Interobserver and intraobserver reliability of two classification systems for intra-articular calcaneal fractures

BACKGROUND: For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Most studies have found reliability and reproducibility to be poor for fracture classification schemes. The purpose of this study was to evaluate the interobserver and intraobserver reliability of the Sanders and Crosby-Fitzgibbons classification systems, two commonly used methods for classifying intra-articular calcaneal fractures. METHODS: Twenty-five CT scans of intra-articular calcaneal fractures occurring at one trauma center were reviewed. The CT images were presented to eight observers (two orthopaedic surgery chief residents, two foot and ankle fellows, two fellowship-trained orthopaedic trauma surgeons, and two fellowship-trained foot and ankle surgeons) on two separate occasions 8 weeks apart. On each viewing, observers were asked to classify the fractures according to both the Sanders and Crosby-Fitzgibbons systems. Interobserver reliability and intraobserver reproducibility were assessed with computer-generated kappa statistics (SAS software; SAS Institute Inc., Cary, North Carolina). RESULTS: Total unanimity (eight of eight observers assigned the same fracture classification) was achieved only 24% (six of 25) of the time with the Sanders system and 36% (nine of 25) of the time with the Crosby-Fitzgibbons scheme. Interobserver reliability for the Sanders classification method reached a moderate (kappa = 0.48, 0.50) level of agreement, when the subclasses were included. The agreement level increased but remained in the moderate (kappa = 0.55, 0.55) range when the subclasses were excluded. Interobserver agreement reached a substantial (kappa = 0.63, 0.63) level with the Crosby-Fitzgibbons system. Intraobserver reproducibility was better for both schemes. The Sanders system with subclasses included reached moderate (kappa = 0.57) agreement, while ignoring the subclasses brought agreement into the substantial (kappa = 0.77) range. The overall intraobserver agreement was substantial (kappa = 0.74) for the Crosby-Fitzgibbons system. CONCLUSIONS: Although intraobserver kappa values reached substantial levels and the Crosby-Fitzgibbons system generally showed greater agreement, we were unable to demonstrate excellent interobserver or intraobserver reliability with either classification scheme. While a system with perfect agreement would be impossible, our results indicate that these classifications lack the reproducibility to be considered ideal.     

3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures

The Neer and AO fracture classifications for fractures of the proximal humerus have shown poor reproducibility based on plain radiography. We wanted to investigate whether the addition of 3-dimensional (3D) reconstructions would increase the reproducibility of classification. 7 observers independently classified 24 fractures of the proximal humerus using both plain radiographs, CT and 3D and the classification was repeated 2 months later. There was a moderate interobserver agreement when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a mean kappa value of 0.44 and the AO had a value of 0.32 for the first assessment. In the second assessment, the mean kappa values were 0.49 and 0.34, respectively. Intraobserver reproducibility was fair to substantial agreement for Neer (kappa range 0.27-0.73) and for AO (kappa range 0.29-0.74). In conclusion, the addition of CT and 3D to plain radiographs did not improve the reproducibility of the classifications of Neer and AO of the proximal humerus.     

Reliability of three classification systems measuring active motion in brachial plexus birth palsy

BACKGROUND: Several classification systems for the categorization of function in patients with brachial plexus birth palsy have been proposed. The purpose of this investigation was to determine the intraobserver and interobserver reliability of the modified Mallet Classification, Toronto Test Score, and Hospital for Sick Children Active Movement Scale in the evaluation of these patients. METHODS: Eighty children with brachial plexus birth palsy were evaluated by two trained examiners on two different occasions. Intraobserver and interobserver reliability was determined with use of the kappa statistic. RESULTS: On the basis of the kappa statistic, intraobserver reliability was good to excellent for individual elements of the modified Mallet Classification, Toronto Test Score, and Active Movement Scale in all age-groups. Interobserver reliability for individual elements of these three systems ranged from fair to excellent. When aggregate Toronto Test and modified Mallet scores were assessed, positive intraobserver and interobserver correlations were noted (Pearson r = 0.70 to 0.98, p < 0.001). Internal consistency (test-retest reliability) as determined by the Cronbach alpha for the aggregate Toronto Test and modified Mallet scores was excellent for each age-group (alpha > 0.90, p < 0.001). CONCLUSIONS: The modified Mallet Classification, Toronto Test Score, and Active Movement Scale are reliable instruments for assessing upper-extremity function in patients with brachial plexus birth palsy. The natural history and surgical outcomes of these patients can now be conducted with use of these reliable outcomes instruments.     

