'Absolute' inter-observer classifications agreement for proximal humeral fractures with a single shoulder anteroposterior X-ray.

PURPOSE: Several studies have been carried out, and there is no classification for proximal humeral fractures (PHF) exempted from variability in interpretation and with questioned reliability. In the present study, we investigated the 'absolute diagnostic reliability' of the most currently used classifications for PHFs on a single anterior-posterior X-ray shoulder image. METHODS: Six orthopaedic surgeons, with varying levels of experience in shoulder pathology, evaluated radiographs from 30 proximal humeral fractures, according to the 'absolute reliability' criteria. Each of the observers rated each fracture according to Neer, Müller/AO and Codman-Hertel's classification systems. RESULTS: The overall inter-observer agreement (κ) has been 0.297 (CI95% 0.280 to 0.314) for the Neer's classification system, 0.206 (CI95% 0.193 to 0.218) for the Müller/AO classification system, and 0.315 (CI95% 0.334 to 0.368) for the Codman-Hertel classification system. We found loss of agreement in Neer's classification as the study progressed, low agreement in the AO classification, and stable values in the different evaluations with the best degree of agreement for Codman-Hertel classification, with a moderate agreement in the second evaluation among the six evaluators. CONCLUSION: The Neer, AO, and Hertel-Codman classification systems for PHF with a single radiographic projection have a difficult interpretation for orthopaedic surgeons of varying levels of experience, and therefore substantial agreements are not obtained.

El Test de Constant-Murley como método de valoración clínica para el seguimiento de las fracturas de extremidad proximal del húmero Revisión y controversias / The Constant-Murley Test as a clinical assessment method for monitoring proximal humerus fractures: Review and controversies

Aplicamos el test para el seguimiento clínico y funcional de tres líneas terapéuticas diferentes en pacientes con fractura de la extremidad proximal del húmero. Resultados: La falta de estandarización en cuanto a la medición de los parámetros que conforman el test genera dificultad en la ejecución e interpretación de los resultados. La cuantificación de las rotaciones interna y externa mediante gestos funcionales no permite cuantificar de forma precisa el rango articular, y el parámetro fuerza tiene gran variabilidad de medición e interpretación según los evaluadores, sin criterios definidos. DISCUSIÓN: Esta revisión respalda el uso del test de Constant para seguimiento clínico de la patología del hombro y protocolos de investigación específicos, pero subraya la necesidad de una mayor estandarización para realizar el procedimiento de medición de rangos articulares y fuerza y la precaución al interpretar las puntuaciones. CONCLUSIONES: El test de Constant-Murley es de fácil aplicabilidad clínica y ofrece ventajas en el seguimiento de diversas patologías del hombro, pero su falta de estandarización en cuanto a la medición de los ítems que lo conforman lo hace poco reproducible, en especial respecto al parámetro fuerza. Existe un vacío de evidencia respecto a las propiedades psicométricas más importantes del test, como la validez del contenido, el cambio mínimo detectable y la diferencia mínima clínicamente importante. Sería necesario la conformación de tablas normalizadas ajustadas a edad y sexo de cada población, para que los resultados de la realización del test fueran óptimos. Así como mejorar la concordancia intra e interobservador para mejorar la comparación de los resultados, tanto del mismo paciente, como del paciente con la población a la que pertenece

The Constant scale, also known as the Constant- Murley test, is one of the most widely used tools to evaluate the functional capacity of the shoulder, which has been shown to be specifically useful for evaluating clinical results in shoulder arthroplasty, rotator cuff reparations, adhesive capsulitis and proximal humerus fractures. Previous clinical trials have shown the different use of this test depending on the population groups (age and sex), the type of the rotator cuff pathology, and the poor results of the reliability and the test reproduction. The aim of this article is to show our experience with the test application in 36 patients with proximal humerus fractures, and the review of the present literature about the use of the scale based on the psycomethric evidence, on the validity, and on the try to decrease the bias relating to the population groups, the previous shoulder pathology and the differences asses in the observer variation. MATERIAL AND METHODS: We have reviewed the actual literature and included 30 published articles between 1969 and 2018. We have applied the test for the clinical and functional follow-up of 3 different treatments in patients with proximal humerus fracture. RESULTS: The lack of the standardization of the parameters measurement makes it difficult to execute and interpret the results. The quantification of the internal and external rotation through functional movement, doesn’t allow to specify the articular range, and the strength has wide measurement and interpretation variability depending on the explorers, withouth specific judgments. Discussion: This review supports the use of the Constant test for the clinical follow up of the shoulder pathology, and the specific investigation protocols, but shows the necessity of better standardization for the joint ranges measurement and strength; making important the precaution in the score interpretation. CONCLUSION: The Constant-Murley test is easy to apply and offers advantages in the follow-up of different shoulder pathologies, but the lack of the standardization in the items measurement makes that difficult to reproduce, specially at the strength. There is no evidence about the most important psychometric properties, such as validity, the detectable minimal change, and the minimal clinical difference. It would be necessary to constitute tables adjusted to the age and sex of each population, for the results would be optimal; and improve the agreement between observers for the better comparison of the results, as the same patient as the population which it belongs to

Fascitis Plantar: Opciones terapéuticas / Plantar Fasciitis: Treatment strategies

La talalgia es la causa más frecuente de consulta a los especialistas en pie y tobillo, entre un 11% y un 15%. En la mayoría de los casos se debe a un proceso de degeneración fibrosa en la inserción fascial de la tuberosidad medial del calcáneo al que llamamos fascitis plantar. Existen multitud de tratamientos que se han mostrado efectivos para la fascitis plantar, desde el uso de plantillas o taloneras hasta la fasciotomia quirúrgica, pasando por las infiltraciones articulares o los suplementos de colágeno en la dieta. Después de analizar la evidencia científica de los diferentes tratamientos utilizados, no se ha encontrado ninguna opción de la que se haya demostrado evidencia fuerte del beneficio en la que basar la práctica clínica, por ello diseñamos un estudio prospectivo en el que establecimos en pacientes que tenían el diagnóstico de fascitis plantar 4 líneas de tratamiento diferentes. El objetivo del presente estudio es conocer los resultados de 4 líneas terapéuticas diferentes en pacientes en los que iniciamos un primer escalón de tratamiento, para conocer si alguna de estas líneas nos aporta beneficios en la eliminación del dolor, la recuperación de la funcionalidad o ambas

Heel pain is the most common cause of medical consultation in foot and ankle specialists, constituting between 11% and 15% of them. In most cases it is due to a process of fibrous degeneration in the fascial insertion of the medial tuberosity of the calcaneus, the plantar fasciitis. Many treatmens have been shown to be effective for plantar fasciitis, starting with the use of orthotics to other more aggressive procedures as surgical fasciotomy passing through other terapies as joint infiltrations or collagen supplements. After a scientific review of the different treatments, no option has demonstrated strong evidence of benefit on which to base clinical practice, thus we designed a prospective study in which we established 4 different lines of treatment in patients who had the diagnosis of plantar fasciitis. Objetive: To analyze the effectiveness of the interventions in the management of plantar fasciitis