Intra- and Interobserver Agreement in the Classification and Treatment of Distal Third Clavicle Fractures

Jones, Grant L.; Bishop, Julie Y.; Lewis, Brian D.; Pedroza, Angela

doi:10.1177/0363546514563281

Cited by 59 publications

(33 citation statements)

References 28 publications

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“…This may be owed to the preference and the more frequent use of the OTA classification system in the daily business in the group of trauma surgeons. While all investigators in this study were independent and experienced consultants, either in the field of musculoskeletal radiology or in the field of trauma surgery, these results are concordant with the results of other reliability evaluating studies [14], that emphasized the importance of assignment of experts to test the classification system itself [30]. Furthermore, it underscores the need for both a meticulous clinical examination as well as imaging in determining individualized treatment options.…”

Section: Discussionsupporting

confidence: 84%

“…Bishop et al [14] demonstrated fair interobserver agreement among 22 shoulder/sports medicine fellowship-trained orthopedic surgeons when using the Neer classification system for lateral clavicle fractures. Cho et al [13] also rated the inter- and intraobserver agreement among nine shoulder specialists and nine orthopedic fellows as fair when using the modified Neer classification system.…”

Section: Discussionmentioning

confidence: 99%

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Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures – reliability comparison between two specialist groups

et al. 2020

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BackgroundAlthough of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures.MethodsRadiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch.ResultsThe overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system.ConclusionsThe low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures – reliability comparison between two specialist groups

et al. 2020

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“…Therefore it is difficult to draw firm conclusions on the usefulness of this parameter. Overall interobserver agreement for assessment of morphologic features of a middle phalanx base fracture was much greater than other anatomic areas (humerus, elbow, clavicle, and olecranon) [1,2,5,8,10]. We found only fair agreement, indicating variation, regarding specific proposed treatments, which might be a reflection of the lack of high-level evidence and relatively small case series on which surgeons base their decisions [7].…”

Section: Discussionmentioning

confidence: 69%

“…Putting aside whether the criteria for recommending operative treatment of a proximal interphalangeal joint fracturedislocation are useful and accurate thresholds, if observers cannot agree on the criteria (unreliable) they may not be useful. Studies of fractures at other anatomic sites (such as the humerus, clavicle, and olecranon) showed that some fracture characteristics are assessed more reliably than others [1,2,5,8,10]. In addition to measuring the reliability of radiographic criteria for recommending operative treatment, better understanding of the criteria that have the greatest influence on recommendation for treatment of middle phalanx base fractures would help direct the development of guidelines and measurement techniques for those criteria.…”

Section: Introductionmentioning

confidence: 99%

What Middle Phalanx Base Fracture Characteristics are Most Reliable and Useful for Surgical Decision-making?

