The impact of the garden classification on proposed operative treatment

The current study evaluates the interobserver reliability and intraobserver reproducibility of the Garden classification of femoral neck fractures, assesses the influence of a lateral radiograph on a fracture's classification, and determines the classification's impact on the surgeon's choice of operative treatment. Forty radiographs of femoral neck fractures were evaluated independently by five orthopaedic surgeons. Kappa values were calculated for interobserver reliability and intraobserver variability with respect to the readers' ability to assess the fractures using the Garden classification and to determine fracture displacement with and without access to a lateral radiograph. In 69% of the instances in which a reader changed the classification of a fracture, the proposed treatment of the fracture did not change. The Garden classification has poor interobserver reliability but good intraobserver reproducibility. The addition of a lateral radiograph does not seem to improve the reliability of the current Garden classification system but may improve the reader's ability to determine fracture displacement. To improve the reliability and usefulness of the Garden classification, the authors suggest that the classification should be modified to have only two stages (Garden A-nondisplaced or valgus impacted and Garden B-displaced) and to include the use of a lateral radiograph.     

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.     

Garden type I fractures myth or reality? A prospective study comparing CT scans with X-ray findings in Garden type I femoral neck fractures

The Garden type I femoral neck fracture is defined as an incomplete fracture of the neck of the femur as seen on the antero-posterior (AP) radiograph of the injured hip. The diagnosis of incomplete femoral neck fractures has decreased in recent years with the development of improved radiographic imaging. We hypothesized that incomplete femoral neck fractures seen on radiographs are in fact complete fractures on computed tomography (CT). The study aims to test this hypothesis by comparing CT scan images to X-ray findings in patients diagnosed with Garden type I femoral neck fractures. From January 2008 to October 2010, our management of femoral neck fractures included a CT scan of the injured hip for all Garden type I fractures. CT findings were reported by a musculoskeletal radiologist. A classification of the fracture was performed by an orthopedic surgeon. Eight hundred and twenty five femoral neck fractures were admitted during the study period. Seventeen of these fractures (2.1%) were considered incomplete based on radiographic evaluation. In 17 cases (100%), the CT scan demonstrated a complete fracture extending through the medial cortex. Subsequently, all 17 fractures were fixed with standard cannulated screw technique on a fracture table. Secondary displacement occurred in one patient prior to fixation. All fractures healed well and no avascular necrosis was noted. In summary, our study shows that incomplete femoral neck fractures identified on X-rays are actually complete fractures based on CT scans. If confirmed by a larger study population, our findings can simplify the Garden classification by eliminating an inaccurate subcategory. The clinical implications are that Garden type I fractures should all likely be fixed with cannulated screws and with an effort to prevent displacement during treatment.     

The clinical significance of impaction at the femoral neck fracture site in the elderly

Introduction Factors influencing clinical outcomes of osteosynthesis for elderly patients with Garden stage I and II femoral neck fractures are not well understood. Materials and methods To determine the factors influencing the clinical outcomes of in situ osteosynthesis in non-displaced femoral neck fractures in the elderly, radiographs and clinical data of patients were retrospectively analyzed. The subjects were 49 patients with femoral neck fractures (Garden stages I and II), who underwent osteosynthesis, with correctly inserted screws and with more than 2 years of follow up. The relationships between preoperative anteroposterior X-ray parameters including Garden stage, the presence or absence of spikes, the Singh grade, the Garden alignment index, the degree of impaction at the fracture site (the capital impaction index) and postoperative outcomes were analyzed. Results Among the 49 cases, there were eight unsuccessfully treated patients, two with non-union and six with late segmental collapse. The “without spikes” fracture type (P < 0.05) and the degree of capital impaction when the capital impaction index (P < 0.0001) was greater than the mean plus the standard deviation, were significantly associated with unsuccessful outcomes. Conclusion Excessive shortening at the fracture site on the anteroposterior radiograph in the femoral neck fracture of Garden stages I and II can be used to predict poor outcomes from in situ osteosynthesis.     

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.     