The reliability of the AOSpine Thoracolumbar Spine Injury Classification System in children: an international validation study

PurposeTo evaluate the AOSpine Thoracolumbar Spine Injury Classification System and if it is reliable and reproducible when applied to the paediatric population globally.MethodsA total of 12 paediatric orthopaedic surgeons were asked to review MRI and CT imaging of 25 paediatric patients with thoracolumbar spine traumatic injuries, in order to determine the classification of the lesions observed. The evaluators classified injuries into primary categories: A, B and C. Interobserver reliability was assessed for the initial reading by Fleiss’s kappa coefficient (k_F) along with 95% confidence intervals (CI). For A and B type injuries, sub-classification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff’s alpha (α_k) along with bootstrapped 95% CIs. A second round of classification was performed one-month later. Intraobserver reproducibility was assessed for the primary classifications using Fleiss’s kappa and sub-classification reproducibility was assessed by Krippendorff’s alpha (α_k) along with 95% CIs.ResultsIn total, 25 cases were read for a total of 300 initial and 300 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF = 0.74; 95% CI 0.71 to 0.78) across all observers. Sub-classification reliability was substantial (α_k= 0.67; 95% CI 0.51 to 0.81), Adjusted intraobserver reproducibility was almost perfect (kF = 0.91; 95% CI 0.83 to 0.99) for both primary classifications and for sub-classifications (α_k = 0.88; 95% CI 0.83 to 0.93).ConclusionThe inter- and intraobserver reliability for the AOSpine Thoracolumbar Spine Injury Classification System was high amongst paediatric orthopaedic surgeons. The AOSpine Thoracolumbar Spine Injury Classification System is a promising option as a uniform fracture classification in children.Level of EvidenceIII     

Intraobserver and interobserver agreement in anal endosonography

BACKGROUND: The aim of this study was to determine intraobserver and interobserver agreement for sonographic measurements of anal canal structures using anal endosonography (AES), and to determine interobserver agreement for the diagnosis of anal sphincter disruption. METHODS: Fifty-one consecutive patients referred for AES for the investigation of possible sphincter abnormality were examined. Studies were reviewed by two observers who measured anal canal structures at defined levels and locations, and recorded an opinion on sphincter integrity. Repeated measurements made by each observer were compared to determine intraobserver agreement, and measurements and diagnoses were compared between observers to determine interobserver agreement. RESULTS: Intraobserver agreement was better than interobserver agreement for measurements of anal canal structures. Interobserver limits of agreement for external sphincter measurements spanned 5 mm, whereas those for the internal sphincter spanned 1.5 mm. Interobserver agreement for diagnosis of sphincter disruption and internal sphincter echogenicity was very good (kappa = 0.80 and 0.74 respectively). CONCLUSION: The limits of agreement for intraobserver and interobserver measurements of anal canal structures on AES have been defined. Interobserver assessment of sphincter disruption is very good.     

Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI

ObjectiveThe purpose of this study was to determine the intra- and interobserver reliability of a modified Modic classification for bone marrow changes seen on lumbar spine magnetic resonance imaging (MRI), taking into consideration mixed signals.MethodsLumbar MRI scans from 94 patients with low back pain were assessed independently by 2 spine specialists (senior [senior1], junior) and a radiologist (senior2). One reviewer (senior1) assessed the MR images twice at a three-week interval for evaluation of intraobserver reliability. Senior2 and junior reviewers assessed the MR images once. Pure edema endplate signal changes were classified as Modic type I, and pure fatty endplate changes as Modic type II. A mixture of types I and II but predominantly edema signal changes was classified as Modic I-2 and a mixture of types I and II but predominantly fatty changes was classified as Modic II-1.ResultsThe intraobserver agreement was excellent (weighted kappa 0.85). The interobserver agreement was moderate to substantial (weighted kappa range 0.56–0.74). Interobserver reliability depended on the experience of the observer, thus highlighting the importance of a learning curve.ConclusionThis study shows that the modified Modic classification is reliable and easy to apply for observers with different clinical experience. The inclusion of mixed marrow changes in the modified classification may have clinical and therapeutic implications.     

