Correlation of pediatric outcomes data collection instrument with measures of active movement in children with brachial plexus birth palsy

BACKGROUND: The purpose of this investigation was to characterize the range of Pediatric Outcomes Data Collection Instrument (PODCI) scores in children with brachial plexus birth palsy (BPBP) and determine its correlation with 3 published measures of active motion and function. METHODS: One hundred fifty children with BPBP between the ages of 2 and 10 years were evaluated. Active upper-extremity motion was assessed using the modified Mallet Classification (MC), the Toronto Test score (TTS), and the Hospital for Sick Children Active Movement Scale. At the time of evaluation, patients and/or families were administered the age-appropriate PODCI questionnaire, and PODCI scores were compared with published normative data. Linear regression analysis was used to assess the correlation between MC, TTS, and Active Movement Scale as predictors of PODCI scores. RESULTS: Mean PODCI global function score in the BPBP patients was 82.4 (range, 35.1-100), significantly lower than the published value of 93.3 in healthy, age-matched norms (P < 0.01). The mean upper-extremity subscore was 70.8 versus 92.0 in healthy age-matched controls (P < 0.01). Sports/physical functioning scores averaged 81 points among BPBP patients compared with 90 points in healthy norms (P < 0.01). Mean mobility, comfort/pain, and happiness subscores were also significantly lower than normative values by 5, 7, and 4 points, respectively (P < 0.01). While significant correlations were observed between PODCI scores and all measures of active movement, the modified MC correlated most highly with PODCI global function scores in patients aged 2 to 5 years, whereas the TTSs best correlated with global function in patients aged 6 to 10 years. CONCLUSION: Brachial plexus birth palsy patients have lower global and upper-extremity function compared with their healthy, age-matched peers, as measured by the PODCI. Physician-derived measures of active movement correlate with the patient/parent-derived PODCI scores and may be used to predict global function, upper-extremity function, and sports/physical activity in children 2 to 10 years of age with BPBP.     

Upper Extremity Size Differences in Brachial Plexus Birth Palsy

The purpose of this investigation was to determine size differences between affected and unaffected upper extremities in patients with brachial plexus birth palsy (BPBP). Forty-eight patients with BPBP underwent measurements of the bilateral upper extremities. Average age at the time of evaluation was 47 months. In addition, patients or families were asked “How important is the difference in arm size and appearance to you?” Active motion was assessed using the modified Mallet classification, Toronto Test Score, and Hospital for Sick Children Active Movement Scale. Correlation between ratios of affected to unaffected limb lengths and girths and measures of active motion were assessed using Spearman’s rank correlation coefficient. Upper arm, forearm, and hand lengths of the affected limbs were, on average, 95%, 94%, and 97% of the contralateral unaffected side, respectively. Upper arm girth, forearm girth, and hand width were, on average, 97%, 98%, and 95% of the contralateral side, respectively. All differences achieved statistical significance (p < 0.01). Furthermore, over 37% of patients or families reported that limb differences were “very” or “extremely important” to them. No statistically significant correlation between age and limb length discrepancy was noted. Furthermore, there were no correlations between upper limb discrepancies and measures of active motion in individual patients. Patients with BPBP and persistent neurological deficits may expect the affected upper extremity to be on average approximately 95% the length and girth of the contralateral limb. These differences do not correlate with patient age or clinical measurements of active movement.     

Interobserver reliability of the Mallet score

The interobserver reliability of the Mallet score for active shoulder function was assessed by three experienced observers in a group of 30 children with an obstetric brachial plexus lesion (mean age 7.1 years, range 4.5-10 years). Interobserver reliability, measured using weighted kappa, was good. Kappa varied between 0.37 and 0.84 and differed between the different aspects of the Mallet score and different pairs of observers. In decreasing order, mean weighted kappa was 0.75 for abduction, 0.73 for hand to neck, 0.67 for hand to spine, 0.6 for external rotation and 0.53 for hand to mouth.     

