Does Additional Review of Initial Radiographs by Musculoskeletal Specialists Limit Additional Advanced Imaging in Suspected Hip Fractures?

Abstract

Patients with suspected fractures of the hip usually require significant time and resources for care, sometimes including advanced imaging. Optimizing care may improve patient outcomes and reduce the financial burden of hip fractures. Few studies have investigated approaches to reduce the utilization of additional imaging to diagnose hip fractures. The objective of this study was to determine if the utilization of computed tomography and magnetic resonance imaging can be reduced for suspected hip fracture patients via additional review of initial hip radiographs by musculoskeletal specialists. This may aid imaging referral guidelines for patients with a clinical suspicion of a hip fracture and reduce the amount of costly additional imaging. A retrospective multicenter study was conducted of hip fracture patients from five hospitals in an academic health system from 2015 to 2018. The study included initial radiographs of 108 patients, all of which were considered inconclusive at the time of service by radiologist reports and subsequently diagnosed with a hip fracture after receiving additional imaging. Four musculoskeletal specialists were asked to evaluate if the radiographs were positive for hip fracture, negative for hip fracture, or required additional imaging. A positive hip fracture was correctly identified by musculoskeletal specialists from the initial radiograph in 37 to 50% of cases. There was no statistically significant difference between reviewers of different levels of training in identifying hip fractures (p = 0.19) or ordering additional imaging (p = 0.235). There was a moderately positive interclass correlation across reviewers who correctly identified a hip fracture (interclass correlation coefficients [ICC] = 0.59, 95% confidence interval [CI]: 0.45–0.70), as well as reviewers who requested additional imaging (ICC = 0.45, 95% CI: 0.25–0.60). Review of initial radiographs by musculoskeletal specialists could reduce the utilization of additional advanced imaging by up to 50% in patients with a suspected hip fracture. This is a level III evidence study.

Keywords

hip fracture - musculoskeletal - advanced imaging - CT - MRI

Authors Contribution

A.M., S.V., S.S., and S.J. served as research coordinators. A.F.A. is a clinical fellow of orthopaedic surgery. S.T. serves as assistant professor of orthopaedic surgery. U.S. serves as associate professor of orthopaedic surgery.

Ethical Approval

The study was approved under IRB00207227.

Publikationsverlauf

Eingereicht: 03. Mai 2022

Angenommen: 29. Dezember 2022

Artikel online veröffentlicht:
16. März 2023

• References

• 1 Swenning T, Leighton J, Nentwig M, Dart B. Hip fracture care and national systems: The United States and Canada. OTA Int 2020; 3 (01) e073
• 2 Adeyemi A, Delhougne G. Incidence and economic burden of intertrochanteric fracture: a medicare claims database analysis. JBJS Open Access 2019; 4 (01) e0045
• 3 LeBlanc KE, Muncie Jr HLJ, LeBlanc LL. Hip fracture: diagnosis, treatment, and secondary prevention. Am Fam Physician 2014; 89 (12) 945-951
• 4 Keeney JA, Nunley RM, Adelani M, Mall N. Magnetic resonance imaging of the hip: poor cost utility for treatment of adult patients with hip pain. Clin Orthop Relat Res 2014; 472 (03) 787-792
• 5 Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009; 37 (02) 144-152
• 6 Haj-Mirzaian A, Eng J, Khorasani R. et al. Use of advanced imaging for radiographically occult hip fracture in elderly patients: a systematic review and meta-analysis. Radiology 2020; 296 (03) 521-531
• 7 Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important?. J Bone Joint Surg Am 2005; 87 (03) 483-489
• 8 Parker MJ. Missed hip fractures. Arch Emerg Med 1992; 9 (01) 23-27
• 9 Pincus D, Ravi B, Wasserstein D. et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA 2017; 318 (20) 1994-2003
• 10 Judd KT, Christianson E. Expedited operative care of hip fractures results in significantly lower cost of treatment. Iowa Orthop J 2015; 35: 62-64
• 11 Middleton M, Wan B, da Assunçao R. Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models. Age Ageing 2017; 46 (03) 465-470
• 12 Gill SK, Smith J, Fox R, Chesser TJS. Investigation of occult hip fractures: the use of CT and MRI. ScientificWorldJournal 2013; 2013: 830319
• 13 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
• 14 McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012; 22 (03) 276-282
• 15 Jordan RW, Dickenson E, Baraza N, Srinivasan K. Who is more accurate in the diagnosis of neck of femur fractures, radiologists or orthopaedic trainees?. Skeletal Radiol 2013; 42 (02) 173-176
• 16 Adams M, Chen W, Holcdorf D, McCusker MW, Howe PD, Gaillard F. Computer vs human: Deep learning versus perceptual training for the detection of neck of femur fractures. J Med Imaging Radiat Oncol 2019; 63 (01) 27-32
• 17 Cheng C-T, Ho T-Y, Lee T-Y. et al. Application of a deep learning algorithm for detection and visualization of hip fractures on plain pelvic radiographs. Eur Radiol 2019; 29 (10) 5469-5477
• 18 Urakawa T, Tanaka Y, Goto S, Matsuzawa H, Watanabe K, Endo N. Detecting intertrochanteric hip fractures with orthopedist-level accuracy using a deep convolutional neural network. Skeletal Radiol 2019; 48 (02) 239-244
• 19 Cheng C-T, Chen C-C, Cheng F-J. et al. A human-algorithm integration system for hip fracture detection on plain radiography: system development and validation study. JMIR Med Inform 2020; 8 (11) e19416
• 20 Yamada Y, Maki S, Kishida S. et al. Automated classification of hip fractures using deep convolutional neural networks with orthopedic surgeon-level accuracy: ensemble decision-making with antero-posterior and lateral radiographs. Acta Orthop 2020; 91 (06) 699-704
• 21 Sato Y, Takegami Y, Asamoto T. et al. Artificial intelligence improves the accuracy of residents in the diagnosis of hip fractures: a multicenter study. BMC Musculoskelet Disord 2021; 22 (01) 407
• 22 Krogue JD, Cheng KV, Hwang KM. et al. Automatic hip fracture identification and functional subclassification with deep learning. Radiol Artif Intell 2020; 2 (02) e190023