McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
BMC Musculoskelet Disord. 2013 Feb 25;14:70. doi: 10.1186/1471-2474-14-70.
Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients' surgery.
A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.
The agreement between surgeons and radiologists for fracture healing was moderate for "general impression of fracture healing" in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.
Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.
尽管髋部骨折在矫形创伤中很突出，但 X 光片对骨折愈合的评估仍然是主观的。骨折愈合评估的变异性对临床研究和患者护理都有重要影响。由于几乎没有关于髋部骨折愈合可靠共识的现有文献，因此进行了这项研究，以确定骨科医生和放射科医生在使用髋部骨折患者的连续 X 光片评估愈合方面的组间可靠性。次要目标包括评估用于评估髋部骨折愈合的检查表，并确定当审查员了解 X 射线相对于患者手术的时间时，是否会提高一致性。
一个由六名评审员（三名骨科医生和三名放射科医生）组成的小组使用 100 例股骨颈骨折和 100 例转子间骨折患者的连续 X 光片独立评估骨折愈合情况。在他们的独立评估中，他们还完成了先前开发的放射学检查表（髋关节放射学愈合评分（RUSH））。计算了组内和组间可靠性评分。将当前研究的数据与之前进行的一项研究进行了比较，在该研究中，同一组评审员在不知道 X 射线拍摄时间的情况下完成了 RUSH 评分。
在股骨颈（ICC=0.60，95%CI：0.42-0.71）和转子间骨折（0.50，95%CI：0.33-0.62）中，外科医生和放射科医生对骨折愈合的总体印象的一致性为中等。使用标准化检查表（RUSH），在股骨颈（ICC=0.85，95%CI：0.82-0.87）和转子间骨折（0.88，95%CI：0.86-0.90）中，一致性几乎为完美。我们还发现，使用接收器操作特征（ROC）分析，愈合与 RUSH 总评分之间具有高度相关性，股骨颈病例的曲线下面积为 0.993，转子间骨折病例为 0.989。在我们的分析中，放射科医生组和外科医生组内的一致性没有显著差异。在所有情况下，与之前研究中审查员不知道 X 射线拍摄时间的情况相比，已知手术时间后的 X 射线照片导致了更高的一致性评分。
使用标准化检查表可以提高髋关节骨折放射学愈合的一致性，并且似乎高度受 X 射线拍摄时间的影响。在评估患者结局和涉及髋部骨折患者的临床研究中，应考虑这些发现。需要进一步的研究计划来进一步评估 RUSH 检查表。