Intraobserver and interobserver reliability of two ultrasound measures of humeral head position in infants with neonatal brachial plexus palsy

BACKGROUND: Ultrasonographic evaluation of the hip in infants is considered both reliable and reproducible in the diagnosis of developmental dysplasia of the hip. Ultrasonographic evaluation of the shoulder in infants has been reported as a valuable diagnostic aid in dysplastic development following neonatal brachial plexus palsy. To our knowledge, there has been no study of the intraobserver reproducibility and interobserver reliability of sonography of the shoulder in infants with and without suspected posterior shoulder dislocation. METHODS: Two identical but randomly ordered sets of the same deidentified sonographic images of shoulders in infants were given to radiologists, pediatric orthopaedists and orthopaedic residents, and fellows with varying degrees of experience in the evaluation of shoulder pathology in infants, who measured the position of the humeral head relative to the axis of the scapula. Intraobserver reproducibility and interobserver reliability of the measurements were assessed. RESULTS: For the position of the humeral head with respect to the glenoid in both normal and abnormal conditions, the Pearson correlation coefficient for intraobserver reproducibility was 0.91 and the intraclass correlation coefficient for interobserver reliability was 0.875. For estimating the percentage of the humeral head posterior to the axis of the scapula, the Pearson correlation was 0.85 and the intraclass correlation coefficient was 0.77. CONCLUSIONS: Ultrasonographic examination of the shoulder in infants to assess for the position of the humeral head with respect to the scapula showed high intraobserver reproducibility and interobserver reliability. It is recommended as a reliable technique for evaluating shoulder position in infants with neonatal brachial plexus palsy.     

The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy

BACKGROUND: Derotational humeral osteotomies have been used in older children with brachial plexus birth palsy and glenohumeral joint deformity to place the upper extremity in a more functional position. The purpose of this study was to determine the effects of these procedures on shoulder function and joint morphology. METHODS: Forty-three patients underwent a derotational humeral osteotomy for functional impairment in the setting of internal rotation contracture and/or glenohumeral joint deformity at our institution from 1996 to 2004. Osteotomies were performed proximal to the deltoid insertion and were stabilized with plate-and-screw fixation. The average age of the patients at the time of surgery was 7.6 years (range, 2.3 to 17.0 years). Shoulder function was graded according to the modified Mallet classification system. Glenohumeral deformity was graded according to the classification scheme of Waters et al. The results for twenty-seven patients who were followed for a minimum of two years (average, 3.7 years) are reported. RESULTS: The average amount of external rotation achieved with osteotomy was 64 degrees (range, 35 degrees to 90 degrees). The mean aggregate Mallet classification score improved from 13 to 18 points (p < 0.01). The mean Mallet classification scores for the individual elements similarly demonstrated improvement following osteotomy, with the greatest gains in hand-to-mouth, hand-to-neck, and external rotation motions. The mean classification of the glenohumeral deformity was type IV preoperatively and postoperatively, signifying the persistence of glenohumeral dysplasia. There were no nonunions. One patient required a revision osteotomy for inadequate initial correction. One patient sustained a humeral fracture distal to the plate fixation because of sports-related trauma. CONCLUSIONS: Derotational humeral osteotomy improves shoulder function in patients with brachial plexus birth palsy, internal rotation contracture, and/or advanced glenohumeral joint deformity. This osteotomy provides an attractive treatment option for patients with brachial plexus birth palsy who have advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.     

Remote therapeutic effect of early nerve transposition in treatment of obstetric al brachial plexus palsy

ＭＤｅｐａｒｔｍｅｎｔｏｆＯｒｔｈｏｐａｅｄｉｃｓａｎｄＨａｎｄＳｕｒｇｅｒｙ,ＦｕｊｉａｎＰｒｏｖｉｎｃｉａｌＨｏｓｐｉｔａｌ,Ｆｕｚｈｏｕ350001,Ｃｈｉｎａ(ＸｕＪ)ＤｅｐａｒｔｍｅｎｔｏｆＨａｎｄＳｕｒｇｅｒｙ,ＨｕａｓｈａｎＨｏｓｐｉｔａｌ,ＳｈａｎｇｈａｉＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ,Ｓｈａｎｇｈａｉ200040,Ｃｈｉｎａ(ＣｈｅｎｇＸＭ,ＤｏｎｇＺａｎｄＧｕＹＤ)ｏｓｔｐａｔｉｅｎｔｓｗｉｔｈｏｂｓｔｅｔｒｉｃａｌｂｒａｃｈｉａｌｐｌｅｘｕｓｐａｌｓｙ(ＯＢＰＰ)ｃａｎｂｅｅｘｐｅｃｔｅｄｔｏｒ…     

AO Spine upper cervical injury classification system: a description and reliability study

