Thierry G. Guitton

Fracture of the distal radius: risk factors for complications after locked volar plate fixation.

PURPOSEnTo identify risk factors for complications after volar locking plate fixation of distal radius fractures.nnnMETHODSnWe assessed early postoperative complications in 594 patients with fracture of the distal radius repaired with a volar locking plate and a minimum 1-month evaluation in the medical record. Later complications were assessed among 321 patients as a subset of the original cohort with a minimum 6 months evaluation. We compared patient demographics, fracture characteristics, and aspects of management between patients with and without complications in bivariate analysis. Multivariable logistic regression analysis was applied to identify the factors independently associated with complications.nnnRESULTSnA total of 47 complications were documented in the medical record. Early complications occurred in 24 of 594, including 8 intra-articular screws and 7 patients with loss of fixation. Late complications occurred in 23 of 321, including 14 patients diagnosed with tendon irritation (one rupture of the flexor pollicis longus tendon) and 5 patients who had subsequent surgery to address dysfunction of the distal radioulnar joint (malunion, synostosis, and arthrofibrosis). Of the 47 complications, 26 were attributed to the plate, of which 9 were considered major (intra-articular screws and tendon rupture; 1.3% (8 out of 594) and less than 1% (1 out of 321) of the early and late groups, respectively). In the logistic regression models, fall from a height and an ipsilateral elbow injury were positive independent predictors of early complications, whereas high-volume surgeons and plates other than the most commonly used plate were positive independent predictors of later complications.nnnCONCLUSIONSnVolar locking plate fixation of distal radius fractures was associated with relatively few plate-related complications in our institutions. Factors indicating higher energy or complexity predicted early complications. The most common late complication was tendon irritation, which is less discrete and perhaps variably diagnosed. Further study is warranted regarding plate design and familiarity, which may help reduce complications.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnPrognostic IV.

Training improves interobserver reliability for the diagnosis of scaphoid fracture displacement.

BackgroundThe diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability.Questions/purposesWe tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans.MethodsSixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel’s multirater kappa and the Z-test was used to test for significance.ResultsThere was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups.ConclusionsOur results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.

Radiographic diagnosis of scapholunate dissociation among intra-articular fractures of the distal radius: interobserver reliability.

PURPOSEnTo evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) among AO type C (compression articular) fractures of the distal radius.nnnMETHODSnA total of 217 surgeons evaluated 21 sets of radiographs with type C fractures of the distal radius for which the status of the scapholunate interosseous ligament was established by preoperative 3-compartment computed tomographic arthrography with direct operative visualization of diagnosed SLD (reference standard). Observers were asked whether SLD was present, and if yes, whether they would recommend operative treatment. Diagnostic performance characteristics were calculated with respect to the reference standard. We assessed interobserver reliability using the Fleiss generalized kappa.nnnRESULTSnThe interobserver agreement for radiographic diagnosis of SLD was moderate (κ = 0.44). Correct diagnosis for a given set of radiographs ranged from 8% to 98% (average, 79%) of observers. Diagnostic performance characteristics were: 69% sensitivity, 84% specificity, 84% accuracy, 68% positive predictive value, and 84% negative predictive value. Based on a prevalence of 5%, Bayes adjusted positive and negative predictive values were 18% and 98%, respectively. Raters recommended operative treatment in 74% to 100% of patients diagnosed with SLD.nnnCONCLUSIONSnRadiographs are moderately reliable and are better at ruling out than ruling in SLD associated with type C fracture of the distal radius.

Scapula fractures: interobserver reliability of classification and treatment.

Objectives: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. Design: Web-based reliability study. Setting: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. Participants: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. Main Outcome Measurements: Fleiss kappa (&kgr;) was used to assess the reliability of agreement between the surgeons. Results: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, &kgr; = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, &kgr; = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), &kgr; = 0.79) was substantial and the agreement about a fractured body (Body (B), &kgr; = 0.57) or process was moderate (Process (P), &kgr; = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (&kgr; = 0.57) with a 73% PA. Conclusions: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Diagnosis of Elbow Fracture Patterns on Radiographs: Interobserver Reliability and Diagnostic Accuracy

BackgroundStudies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably.Questions/PurposesWe therefore determined (1) the interobserver reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons; and (2) the diagnostic accuracy of radiographic diagnosis.MethodsSeventy-three orthopaedic surgeons evaluated 53 sets of radiographs and diagnosed one of five common patterns of traumatic elbow instability by using a web-based survey. The interobserver reliability was analyzed using Cohen’s multirater kappa. Intraoperative diagnosis was the reference for fracture pattern in calculations of the sensitivity, specificity, accuracy, and positive predictive and negative predictive values of radiographic diagnosis.ResultsThe overall interobserver reliability for patterns of traumatic elbow instability on radiographs was κ = 0.41. Treatment of greater than five such injuries a year was associated with greater interobserver agreement, but years in practice were not. Diagnostic accuracy ranged from 76% to 93% and was lowest for the terrible triad pattern of injury.ConclusionsSpecific patterns of traumatic elbow instability can be diagnosed with moderate interobserver reliability and reasonable accuracy on radiographs.Level of EvidenceLevel III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Anterior Olecranon Fracture-Dislocations of the Elbow in Children A Report of Four Cases

