We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation. Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow. Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used. Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon. Each surgeon graded 176 MRI images twice. The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5. Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%. The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%. It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time. Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers

Introduction. Tip apex distance (TAD) is reported as a predictor for cut outs of lag screws in the treatment of intertrochanteric fractures, and surgeons are adviced to strive for TAD within 20 mm. However the definition of neck axis and the limb position of lateral radiograph are not clearly described in the original literature. We propose the refined TAD by defining these factors. The objective of this study was to analyze the interobserver agreement of this refined TAD. Materials and Method. X rays of 130 cases of unstable trochanteric fractures were used for the analysis of the refined TAD. In the refined TAD, neck axis was defined as the line between the center of femoral head and midpoint of narrowest part of the femoral neck, and lateral radiograph was taken with hip flexion 90 degrees and abduction 45 degrees. The refined TAD was independently measured by 2 experienced (observer 1,2) and 2 inexperienced (observer 3,4) orthopaedic surgeons who were trained with the new method before the measurement. Intraclass correlation coefficient (ICC [2,4]) was calculated to assess the interobserver agreement. Result. The mean refined TADs were 18.2:18.4:18.2:18.2 for observer 1:2:3:4. There was a strong correlation among all four observers (ICC 0.998, (95% CI: 0.998, 0.999). Discussion. Regardless of the clinical experience of observers, the refined TAD is a reliable tool and can be used to develop new TAD recommendations for predicting failure of fixation

We recorded inter- and intra-observer variations in the classification of ankle fractures by the Lauge Hansen and Weber systems. Radiographs of 94 patients were classified independently by four observers. The observer variation was calculated by kappa statistics, which corrects the obtained values for the agreement expected by chance. There was an acceptable level of agreement for the overall classification into both systems. For the staging of supination-adduction and supination-eversion fractures in the Lauge Hansen system the agreement was poor. The results indicate that future classification systems should be subject to reliability analysis before they are accepted

A study was undertaken to assess the degree of inter-observer error when a panel of observers classified the radiographs of patients with early Perthes' disease, using Catterall grouping and "at risk" signs. The anteroposterior and lateral radiographs, taken within three months of diagnosis of Perthes' disease, were available for 69 hips and were shown in turn to 10 observers. The radiological end-results were assessed at least four years from diagnosis. The results showed a poor ability of the observers to delineate Groups 1, 2 and 3, with a more satisfactory performance in Group 4 and when Groups 2 and 3 were combined. Interpretation of "at risk" signs was unsatisfactory except when there was an increase in medial joint space greater than two millimetres. The end-results correlated well with early Catterall grouping and "at risk" signs when these were correctly interpreted

We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact

To determine the Inter & Intra-observer Agreement in Assessment & Classification of Non-unions of fractures based on Radiological appearance. Medical records and X-rays of patients who attended the Limb Reconstruction Clinic (1987 to 2000) in a University Hospital for fracture non-union were studied. X-rays of one hundred adult patients with established non-union were selected by random sampling. Common denominators of various classification / assessment systems were selected for study. Observers were selected in 3 categories (2 in each): Senior Limb Reconstruction specialist, Consultant Musculoskeletal Radiologists, Senior trainees (Post-FRCS Orth). Data was analysed by calculating kappa coefficients (95% confidence intervals). Kappa measures between observer agreements having been corrected for chance. Radiologists were unable to comment on vascularity. (S= substantial, M= moderate, F= fair & P= poor). It would appear that the agreement for classification of atrophic/hypertrophic non-union is good all round (both inter & intra). Within this classification, radiologists showed better agreement than trainees whose results were better than Orthopaedic specialists. Agreement of healing potential & infection was fair to poor only. Radiographic analysis of non-union remains poor indicating the need for further study to see whether identifiable features exist

Study Design: A radiographic study using disarticulated cadaver thoracic vertebrae. Objective: To determine the accuracy of orthogonal X-rays in detecting thoracic pedicle screw position by different groups of observers. Summary of Background Data: Pedicle screws are increasingly being used for internal fixation of the thoracic spine. Surgeons and radiologists are often required to make decisions on the pedicle screw position by plain antero-posterior (AP) and lateral radiographs. Materials and Methods: 23 disarticulated fresh adult thoracic vertebrae were used in this study. Pedicle screws were inserted completely within the pedicle; or deliberately violating the lateral or medial cortex of the pedicle. AP and lateral radiographs of each vertebrae were assessed by 2 spine surgeons, 2 spine trainees, and 2 musculoskeletal radiologists in a sequence of AP alone, and AP + lateral views. They were supposed to cataogorize the pedicular screw as ‘out laterally’/‘inside the pedicle’/‘out medially’ or ‘unsure’. Their assessments were compared to the actual position of the screws determined by the axial views. Results: For each screw position, trend was found towards slightly better accuracy with availability of AP & lateral views in combination. From either AP alone or AP + lateral views, significantly higher accuracy was found in detecting screws “out laterally” than “inside pedicle” (p< 0.01), or “out medially”(p< 0.05), respectively. Nearly 30% of screws that were deliberately placed through the medial pedicle wall were not correctly identified. In addition, surgeons have highest accuracy from either AP alone, or AP + lateral views, followed by the spine trainees and radiologists. Radiologists provided more “unsure” answers than surgeons or trainees. Conclusions: Screws that perforated the lateral cortex were the easiest, and those that were wholly within the pedicle were the most difficult to identify correctly. The use of plain radiographs to detect thoracic pedicle screws placed through the critical medial cortex is unreliable. The positions of thoracic pedicle screws appear to be more accurately detected by AP + lateral, however, the major contribution was from AP views. Surgeon experience continues to be vitally important in the safe placement of thoracic pedicle screws. Key points:. Screws that perforated the lateral cortex were the easiest, and those that were wholly within the pedicle were the most difficult to identify correctly. The use of plain radiographs to detect thoracic pedicle screws placed through the critical medial cortex is unreliable. AP + lateral views provides higher accuracy in determining the screw position, while, the major contribution comes from AP views. Surgeon experience, in the use of tactile skills and anatomical knowledge continue to be vitally important in the safe placement of thoracic pedicle screws