Background ContextPrior upper cervical spine injury classification systems have focused on injuries to the craniocervical junction (CCJ), atlas, and dens independently. However, no previous system has classified upper cervical spine injuries using a comprehensive system incorporating all injuries from the occiput to the C2–3 joint.PurposeTo (1) determine the accuracy of experts at correctly classifying upper cervical spine injuries based on the recently proposed AO Spine Upper Cervical Injury Classification System (2) to determine their interobserver reliability and (3) identify the intraobserver reproducibility of the experts.Study Design/SettingInternational Multi-Center Survey.Patient SampleA survey of international spine surgeons on 29 unique upper cervical spine injuries.Outcome MeasuresClassification accuracy, interobserver reliability, intraobserver reproducibility.MethodsThirteen international AO Spine Knowledge Forum Trauma members participated in two live webinar-based classifications of 29 upper cervical spine injuries presented in random order, four weeks apart. Percent agreement with the gold-standard and kappa coefficients (?) were calculated to determine the interobserver reliability and intraobserver reproducibility.ResultsRaters demonstrated 80.8% and 82.7% accuracy with identification of the injury classification (combined location and type) on the first and second assessment, respectively. Injury classification intraobserver reproducibility was excellent (mean, [range] ?=0.82 [0.58-1.00]). Excellent interobserver reliability was found for injury location (? = 0.922 and ?=0.912) on both assessments, while injury type was substantial (?=0.689 and 0.699) on both assessments. This correlated to a substantial overall interobserver reliability (?=0.729 and 0.732).ConclusioNSEarly phase validation demonstrated classification of upper cervical spine injuries using the AO Spine Upper Cervical Injury Classification System to be accurate, reliable, and reproducible. Greater than 80% accuracy was detected for injury classification. The intraobserver reproducibility was excellent, while the interobserver reliability was substantial.     

Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy

The objective of this study was to test the interobserver and intraobserver reproducibility of videographic gait analysis in paediatric cerebral palsy patients following botulinum toxin type-A injections. Standardized videos according to gait-specific functional criteria were assessed for 1 h. For intraobserver reproducibility, 13 of 17 items showed good/moderate correlation, one mediocre and three poor correlation. For interobserver reproducibility, 12 of 17 items showed excellent, good or moderate agreement, five items showed poor agreement. Overall, 9 of 17 items showed good intraobserver or interobserver reproducibility. Mean interobserver scores for sagittal plane items were slightly lower than mean intraobserver scores (kappa=0.509 and 0.536, respectively). In conclusion, video analysis of children with cerebral palsy based on functional criteria is useful.     

Transfer of pectoral nerves to the musculocutaneous nerve in obstetric upper brachial plexus palsy

OBJECTIVE: To investigate the results of transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric brachial palsy. METHODS: In 25 cases of obstetric brachial palsy (20 after breech deliveries), branches of the pectoral nerve plexus were transferred directly to the musculocutaneous nerve. For all patients, the nerve transfer was part of an extended brachial plexus reconstruction. Results were tested both clinically and with the Mallet scale, at a mean follow-up time of 70 months (standard deviation, 34.3 mo). RESULTS: There were two complete failures, which were attributable to disconnection of the transferred nerve endings. The results after transfer were excellent in 17 cases and fair in 5 cases. Steindler flexorplasty improved elbow flexion for three patients. CONCLUSION: Transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric upper brachial palsy may be effective, if the specific anatomic features of the pectoral nerve plexus are sufficiently appreciated.     

The reliability and validity of the modified Unified Classification System for periprosthetic femoral fractures after hip arthroplasty

BackgroundThis study assessed the reliability and validity of the modified Unified Classification System for femur fractures after hip arthroplasty.MethodsFour hundred and two cases were evaluated by 6 observers, 3 experts and 3 trainee surgeons. Each observer read the radiographs on 2 separate occasions and classified each case as to its type. 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. Interobserver and intraobserver agreement and validity were analyzed, using weighted kappa statistics.ResultsThe mean k value for interobserver agreement was found to be 0.882 (0.833–0.929) for consultants (almost perfect agreement) and 0.776 (0.706–0.836) for the trainees (substantial agreement). Intraobserver k values ranged from 0.701 to 0.972, showing substantial to almost perfect agreement. Validity analysis of 299 type B cases revealed 89.854% agreement with a mean k value of 0.849 (0.770–0.946) (almost perfect agreement).ConclusionsThis study has shown that the modified Unified Classification System is reliable and valid. We believe it is useful to improve the judgment of the implant stability, and establish the therapeutic strategy for periprosthetic femoral fracture.     

