Development and validation of an artificial intelligence model for the classification of hip fractures using the AO-OTA framework.

BACKGROUND AND PURPOSE: Artificial intelligence (AI) has the potential to aid in the accurate diagnosis of hip fractures and reduce the workload of clinicians. We primarily aimed to develop and validate a convolutional neural network (CNN) for the automated classification of hip fractures based on the 2018 AO-OTA classification system. The secondary aim was to incorporate the model's assessment of additional radiographic findings that often accompany such injuries. METHODS: 6,361 plain radiographs of the hip taken between 2002 and 2016 at Danderyd University Hospital were used to train the CNN. A separate set of 343 radiographs representing 324 unique patients was used to test the performance of the network. Performance was evaluated using area under the curve (AUC), sensitivity, specificity, and Youden's index. RESULTS: The CNN demonstrated high performance in identifying and classifying hip fracture, with AUCs ranging from 0.76 to 0.99 for different fracture categories. The AUC for hip fractures ranged from 0.86 to 0.99, for distal femur fractures from 0.76 to 0.99, and for pelvic fractures from 0.91 to 0.94. For 29 of 39 fracture categories, the AUC was ≥ 0.95. CONCLUSION: We found that AI has the potential for accurate and automated classification of hip fractures based on the AO-OTA classification system. Further training and modification of the CNN may enable its use in clinical settings.

Morbilidad de pacientes operados de fractura de cadera / Morbidity of Patients Operated On For Hip Fracture

Introducción: La fractura de cadera en el anciano ha experimentado un incremento durante los últimos años como consecuencia del aumento de la expectativa de vida de la población. Cuba no está ajena a este fenómeno, por lo que es necesaria la preparación de todo el personal de salud para prevenir y tratar esta lesión traumática. Objetivo: Determinar la morbilidad de los pacientes con fractura de cadera. Métodos: Se realizó un estudio observacional descriptivo, en pacientes intervenidos quirúrgicamente en el Hospital Militar Dr. Joaquín Castillo Duany de Santiago de Cuba por presentar diagnóstico de fractura de cadera durante el período comprendido de enero 2013 a diciembre 2019. La muestra estuvo constituida por 69 pacientes. Se utilizó el porcentaje como medida resumen para el análisis. Resultados: La hipertensión arterial fue la comorbilidad más representada (58,0 por ciento). Prevaleció el tiempo quirúrgico medio (79,7 por ciento) y la infección de la herida quirúrgica fue la complicación más frecuente (23,5 por ciento). Conclusiones: Los pacientes operados de fractura de cadera presentan a la hipertensión arterial como la comorbilidad más representada. Prevalece el tiempo quirúrgico medio y las artroplastias tienen mayor grado de complejidad y dificultad para su colocación(AU)

Introduction: Hip fracture in the elderly has experienced an increase in recent years as a result of the increase in life expectancy of the population. Cuba is not immune to this phenomenon, so it is necessary to prepare all health personnel to prevent and treat this traumatic injury. Objective: To determine the morbidity of patients with hip fracture. Methods: A descriptive observational study was carried out from January 2013 to December 2019, in patients who underwent surgery at Dr. Joaquín Castillo Duany Military Hospital in Santiago de Cuba due to diagnosis of hip fracture. The sample consisted of 69 patients. The percentage was used as a summary measure for the analysis. Results: Arterial hypertension was the most represented comorbidity (58.0 percent). The average surgical time prevailed (79.7 percent) and the infection of the surgical wound was the most frequent complication (23.5 percent). Conclusions: Patients operated on due to hip fracture present arterial hypertension as the most represented comorbidity. The average surgical time prevails and the arthroplasties have higher degree of complexity and difficulty in their placement(AU)

Evaluation of the Intraobserver and Interobserver Agreements of the New AO/OTA Classification for Fractures of the Trochanteric Region and the Femoral Neck / Avaliação das concordâncias intra e interobservadores da nova classificação AO/OTA para fraturas da região trocantérica e do colo do fêmur

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.