Prophylaxis for heterotopic ossification after primary total hip arthroplasty. A cohort study between indomethacin and meloxicam

The authors have conducted a prospective cohort study of the efficacy of a 7 days administration of Indomethacin (n = 89) versus Meloxicam (n = 92), in the prophylaxis of heterotopic ossification (HO) in primary total hip arthroplasty. To assess the interobserver variability of the Brooker classification, all radiographs were evaluated by three investigators. In the Indomethacin group 25 patients developed HO (grade I: 22, grade III: 2 and grade IV: 1). In the Meloxicam group 34 developed HO (grade I: 30, grade II: 1 and grade III: 3). We were not able to show any difference between Indomethacin and Meloxicam in preventing heterotopic ossification after primary hip arthroplasty. We found a high interobserver variability in the grading system according to Brooker, in particular for the higher grades(grade II, III and IV).     

Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications

BACKGROUND: Accurate and reliable radiographic classifications of the relative severity and outcome of Legg-Calve-Perthes disease are essential in the study of that disease. As part of a prospective multicenter study, we sought to define more clearly the lateral pillar classification of severity and the Stulberg classification of outcome; we sought especially to define the borderlines between classification groups. METHODS: We performed interobserver and intraobserver trials of the lateral pillar and Stulberg classifications using sets of twenty radiographs chosen from a prospective study of 345 hips. To establish reliable definitions of the lateral pillar classification, we added a new, intermediate group termed the B/C border group, which includes femoral heads with a thin or poorly ossified lateral pillar and those with a loss of exactly 50% of the original height of the lateral pillar. The resulting classification consists of four groups: A, B, B/C border, and C. In our application of the classification system of Stulberg et al., we defined a class-II femoral head as round and fitting within 2 mm of a circle on both anteroposterior and frog-leg lateral radiographs. We defined a Stulberg class-III femoral head as out of round by more than 2 mm on either view and a Stulberg class-IV femoral head as one with at least 1 cm of flattening of the weight-bearing articular surface. To assess interobserver and intraobserver agreement, we performed two trials of each classification with six orthopaedic surgeons reviewing twenty radiographs or pairs of radiographs. RESULTS: In the first trial of the lateral pillar classification, there was 81% agreement per radiograph and the average weighted kappa was 0.71. In the second trial, there was 85% agreement per radiograph and the weighted kappa averaged 0.79. Intraobserver reliability testing showed a 77% match between Trials 1 and 2, an average weighted kappa of 0.81, and an average generalizability coefficient of 0.91. In Trial 1 of the Stulberg classification, there was 91% agreement per radiograph and an average weighted kappa of 0.82. In Trial 2, there was 92% agreement per radiograph and an average weighted kappa of 0.82. Intraobserver reliability testing showed an 89% match between Trials 1 and 2, an average weighted kappa value of 0.88, and an average generalizability coefficient of 0.92. CONCLUSIONS: The interobserver and intraobserver trials of these classifications produced kappa values and generalizability coefficients in the excellent range. The modified lateral pillar classification and the redefined Stulberg classification are sufficiently reliable and accurate for use in studies of Legg-Calve-Perthes disease.     

A multicentric European study testing the reproducibility of the WHO classification of endometrial hyperplasia with a proposal of a simplified working classification for biopsy and curettage specimens.