Observer variabilities of radiological classifications of calcified deposits in calcifying tendinitis of the shoulder

The radiological morphology of calcified deposits in calcifying tendinitis of the shoulder is classified according to Patte and Goutallier and according to Mole et al. The results of these classifications influence the choice of therapeutic procedures. In this study, the intraoberserver reproducibility and interobserver reliability of these classifications were determined. Plain anteroposterior radiographs of shoulders from 100 patients with symptomatic calcified deposits of the rotator cuff were classified according to the criteria of Patte and Goutallier as well as to the criteria of Mole et al, by six independent observers, twice within four months. The kappa values of intraoberserver reproducibility and interobserver reliability were calculated. Classification of Patte and Goutallier: intraoberserver reproducibility, mean kappa value 0.458 (standard deviation 0.098); interobserver reliability, mean kappa values 0.4 (first test) and 0.354 (second test). Classification of Mole et al: intraoberserver reproducibility, mean kappa value 0.402 (standard deviation 0.092); interobserver reliability, mean kappa values 0.239 (first test) and 0.191 (second test). Both classifications demonstrated a satisfactory to sufficient intraobserver reproducibility. The classification of Patte and Goutallier showed a satisfactory interobserver reliability, whereas the classification of Mole et al had a satisfactory to insufficient interobserver reliability. Studies dealing with both classifications should therefore be interpreted carefully.     

Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy

BACKGROUND: Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint deformity in patients with brachial plexus birth palsy. The objective of this investigation was to determine the effects of correction of external rotation weakness and internal rotation contractures with tendon transfers and extra-articular soft-tissue releases on glenohumeral development in patients with brachial plexus birth palsy. METHODS: Twenty-five patients with brachial plexus birth palsy who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff-with or without concomitant musculotendinous lengthenings-were evaluated clinically and radiographically before the operation and at a minimum of two years (average, forty-three months) postoperatively. Shoulder function was prospectively assessed with use of the modified Mallet classification system, in which aggregate shoulder function is assigned a score of 5 to 25 points. Glenoid version and humeral head subluxation were quantified with magnetic resonance imaging or computed tomography, and glenohumeral deformity was graded. RESULTS: Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 13 points preoperatively to 18 points postoperatively (p < 0.01). As seen radiographically, the mean glenoid retroversion improved from 22 degrees preoperatively to 16.5 degrees postoperatively (p = 0.012). The mean posterior humeral head subluxation improved from 30% to 37% (p = 0.03). No patient had progressive worsening of the glenohumeral deformity. CONCLUSIONS: Latissimus dorsi and teres major tendon transfers to the rotator cuff, combined with appropriate extraarticular musculotendinous lengthenings, significantly improved global shoulder function but led to only modest improvements in glenoid retroversion and humeral head subluxation. No profound glenohumeral remodeling occurs after these extra-articular rebalancing procedures, even when they are performed in patients of a young age. While the long-term clinical and radiographically apparent effects at skeletal maturity are uncertain, soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a two to five-year follow-up.     

Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy.

BACKGROUND: The purposes of this study were to document the natural history of brachial plexus birth palsy, in relation to the recovery of biceps function, in the first six months of life; to assess the outcome after microsurgical repair of the brachial plexus in patients who had no recovery of biceps function at six months; and to compare the results of transfer of the latissimus dorsi and teres major tendons with the results of derotation osteotomy of the humerus and to compare the results of the tendon transfers and the osteotomy with the natural history of the disorder. METHODS: Sixty-six patients (sixty-seven lesions) who had brachial plexus birth palsy were seen for an initial evaluation when they were less than three months old. The time of recovery of biceps function was recorded for each month of life for six months from the date of birth. The patients were divided into groups according to the month of life during which recovery of biceps strength was noted. A physical examination and an assessment with use of the functional criteria of Mallet were performed each month. Microsurgical repair of the brachial plexus was performed in six infants who had no evidence of biceps function within the first six months of life. Another group of twenty-seven patients were referred for evaluation of chronic neuropathy after they were six months old. A transfer of the latissimus dorsi and teres major tendons to the rotator cuff was performed in nine of these patients and a derotation osteotomy of the humerus was performed in seven because of an internal rotation contracture or functional weakness of the external rotators of the shoulder. RESULTS: Twenty-two infants had recovery of biceps function within the first three months of life and had normal function at the time of the latest evaluation. Infants who had recovery of biceps function during the fourth, fifth, or sixth month of life later had significantly worse function, according to the criteria described by Mallet, than those who had had recovery in the first three months (p<0.005). The clinical results for the six patients who had had microsurgical repair six months after birth were significantly better (p<0.04) than those for the fifteen patients who had had recovery of biceps function in the fifth month of life. However, the results for the patients who had had repair of the brachial plexus were not found to be better than those for the eleven patients who had had recovery of biceps function in the fourth month of life. The improvement in function, as assessed with use of the Mallet criteria, after tendon transfer (p<0.001) and humeral osteotomy (p<0.0001) was significant. CONCLUSIONS: The present study confirms the observation of Gilbert and Tassin that it is rare for infants who have recovery of biceps function after the age of three months to have complete neurological recovery. Microsurgical repair was effective in improving function in the small subgroup of patients who had no evidence of recovery of biceps function within the first six months of life.     