Resumo Objetivo Neste estudo, investigamos a concordância intra e interobservador da nova classificação Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) para fraturas da extremidade proximal do fêmur. Métodos Foram selecionadas 100 radiografias do quadril de pacientes que sofreram fraturas da região trocantérica ou do colo do fêmur. Quatro ortopedistas cirurgiões de quadril e quatro residentes de ortopedia e traumatologia avaliaram e classificaram as fraturas segundo o novo sistema AO/OTA em duas ocasiões distintas. O coeficiente de kappa (k) foi utilizado para avaliar a concordância intra e interobservadores nos diferentes passos da classificação, a saber: tipo, grupo, subgrupo e qualificador. Resultados Especialistas em cirurgia do quadril obtiveram concordância intraobservador quase perfeita de tipo, substancial para grupo e, apenas moderada para subgrupo e qualificadores. Os residentes tiveram desempenho inferior, com concordância substancial para o tipo, moderada para o grupo, e razoável para o subgrupo e qualificador. Na avaliação interobservadores dos especialistas, também se observou queda gradual da concordância entre tipo (quase perfeita) e grupo (moderada), que se mostrou ainda menor parasubgrupo e qualificadores.Residentestiveramumaconcordânciainterobservadoressubstancialparatipo, moderada para grupo e razoável nas demais ramificações. Conclusão A Nova Classificação AO/OTA para fraturas da região trocantérica e do colo do fêmur mostrou concordâncias intra e interobservadores consideradas adequadas para tipo e grupo com queda nas ramificações subsequentes ou seja para subgrupo e qualificador. Ainda assim em relação à classificação AO/OTA antiga houve melhora nas concordâncias para subgrupo.

Machine learning outperforms clinical experts in classification of hip fractures.

Hip fractures are a major cause of morbidity and mortality in the elderly, and incur high health and social care costs. Given projected population ageing, the number of incident hip fractures is predicted to increase globally. As fracture classification strongly determines the chosen surgical treatment, differences in fracture classification influence patient outcomes and treatment costs. We aimed to create a machine learning method for identifying and classifying hip fractures, and to compare its performance to experienced human observers. We used 3659 hip radiographs, classified by at least two expert clinicians. The machine learning method was able to classify hip fractures with 19% greater accuracy than humans, achieving overall accuracy of 92%.

Análisis epidemiológico multicéntrico de las fracturas de cadera en Uruguay: importancia y planificación de un registro nacional / Multicenter epidemiological analysis of hip fractures in Uruguay: importance and planning of a national register / Análise epidemiológica multicêntrica de fraturas de quadril no Uruguai: importância e planejamento de um registro nacional

Introducción: La incidencia de fracturas de cadera presenta un aumento dramático desde la mediana edad, constituyendo un problema de salud prevalente en adultos mayores. Se realizó una revisión bibliográfica de los registros internacionales de fracturas de cadera y un estudio epidemiológico multicéntrico para conocer la incidencia, los costos y la mortalidad de esta patología en nuestro país. Material y métodos: Se realizó una búsqueda, revisión y análisis de todos los registros internacionales de fracturas de cadera existentes en el mundo. Posteriormente, se llevó a cabo un análisis descriptivo observacional retrospectivo y multicéntrico en 4 instituciones de pacientes mayores de 50 años intervenidos quirúrgicamente con osteosíntesis por fractura de cadera en el año 2019. En los datos anonimizados se evaluaron edad, sexo, tipo de fractura, incidencia y costos. Se incluyeron y asociaron, además, datos estadísticos y económicos del Registro del Fondo Nacional de Recursos. Se utilizó el software estadístico SPSS para establecer asociaciones univariadas, bivariadas y multivariadas. Para comparar las proporciones se empleó el test estadístico de chi cuadrado. Resultados: Se resume la revisión de registros en una tabla. El análisis multicéntrico contó con 646 pacientes con fracturas de cadera. Destacamos la alta prevalencia de esta patología en pacientes mayores de 79 años (63,1%) y en el sexo femenino (77,6%), en concordancia con los registros internacionales, con asociación significativa entre ambas variables (p < 0,0001). A diferencia de otros registros, y quizás dato erróneo, la fractura más frecuente fue la del cuello de fémur (43%). El tiempo entre la fractura y la cirugía y los días de internación fueron de 2,6 y 7,2 días, respectivamente, en la institución de asistencia más efectiva. Nuestro cálculo mostró una incidencia de fractura de cadera en Uruguay que oscila entre 235 y 391 en 100.000 habitantes mayores de 50 años. El costo calculado de la serie evaluada fue de unos U$S 2.855.320 y, en general, esta patología provoca un gasto para nuestro país que se aproxima a U$S 20.000.000 por año. Conclusión: La fractura de cadera presenta una elevada incidencia, costos y morbimortalidad en la población de adultos mayores, comparable con datos internacionales. Es necesario contar con un Registro Nacional de Fracturas de Cadera que permita conocer datos estadísticos certeros para poder establecer políticas adecuadas de prevención, tratamiento y control de gastos.