Impact of MRI on treatment plan and fracture classification of tibial plateau fractures

OBJECTIVE: To evaluate the interobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI). DESIGN: Prospective study to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures among three orthopaedic surgeons. SETTING/PARTICIPANTS: Patients presenting with tibial plateau fractures to a level I trauma center were evaluated with plain knee radiographs (anteroposterior, lateral, two oblique views), CT scan, and MRI. Three experienced attending orthopaedic trauma surgeons were randomly presented three sets of studies for each injury: radiographs alone, radiographs with CT, and radiographs with MRI (including soft tissue injuries documented by an experienced MRI radiologist). The surgeons were asked to render fracture classification and treatment plan based upon the blind reading of each individual radiographic set. MAIN OUTCOME MEASURES: Agreement among the three surgeons was measured using kappa coefficients. RESULTS: For fracture classification, radiographs alone yielded a mean kappa coefficient of 0.68, which increased to 0.73 for radiographs with CT scan and 0.85 for radiographs with MRI. Fracture classification (Schatzker) was changed an average of 6% with the addition of the CT scan and 21% based on radiographs with MRI. For the fracture management plan, the mean interobserver kappa coefficient for radiographs alone was 0.72, which increased to 0.77 for radiographs with CT scan and 0.86 for radiographs with MRI. MRI changed treatment plan in 23% of the cases. CONCLUSION: Magnetic resonance imaging increases the interobserver agreement on fracture classification and operative management of tibial plateau fractures.     

Low interobserver reliability of radiographic signs predicting healing disturbance in displaced intracapsular fracture of the femoral neck

We determined the interobserver agreement of 3 radiographic signs previously shown to predict a disturbance in healing of femoral neck fractures. 6 orthopedic surgeons evaluated 32 radiographs for the presence of comminution of the femoral calcar, varus displacement in excess of 30 degrees and a small head fragment. They also classified the radiographs with Garden's method and determined the presence or absence of displacement. The kappa values were 0.2 for comminution of the calcar, 0.5 for varus displacement and 0.4 for a small head fragment. In the Garden classification, the kappa value was 0.4, increasing to 0.6 when divided into Garden 1-2 and 3-4. When the fracture was classified as displaced or undisplaced, the kappa value was 0.5. The strength of agreement of signs predicting a disturbance in healing was thus shown to be poor to moderate.     

Role of computed tomography in the classification and management of pediatric pelvic fractures

In adults, pelvic computed tomography (CT) scanning plays an important role in the treatment of pelvic fractures; however, the role of CT scanning in the management of pediatric pelvic fractures is unclear. The purpose of this study was to investigate the efficacy of CT scanning in the management of pelvic fractures in children. One hundred three consecutive patients were identified. All patients underwent anteroposterior plain radiographic evaluation; CT scans were performed in 62. Three orthopaedic surgeons independently reviewed the plain radiographs and determined fracture classification and management. Subsequently, each observer was shown corresponding CT scans and again determined classification and management. Interobserver agreement was calculated using Kappa statistics. After the addition of CT scans, the mean changes in classification were nine (15%) and in management two (3%). Plain radiographs alone reliably predicted the need and type of operative intervention. Kappa statistics demonstrated "excellent" agreement for classification and management without and with CT scans. We reliably determined fracture classification and management based on plain radiographs alone.     

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.     

Assessment of articular fragment displacement in acetabular fractures: a comparison of computerized tomography and plain radiographs