The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy

Newborns with peripheral nerve lesions involving the upper extremity are difficult to evaluate. The reliability of the Active Movement Scale (AMS), a tool for assessing motor function in infants with obstetrical brachial plexus palsy (OBPP), was examined in 2 complementary studies. Part A was an interrater reliability study in which 63 infants younger than 1 year with OBPP were independently evaluated by 2 physical therapists using the AMS. The scores were compared for reliability and controlled for chance agreement by using kappa statistics. Overall kappa analysis of the 15 tested movements showed a moderate strength of score agreement (kappa = 0.51). Quadratic-weighted kappa (kappa(quad)) statistics showed that 8 of the 15 movements tested were in the highest strength of agreement category (kappa(quad) = 0.81-1.00). Five movements showed substantial agreement (kappa(quad) = 0.61-0.80), and 2 movements had moderate agreement (kappa(quad) = 0.41- 0.60). The overall kappa(quad) was 0.89. Part B was a variability study designed to examine the dispersion of scores when infants with OBPP were evaluated with the AMS by multiple raters. Ten pediatric physical therapists with varying degrees of experience using the scale attended a 1(1/2)-hour instructional workshop on administration of the tool for infants with OBPP. A chain-block study design was used to obtain 30 assessments of 10 infants by 10 raters. A 2-way analysis of variance indicated that the variability of scores due to rater factors was low compared with the variability due to patient factors and that variation in scores due to rater experience was minimal. The results of part A indicate that the AMS is a reliable tool for the assessment of infants with OBPP when raters familiar with the scale are compared. The results of part B suggest that, with minimal training, raters with a range of experience using the AMS are able to reliably evaluate infants with upper-extremity paralysis.     

Long-term results of surgery for brachial plexus birth palsy

BACKGROUND: The long-term results of surgical treatment of brachial plexus birth palsy have not been reported. We present the findings of a nationwide study, with a minimum five-year follow-up, of the outcomes of surgery for brachial plexus birth palsy in Finland. METHODS: Of 1,717,057 newborns, 1706 with brachial plexus birth palsy requiring hospital treatment were registered in Finland between 1971 and 1997. Of these patients, 124 (7.3%) underwent surgery on the brachial plexus at a mean age of 2.8 months (range, 0.4 to 13.2 months). The most commonly performed surgical procedure was direct neurorrhaphy after neuroma resection. One hundred and twelve patients (90%) returned for a clinical and radiographic follow-up examination after a mean of 13.3 years. Activities of daily living were recorded on a questionnaire, and the affected limb was assessed with use of joint-specific functional measures. RESULTS: Two-thirds (63%) of the patients were satisfied with the functional outcome, although one-third of all patients needed help in activities of daily living. One-third of the patients, including all nine with a clavicular nonunion from the surgical approach, experienced pain in the affected limb. All except four patients used the hand of the unaffected limb as the dominant hand. Shoulder function was moderate, with a mean Mallet score of 3.0. Both elbow and hand function were good, with a mean score on the Gilbert elbow scale of 3 and a mean Raimondi hand score of 4. Incongruence of the glenohumeral joint was noted in sixteen (16%) of the ninety-nine patients in whom it was assessed, and incongruence of the radiohumeral joint was noted in twenty-one (21%). The extent of the brachial plexus injury was found to be strongly associated with the final shoulder, elbow, and hand function in a multivariate analysis. CONCLUSIONS: Following surgical treatment of brachial plexus birth palsy, substantial numbers of the patients continued to need help performing activities of daily living and had pain in the affected limb, with the pain due to a clavicular nonunion in one-fourth of the patients. The strongest prognostic factor predicting outcome appears to be the extent of the primary plexus injury.     

Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study

Purpose

The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy.

Methods

Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up.

Results

After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2–8.7), and mean follow-up length was 6.5 years (2.9–9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up.