Introduction: The incidence of hip fractures dramatically increases from middle age on, posing a prevalent health problem in elderly people. A literature review of the international hip fracture registers, as well as a multicenter, epidemiological study were carried out in order to assess the incidence, costs, and mortality of this pathology in our country. Material and methods: All international hip fracture registers in the world were searched, reviewed and analyzed. An observational, retrospective, multicenter descriptive analysis was then carried out in 4 health-care centers for patents over 50 years of age who underwent surgery with osteosynthesis due to hip fracture in 2019. Age, sex, type of fracture, incidence and costs were assessed from the anonymized data. Statistical and economic data from the National Resources Fund Register were also included and associated. The SPSS statistical software was used to establish univariate, bivariate, and multivariate associations. The chi-squared statistical test was used to compare proportions. Results: Review of the registers is summarized in a table. The multicenter analysis included 646 patients with hip fractures. Worth of note is the high prevalence of this pathology in patients over 79 years of age (63.1%) and females (77.6%), in line with the international registers, and a significant association between both variables (p < 0.0001). Unlike other registers, and probably due to inaccurate data, the most frequent fracture was that of femoral neck (43%). The time from fracture to surgery and inpatient days were 2.6 and 7.2 days, respectively, in the most effective health care center. Our calculation showed a hip fracture incidence in Uruguay between 235 and 391 per 100,000 inhabitants over 50 years of age. The estimated cost of the assessed series was about U$S 2,855,320, and in general this pathology generates an annual expense of about U$S 20,000,000 for our country. Conclusion: Hip fractures have high incidence, costs and mortality and morbidity in the elderly population comparable with international data. It is necessary to have a National Hip Fracture Register that provides accurate statistical data in order to establish adequate prevention, treatment and cost control policies.

Introdução: A incidência de fraturas de quadril apresenta um aumento dramático a partir da meia-idade, constituindo um problema de saúde prevalente em idosos. Uma revisão bibliográfica dos Registros Internacionais de Fratura de Quadril e um estudo epidemiológico multicêntrico foram realizados para determinar a incidência, os custos e a mortalidade dessa patologia em nosso país. Material e métodos: Foi realizada uma busca, revisão e análise de todos os Registros Internacionais de fraturas de quadril existentes no mundo. Posteriormente, foi realizada uma análise observacional descritiva retrospectiva e multicêntrica, em 4 Instituições, de pacientes maiores de 50 anos, submetidos à cirurgia com osteossíntese, para fratura de quadril em 2019. Nos dados anônimos foram avaliados idade e sexo, tipo de fratura , incidência e custos. Dados estatísticos e econômicos do Registro do Fundo Nacional de Recursos também foram incluídos e associados. O software estatístico SPSS foi usado para estabelecer associações univariadas, bivariadas e multivariadas. O teste estatístico do qui quadrado foi usado para comparar as proporções. Resultados: a revisão dos registros é resumida em uma tabela. A análise multicêntrica incluiu 646 pacientes com fraturas de quadril. Destaca-se a alta prevalência dessa patologia em pacientes maiores de 79 anos (63,1%) e no sexo feminino (77,6%), de acordo com registros internacionais, com associação significativa entre as duas variáveis ​​(p <0,0001). Ao contrário de outros registros, e talvez dados errôneos, a fratura mais frequente foi a do colo do fêmur (43%). O tempo decorrido entre a fratura e a cirurgia e os dias de internação foram de 2,6 e 7,2 dias, respectivamente, na instituição assistencial mais efetiva. Nosso cálculo mostrou uma incidência de fratura de quadril no Uruguai, variando entre 235 e 391 em 100.000 habitantes com mais de 50 anos de idade. O custo calculado da série avaliada foi em torno de US $ 2.855.320 e, em geral, essa patologia acarreta um gasto para o nosso país que é próximo a US $ 20.000.000 por ano. Conclusão: A fratura de quadril tem alta incidência, custo e morbimortalidade na população idosa, comparável a dados internacionais. É necessário um Cadastro Nacional de Fraturas de Quadril, que permita conhecer dados estatísticos precisos, para estabelecer políticas adequadas de prevenção, tratamento e controle de custos.

Long-term Bisphosphonates for Osteoporosis: A Factor Effecting Fracture Pattern?

BACKGROUND: The incidence of fragility hip fractures, intracapsular and extracapsular, has been increasing worldwide. Fracture stability is important for treatment decision-making and is related to the expected rate of complications. It is unclear whether metabolic therapy explains the increased incidence of unstable fractures. OBJECTIVES: To investigate the possible association between treatment with bisphosphonates and the various patterns encountered with intertrochanteric hip fractures. METHODS: Patients with fragility hip fractures who were treated in our department between 2013 and 2014 were included in this study. They were classified into three groups: group 1 had a stable extracapsular fracture, group 2 had an unstable extracapsular fracture, and group 3 had an intracapsular fracture. Collated data included: osteoporosis preventive therapy and duration, fracture-type, history of previous fractures, and vitamin D levels. RESULTS: Of 370 patients, 87 were previously treated with bisphosphonates (18.3% prior to fracture in group 1, 38.3% in group 2, and 13.8% in group 3). Of those treated with bisphosphonates, 56.3% had an unstable fracture, 21.8% had a stable fracture, and the rest an intracapsular fracture. In contrast, only 27.9% of patients who were not treated with bisphosphonates had an unstable fracture and 30.0% had stable fractures. CONCLUSIONS: Our findings show a higher proportion of complex and unstable fractures among patients with fragility hip-fractures who were treated with bisphosphonates than among those who did not receive this treatment. The risk for complex and unstable fracture may affect the preferred surgical treatment, its complexity, length of surgery, and rehabilitation.