OBJECTIVES: Quantitatively evaluate plain radiographs, relative to computed tomography (CT) scans, for assessment of articular fragment displacement (step and gap) in displaced acetabular fractures and in canine osteotomized acetabular specimens. DESIGN: Retrospective evaluation of a consecutive series of CT scans and plain radiographs of patients with displaced acetabular fractures and canine acetabulae osteotomized to represent acetabular fractures with displacement. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Computed tomography scans and plain radiographic images of 62 consecutive patients with displaced acetabular fractures were reviewed; 20 patients met the inclusion criteria regarding location, fracture pattern, availability of plain radiographs and CT scans, and the position of the femoral head at the time of radiographic assessment. The hemipelvi of five adult mongrels underwent osteotomy of the acetabulum and similar radiographic evaluation. INTERVENTION: Three independent reviewers measured step and gap deformity on plain radiographs and CT scans utilizing a standardized measurement technique. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of plain radiographs for detecting step and gap displacement (2 mm and 4 mm) relative to CT scans were determined. Intraclass correlation coefficient and intraobserver reliability was also calculated. For the canine specimens, sensitivities of each imaging method were determined relative to actual fragment displacement measurements. RESULTS: In the clinical images, when compared to CT, plain radiographs showed poor sensitivity at detecting step deformity (sensitivity = 25%). When analyzed by fracture type, plain radiographs were particularly poor at detecting step deformities in fractures involving a single column of the acetabulum (sensitivity = 0%). Excellent intraobserver and intraclass reliability existed among the three reviewers. Computed tomography scans were considerably more accurate in measuring step and gap displacement relative to actual measurements than plain radiographs in the canine specimens. CONCLUSIONS: 1) Plain radiographs showed poor sensitivity for the detection of step and gap deformities in patients with acetabular fractures and in osteotomized canine specimens, relative to CT scans; 2) differences between CT and plain radiographs in both specimen types were greatest with the most clinically relevant deformity-i.e., step; and 3) CT scans are essential and should continue to be used in conjunction with plain radiographs in the preoperative evaluation of displaced acetabular fractures and perhaps should be considered in the postoperative assessment of fracture reduction.     

Interobserver reliability and intraobserver reproducibility of powers ratio for assessment of atlanto-occipital junction: comparison of plain radiography and computed tomography

Powers ratio, as assessed on plain radiographs or computed tomography (CT) images, appears to have clinical and prognostic value. To date, the validation of this assessment tool has been limited to a small number of observers at a single site. No study has examined the intraobserver reproducibility and interobserver reliability of the Powers ratio measurement on plain radiographs or CT images among a large cohort of spine surgeons. This type of validation is critical to allow for the broader use of the Powers ratio methodology in research studies and clinical applications. Plain radiographs and spiral CT images of the cervical spine of 32 patients were assessed, and the Powers ratio was determined by five spine surgeons. Each surgeon performed three readings, 7 months apart. In the first round of measurements, the observers used only the Powers’ method of instruction. The second and third measurement sets were obtained after an interactive teaching session on the methodology. The order of the images was altered for the second and third set of measurements. The coefficient of variation (Cv) was calculated to determine the intraobserver repeatability and interobserver reliability for each imaging technique. A Bland-Altman plot was then used to assess the agreement between the two imaging techniques. For interobserver reliability, the mean Cv of the Powers ratio was 9.09 and 4.31% for plain radiographs and CT, respectively. The Cv mean value for intraobserver reproducibility averaged 4.95% (range 1.39–9.08) when CT scans were used and 14.17% (range 7.54–34.30) when plain radiographs were used. For intraobserver reproducibility, the lowest and highest Cv mean value of five raters was 1.39 and 9.08% using CT scans and 7.54 and 34.3% using plain radiographs. The Bland-Altman plot, demonstrated that the two methods were in close agreement on the −0.8 and 0.89% interval for limits of agreement (bias ± 1.96σ). The intraobserver reproducibility and interobserver reliability of Powers ratio measurement was acceptable (<5%) with CT scans but not with plain radiographs. However, despite the statistically inferior reliability and repeatability, the Bland-Altman plot analysis showed that given the −0.8 and 0.89% limits of agreement, the two methods may be used interchangeably in clinical practice.     

Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment?

The purpose of this study is to determine whether the addition of computed tomography (CT) results in changes in the evaluation and treatment of intra-articular distal radius fractures. Fifteen intra-articular distal radius fractures were evaluated independently by 4 hand surgeons. Plain x-rays were reviewed initially followed by the corresponding CT scans for comparison of articular step-off and gapping, comminution, and treatment. Kappa coefficients (kappa) of intraobserver and interobserver reliability for treatment plans were generated. Computed tomography scans improved the sensitivity of measurement of articular surface gapping, improved the accuracy of detection of comminution and distal radioulnar joint involvement, and altered proposed treatment plans within observers (intraobserver agreement: kappa =.54, moderate) and improved agreement of proposed treatment plans between observers (kappa =.34 to kappa =.44, fair to moderate). Computed tomography scanning influenced observers to change treatment plans and resulted in increased interobserver reliability in the proposed management of these injuries.     

Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures?

Computed tomography (CT) has been deemed a necessary part of management for Tillaux and triplane pediatric ankle fractures. However, no previously published study has attempted to quantify its usefulness in changing management. Six third-party, blinded orthopedic surgeons (F.A.L., E.N.K., D.M.P., K.J.K., D.S.F., K.A.E.) were randomly assigned to evaluate 24 pediatric Tillaux or triplane fractures with plain radiographs; after 6 months, they were again randomly assigned to evaluate the 24 radiographs plus CT scans, totaling 144 third-party, blinded evaluations. Intra- and interobserver agreements were assessed via correlation coefficient analysis. Evaluation of CT scans changed the original diagnosis of fracture type from Tillaux to triplane fracture in 7 (4.9%) of 144 evaluations. Inter- and intraobserver agreements regarding primary treatment plans did not significantly differ between radiographs and radiographs plus CT scans (0.5 vs 0.4, respectively; P>.05). The addition of CT did not significantly change the impression of the amount of displacement per case. By adding CT, more patients who were assigned nonoperative management were reassigned to operative treatment (P=.033). Adding CT, although it may influence the decision to operate on Tillaux and triplane fractures, may not be as useful as previously thought.     

CT和X线片对髋臼骨折移位程度评价的比较

目的 探讨CT和X线片对髋臼骨折移位程度的评价。方法 回顾性分析我院1998年1月～2003年5月收冶的64例髋臼骨折患者的CT和X线片。根据病例纳入标准，把其中20例患者的CT和X线片作为研究对象。应用单盲法，在CT和X线片上，让3名医生各自利用一个标准的测量方法对沿髋臼关节面的横行和垂直移位进行测量。以CT为标准，分别计算出横行和垂直移位2mm和4mm的X线片的灵敏度和特异度，同时对每个测量者和测量者之间的测量可靠性进行评价。结果 X线片对检测垂直移位的灵敏度较差(灵敏度=44．3％)。其中对于单柱骨折垂直移位的灵敏度更差(灵敏度=0)。每个测量者和测量者之间的测量值具有较好的一致性。结论 X线片对检测髋臼骨折横向和垂直移位均显示较差的灵敏度；而对垂直移位的灵敏度就更差；因此，CT不仅优于X线片用于术前选择髋臼骨折患者的诊断和治疗方法，而且还用于评价术后骨折复位程度和预后。     

Interobserver and intraobserver variability in radiographic assessment of osteolysis

This study quantified the variability associated with diagnosing periprosthetic osteolysis from the radiographs of total hip arthroplasty patients. Four joint arthroplasty surgeons independently assessed radiographs of 60 patients for evidence of osteolysis in different zones. The surgeons agreed on the presence of lesions in at most 57% of the zones. kappa coefficients, used to quantify the extent of agreement among the surgeons, denoted poor interobserver reproducibility (kappa =.28 to.44). Intraobserver reliability-determined by comparing 2 reviews of the same radiographs done by 1 surgeon 2 weeks apart-was moderate to excellent (kappa =.48 to.84). We also compared the results from the most recent radiograph with those from a time series. Agreement improved when a series was reviewed. Reliable comparisons cannot be made with osteolysis rates reported by different observers. In the research setting, osteolysis rates are more reliable if they are determined by a single reviewer whose intraobserver variability has been reported. In assessing a patient for osteolysis, it is more accurate to analyze a series of radiographs than the most recent radiograph.     

The Inter-Observer and Intra-Observer Reliability of the Paprosky Femoral Bone Loss Classification System

The Paprosky classification provides a straightforward algorithm for defining bone loss and directing treatment for femoral revision. The purpose of this study was to test the inter-observer and intra-observer reliability of this system. Four arthroplasty surgeons reviewed radiographs of 205 consecutive femoral revisions. For each radiograph, the pattern of femoral bone loss was classified by Paprosky type on two separate occasions. A kappa value was used to calculate the reliability, which demonstrated an inter-observer reliability of 0.61, indicating substantial agreement between surgeons. The intra-observer reliability for each of the 4 participating surgeons was 0.81, 0.78, 0.76, and 0.75, indicating substantial to almost perfect agreement. There is substantial agreement among experienced arthroplasty surgeons when using the Paprosky Classification to characterize femoral bone loss.     