Conclusion

Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.

     

肱骨旋转截骨治疗大龄产瘫后肩关节内旋挛缩畸形

目的初步探讨肱骨旋转截骨治疗大龄产瘫后肩关节内旋挛缩畸形的疗效。方法2000年10月起，对17例肩胛下肌挛缩型大龄产瘫后肩关节内旋挛缩畸形的患者，采用肱骨旋转截骨术进行治疗。并用Mallet评分及Gilbert分级两项评价系统来评价术前、术后的功能。结果术后17例获得1年以上的随访。按改良Mallet评分法评分：7～8分3例，9～10分4例，11～14分10例；平均得分从术前的8．5分上升到11．0分。术后按Gilbert分级：1级1例，2级2例，3级4例，4级10例；平均级别由术前的2级上升到术后的4级。结论肱骨旋转截骨术是治疗大龄产瘫后肩关节内旋挛缩畸形的有效方法。     

Interobserver and Intraobserver Reliability Assessment of Calcaneal Fracture Classification Systems

The aim of the present study was to assess the reliability of commonly used intra-articular calcaneal fracture classification systems and to compare them with the newer AO Integral Classification of Injuries (ICI) system. Forty computed tomography and radiographic images of 40 intra-articular calcaneal fractures were reviewed independently by 3 reviewers on 2 separate occasions and classified according to the Essex-Lopresti, Atkins, Zwipp and Tscherne, Sanders, and AO-ICI classification systems. The reviewers were unaware of the patients' identity and all aspects of clinical care. The data were analyzed using kappa (κ) statistics to assess the intra- and interobserver reliability. The κ values were calculated for Essex-Lopresti (κ = 0.85 intraobserver, κ = 0.78 interobserver), Atkins (κ = 0.42 intraobserver, κ = 0.73 interobserver), Zwipp and Tscherne (κ = 0.40 intraobserver, κ = 0.47 interobserver), Sanders (κ = 0.31 intraobserver, κ = 0.35 interobserver), and AO-ICI (κ = 0.41 intraobserver, κ = 0.33 interobserver). The AO-ICI classification system had levels of reproducibility similar to that of the Sanders classification, currently the most widely used system. The Essex-Lopresti classification demonstrated improved reliability compared with that reported in previous studies. This can be attributed to using sagittal computed tomography images, in addition to the originally described plain radiographs, for assessment. This improvement is relevant because of its accepted prognostic predictability.     

Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy

BACKGROUND: Complex fractures of the distal part of the humerus can be difficult to characterize on plain radiographs and two-dimensional computed tomography scans. We tested the hypothesis that three-dimensional reconstructions of computed tomography scans improve the reliability and accuracy of fracture characterization, classification, and treatment decisions. METHODS: Five independent observers evaluated thirty consecutive intra-articular fractures of the distal part of the humerus for the presence of five fracture characteristics: a fracture line in the coronal plane; articular comminution; metaphyseal comminution; the presence of separate, entirely articular fragments; and impaction of the articular surface. Fractures were also classified according to the AO/ASIF Comprehensive Classification of Fractures and the classification system of Mehne and Matta. Two rounds of evaluation were performed and then compared. Initially, a combination of plain radiographs and two-dimensional computed tomography scans (2D) were evaluated, and then, two weeks later, a combination of radiographs, two-dimensional computed tomography scans, and three-dimensional reconstructions of computed tomography scans (3D) were assessed. RESULTS: Three-dimensional computed tomography improved both the intraobserver and the interobserver reliability of the AO classification system and the Mehne and Matta classification system. Three-dimensional computed tomography reconstructions also improved the intraobserver agreement for all fracture characteristics, from moderate (average kappa [kappa2D] = 0.554) to substantial agreement (kappa3D = 0.793). The addition of three-dimensional images had limited influence on the interobserver reliability and diagnostic characteristics (sensitivity, specificity, and accuracy) for the recognition of specific fracture characteristics. Three-dimensional computed tomography images improved intraobserver agreement (kappa2D = 0.62 compared with kappa3D = 0.75) but not interobserver agreement (kappa2D = 0.24 compared with kappa3D = 0.28) for treatment decisions. CONCLUSIONS: Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization. The influence of three-dimensional computed tomography was much more notable for intraobserver comparisons than for interobserver comparisons, suggesting that different observers see different things in the scans-most likely a reflection of the training, knowledge, and experience of the observer with regard to these relatively uncommon and complex injuries.     

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.