Fracturas de cadera en adultos mayores del Hospital General Agustín O´Horán entre 2015 y 2019 / Hip Fractures in elder Adults at Agustin O´Horán General Hospital from 2015 to 2019

Introducción: El motivo de hospitalización más común en los servicios ortopédicos son las fracturas de cadera, de las cuales, las más frecuentes son las del cuello femoral y pertrocantéreas y/o transtrocantéricas. Existen diversos factores de riesgo entre los adultos de 60 años o más, entre ellos, vivir en una residencia de ancianos, deterioro mental, tipo de fractura, entorno social habitual, y presencia de enfermedades sistémicas asociadas con el envejecimiento. Objetivo: Describir y analizar las fracturas de cadera más frecuentes en adultos mayores en el Hospital General Agustín O´Horán, así como describir la distribución bimestral y anual de los casos ocurridos en el estado de Yucatán. Método: Estudio transversal, descriptivo y retrospectivo que incluyó sujetos de ambos géneros de 60 años y más, que habían ingresado por fractura de cadera entre noviembre 2015 y abril 2019. Se utilizaron las variables género, edad, bimestre, año, ubicación anatómica y tipo de traumatismo, clasificación extracapsular e intracapsular. Resultados: La mayoría de los pacientes fueron del sexo femenino (64,53 por ciento), la edad promedio fue 77,67 años. La fractura con mayor número de casos fue la extracapsular (62,25 por ciento) con su subtipo más prevalente que fue la transtrocantérica (35,78 por ciento). El mayor número de casos se presentó en el año 2016, en los meses de enero a abril hubo mayor número de pacientes ingresados. Conclusiones: Existe una prevalencia de fracturas de cadera en mujeres mayores de 60 años, lo que se corresponde con lo reportado a nivel nacional(AU)

Introduction: The most common reason for hospitalization in orthopedic services are hip fractures, of which the most frequent are those of the femoral neck and pertrochanteric and / or transtrochanteric. There are several risk factors among adults age 60 and over, including living in a nursing home, mental decline, type of fracture, common social environment, and presence of systemic diseases associated with aging. Objective: To describe and analyze the most frequent hip fractures in older adults at Agustin O'Horan General Hospital, as well as to describe the bimonthly and annual distribution of the cases that occurred in the state of Yucatan. Method: Cross-sectional, descriptive and retrospective study that included subjects of both genders aged 60 years and over, who had been admitted for hip fracture from November 2015 to April 2019. The variables were used gender, age, two-month period, year, anatomical location and type of trauma, extracapsular and intracapsular classification. Results: Most of the patients were female (64.53 percent), the average age was 77.67 years. The highest number of cases had extracapsular fracture (62.25 percent), the transtrochanteric subtype was the most prevalent (35.78 percent). The largest number of cases occurred in 2016. January to April there the months with higher number of patients admitted. Conclusions: The prevalence of hip fractures in women over 60 years of age, corresponds to that reported at the national level(AU)

Implants for trochanteric fractures in Norway: the role of the trochanteric stabilizing plate-a study on 20,902 fractures from the Norwegian hip fracture register 2011-2017.

BACKGROUND: The trochanteric stabilizing plate (TSP) is used as an adjunct to the sliding hip screw (SHS) in unstable trochanteric and subtrochanteric fractures. We wanted to describe the choice of implant for trochanteric fractures with a focus on the TSP in Norway. METHODS: A total of 20,902 fractures from the Norwegian Hip Fracture Register treated surgically in 43 hospitals from 2011 to 2017 were included. Logistic regression analyses were performed to detect factors potentially influencing implant choice. RESULTS: The mean age was 83 years, and 15,137 (72%) were women. An SHS was used in 13,273 (63%) fractures, of them 4407 (33%) with a TSP. Fracture classification was the most important determinant of TSP. In cases where an SHS was used, the odds ratio (OR) for using a TSP was 14 for AO/OTA 31A2 fractures and 71 for AO/OTA 31A3 and subtrochanteric fractures, compared to AO/OTA 31A1 fractures. The probability of receiving a TSP was higher in urban, academic, and high-volume hospitals (OR 1.2 to 1.3) and lower in Central and Northern Norway (OR 0.3 to 0.7). The use of an intramedullary nail (IMN) (n = 7629 (36%)) was also to a degree decided by fracture classification (OR 1.8 to 5.3). However, hospital factors, with OR 0.1 to 0.4 for IMN in academic, urban, and high-volume hospitals and OR 1.5 to 2.6 outside South-Eastern Norway (all p < 0.001), were also important. CONCLUSIONS: Fracture classification was the main determinant for TSP use. Any additional benefit from a TSP on postoperative fracture stability or clinical outcome needs to be clarified.

