Interobserver agreement for detecting Hill-Sachs lesions on magnetic resonance imaging.

BACKGROUND: Our aim is to determine the interobserver reliability for surgeons to detect Hill-Sachs lesions on magnetic resonance imaging (MRI), the certainty of judgement, and the effects of surgeon characteristics on agreement. METHODS: Twenty-nine patients with Hill-Sachs lesions or other lesions with a similar appearance on MRIs were presented to 20 surgeons without any patient characteristics. The surgeons answered questions on the presence of Hill-Sachs lesions and the certainty of diagnosis. Interobserver agreement was assessed using the Fleiss' kappa (κ) and percentage of agreement. Agreement between surgeons was compared using a technique similar to the pairwise t-test for means, based on large-sample linear approximation of Fleiss' kappa, with Bonferroni correction. RESULTS: The agreement between surgeons in detecting Hill-Sachs lesions on MRI was fair (69% agreement; κ, 0.304; p<0.001). In 84% of the cases, surgeons were certain or highly certain about the presence of a Hill-Sachs lesion. CONCLUSIONS: Although surgeons reported high levels of certainty for their ability to detect Hill-Sachs lesions, there was only a fair amount of agreement between surgeons in detecting Hill-Sachs lesions on MRI. This indicates that clear criteria for defining Hill-Sachs lesions are lacking, which hampers accurate diagnosis and can compromise treatment.

Prevalence of Osteochondral Lesions in Rotational Type Ankle Fractures With Syndesmotic Injury.

BACKGROUND:: The aim of this study was to report the incidence of associated osteochondral lesions (OCLs) on postop CTs, which may benefit from arthroscopic treatment, in patients with rotational type ankle fractures with syndesmotic injury. The diagnosis and treatment of associated OCLs may be an additional benefit of the use of arthroscopy in the management of rotational type ankle fractures with syndesmotic injury. METHODS:: We retrospectively reviewed data of a prospective cohort study of patients who underwent open reduction and surgical fixation of an ankle fracture with syndesmotic injury. These patients underwent routine bilateral postoperative CT assessment. Two independent observers classified ankle fractures according to Weber and OCLs according to the classification system by Berndt and Harty. Fifty-nine patients were included. There were 19 (32%) Weber B type ankle fractures and 39 (66%) Weber C type fractures. One patient (2%) had fixation for a medial malleolus fracture and syndesmotic rupture without fibula fracture. RESULTS:: Talar OCLs were present in 8 patients (14%). In one patient, 2 OCLs were found, which resulted in a total of 9 lesions. Two lesions were found on the medial side, both anterior. The other 7 were located laterally, of which 1 was anterior, 3 central, and 3 posterior on the talus. According to the Berndt and Harty classification, 1 was classified as stage I, 4 as stage III, and 4 as stage IV. CONCLUSION:: The prevalence of OCLs in ankle fractures with syndesmotic instability was 14%. We believe that lesions were arthroscopically accessible in 6 patients (10%). Moreover, most lesions were located on the lateral dome, and thus also potentially approachable through an anterolateral arthrotomy during open reduction and internal fixation. The majority of OCLs found in this series were Berndt and Harty type III or IV, and so likely would preferably have been addressed during the index procedure. LEVEL OF EVIDENCE:: Level III, diagnostic cohort study.

An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score.

BACKGROUND: The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability. METHODS: A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors. RESULTS: We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors. CONCLUSIONS: RCTs reporting on shoulder instability surgery are well performed but poorly reported.

Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique.

INTRODUCTION: The purpose of this study is to evaluate the intra- and inter-observer reliability of low-dose protocolled bilateral postoperative Computed Tomography (CT)-assessment of rotational malalignment after intramedullary nailing (IMN) of tibial shaft fractures. MATERIALS AND METHODS: 156 patients were prospectively included with tibial shaft fractures that were treated with IMN in a Level-I Trauma Centre. All patients underwent post-operative bilateral low-dose CT-assessment (effective dose of 0.03784 - 0.05768 mGy) as per hospital protocol. Four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. The Intra-Class Coefficient (ICC) was calculated to evaluate intra- and inter-observer reliability. The intra- and inter-observer reliability was categorized according to Landis and Koch. RESULTS: Intra-observer reliability for quantification of rotational malalignment on post-operative CT after IMN of tibial shaft fractures was excellent with 0.95 (95% CI = 0.92-0.97). The overall inter-observer reliability was 0.90 (95% CI = 0.87-0.92), also excellent according Landis and Koch. CONCLUSION: Firstly, bilateral post-operative low-dose -similar radiation exposure as plain chest radiographs- CT assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following IMN of tibial shaft fractures and it allows for early revision surgery. Secondly, it may contribute to our understanding of the incidence-, predictors- and clinical relevance of post-operative tibial rotational malalignment in patients treated with IMN for a tibial shaft fracture, and facilitates future studies on this topic.

Volar plating in distal radius fractures: A prospective clinical study on efficacy of dorsal tangential views to avoid screw penetration.

PURPOSE: The purpose of this prospective cohort study of patients treated with volar plating for distal radius fractures is to evaluate the efficacy (defined as detection rate, or the ability to detect dorsally protruding screws) of additional dorsal tangential views (DTV) after obtaining standard anteroposterior (AP) and elevated lateral views by evaluating the change in intraoperative strategy in 100 patients. MATERIALS AND METHODS: 100 patients aged 18 years and older undergoing volar plating for acute extra- or intra- articular distal radius fractures were prospectively enrolled. Intraoperative fluoroscopy views, including AP, elevated lateral and DTV were obtained. Intraoperative -screw- revision frequency for dorsal screw protrusion, screw position relative to volar plate and to dorsal compartment, and screw lengths were evaluated. RESULTS: Additional DTV led to a change of intraoperative management in 31 of 100 (31%) of patients. A total of 35 out of 504 screws (6.9%) were changed. Screws in the two most radial screws in the plate were at the highest risk of being revised; 16 (46%) screws in most radial position and nine (26%) screws in the 2nd from radial position were revised. Furthermore, five (14%) screws in both the 2nd from ulnar and most ulnar screw holes were revised after DTV. No screws were revised in the central hole. The median length of revised protruding screws was 22 mm (range, 12-26 mm), and these were changed to a mean length of 20  mm (range, 10-22 mm). CONCLUSION: In this prospective series of 100 patients, obtaining additional DTV is found to be efficacious as it led to change in intraoperative strategy in one-third of patients. We concur with previous pilot studies that DTV, after obtaining conventional AP and elevated lateral views, is advised to avoid dorsally protruding screws, which could minimise the potential for iatrogenic extensor tendon rupture after volar plating for distal radius fractures. Diagnostic accuracy of DTV is subject of a subsequent prospective cohort study with post-operative CT to serve as the reference standard. LEVEL OF EVIDENCE: .Prognostic I.