Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons
Introduction
There are several classification systems for intertrochanteric fractures of the proximal femur, which have been widely used in clinical practice. Evans8 developed a classification system based on the direction of the fracture line and the assessment of stability on the likelihood of fracture reduction and redisplacement. Thereafter, Boyd and Griffith2 and Kyle et al.11 described their classifications. In 1990, the AO classification system13 was introduced. These classification systems have been used for planning treatment and predicting the outcome.
Any ideal classification system must be reliable5. Studies have assessed the reliability of the AO and Evans classifications1, 9, 14, 15. These studies show that the AO (group) classification is reliable, but the AO (subgroup) and Evans classification systems have poor agreement. The observers participating in these studies were not usually fully trained specialists. This may explain the unacceptably low levels of reliability demonstrated in these studies. Specialists have been shown to have a higher reliability than non-specialists for some classification systems6, 7, 16.
The aim of this study was to determine the reliability of currently used classification systems for intertrochanteric fractures of the proximal femur, and to determine whether they have an acceptable reliability when applied by experienced orthopaedic surgeons.
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Materials and methods
We included all patients treated for intertrochanteric fractures of the proximal femur in our hospital between January and March 2003. We excluded patients whose radiographs were of inadequate quality, leaving a total of 40 patients. Plain anteroposterior and lateral radiographs were available for all cases.
These radiographs were reviewed by five orthopaedic surgeons who each had more than 10 years experience in orthopaedic trauma. Each observer was given a brief introduction and shown the
Results
The results of interobserver and intraobserver agreement were summarised in Table 1, Table 2, Table 3.
For the classification with AO groups, the mean kappa value of interobserver agreement was 0.80 (range, 0.62–0.91) in the first classification session and 0.75 (range, 0.62–0.91) in the second session. The mean kappa value for intraobserver agreement between the two sessions was 0.82 (range, 0.69–0.90). When the fractures were classified with AO subgroups, the mean kappa value of interobserver
Discussion
Our study demonstrated almost perfect or substantial interobserver and intraobserver agreement for the AO groups. In contrast, poorer interobserver and intraobserver agreement was found with the remaining three systems. Only a few studies have addressed the reliability of classification systems for intertrochanteric fractures of the proximal femur. Andersen et al.1 examined the reliability of Evans classification of trochanteric femoral fractures. Their kappa values showed moderate agreement
References (16)
- et al.
Evans’ classification of trochanteric fractures: an assessment of the interobserver and intraobserver reliability
Injury
(1990) - et al.
Classification of trochanteric fracture of the proximal femur: a study of the reliability of current systems
Injury
(2002) - et al.
Classification and treatment of trochanteric fractures
Arch Surg
(1949) - et al.
Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists
Int Orthop
(2002) - et al.
Improved interobserver variation after training of doctors in the Neer system: a randomised trial
J Bone Joint Surg [Br]
(2002) Fracture classification systems: do they work and are they useful?
J Bone Joint Surg [Am]
(1993)- et al.
Effects of binary decision making on the classification of fractures of the ankle
J Orthop Trauma
(1998) - et al.
A critical assessment of factors influencing reliability in the classification of fractures, using fractures of the tibial plafond as a model
J Orthop Trauma
(1997)
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