Evaluation of Judet view radiographs accuracy in classification of acetabular fractures compared with three-dimensional computerized tomographic scan: a retrospective study.

BACKGROUND: In the current diagnostic procedure, generally, both plain radiographs and 3D-CT scans are used for the diagnosis of acetabular fractures. There is no consensus regarding the value of a three-dimensional computerized tomographic (3D-CT) scan alone in the classification of acetabular fractures. In this study, we compared the accuracy of 3D-CT scan and plain radiography through the evaluation of their agreement with the intraoperative surgeon's classification. METHOD: In a retrospective study, patients who were referred to our center with an acetabular fracture and underwent surgical treatment were included. The classification of acetabular fractures was performed once using Judet view plain radiographs and once using a 3D-CT scan by the corresponding one Experienced musculoskeletal radiologist one independent trauma fellowship-trained orthopaedic who routinely treat acetabular fractures and based on Letournel and Judet classification (17 and 23 years of experience respectively). Cohen's kappa value was used for the assessment agreement between the two imaging modalities, as well as between the imaging modalities and intraoperative classification. RESULTS: Medical files of 152 patients with acetabular fracture were retrospectively reviewed. A kappa value of 0.236 was obtained as the agreement level between radiographs and intraoperative findings (p < 0.001). A kappa value of 0.943 was obtained as the agreement level between 3D-CT and intraoperative classification (p < 0.001). An agreement level of 0.264 was found between the Judet radiographs and 3D-CT scans (p < 0.001). CONCLUSIONS: 3D-CT scans are reliable enough in the classification of acetabular fractures, and plain radiographs could be omitted to avoid radiation exposure as well as to reduce the cost for patients who sustain acetabular fractures.

Incidence and pattern of periprosthetic hip fractures around the stem in different stem geometry.

BACKGROUND: The number of total hip arthroplasties (THA) is expected to increase worldwide; thus, complications are likely to increase at the same ratio. In this scenario, periprosthetic femoral fractures (PFFs) are an increasing concern. Identifying the predisposing factors is important in order to prevent as much as possible the risk of PFF in the future. PATIENTS AND METHODS: The purpose of this study was to correlate the risk of periprosthetic femoral fractures to the most common patients' comorbidities and stem geometry. We reviewed all THA for non-oncologic indications between 2004 and 2014 with a mean follow-up of six years (range, 2-12). Three thousand two hundred forty-eight patients (3593 implants) were enrolled in the study, and 45 PFF were registered during this time period. Two thousand five hundred seventy-seven implants (71%) were straight stems, and 1015 (28.3%) were anatomic stems. All X-rays were then analyzed and classified according to the modified Vancouver classification. RESULTS: Periprosthetic femoral fractures incidence was associated with anatomic stem geometry (p < 0.001, OR = 2.2), BMI (p < 0.001), and diabetes (p < 0.001, OR = 5.18). PFFs were not significantly associated with age, gender, and all the other variables. Fracture pattern was different between straight and anatomic stems. Clamshell fractures were more likely to occur in anatomic stems compared to straight stems (p < 0.005). CONCLUSIONS: Periprosthetic femoral fractures are highly associated with obesity and osteoporosis. Anatomic stems reported a higher incidence of PPF than straight stems. The typical fracture type for anatomical stems is the clamshell pattern, while straight stems are more likely affected by type B fractures.

Cognitive Impairment Level and Elderly Hip Fracture: Implications in Rehabilitation Nursing.

PURPOSE: The aim of the study was to determine the cognitive impairment level influence in descriptive characteristics, comorbidities, complications, and pharmacological features of older adults with hip fracture. DESIGN: Cross-sectional study. METHOD: Five hundred fifty-seven older adults with hip fracture were recruited and divided into cognitive impairment levels (severe/moderate, mild, no impairment). Descriptive characteristics, comorbidities, complications, and pharmacological data were collected. FINDINGS: Significant differences (p < .05, R = .012-.475) between cognitive impairment levels were shown. Shorter presurgery hospital length of stay and lower depression and Parkinson comorbidities; delirium complication; and antidepressants, antiparkinsonians, and neuroleptics use were shown for the no-impairment group. With regard to the cognitive impairment groups, lower presence of cardiopathy and hypertension; higher presence of dementia; antihypertensives, antiplatelets, and antidementia medication; infection/respiratory insufficiency complications; and lower constipation complications were shown. CONCLUSION: Cognitive impairment levels may determine the characteristics, comorbidities, pharmacology, and complications of older adults with hip fracture. CLINICAL RELEVANCE: Cognitive impairment level may impact rehabilitation nursing practice, education, and care coordination.

