip angle in 77 hip radiographs of children with a slipped capital femoral epiphysis

Background and purpose — The decision on and the outcome of treatment for a slipped capital femoral epiphysis (SCFE) depend on the severity of the slip. In 2015, web-based registration was introduced into the Swedish Pediatric Orthopedic Quality (SPOQ) register. To determine whether the inclusion of commonly used methods in Sweden for radiographic measurement of SCFE (the calcar femorale [CF] method and the Billing method) is justified, we measured the inter- and intraobserver reliability of these 2 measurements. We also evaluated the internationally more commonly used head-shaft angle (HSA) method.

Material and methods — 4 observers with different levels of experience with radiographic measurements analyzed 77 routine preoperative hip radiographs of children with SCFE. Inter- and intraobserver reliability was evaluated.

Results — The interobserver reliability analysis for the 4 observers showed for CF an ICC of 0.99 (CI 0.97–0.99) and for Billing an ICC of 0.99 (CI 0.98–0.99). The interobserver reliability analysis for 2 observers showed for HSA an ICC of 0.98 (CI 0.97–0.99).

Intraobserver reliability (2 observers) showed a mean difference below 1° for all 3 methods and with a 95% limit of agreement not exceeding ±6.8°.

Interpretation — We found good reliability for both intra- and interobserver measurements of all 3 methods used for the assessment of the slip angle on routine preoperative lateral hip radiographs.     

Angular malalignment after intramedullary nailing of femoral shaft fractures

OBJECTIVES: To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde). DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures. INTERVENTION: Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing. MAIN OUTCOME MEASURE: Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment. RESULTS: Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns. CONCLUSIONS: Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.     

Inter- and intraobserver reliability assessment of the Cobb angle: manual versus digital measurement tools

The objective of this study is to determine the intraobserver and interobserver reliability of end vertebra definition and Cobb angle measurement using printed and digital radiographs of 48 patients with scoliosis. The Cobb angle and the end vertebra were assessed by six observers in 48 patients with scoliosis using printed and digital radiographs. Definition of end vertebra and measurement of the Cobb angle was repeated three times with a 3 week interval. Intraclass correlation coefficients (ICC) were used to determine the interobserver and intraobserver reliabilities. 95% prediction limits for the errors in measurements are provided. For the Cobb angle a mean ICC of 0.97 was determined for intra- and interobserver reliability measurement of the printed radiographs. For the electronic radiographs a mean ICC value of 0.93 was determined for interobserver reliability and a mean ICC value of 0.96 for intraobserver reliability. Intraobserver ICC for definition of end vertebrae was 0.8 for both methods. Interobserver ICC was 0.83 for the manual and 0.74 in the digital method. One pitfall in angle measurement implies the Cobb method itself which measures in two dimensions. Until we develop a proper tri-dimensional measuring system an error is introduced. For the Cobb angle measurement the definition of end vertebrae introduces the main source of error. Digital radiography does not improve the measurement accuracy.     

Reliability of the skin compliance device in the assessment of scar pliability.

The purpose of the study was to determine the intrarater and interrater reliability of the Skin Compliance Device, a tool to measure scar pliability. Three points on 25 scars and the corresponding areas on the uninvolved upper extremities were tested by two evaluators. Testing locations were standardized using a wound-tracing device. Intrarater reliability was excellent for both raters for all points tested on both extremities (intraclass correlation coefficient [ICC]>0.88). On the involved side, good inter-rater reliability was found for the most adherent point (ICC=0.79) and the most distal point (ICC=0.77). Fair interrater reliability was found for the most proximal point on the involved side (ICC=0.29) and fair-to-moderate reliability for all points on the unscarred extremity. The Skin Compliance Device demonstrates excellent intrarater reliability and good interrater reliability for measuring the most adherent aspect of scars.     

Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique

IntroductionThe purpose of this study is to evaluate the intra- and inter-observer reliability of low-dose protocolled bilateral postoperative Computed Tomography (CT)-assessment of rotational malalignment after intramedullary nailing (IMN) of tibial shaft fractures.Materials and methods156 patients were prospectively included with tibial shaft fractures that were treated with IMN in a Level-I Trauma Centre. All patients underwent post-operative bilateral low-dose CT-assessment (effective dose of 0.03784 – 0.05768 mGy) as per hospital protocol. Four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. The Intra-Class Coefficient (ICC) was calculated to evaluate intra- and inter-observer reliability. The intra- and inter-observer reliability was categorized according to Landis and Koch.ResultsIntra-observer reliability for quantification of rotational malalignment on post-operative CT after IMN of tibial shaft fractures was excellent with 0.95 (95% CI = 0.92-0.97).The overall inter-observer reliability was 0.90 (95% CI = 0.87-0.92), also excellent according Landis and Koch.ConclusionFirstly, bilateral post-operative low-dose –similar radiation exposure as plain chest radiographs– CT assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following IMN of tibial shaft fractures and it allows for early revision surgery. Secondly, it may contribute to our understanding of the incidence-, predictors- and clinical relevance of post-operative tibial rotational malalignment in patients treated with IMN for a tibial shaft fracture, and facilitates future studies on this topic.