Reproducibility of three classifications of proximal humeral fractures

Abstract

Objective: To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra-and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study. Methods: A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis. Results: The mean intra-observer Kappa agreement index (k=0.687) of the new classification, was higher than both the Neer classification (k=0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k=0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.028). Conclusion: the new classification considering bone compression had higher results for intra-and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system. Keywords

Inter/Intra-Observer Evaluation Between Radiographs and Tomographies for Proximal Humerus Fracture

“…However, computed tomography is expected to facilitate and improve the reproducibility of the analyzed fractures, providing a greater intra-observer agreement, enabling a better choice of treatment and a more reliable and reproducible classification system. 7,10 Despite numerous complaints regarding its reproducibility, Neer classification is widely accepted and commonly used to guide treatment and anticipate prognosis; it is pedagogically useful, of easy learning and separates fractures into broad categories, being easy to understand. 5,7 AO classification (Arbeitsgemeinschaft für Osteosynthesefragen) divides fractures according to their complexity and facilitates choice of treatment and prognosis.…”

“…7,10 Despite numerous complaints regarding its reproducibility, Neer classification is widely accepted and commonly used to guide treatment and anticipate prognosis; it is pedagogically useful, of easy learning and separates fractures into broad categories, being easy to understand. 5,7 AO classification (Arbeitsgemeinschaft für Osteosynthesefragen) divides fractures according to their complexity and facilitates choice of treatment and prognosis. The AO is one of the most complete classification system, however, its intra-and inter-observer reproducibility has reduced.…”

“…[4][5][6] However, its reliability is increasingly contested due to the low inter-observer agreement, 4 explained by the poor image quality and poor positioning of patients. 7 Charles Neer claims this low agreement occurs due surgeons' inexperience, in the case of 4-part fracture. 8 The AO classification (Arbeitsgemeinschaft für Osteosynthesefragen) values the vascularization of the humeral head.…”

Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures

“…Like other PHF classification systems, the Neer system has shown limited interobserver and intraobserver agreement. 7,8,11,28 A recent systematic literature review found that levels of interobserver and intraobserver agreement for PHF classification was lowest for x-ray, increased with two-dimensional (2D) computed tomography (CT), and highest with 3D CT. The same study suggested CT may increase interobserver agreement to a greater extent for less experienced observers.…”