Comparison of three-dimensional and two-dimensional computed tomographies in the classification of acetabular fractures.

PURPOSE: This study compared the accuracy and timeliness of two-dimensional computed tomography (2DCT) and three-dimensional computed tomography (3DCT) in the diagnosis of different types of acetabular fractures and by different groups of interpreters using the Letournel and Judet classification system. METHODS: Twenty-five fractures cases, five each of five common types of acetabular fractures, were selected. Nineteen interpreters with different levels of experience (ten graduate trainees and nine radiologists) individually classified the fractures using multiplanar 2D and standardized 3DCT images. The 3DCT image set was comprised of 39 images of rotational views of the entire pelvis and the disarticulated fracture hip. Consensus reading by three experts served as a reference standard. RESULTS: Classification accuracy was 66% using 2DCT, increasing to 73% (p = 0.041) when 3DCT was used. Improvement occurred in the interpretation of transverse and posterior wall-type fractures (p < 0.01 and p = 0.015, respectively), but not in T-type, transverse with posterior wall, or both-column fractures. The improvement was noted only in the graduate trainee group (p = 0.016) but not the radiologist group (p = 0.619). Inter-observer reliability in the graduate trainee group improved from poor to moderate with 3DCT, but remained at a moderate level in both 2DCT and 3DCT in the radiologist group. The overall average interpretation time per case with correct diagnosis was 60 s for 2DCT but only 32 s for 3DCT. CONCLUSIONS: Standardized 3DCT provides greater reliability and faster diagnosis of acetabular fractures and helps improve the accuracy in transverse- and posterior wall-type fractures. In addition, it helps improve the accuracy of less experienced interpreters.

PFNA and DHS for AO/OTA 31-A2 fractures: radiographic measurements, morbidity and mortality.

PURPOSE: For this retrospective cohort study, we assessed pertrochanteric fracture types AO/OTA 31-A2. PFNA and DHS were the devices used. We determined both devices in relation to peri-operative variables, postoperative radiographic measurements, implant-related complications and mortality up to 2 years. The null hypothesis was no effect between the two devices. METHODS: This single-centre study was conducted based on our computerized data. The treatment period ranged from 2006 to 2015. Only patients with type AO/OTA 31-A2 fractures and an age ≥ 65 years were included. Apart from descriptive variables, the following measurements were assessed: (1) duration of surgery, (2) blood loss, (3) transfusion, (4) hospitalization, (5) tip-apex distance (TAD), (6) fracture reduction, (7) screw position, (8) implant-related complications, and (9) mortality. The follow-up was 2 years for each living patient. Missing data were evaluated by telephone call. RESULTS: A total of 375 consecutive patients were enrolled into three groups: (1) 75 patients treated with DHS and antirotation screw (ARS); (2); 100 patients treated with DHS + ARS + TSP (trochanteric stabilization plate); and (3) 200 patients treated with PFNA. Apart from dementia, the descriptive data (e.g., age and BMI) demonstrated no effects between the three groups. Compared to PFNA, DHS with or without TSP was adversely affected by a longer operation time, higher blood loss, increase in transfusion, and more implant-related complications including cut-out, infection and failure. The rate of cut-out was significantly higher in TAD ≥ 25 mm (p = 0.005), and PFNA demonstrated significantly better TAD measurements (p = 0.001), better fracture reduction (0.002), more central-central screw positions (p = 0.014), and less poor screw placement (p = 0.001). The mortality rate was without effect between the three groups (log rank 0.698). CONCLUSIONS: DHS with or without TSP was associated with significantly higher rates of implant-related complications based on inferior radiographic measurements. Therefore, we only recommend PFNA for the treatment of proximal type AO/OTA 31-A2 femoral fractures. LEVEL OF EVIDENCE: Therapeutic level III.

Geographic Variations in Intertrochanteric Femoral Fractures in China.

