Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists

Brorson, Stig; Bagger, Jens Peder; Sylvest, A.; Hróbjartsson, Asbjørn

doi:10.1007/s00264-002-0369-x

Cited by 30 publications

(3 citation statements)

References 14 publications

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“…Moreover, only patients with 2-part PHFs involving the surgical neck were included in the trial. Previously, there has been disagreement over recognizing different fracture categories [29]. In our previous publication, however, we found substantial intra- and interobserver agreement in re-categorized Neer classification [30].…”

Section: Discussionmentioning

confidence: 60%

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

et al. 2019

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Background Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures. Methods and findings The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant–Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group’s 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI −7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded. Conclusions This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. Trial registration ClinicalTrials.gov NCT01246167 .

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Section: Discussionmentioning

confidence: 60%

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

et al. 2019

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“…Despite the use of CT imaging in some studies, it has not been shown to improve the results uniformly [2, 11–13, 19]. The kappa values obtained from these studies improve only slightly or not at all, when the classification systems were simplified or reduced to two options, displaced or undisplaced [1, 14, 20]. However, it has been suggested in one study that the use of CT-based stereo visualisation may substantially improve classification reliability, which has also been seen in tibial plateau fractures [21, 22].…”

Section: Discussionmentioning

confidence: 99%

Validity of humerus fracture classification in the Swedish fracture register

Wennergren

Stjernström

Möller

et al. 2017

BMC Musculoskelet Disord

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BackgroundThe ability to correctly classify fractures is of importance for choosing the appropriate treatment and for providing appropriate data for research and quality registers. In the Swedish Fracture Register (SFR) fractures of all types are registered by the attending physician, often a junior doctor. For the majority of fractures, a modified AO/OTA classification is used. This study aimed to validate the accuracy of classification of humerus fractures in the SFR and also at providing insight into inherent classification uncertainties.MethodsOne hundred and sixteen humerus fractures (among them 90 proximal) were retrieved by computer randomisation from the SFR and reassessed independently at two occasions, 6 weeks apart, by three senior orthopaedic surgeons blinded to patient information and a consensus “gold standard” classification was established. This was compared with the classifications that had been entered into the register.ResultsThe agreement between gold standard classification and original classification in the SFR was kappa = 0.57 for all humerus fractures. For proximal humerus fractures kappa-coefficient for intra-observer agreement was 0.593, 0.599 and 0.752 for the three observers respectively. Taking into account the similarities between certain fracture groups, a modified calculation of agreement was performed. With this modification the intra-observer agreement was 0.910-0.974 and inter-observer agreement was 0.912.ConclusionThe classification of humerus fractures in the Swedish Fracture Register was just as accurate as in previous studies, i.e. moderate as defined by Landis and Koch. However, when we introduced a modified analysis, that takes into account the similarities between certain fractures, the accuracy was “near perfect”.

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“…On the other hand, a few studies have supported the role of experience. Brorson et al showed significantly higher confidence intervals in specialists when compared to residents and fellows, and although not explicitly stated as a study aim, Bernstein et al showed higher absolute kappa values among attending surgeons when compared to residents [ 4 , 7 , 8 ]. As a response to the challenge of the 4-type classification system, Neer commented that inter-observer variability is likely the combination of "suboptimal quality of current imaging and inexperienced interpreters [ 22 ]."…”

Section: Discussionmentioning

confidence: 99%

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience

et al. 2011

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SummaryProximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs.MethodsInter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience.ResultsAll kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores.ConclusionsAlthough 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.

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Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists

Cited by 30 publications

References 14 publications

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

Validity of humerus fracture classification in the Swedish fracture register

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience

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