Janssen

Molleman

Guitton

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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BackgroundFracture-dislocations of the proximal interphalangeal joint are vexing because subluxation and articular damage can lead to arthrosis and the treatments are imperfect. Ideally, a surgeon could advise a patient, based on radiographs, when the risk of problems merits operative intervention, but it is unclear if middle phalanx base fracture characteristics are sufficiently reliable to be useful for surgical decision making. Questions/purposesWe evaluated (1) the degree of interobserver agreement as a function of fracture characteristics, (2) the differences in interobserver agreement between experienced and less-experienced hand surgeons, and (3) what fracture characteristics and surgeon characteristics were associated with the decision for operative treatment. Methods Ninety-nine (33%) of 296 hand surgeons evaluated 21 intraarticular middle phalanx base fractures on lateral radiographs. Eighty-one surgeons (82%) were in academic practice and 57 (58%) had less than 10 years experience. Participants assessed six fracture characteristics and recommended treatment (nonoperative or operative: One of the authors (DR) certifies that he, or a member of his immediate family, has or may receive payments or benefits, during the study period, an amount less than USD 10,000 from Wright Medical (Memphis, TN, USA); an amount less than USD 10,000 from Skeletal Dynamics (Miami, FL, USA); an amount less than USD 10,000 from Biomet (Warsaw, IN, USA); an amount less than USD 10,000 from AO North America (Paoli, PA, USA); and an amount less than USD 10,000 from AO International (Dubendorf, Switzerland). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. Results With all surgeons pooled together, the interobserver agreement for fracture characteristics was substantial for assessment of a 2-mm articular step or gap (kappa, 0.73; 95% CI, 0.60-0.86; p \ 0.001), subluxation or dislocation (kappa, 0.72; 95% CI, 0.58-0.86; p \ 0.001), and percentage of articular surface involved (intraclass correlation coefficient [ICC], 0.67; 95% CI, 0.54-0.81; p \ 0.001); moderate for comminution (kappa, 0.55; 95% CI, 0.39-0.70; p \ 0.001) and stability (kappa, 0.54; 95% CI, 0.39-0.69; p \ 0.001); and fair for the number of fracture fragments (ICC, 0.39; 95% CI, 0.27-0.57; p \ 0.001). When recommending treatment, interobserver agreement was substantial (kappa, 0.69; 95% CI, 0.50-0.88; p \ 0.001)...

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“…However, fracture type does not always determine individual surgical indications or implant selection. A study by Bishop et al 28 showed that the decision to operate on distal clavicle fractures was largely determined by the surgeon's assessment of fracture stability rather than the Neer classification or the size of the distal clavicle fracture fragment. Another consideration is that the indications for standard clavicle plates vs hook plates are variable, making direct comparison of treatment groups and outcomes difficult.…”

Section: Limitationsmentioning

confidence: 99%

Predictors of Persistent Pain After Fixation of Distal Clavicle Fractures in an Active Military Population

Lanier¹,

Speirs²,

Koehler³

et al. 2018

Orthopedics

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Patients who undergo open reduction and internal fixation of distal clavicle fractures have a high rate of hardware removal and persistence of symptoms, particularly when attempting to return to high-demand activities. This study evaluated the outcomes of military servicemembers after surgical treatment of distal clavicle fractures. The authors performed a retrospective analysis of active duty servicemembers who underwent open reduction and internal fixation of Neer type II distal clavicle fractures between October 17, 2007, and July 20, 2012, with a minimum of 2-year clinical follow-up. The electronic health record was queried to extract demographic features and clinical outcomes, primarily persistence of pain, removal of hardware, and postoperative return to high-level activity. A total of 48 patients were identified, with mean follow-up of 3.8 years. A total of 44% of patients underwent subsequent hardware removal. All fractures achieved radiographic union, and 35% of patients had persistence of symptoms. Patients who were treated with hook plating had a 3.64-fold higher risk of persistence of pain compared with those treated with conventional plating techniques. A total of 35% of patients successfully returned to full military function and completed a postoperative military deployment. Coracoclavicular reconstruction did not improve outcomes. Persistence of symptoms and requirement for hardware removal were not associated with the rate of postoperative deployment. Achieving excellent functional outcomes with open reduction and internal fixation of distal clavicle fractures remains a challenge. Where possible, conventional plate fixation should be considered over hook plate fixation. However, subsequent hardware removal and continuing shoulder pain do not preclude a return to high-level activity. [Orthopedics. 2018; 41(1):e117-e126.].

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Intra- and Interobserver Agreement in the Classification and Treatment of Distal Third Clavicle Fractures

Abstract: Fracture stability determination and the decision to operate had the highest interobserver agreement. Fracture stability was the key determinant of treatment, rather than the Neer classification system or the size of the distal fragment.

Cited by 59 publications

References 28 publications

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures – reliability comparison between two specialist groups

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures – reliability comparison between two specialist groups

What Middle Phalanx Base Fracture Characteristics are Most Reliable and Useful for Surgical Decision-making?

Predictors of Persistent Pain After Fixation of Distal Clavicle Fractures in an Active Military Population

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