BACKGROUND: Hip fracture is one of the major risk factors of global mortality and disability. The aim of this study was to map the pattern of intertrochanteric femoral fractures in China, providing a pilot national dataset and basis for medical policy proposals. METHODS: A multistage probability sampling strategy was applied in the national baseline survey. Thirty provinces in mainland China were included in this survey. A standardized questionnaire survey was conducted to collect information about basic characteristics such as age, working seniority, hospital level, and residence, with two other parts including perioperative and postoperative treatment parameters. Odds ratios and 95% confidence interval were used to determine essential statistical differences. The proportion of the options in each region was compared using the chi-square (χ 2) test. The histogram and choropleth map of the monthly number of admissions were created using Excel 2016 to show the distribution characteristics. RESULTS: In total, 1065 valid responses were included, representing a 96.7% survey capture rate. Perioperative treatment and postoperative care distinctly varied across regions and hospital levels. The monthly number of admissions was relatively lower in the Northern region, with higher proportion of hospitalizations to secondary hospitals compared with the Eastern region. The patients in the Eastern region or tertiary hospitals had shorter preoperative waiting time and hospitalization period. CONCLUSIONS: We found apparent geographic variations in intertrochanteric femoral fractures in this study, and the data can be used for drafting national healthcare plans and medical policies.

A novel three-dimensional classification system for intertrochanteric fractures based on computed tomography findings.

A novel three-dimensional fragment-based classification system based on computed tomography findings was established to characterize femoral intertrochanteric fractures. The intertrochanteric bone fragments were defined as follows : neck, posterior portion of the greater trochanter, anterior portion of the greater trochanter, lesser trochanter, and shaft. Each type of fracture was classified as 2-, 3-, 4-, or 5-fragment according to the number of floating bone fragments. Following the description of the fracture type, each floating bone fragment was appended, with the exception of a fragment involving the shaft. Ninety-five intertrochanteric fractures were classified by the same surgeon. The fractures occurred in 14 men and 81 women with a mean age of 84.7 years. The frequency of each type of fracture was investigated. Thirty-one fractures (32.6%) were 2-fragment and 64 (67.4%) were ≥ 3-fragment. A fragment of the anterior portion of the greater trochanter, which cannot be classified using conventional systems, was included in 29 cases (30.5%). A 5-fragment fracture was detected in two cases (2.1%). Using this fragment-based classification system, intertrochanteric fractures can be evaluated in more detail than is possible using conventional classification systems. J. Med. Invest. 66 : 362-366, August, 2019.

Interpreting and reporting fracture classification and operation type in hip fracture: implications for research studies and routine national audits.

AIMS: This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review. PATIENTS AND METHODS: At 17 centres, an expert surgeon reviewed a randomly selected subset of cases from their centre with regard to fracture classification using the AO system and type of operation performed. Agreement for these variables was then compared with the data collected during conduct of the World Hip Trauma Evaluation (WHiTE) cohort study. Both types of surgery and fracture classification were collapsed to identify the level of detail of reporting that achieved meaningful agreement. In the National Hip Fracture Database (NHFD), the types of operation and fracture classification were explored to identify the proportion of "highly improbable" combinations. RESULTS: The records were reviewed for 903 cases. Agreement for the subtypes of extracapsular fracture was poor; most centres achieved no better than "fair" agreement. When the classification was collapsed to a single option for "extracapsular" fracture, only four centres failed to have at least "moderate" agreement. There was only "moderate" agreement for the subtypes of intracapsular fracture, which improved to "substantial" when collapsed to "intracapsular". Subtrochanteric fracture types were well reported with "substantial" agreement. There was near "perfect" agreement for internal fixation procedures. "Perfect" or "substantial" agreement was achieved when the type of arthroplasty surgery was reported at the level of "hemiarthroplasty" and "total hip replacement". When reviewing data submitted to the NHFD, a minimum of 5.2% of cases contained "highly improbable" procedures for the stated fracture classification. CONCLUSION: The complexity of collecting fracture classification data at a national scale compromises the accuracy with which detailed classification systems can be reported. Data around type of surgery performed show similar tendencies. Data capture, reporting, and interpretation in future studies must take this into account. Cite this article: Bone Joint J 2019;101-B:1292-1299.

Does Computed Tomography Improve Reproducibility in the Classification of Transtrochanteric Fractures? / A tomografia computadorizada melhora a reprodutibilidade na classificação das fraturas transtrocanterianas?