A subset of olecranon fractures with loss of normal articular apposition (subluxation or dislocation) is recognized in adults as anterior and posterior olecranon fracture-dislocations1-6, but such injuries in skeletally immature patients have been rarely described7-9. The anterior olecranon fracture-dislocation may resemble an anterior Monteggia lesion in that there is anterior dislocation of the radial head with respect to the capitellum; however, the forearm (the radioulnar relationship) remains intact and the injury is primarily to the ulnohumeral joint by means of disruption of the trochlear notch (Figs. 1-A and 1-B). The coronoid is fractured in approximately half of the patients, the radial head is rarely injured, and the collateral ligaments are generally spared10. Olecranon fractures are relatively uncommon in skeletally immature patients11-13, and we were able to identify the cases of only three skeletally immature patients with an apparent anterior olecranon fracture-dislocation reported in the literature7-9.nnFigs. 1-A and 1-B Drawings differentiating between anterior olecranon fracture-dislocation and anterior Monteggia injuries. Fig. 1-A In the anterior olecranon fracture-dislocation, the proximal radioulnar joint remains aligned and intact, but there is an anterior dislocation of the radiocapitellar joint along with the rest of the forearm. Fig. 1-B In the anterior Monteggia fracture, there is a fracture of the ulna with anterior dislocation of the radial head.nnnnnnnnWe identified four skeletally immature patients with an anterior olecranon fracture-dislocation from a fracture registry. This report describes the injury characteristics, treatment methods, and results of these four patients.nn### Materials and MethodsnnBetween 1974 and 2002, all fractures treated at our institution were entered into a database …

Osteochondritis dissecans of the humeral capitellum: Reliability of four classification systems using radiographs and computed tomography

BACKGROUNDnThe radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system.nnnMETHODSnThirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater κ.nnnRESULTSnAll OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (κxa0=xa00.20), had fair interobserver agreement: κ was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (Pxa0<xa0.001).nnnCONCLUSIONSnThe Minami Classification was the most reliable for classifying different stages of OCD of the humeral capitellum. However, it is unclear whether radiographic evidence of OCD of the humeral capitellum, as categorized by the Minami Classification, guides treatment in clinical practice as a result of this fair agreement.

Decision making in displaced fractures of the proximal humerus: fracture or surgeon based?

PurposeThe aim of this study was to analyse the factors that influence surgeon decision-making in the treatment of proximal humerus fractures that might be considered for arthroplasty or open reduction and internal fixation.MethodsA total of 217 surgeons evaluated radiographs and clinical vignettes of ten patients with fractures of the proximal humerus. In addition to radiographs, we provided patient age, sex, trauma mechanism, activity level (sedentary-vigorously active), and physical status (normal healthy-moribund). Observers were asked to: (1) choose open reduction and internal fixation or hemiarthroplasty (closed question, one option) and (2) to briefly describe the factors that led to their decision (open-ended question). We assessed interobserver reliability using the Fleiss generalized kappa and analysed factors that influenced decision-making according to treatment choice.ResultsInternal fixation was the preferred treatment for the majority of fractures. The overall multirater agreement was fair (κu2009=u20090.30), with a 75xa0% proportion of agreement. When asked to describe the factors that influenced decision-making, surgeons favouring internal fixation described patient-based factors in 52xa0%, fracture morphology in 51xa0%, surgeon factors in 42xa0%, and bone quality in 11xa0%. In contrast, fracture morphology was the most common factor (67xa0%) described by surgeons recommending replacement. Patient age, sex, activity level, physical status and the presence of angular displacement were associated with a recommendation for internal fixation.ConclusionThere is substantial variation in recommendations for internal fixation vs. arthroplasty for fractures of the proximal humerus that arises in large part from patient and surgeon factors.

Long-term Outcome of Displaced, Transverse, Noncomminuted Olecranon Fractures

BackgroundOperative treatment of a displaced, transverse, noncomminuted fracture of the olecranon is associated with good to excellent elbow function in retrospective short-term followup studies. However, to our knowledge, no studies have evaluated objective and subjective outcomes using standardized outcome instruments (ie, DASH and Mayo Elbow Performance Index [MEPI]) to quantify long-term outcome of these specific fractures.Questions/purposesWe evaluated (1) factors associated with disability, as measured with the DASH questionnaire; (2) factors associated with ulnohumeral motion; (3) factors associated with pain intensity; and (4) general descriptive findings for posttraumatic arthrosis, MEPI, ulnar neuropathy symptoms, and return to work between 10 and 32xa0years after open reduction and internal fixation (ORIF) of a transverse, noncomminuted fracture of the olecranon.MethodsBetween 1977 and 1997, we performed ORIFs of transverse, noncomminuted olecranon fractures in 109 patients, of whom 35 had died, 14 had incomplete data in our registry, and 19 were lost to followup or declined participation, leaving 41 patients available for followup at a minimum of 10xa0years after surgery. During that time, our general indication for performing ORIF was greater than 2xa0mm displacement. The average age of these patients at the time of injury was 35xa0years (range, 18–73xa0years). Patient-reported outcome was quantified using the DASH questionnaire, and physician-based outcome was evaluated using the MEPI. To identify factors associated with disability (DASH), impairment (MEPI), ulnohumeral motion, and pain, we examined demographic and clinical data in bivariate analyses, and subsequently significant factors in multivariate analysis to identify independent predictors of outcome.ResultsThe sole factor associated with higher DASH scores in multivariable analysis was age at surgery, explaining 20% of the variability, with younger patients performing better. The mean arc of elbow flexion was 142° (range, 110°–160°), and the variation was associated with arthrosis alone (ie, a greater arc of motion was associated with a lesser grade of arthrosis according to the system of Broberg and Morrey). Pain was uncommon and generally was correlated with adverse events.ConclusionsThe good results of operative fixation (tension-band wiring) of a transverse, displaced olecranon fracture are durable with time. Patient-reported outcomes are excellent in the majority of patients. Residual patient-rated disability does not correlate with arthrosis or loss of extension.Level of EvidenceLevel IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The factors influencing the decision making of operative treatment for proximal humeral fractures

BACKGROUNDnThe factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations.nnnMETHODSnA total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment.nnnRESULTSnParticipants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon.nnnCONCLUSIONnPatient information-older age in particular-is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.