Ianiv Klaber

Inter and intra-observer agreement evaluation of the AO and the Tronzo classification systems of fractures of the trochanteric area

INTRODUCTION We performed an agreement study of the AO and the Tronzo classifications of fractures of the trochanteric area to determine if they allow communication among practitioners with different levels of expertise. MATERIAL AND METHODS Complete radiographs of 70 patients with trochanteric fractures were classified by nine evaluators (three hip sub-specialists, three orthopaedic surgery residents and three medical interns) using the AO and the Tronzo classifications. After a six-week interval, all cases were presented in a random sequence for repeat evaluation. The Kappa coefficient (k) was used to determine inter- and intra-observer agreement. RESULTS Inter-observer: considering the main AO fracture types, the agreement was moderate for sub-specialists (k = 0.60 [0.50-0.70]), residents (k = 0.58 [0.48-0.69]) and medical interns (k = 0.56 [0.45-0.69]). Using AO sub-types, all groups achieved fair agreement (sub-specialists: k = 0.31 [0.25-0.38]; residents: k = 0.32 [0.26-0.38]; medical interns: k = 0.30 [0.24-0.36]). For the Tronzo classification, sub-specialists (k = 0.56 [0.48-0.65]) and residents (k = 0.47 [0.39-0.55]) obtained moderate agreement; medical interns reached fair agreement (k = 0.33 [0.25-0.41]). Intra-observer: considering the main AO fracture types, sub-specialists (k = 0.79 [0.69-0.89]), residents (k = 0.71 [0.60-0.81]) and medical interns (k = 0.70 [0.59-0.82]) obtained substantial agreement. Considering AO sub-types, sub-specialists (k = 0.50 [0.45-0.56]) and medical interns (k = 0.54 [0.48-0.69]) achieved moderate agreement; residents (k = 0.39 [0.33-0.45]) achieved fair agreement. Using the Tronzo classification, all groups obtained substantial agreement (sub-specialists: k = 0.66 [0.58-0.74]; residents: k = 0.63 [0.55-0.71]; medical interns: k = 0.68 [0.60-0.76]). CONCLUSION The AO classification allows an adequate communication when considering the main fracture types; the agreement within sub-types is not satisfactory. The Tronzo classification does not allow reliable communication between medical professionals.

Thoracic scoliosis prevalence in patients 50 years or older and its relationship with age, sex, and thoracic kyphosis.

Study Design. Cross-sectional study. Objective. To determine the prevalence of thoracic scoliosis in patients aged 50 years or older and to investigate the association of adult thoracic scoliosis with age, sex, and thoracic sagittal curve. Summary of Background Data. The prevalence of adult thoracic scoliosis has not been clearly determined. In addition, limited data are available on the correlation of adult thoracic scoliosis to age, sex, and thoracic kyphosis. Methods. We studied 760 patients aged 50 years or older (380 males and 380 females) who were evaluated using standing chest plain radiographs. The thoracic curvatures in the coronal and sagittal planes were measured using the Cobb method. Scoliosis was defined by the presence of a coronal curvature 10° or more. We performed a correlation analysis of the coronal curve with age and sagittal curve; in addition, a linear regression analysis was carried out to evaluate age, sex, and sagittal curve as independent predictors of the coronal Cobb angle of the thoracic spine. Results. The prevalence of thoracic scoliosis was 24.2% (184 cases); 160 patients (21.1%) had curves 10° or more but less than 20°; 20 patients (2.6%) had curves 20° or more but less than 30°; and 4 patients (0.5%) had curves 30° or more. Females exhibited a higher prevalence of scoliosis (28.9%) than did males (19.4%), P < 0.01. The older patients exhibited increased scoliosis, but no differences were observed in thoracic kyphosis with increasing scoliosis. Age and sex were independent predictors of the coronal Cobb angle; however, the sagittal angle was not. Conclusion. We found a 24.2% prevalence of thoracic scoliosis in patients 50 years or older; most curves were less than 20°. Thoracic scoliosis was more common in females and in older patients. Level of Evidence: 3

Prevalencia de insuficiencia y deficiencia de vitamina D en adultos mayores con fractura de cadera en Chile