Abstract With the aging of the population, there was a significant increase in the prevalence of hip fractures, with high mortality rates, sequelae and expenses. Understanding the fracture profile and classifying it correctly is critical to define the appropriate treatment. Several radiographic classifications have been developed for transtrochanteric fractures, such as Tronzo, Evans-Jensen, AO and Boyd-Griffin, but their reproducibility is not always satisfactory. The present review aimedto elucidatewhether the addition of computed tomography (CT) implies a greater reproducibility than simple radiography in the classification of transtrochanteric fractures, andwhether this is a better examination to identify the fracture trait. A search was conducted in the PubMed, Lilacs, Scielo and Cochrane databases between July 2016 and June 2017, limited to the last 15 years. All retrospective, prospective and systematic reviews articles published in the English language, with evaluation of men and/or women, were considered for review. We have excluded case reports, studies that evaluated tomography or radiographs in isolation, and duplicate studies. The research presented 112 articles, of which 5 contemplated the proposed criteria. Reproducibility for the classification of transtrochanteric fractures presented variable results and was influenced by factors such as the type of classification, the use of the simplified or complete classification, the specialty of the evaluator, his experience, and themethodology proposed by the works. There are indications that there is benefit for the use of CT, especially for fractures considered unstable, but its use as a tool to ensure better reproducibility (intraand interobserver) remains controversial and needs further studies.

Resumo Com o envelhecimento populacional, houve um aumento significante da prevalência das fraturas do quadril, com alto índice de mortalidade, de sequelas, e alto custo. Compreender o perfil da fratura e classificá-la de forma correta é fundamental para definir o tratamento adequado. Diversas classificações radiográficas foram desenvolvidas para as fraturas transtrocanterianas, tais como as de Tronzo, de Evans-Jensen, de Boyd-Griffin e AO, porém sua reprodutibilidade nem sempr é satisfatória. O presente trabalho objetivou analisar se o acréscimo da tomografia computadorizada (TC)implica em maior reprodutibilidade do que a radiografia simples na classificação das fraturas transtrocanterianas e se esta é melhor para a identificação do traço de fratura. Foi realizada uma pesquisa nas bases de dados PubMed, Lilacs, Scielo e Cochrane entre julho de 2016 e junho de 2017, limitada aos últimos 15 anos. Todos os trabalhos retrospectivos, prospectivos e revisões sistemáticas publicados na língua inglesa, com avaliação de homens e/ou de mulheres, foram considerados para a revisão. Foram excluídos relatos de casos, estudos que avaliaram de forma isolada a TC ou radiografias e estudos duplicados. A pesquisa apresentou 112 artigos, dos quais 5 preencheram os critérios propostos. A reprodutibilidade para a classificação das fraturas transtrocanterianas apresentou resultados variáveis e influenciados por fatores como o tipo de classificação, o uso da classificação simplificada ou completa, a especialidade do avaliador, a experiência e a metodologia proposta pelos trabalhos. Há indícios de que há algum benefício para o uso da TC, sobretudo para fraturas consideradas instáveis,

Fragility Fractures of the Pelvis Classification: A Multicenter Assessment of the Intra-Rater and Inter-Rater Reliabilities and Percentage of Agreement.

BACKGROUND: The fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking. METHODS: Six experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references. RESULTS: The intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III. CONCLUSIONS: The FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities. CLINICAL RELEVANCE: With moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.

Clustering of morphological fracture lines for identifying intertrochanteric fracture classification with Hausdorff distance-based K-means approach.

OBJECTIVES: The aim of this study was to develop a systematic three-dimensional (3D) classification of intertrochanteric fractures by clustering the morphological features of fracture lines using the Hausdorff distance-based K-means approach and assess the usefulness of it in the clinical setting. METHODS: We retrospectively analyzed the data of 504 patients with intertrochanteric fractures who underwent closed reduction and intramedullary internal fixation. The morphological fracture lines of all patients extracted from computed tomography were transcribed freehand onto the template. All fracture lines were then clustered into five distinct types using the Hausdorff distance-based K-means clustering method. Five radiographic parameters and four functional parameters were used to evaluate the postoperative functional states and mobilization levels. Postoperative complications were also recorded. RESULTS: Intertrochanteric fractures were classified into five types: type I (108/504, 21.4%), simple fracture with intact lateral femoral wall and greater trochanter fragment; type II (85/504, 16.9%), simple fracture with intact lateral femoral wall with/without lesser trochanter detachment; type III (147/504, 29.2%), fractures with intertrochanteric crest detachment involving the lesser trochanter and greater trochanter with an intact lateral femoral wall; type IV (113/504, 22.4%), fractures with large intertrochanteric crest detachment and large lesser trochanter and greater trochanter detachment partially involving the lateral femoral wall and less medial cortical support; type V (51/504, 10.1%), a combination of pertrochanteric and lateral fracture line involving the entire lateral femoral wall and lesser trochanter detachment. Parameters of femoral neck-shaft angle and sliding distance of the cephalic nail were significantly different among types. The complication rate generally increased from type I to type V (P = 0.035). CONCLUSIONS: The unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance. The Tang classification can be used to describe fracture morphology, predict the possibility of achieving stable reduction and the risk of complications following intramedullary fixation.