Evaluation of the Intraobserver and Interobserver Agreements of the New AO/OTA Classification for Fractures of the Trochanteric Region and the Femoral Neck^[*]

Abstract

Objective In the present study, we investigated the intra and interobserver agreement of the new Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification for fractures of the proximal extremity of the femur.

Methods One hundred hip radiographs were selected from patients who suffered fractures of the trochanteric region or femoral neck. Four orthopedists, fellowship trained hip surgeons, and four orthopedic residents evaluated and classified fractures according to the new AO/OTA system on two separate occasions. The kappa (k) coefficient was used to evaluate intra and interobserver agreement in the different steps of the classification, namely: type, group, subgroup, and qualifier.

Results Hip surgery experts obtained almost perfect intraobserver agreement of type, substantial for group and, only moderate, for subgroup and qualifiers. The residents had lower performance, with substantial agreement for type, moderate for group, and reasonable for subgroup and qualifier. In the specialists' interobserver evaluation, there was also a gradual decrease in the agreement between type (almost perfect) and group (moderate), which was even lower for subgroup and qualifiers. Residents had a substantial interobserver agreement for type, moderate for group, and reasonable in the other branches.

Conclusion The new AO/OTA classification for fractures of the trochanteric region and femoral neck showed intra and interobserver agreements considered appropriate for type and group, with a drop in the subsequent branches, that is, for subgroup and qualifier. Still, in relation to the old AO/OTA classification, there was an improvement in the agreements for subgroup.

Keywords

femur neck - hip fractures - classification

Financial Support

There was no financial support from public, commercial, or non-profit sources.

^* Research developed in Criar - Joint Reconstruction Center and Research Institute. Hospital Angelina Caron, Campina Grande do Sul, Paraná, Brazil.

Publication History

Received: 28 May 2020

Accepted: 01 December 2020

Article published online:
14 December 2021

• Referências

• 1 Rapp K, Becker C, Lamb SE, Icks A, Klenk J. Hip fractures in institutionalized elderly people: incidence rates and excess mortality. J Bone Miner Res 2008; 23 (11) 1825-1831
• 2 Martinez-Reig M, Ahmad L, Duque G. The orthogeriatrics model of care: systematic review of predictors of institutionalization and mortality in post-hip fracture patients and evidence for interventions. J Am Med Dir Assoc 2012; 13 (09) 770-777
• 3 Pervez H, Parker MJ, Pryor GA, Lutchman L, Chirodian N. Classification of trochanteric fracture of the proximal femur: a study of the reliability of current systems. Injury 2002; 33 (08) 713-715
• 4 Mattos CA, Jesus AAK, Floter MS, Nunes LFB, Sanches BB, Zabeu JLA. Reprodutibilidade das classificações de Tronzo e AO para fraturas transtrocanteriana. Rev Bras Ortop 2015; 50 (05) 495-500
• 5 Oliveira FAS, Basile R, Pereira BCB, Cunha RLL. Avaliação da reprodutibilidade da classificação de Tronzo para fraturas intertrocantéricas do fêmur. Rev Bras Ortop 2014; 49 (06) 581-585
• 6 Urrutia J, Zamora T, Besa P, Zamora M, Schweitzer D, Klaber I. Inter and intra-observer agreement evaluation of the AO and the Tronzo classification systems of fractures of the trochanteric area. Injury 2015; 46 (06) 1054-1058
• 7 Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br 1961; 43 (03) 647-663
• 8 Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br 1949; 31B [phone]
• 9 Boyd HB, Griffin LL. Classification and treatment of trochanteric fractures. Arch Surg 1949; 58 (06) 853-866
• 10 Tronzo RG. Surgery of the Hip Joint. Philadelphia: Lea & Febiger; 1973
• 11 Müller ME, Nazarian S, Koch P. Classification AO des fractures. Tome I. Les os longs.. Berlin: Springer-Verlag; 1987
• 12 Jin WJ, Dai LY, Cui YM, Zhou Q, Jiang LS, Lu H. Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons. Injury 2005; 36 (07) 858-861
• 13 Schipper IB, Steyerberg EW, Castelein RM, van Vugt AB. Reliability of the AO/ASIF classification for pertrochanteric femoral fractures. Acta Orthop Scand 2001; 72 (01) 36-41
• 14 Schwartsmann CR, Boschin LC, Moschen GM, Gonçalves R, Ramos AS, Gusmão PD. Classificação das fraturas trocantéricas: avaliação da reprodutibilidade da classificação AO. Rev Bras Ortop 2006; 41 (07) 264-267
• 15 Van Embden D, Rhemrev SJ, Genelin F, Meylaerts SA, Roukema GR. The reliability of a simplified Garden classification for intracapsular hip fractures. Orthop Traumatol Surg Res 2012; 98 (04) 405-408
• 16 Crijns TJ, Janssen SJ, Davis JT, Ring D, Sanchez HB. Science of Variation Group. Reliability of the classification of proximal femur fractures: Does clinical experience matter?. Injury 2018; 49 (04) 819-823
• 17 Gusmão PD, Mothes FC, Rubin LA, Gonçalves RZ, Teloken MA, Schwartsmann CR. Avaliação da reprodutibilidade da classificação de Garden para fraturas do colo femoral. Rev Bras Ortop 2002; 37 (09) 381-386
• 18 Audigé L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand 2004; 75 (02) 184-194
• 19 Hartline BE, Achor TS. Use of the 95-degree Angled Blade Plate to Treat a Proximal Femur Fracture. J Orthop Trauma 2018; 32 (Suppl. 01) S26-S27
• 20 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
• 21 Fung W, Jonsson A, Buhren V, Bhandari M. Classifying intertrochanteric fractures of the proximal femur: does experience matter?. Med Princ Pract 2007; 16 (03) 198-202
• 22 Radaideh AM, Qudah HA, Audat ZA, Jahmani RA, Yousef IR, Saleh AAA. Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures. J Clin Med 2018; 7 (04) 78
• 23 Zhang WQ, Sun J, Liu CY, Zhao HY, Sun YF. Comparing the Intramedullary Nail and Extramedullary Fixation in Treatment of Unstable Intertrochanteric Fractures. Sci Rep 2018; 8 (01) 2321
• 24 Knobe M, Gradl G, Ladenburger A, Tarkin IS, Pape HC. Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany?. Clin Orthop Relat Res 2013; 471 (09) 2831-2840
• 25 Cech O, Kostál R, Váchal J. [Unstable pertrochanteric fractures, biomechanic, classification and therapy.]. Acta Chir Orthop Traumatol Cech 2000; 67 (01) 17-27
• 26 Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004; (425) 82-86
• 27 Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P. Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am 2007; 89 (03) 470-475
• 28 Hsu CE, Shih CM, Wang CC, Huang KC. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J 2013; 95-B [phone]
• 29 Tawari AA, Kempegowda H, Suk M, Horwitz DS. What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix?. J Orthop Trauma 2015; 29 (Suppl. 04) S4-S9