Inter-rater agreement among shoulder surgeons on treatment options for proximal humeral fractures among shoulder surgeons

Background: The treatment approach for proximal humeral fractures is determined by various factors, including patient age, sex, dominant arm, fracture pattern, presence of osteoporosis, preexisting arthritis, rotator cuff status, and medical comorbidities. However, there is a lack of consensus in the literature regarding the optimal treatment for displaced proximal humeral fractures. This study aimed to assess and quantify the decision-making process for either conservative or surgical treatment and the choice of surgical method among shoulder surgeons when treating proximal humeral fractures.Methods: Forty sets of true anteroposterior view, scapular Y projection view, and three-dimensional computed tomograms of proximal humeral fractures were provided to 12 shoulder surgeons along with clinical information. Surveys regarding Neer classification, decisions between conservative and surgical treatments, and chosen methods were conducted twice with an interval of 2 months. The factors affecting the treatment plans were also assessed.Results: The inter-rater agreement was fair for Neer classification (kappa=0.395), moderate for the decision between conservative and surgical treatments (kappa=0.528), and substantial for the chosen method of surgical treatment (kappa=0.740). The percentage of agreement was 71.1% for Neer classification, 84.6% for the decision between conservative and surgical treatment, and 96.4% for the chosen method of surgical treatment. The fracture pattern was the most crucial factor in deciding between conservative and surgical treatments, followed by age and physical activity.Conclusions: The decision between conservative and surgical treatment for proximal humeral fractures showed good agreement, while the chosen method between osteosynthesis and arthroplasty showed substantial agreement among shoulder surgeons.

K-Wire Fixation of Proximal Three Part Humerus Fractures - An Everlasting Result Oriented Technique

BACKGROUND Proximal humerus (3rd) part fractures have always been posing great challenges to the orthopaedicians, due to extreme complexity involved in it, mainly, deformed muscular forces around fracture site, osteoporosis and non-affordability to new generation plates and screws etc. Ever since the inception of internal fixation, different approaches have been used, for proximal humerus (3rd) part fractures, like fixation with anatomically contoured locking plates with locking screws and nonlocking plates, hemi-arthroplasty, percutaneous k-wire etc. but only little had been compiled and recorded on such fractures. This study was conducted to evaluate and determine the efficacy of K-wire fixation in such fractures with supporting data to draw a clear-cut favourable conclusion over other methods of fixation of such fractures. METHODS 20 patients were included (matching our inclusion criteria), rest were treated differently and were excluded from the study. All fractures were classified in accordance with Neer classification. All patients were treated with K-wire fixation; only the number of K-wires differed from case to case. After their discharge from hospital, all patients were called for stringent review for 15, 30, 60, 90 days on half yearly and yearly basis. Final outcome was evaluated using constant Murley score. RESULTS The average union time was 22 weeks; the mean constant Murley’s score was 82 points. Only 3 post-operative complications were noted among all the 20 patients; these were, one mal-union and two cases of pin tract infection. Result was overwhelming success for us. The results of our study were extremely encouraging and in favour of K-wire fixation of such fractures. CONCLUSIONS K-wire fixation of proximal humerus [3rd part] fractures provide stable fixation of such fractures, with negligible post-operative complications and at an extremely cheap cost, easily affordable to average and low-income group patients with early discharge from the hospital, with very low intra operative blood loss and very low operative time, and exposure to C-arm machine. KEY WORDS Proximal Humerus [3rd] Part Fracture, Percutaneous K-Wire Fixation, Neer Classification, Greater Tuberosity

Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures

Background Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. Methods The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. Results The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). Conclusions The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients’ prognosis than the conventional Neer classification.

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

Background Although 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. Methods Radiographs 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. Results The 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. Conclusions The 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.