This study was designed to assess intraobserver and interobserver agreement in the diagnosis of 56 endometrial specimens by five European expert gynecologic pathologists using the WHO classification and to establish which histologic features are significantly associated with each classification category. The seven categories were simple hyperplasia, complex hyperplasia, atypical hyperplasia, well-differentiated adenocarcinoma, proliferative endometria, secretory endometria, and other. Slides were reviewed twice for diagnosis, with accompanying evaluation of a checklist of histologic features. These seven categories were eventually reduced to four and three for the purposes of data analysis. The four modified diagnostic categories consisted of hyperplasia (previously simple hyperplasia and complex hyperplasia), atypical hyperplasia, well-differentiated adenocarcinoma, and cyclical endometrium (previously proliferative, secretory, and other). The three diagnostic categories consisted of hyperplasia, endometrioid neoplasia (previously atypical hyperplasia and well-differentiated adenocarcinoma), and cyclical endometrium. Intraobserver and interobserver agreement was assessed using the percentage agreement and kappa statistics. The associations among the various histologic features and diagnoses was analyzed using multiple logistic regression to identify those features that were useful for distinguishing diagnostic categories. When using seven categories, kappa values ranged from 0.53 to 0.74 (percentage agreement, 61-79%) and from 0.33 to 0.59 (percentage agreement, 43-63%) for intraobserver and interobserver agreement, respectively. When using four categories, kappa values ranged from 0.68 to 0.73 (percentage agreement, 77-80%) and from 0.39 to 0.64 (percentage agreement, 54-73%) for intraobserver and interobserver agreement, respectively. When using three categories, kappa values ranged from 0.70 to 0.83 (percentage agreement, 80-89%) and from 0.55 to 0.73 (percentage agreement, 70-82%) for intraobserver and interobserver agreement, respectively. Data were analyzed in each diagnostic category. When using four or three diagnostic categories, the mean intraobserver and interobserver agreements varied less between categories and achieved higher values, with smaller 95% confidence intervals. The mean percentage agreement was lowest for complex hyperplasia and for atypical hyperplasia. For distinguishing cyclical endometrium versus hyperplasia, the useful histologic feature was glandular crowding. For hyperplasia versus atypical hyperplasia and for hyperplasia versus endometrioid neoplasia, the useful features were nuclear enlargement, nuclear pleomorphism, vesicular chromatin, and nucleoli, but of these, only nuclear pleomorphism achieved substantial mean intraobserver and interobserver agreements. For discriminating atypical hyperplasia from well-differentiated adenocarcinoma, the only useful feature was stromal alterations, which achieved only fair mean intraobserver and interobserver agreements. In summary, in endometrial biopsy or curettage specimens, the lack of agreement in the diagnoses of complex hyperplasia and atypical hyperplasia and the lack of reproducibility in the recognition of the histologic feature of stromal alterations to differentiate atypical hyperplasia from well-differentiated adenocarcinoma suggest that the histologic classification should be simplified by including a combined category for simple and complex hyperplasia, called hyperplasia, and a combined category for atypical hyperplasia and well-differentiated adenocarcinoma, called endometrioid neoplasia. Diagnoses of hyperplasia and endometrioid neoplasia are highly reproducible between observers from different institutions. Glandular crowding is the best histologic feature to differentiate cyclical endometrium from hyperplasia, whereas nuclear pleomorphism is the reproducible cytologic feature to differentiate hyperplasia from endometrioid neoplasia.     

Intraobserver and interobserver reproducibility of the Nidek EAS-1000 Anterior Eye Segment Analysis System.

The NIDEK EAS-1000 is a camera and computer system designed to facilitate measurement and analysis of the anterior segment of the eye. To evaluate the interobserver reproducibility of the system, three examiners assessed the anterior chamber depth and peripheral angle measurement in 20 disease-free eyes. Intraobserver reproducibility was determined by each investigator's photographing and analyzing the same eye on three different occasions. Interobserver correlation for the anterior chamber depth (using the first three readings of the same eye made by each examiner) was 0.97, with an 95% CI of 0.94 to 0.98. Interobserver correlation for angle measurement (again using the first three readings of the same eye made by each examiner) was 0.89, with a 95% confidence interval (CI) of 0.81 to 0.95. Intraobserver correlations for anterior chamber depth were 0.98 for each of the three examiners (mean, 0.98), wiht a 95% CI of 0.91 to 0.99. Intraobserver correlations for anterior chamber depth were 0.98 for each of the three examiners (mean, 0.98), with a 95% CI of 0.91 to 0.99. The intraobserver CI for angle measurement was 0.97 (range, 0.95 to 0.99). The intraobserver and interobserver reproducibility of the NIDEK EAS-1000 system was excellent.     

The reliability and validity of the Vancouver classification of femoral fractures after hip replacement

This study assessed the reliability and validity of a new classification system for fractures of the femur after hip arthroplasty. Forty radiographs were evaluated by 6 observers, 3 experts and 3 nonexperts. Each observer read the radiographs on 2 separate occasions and classified each case as to its type (A, B, C) and subtype (B1, B2, B3). Reliability was assessed by looking at the intraobserver and interobserver agreement using the kappa statistic. Validity was assessed within the B group by looking at the agreement between the radiographic classification and the intraoperative findings. Our findings suggest that this classification system is reliable and valid. Intraobserver agreement was consistent across observers, ranging from 0.73 to 0.83. There was a negligible difference between experts and nonexperts. Interobserver agreement was 0.61 for the first reading and 0.64 for the second reading by kappa analysis, indicating substantial agreement between observers. Validity analysis revealed an observed agreement kappa value of 0.78, indicating substantial agreement. This study has shown that this classification is reliable and valid.     

