Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, 329-0498, Japan.
Jichi Medical University Hospital Life Saving Emergency Center, Shimotsuke, Japan.
Injury. 2021 Nov;52(11):3363-3368. doi: 10.1016/j.injury.2021.09.031. Epub 2021 Sep 23.
The AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability.
A retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior-posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability.
In the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239-0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305-0.428; low-experience group: κ = 0.304, 95% CI 0.246-0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428-0.539 and κ = 0.409, 95% CI 0.352-0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322-0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups.
The current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.
2018 年，AO/OTA 分类法对股骨转子间骨折（31A 型骨折）的诊断进行了修订。目前还没有研究调查在使用当前的 AO/OTA 标准进行放射诊断的基础上，增加 CT 是否可以提高分类的组内可靠性。本研究旨在检验以下假设，即增加三维 CT（3D-CT）可提高诊断的可靠性。
回顾性评估了当前 AO/OTA 标准对 31A 型骨折的分类诊断的可靠性。评估了 89 例病例的放射照片和 3D-CT 图像。9 位骨科医生根据其临床经验将主要骨折类型（A1、A2 和 A3）和亚组进行诊断，并将其分为三组（高、中、低经验组）。前后位和侧位 X 线片用于诊断骨折类型（第一次评估）。6 周后，每位评估者均对所有病例的 X 线片和 3D-CT 图像进行了评估（第二次评估）。使用 Fleiss Kappa 来确定组内可靠性。
在第一次评估中，所有组的 Kappa 值均显示出中度的组内可靠性（高经验组：κ=0.296，95%置信区间[CI]0.239-0.352；中经验组：κ=0.367，95%CI 0.305-0.428；低经验组：κ=0.304，95%CI 0.246-0.362）。增加 3D-CT（第二次评估）后，高经验组和中经验组的可靠性从中等提高到中度（κ=0.483，95%CI 0.428-0.539 和 κ=0.409，95%CI 0.352-0.466）。相比之下，低经验组的可靠性仍为中度（κ=0.322，95%CI 0.322-0.431）。在所有三组中，A2.3 和 A3.1 的亚组骨折类型的组内可靠性提高，在中经验组和低经验组中，A3.2 和 A3.3 的组内可靠性也提高。
2018 年修订的当前 AO/OTA 分类法在所有三组外科医生中对股骨转子间骨折的诊断均具有中度可靠性。在放射图像评估中增加 3D-CT 可提高高、中专业水平组的可靠性。尽管骨折亚组之间存在一些差异，但增加 3D-CT 对放射评估通常可以提高不稳定骨折的诊断可靠性。