Treatment of undisplaced femoral neck fractures in the elderly

BACKGROUND: While the treatment for displaced femoral neck fractures in the elderly (Garden types III and IV) is quite clear, the procedure for impacted or undisplaced femoral neck fractures (Garden types I and II) is still a subject of controversy. Methods: Thirty-seven (all >80 years old) patients with undisplaced femoral neck fractures were treated with osteosynthesis by cannulated screws fixation. The clinical outcomes were followed up retrospectively for at least two years. RESULTS: The overall union rate was 94.59% (35 patients) at 6 months after primary internal fixation. The overall success rate was 83.78% (31 patients), and the overall failure rate was 16.22% (6 patients). CONCLUSIONS: Osteosynthesis with cannulated screws fixation is a simple, safe, economical, and reasonably effective procedure for the treatment of undisplaced femoral neck fractures in patients older than 80 years.     

Perception of Garden’s classification for femoral neck fractures: an international survey of 298 orthopaedic trauma surgeons

The Garden classification is the most popular femoral neck fracture classification system. We surveyed orthopaedic surgeons about their preferences for femoral neck fracture classification systems and their belief about their ability to discriminate between the four different Garden fracture types. A questionnaire was developed to examine surgeons’ training and experience and their preferences for classification of femoral neck fractures by consulting five orthopaedic surgeons in Canada and the United States, and the previous literature. The Garden classification was the preferred femoral neck fracture classification for 72% of all the surveyed surgeons (n=298). Only 39% of all the surveyed surgeons believed they were able to distinguish all four Garden fracture types. However, 96% of the surgeons felt they could differentiate between undisplaced (Garden I/II) and displaced (Garden III/IV) fractures. High variability in the surgeons’ perceptions of the Garden classification system provides a rationale for discontinuing the use of this system in daily practice.     

Intraobserver and interobserver reliabilty of measures of kyphosis in thoracolumbar fractures

Background contextConsensus documents have recently been developed enumerating the radiographic parameters thought to be most valid in the clinical evaluation of patients with thoracolumbar fractures.PurposeThe objective of this study was to assess the measurement reliability of plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) and their inter-modality agreement, as the three imaging modalities are often clinically interchangeable. This process is an essential reliability evaluation of the measurement parameters being proposed.Study designThis study evaluated the interobserver and intraobserver reliability of plain radiographs, CT, and MRI measurements of sagittal kyphosis in thoracolumbar fractures.Patient sampleSuitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined.MethodsSuitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined by ten independent spine surgery fellowship-trained observers.Outcome measuresCobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage were measured.ResultsRegardless of the imaging modality or the parameter being measured, the intraobserver reliability is always better than the interobserver. Plain radiography has better overall, interobserver and intraobserver reliability, followed by CT and then MRI. Reliability is very high in general, with the highest reliability for intraobserver reliability of the linear measures on plain radiographs. The inter-modality agreement is highest for plain X-ray and CT.ConclusionsThis study demonstrates that Cobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage are reliable measures of thoracolumbar fracture kyphosis with very high interobserver and intraobserver reliability and very high inter-modality agreement of plain X-ray with CT.     

Improved operations for femoral neck fracture. A radiographic evaluation

A radiographic investigation was undertaken to determine whether an increased interest in femoral neck fractures improved the operative result. In 1977, all femoral neck fractures were operated on by any of 30 surgeons of the orthopedic department, but in 1981 all fractures were operated on by one of six specially devoted surgeons. Preoperative fracture classification was performed with three parameters and proved equal in the 1977 and 1981 groups of 105 and 114 fractures, respectively. The quality of fracture reduction, determined with four parameters, was improved somewhat. The position of the nail(s), also determined with four parameters, improved considerably. The technical result was better in Garden IV fractures than in Garden III fractures. An increased interest in femoral neck fracture treatment improved reduction and fixation.