A comparison of the reliability and validity of bone stock loss classification systems used for revision hip surgery

Three femoral (Paprosky, American Academy of Orthopaedic Surgeons [AAOS], and Endo-Klinik) and 2 acetabular (Paprosky, AAOS) bone stock loss classification systems were evaluated for reliability. Four observers (2 consultants, 2 registrars) graded the bone loss in 25 patients using preoperative radiographs. Grading was repeated after a minimum of 2 weeks. Interobserver and intraobserver reliability was investigated. The kappa statistic was used to assess levels of agreement. Intraobserver agreement ranged from poor to good. Interobserver agreement ranged from fair to moderate. The validity of the Paprosky classification system was evaluated, comparing preoperative bone stock loss assessment with intraoperative findings. Agreement levels of moderate (femoral classification system) to good (acetabular classification system) were achieved. Bone stock loss classification systems are shown to be inconsistent and unreliable.     

Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty

The Vancouver classification system of periprosthetic fractures has been revalidated in this study, using the radiographs of 45 patients. Three consultants and 3 trainees reviewed the radiographs independently, on 2 separate occasions, at least 2 weeks apart. Interobserver and intraobserver agreement and validity were analyzed, using weighted κ statistics. The mean κ value for interobserver agreement was found to be 0.69 (0.63-0.72) for consultants and 0.61 (0.56-0.65) for the trainees, both representing substantial agreement. Intraobserver κ values ranged from 0.74 to 0.90, showing substantial agreement. Validity analysis of 37 type B cases revealed 81% agreement within B1, B2, and B3 subgroups with a κ value of 0.68 (substantial agreement). This study has reconfirmed the reliability and validity of the Vancouver classification while it also emphasizes the intraoperative assessment of implant stability.     

Reproducibility of the Banff classification in subclinical kidney transplant rejection

The Banff classification for kidney allograft pathology has proved to be reproducible, but its inter and intraobserver agreement can vary substantially among centres. The aim of this study was to evaluate Banff reproducibility of surveillance renal allograft biopsies among renal pathologists from different transplant centres. This study included 32 renal transplant patients with stable graft function. Biopsies were performed 2 and 12 months post-transplant. Histology was interpreted according to the Banff schema by three renal pathologists, and inter and intraobserver agreement were measured. The best reproducibility was obtained for the presence or absence of acute rejection (AR), with kappa values ranging from moderate (kappa = 0.47; p = 0.006) to good (kappa = 0.72; p = 0.0001). However, the agreement for 'suspicious for AR' category was poor between all observers. For scoring and grading interstitial inflammation and intimal arteritis the agreement were poor and moderate, respectively. Reproducibility for the presence or absence of chronic allograft nephropathy (CAN) was heterogeneous, ranging from poor (kappa = 0.13; p = NS) to moderate (kappa = 0.56; p = 0.007). Scoring chronic changes such as fibrous intimal thickening gave a reasonable interobserver agreement. Intraobserver reproducibility was good for presence or absence of AR, but was poor for the diagnosis of CAN. In conclusion, histologic analysis of stable renal allografts based on Banff criteria showed a good agreement for the diagnosis of AR and a reasonable kappa for CAN, but reproducibility for scoring and grading showed a substantial interobserver variation.     

Reliability of a modified Gartland classification of supracondylar humerus fractures

Fracture-classification systems are used to recommend treatment and predict outcomes. In this study, a modified Gartland classification system of supracondylar humerus fractures in children was assessed for intraobserver and interobserver variability. Five observers classified radiographs of 50 consecutive children with extension supracondylar humerus fractures on three separate occasions. After a 2-week interval, 90% of fractures were classified the same on both readings, with and intraobserver kappa value of 0.84. After a 36-week interval, 89% of the fractures were classified the same, with a kappa value of 0.81. Interobserver reliability was evaluated by pairwise comparison among observers, resulting in an overall kappa value of 0.74. The reliability of the Gartland classification for supracondylar humerus fractures in children is better than that published for other fracture-classification systems. However, 10% of the time, a second reading by the same observer is different. This makes treatment recommendations based only on fracture type imprecise.     

Observer variability in the radiographic measurement and classification of metatarsus adductus.

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.     