Background: Vitamin D deficiency is a common condition affecting 40-100% of geriatric population. Aim: To determine the prevalence of vitamin D insufficiency and deficiency in geriatric population surgically treated for hip fracture. Patients and Methods: Analysis of a database of patients aged over 60 years operated for a low energy hip fracture in a three years period. Vitamin D was measured in identified patients, using a blood sample obtained on admission to the hospital. A logistic regression was carried out to evaluate age, gender, morbidity index and season as predictors of vitamin D deficiency. Results: Two hundred and twenty-eight patients aged 84 ± 7 years (82% females), were included in the analysis. One hundred eighty-three patients (80%) presented vitamin D levels below 20 ng/dl (deficiency) and 39 patients (18%) presented with levels between 20 and 30ng/dl (insufficiency), totaling 98% of patients with hypovitaminosis D. Vitamin D deficiency was especially common among patients with higher American Society of Anesthesiologists (ASA) Physical Status Classification System and during winter-spring period. A negative correlation between age and the proportion of subjects with vitamin D deficiency was found. There was no relation between gender and vitamin D levels. Conclusions: Vitamin D deficiency is especially prevalent in older subjects with hip fracture, reaching 98% in the studied population.BACKGROUND Vitamin D deficiency is a common condition affecting 40-100% of geriatric population. AIM To determine the prevalence of vitamin D insufficiency and deficiency in geriatric population surgically treated for hip fracture. PATIENTS AND METHODS Analysis of a database of patients aged over 60 years operated for a low energy hip fracture in a three years period. Vitamin D was measured in identified patients, using a blood sample obtained on admission to the hospital. A logistic regression was carried out to evaluate age, gender, morbidity index and season as predictors of vitamin D deficiency. RESULTS Two hundred and twenty-eight patients aged 84 ± 7 years (82% females), were included in the analysis. One hundred eighty-three patients (80%) presented vitamin D levels below 20 ng/dl (deficiency) and 39 patients (18%) presented with levels between 20 and 30 ng/dl (insufficiency), totaling 98% of patients with hypovitaminosis D. Vitamin D deficiency was especially common among patients with higher American Society of Anesthesiologists (ASA) Physical Status Classification System and during winter-spring period. A negative correlation between age and the proportion of subjects with vitamin D deficiency was found. There was no relation between gender and vitamin D levels. CONCLUSIONS Vitamin D deficiency is especially prevalent in older subjects with hip fracture, reaching 98% in the studied population.

Do thoraco-lumbar spinal injuries classification systems exhibit lower inter- and intra-observer agreement than other fractures classifications?: A comparison using fractures of the trochanteric area of the proximal femur as contrast model.

INTRODUCTION It has been postulated that the complex patterns of spinal injuries have prevented adequate agreement using thoraco-lumbar spinal injuries (TLSI) classifications; however, limb fracture classifications have also shown variable agreements. This study compared agreement using two TLSI classifications with agreement using two classifications of fractures of the trochanteric area of the proximal femur (FTAPF). MATERIAL AND METHODS Six evaluators classified the radiographs and computed tomography scans of 70 patients with acute TLSI using the Denis and the new AO Spine thoraco-lumbar injury classifications. Additionally, six evaluators classified the radiographs of 70 patients with FTAPF using the Tronzo and the AO schemes. Six weeks later, all cases were presented in a random sequence for repeat assessment. The Kappa coefficient (κ) was used to determine agreement. RESULTS Inter-observer agreement: For TLSI, using the AOSpine classification, the mean κ was 0.62 (0.57-0.66) considering fracture types, and 0.55 (0.52-0.57) considering sub-types; using the Denis classification, κ was 0.62 (0.59-0.65). For FTAPF, with the AO scheme, the mean κ was 0.58 (0.54-0.63) considering fracture types and 0.31 (0.28-0.33) considering sub-types; for the Tronzo classification, κ was 0.54 (0.50-0.57). Intra-observer agreement: For TLSI, using the AOSpine scheme, the mean κ was 0.77 (0.72-0.83) considering fracture types, and 0.71 (0.67-0.76) considering sub-types; for the Denis classification, κ was 0.76 (0.71-0.81). For FTAPF, with the AO scheme, the mean κ was 0.75 (0.69-0.81) considering fracture types and 0.45 (0.39-0.51) considering sub-types; for the Tronzo classification, κ was 0.64 (0.58-0.70). CONCLUSION Using the main types of AO classifications, inter- and intra-observer agreement of TLSI were comparable to agreement evaluating FTAPF; including sub-types, inter- and intra-observer agreement evaluating TLSI were significantly better than assessing FTAPF. Inter- and intra-observer agreements using the Denis classification were also significantly better than agreement using the Tronzo scheme.

Optimización perioperatoria del paciente anciano con fractura osteoporótica de cadera

The number of osteoporotic fractures is increasing along with population aging. Most patients with these type of fractures are older than 65 years, with multiple chronic conditions and different degrees of disability. Hip fracture is the most relevant osteoporotic fracture due to its frequency, costs, severity and complications. Multidisciplinary management is of the utmost importance to obtain good therapeutic results. We herein review the management of this fracture. Orthogeriatric joint management should be incorporated in fragility fracture treatment. We contribute with general recommendations for the perioperative management, which can be homologated for the management of older patients with other type of fragility fractures.

Surgical dislocation of the hip without trochanteric osteotomy

Background: Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients. Methods: Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded. Results: Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2–4.5 years). Median mHHS was 92 (90–96). There were no intraoperative nor postoperative complications. Conclusions: Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.