Computed tomography assessment of sacroiliac screw placement relative to the first sacral neuroforamen

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.     

Core biopsies of renal tumors: a study on diagnostic accuracy, interobserver, and intraobserver variability

OBJECTIVE: The diagnostic accuracy of in-bench core biopsies (CBs) from renal masses, and the interobserver and intraobserver variability in pathological subtyping of renal tumors were assessed. METHODS: We performed two CBs in 62 consecutive renal masses suspected for renal cell carcinoma (RCC), obtained after radical or partial nephrectomy and, in one case, after autopsy. Routine hematoxylin-eosin (HE)-stained sections from each CB were evaluated by five pathologists on two occasions. The surgical specimen was the reference standard. Diagnostic accuracy and the generalized kappa for intraobserver and interobserver agreement were calculated. RESULTS: Five tumors were benign and 57 malignant. Eight percent to 16% of the CBs were considered inadequate for diagnosis. In 0-8% of the cases, the pathologist could not discriminate between a benign or malignant tumor. Overall accuracy ranged from 77% to 90%. Sensitivity (79-100%) and positive predictive value (100%) were high with narrow 95% confidence interval (95%CI). Specificity (100%) was high but negative predictive value (29%-100%) varied, with wide 95% CI. Interobserver agreement was fair to almost perfect (kappa=-0.010 to 0.830) for the different subtypes. In 64-81% of the CBs, the subtype was correctly classified. Intraobserver agreement was substantial (mean kappa=0.628) for all pathologists. CONCLUSION: Diagnostic accuracy of CBs was high, with a diagnostic yield varying between 84% and 92%. Pathological subtyping of CBs was highly reproducible with the exception of the chromophobe renal cell carcinoma, which was problematic on HE-stained sections only.     

Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery

BackgroundSanders classification, based on the number of displaced fractured fragments of posterior facet, can predict the prognosis of calcaneal intraarticular fractures. The aim of the study was assessing not only intraobserver reproducibility and interobserver reliability of Sanders classification but also the agreement between preoperative reported types based on computed tomography (CT) scan and direct observation during the surgery.MethodsIn this cross-sectional study, preoperative CT scans of 100 patients with intra-articular calcaneal fracture operated by a single surgeon were studied by two orthopedic and trauma surgeons (A & B), twice with an interval of three weeks. Their result were compared with each other and with the number of displaced fractured fragments recorded in the operation notes. Quadratic weighted kappa test was used to check the agreement between two observers and between the observers and the surgeon.ResultsIntraobserver reproducibility for Sanders classification of intraarticular calcaneal fractures was found to be good to excellent (A1–A2: 0.91 and B1–B2: 0.75). There was a moderate agreement between the two observers (A1–B1: 0.56, A1–B2:0.58, A2–B1:0.48, and A2–B2:0.51). The agreement between reported types of Sanders classification and the number of displaced fractured fragments seen during the surgery was fair (A1-surgeon: 0.27, A2-surgeon: 0.29, B1-surgeon: 0.38, and B2-surgeon: 0.50).ConclusionsAgreement between Sanders classification and what is real during surgery is fair. Hence, Sanders classification as determined in the widest cut of coronal CT scan extended posteriorly should be cautiously interpreted for surgery.     

Assessment of interobserver variation in Garden classification and management of fresh intracapsular femoral neck fracture in adults

Objective： To assess the interobserver agreement on Garden classification of fresh femoral neck fracture and management plan based on anteroposterior （AP） view and also assess if the addition of lateral view changes the classification and management plan. Methods： Ten orthopaedic surgeons were asked to classify 35 femoral neck fractures on AP view only and propose the management plan. Then the same films were reshown in conjunction with their lateral view after 10 days. Results were compared with respect to the classification and management plan between two groups. Interobserver agreement was calculated using Fleiss＇ kappa. Results： There was only a fair interobserver agreement （kappa value 0.39） on Garden classification on AP view only which improved to moderate agreement （kappa value 0.52） after adding a lateral view. While there was only a slight improvement in the interobserver agreement on the management plan on AP view only （kappa value 0.50） and AP combined with lateral views （kappa value 0.52）. Supplementation of the lateral view changed the classification in 15.42% of the cases and altered the management plan in 23.14% of the cases. Conclusion： We conclude that lateral view should be obtained routinely on all patients with suspected femoral neck fracture as it definitely has a role in planning treatment of femoral neck fracture.