Over the last 15 years there have been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management.

Aim. To assess the results of open elbow arthrolysis in patients who did not receive any physiotherapy after discharge from hospital, although this is routinely prescribed by many surgeons.

Patients and Methods. Prospectively collected data of 34 patients with a minimum follow-up of 1 year after arthrolysis was analysed. All the procedures were performed by the same surgeon, achieving as much improvement in elbow motion as possible at operation. All the patients had continuous brachial plexus blocks and continual passive motion for 2–3 days postoperatively but none received any physiotherapy after discharge. At review, a senior physiotherapist formally assessed all the patients, including measuring elbow motion with a goniometer.

Results. All patients’ arc of movement improved from, with mean elbow flexion increasing by 16 degrees and extension 20 degress at the last follow-up. Upper limb function, assessed with a Disabilities of the Arm, Shoulder and Hand score (DASH), had improved 30%. Pain had decreased from 4.8 to 3.1 using the Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows – 5 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 96 degrees by the time of the last review. Only early complications occurred – ulnar neuritis and significant pain – but these symptoms had largely settled by the time of the last review.

Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2–3 days post-operatively. There appears to be little evidence to support formal treatment with physiotherapy after discharge from hospital, as our results are similar to other reported series.

Aim

Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital.

Background: An acromiohumeral interval narrower than six millimeters has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study was conducted as an assessment of inter- and intraobserver variation in the radiographic measurement of the acromiohumeral interval and its critical value.

Material and Methods: Thirty blinded, standardized anteroposterior shoulder radiographs were independently reviewed by five board certified orthopedic shoulder surgeons. The acromiohumeral distance, from the inferior anterior acromial aspect to the humeral head was measured in millimeters. The five investigators classified each film a second time in random order.

Results: Finally the same 27 radiographs (90%) have been evaluated by five investigators at both examination time points. The results of three investigators showed significant intra-observer variation ranging from 4 to 11 millimeters for the same radiograph. Six investigator pairs showed significant inter-observer variation at both examination time points (p< 0.05). The maximum inter-observer difference for the same radiograph was 11 millimeters (ranging from 1 to 11, SD 0.3 – 4.2).

Conclusion: In view of our results the assessment of the acromiohumeral interval using anteroposterior x-rays does not seem to be a reproducible method of measurement. Further investigations in combination with CT or MRI are necessary to ensure our findings.

Introduction

Regenerative medicine is a rapidly expanding discipline. However due to a lack of validated outcome measures, clinical trials have been far few. This study aims to assess the validity, inter-observer reliability and intra-observer reproducibility of experimental fracture healing assessment on plain radiographies. This technique involves implantation of mesenchymal stem cell (MSC) seeded constructs on only one side of the fracture after randomisation.

Aims. Taper corrosion has been widely reported to be problematic for modular total hip arthroplasty implants. A simple and systematic method to evaluate taper damage with sufficient resolution is needed. We introduce a semiquantitative grading system for modular femoral tapers to characterize taper corrosion damage. Methods. After examining a unique collection of retrieved cobalt-chromium (CoCr) taper sleeves (n = 465) using the widely-used Goldberg system, we developed an expanded six-point visual grading system intended to characterize the severity, visible material loss, and absence of direct component contact due to corrosion. Female taper sleeve damage was evaluated by three blinded observers using the Goldberg scoring system and the expanded system. A subset (n = 85) was then re-evaluated following destructive cleaning, using both scoring systems. Material loss for this subset was quantified using metrology and correlated with both scoring systems. Results. There was substantial agreement in grading among all three observers with uncleaned (n = 465) and with the subset of cleaned (n = 85) implants. The expanded scoring criteria provided a wider distribution of scores which ultimately correlated well with corrosion material loss. Cleaning changed the average scores marginally using the Goldberg criteria (p = 0.290); however, using the VGS, approximately 40% of the scores for all observers changed, increasing the average score from 4.24 to 4.35 (p = 0.002). There was a strong correlation between measured material loss and new grading scores. Conclusion. The expanded scoring criteria provided a wider distribution of scores which ultimately correlated well with corrosion material loss. This system provides potential advantages for assessing taper damage without requiring specialized imaging devices. Cite this article: Bone Joint Res 2023;12(3):155–164

The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC. Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result. All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process. Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%. Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441. Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773). Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement. This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases

Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration

Aims. This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems. Methods. Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss’ kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs. Results. Interobserver reliability percentage agreement was 58.5% and the overall kappa value was 0.442 (moderate agreement). Lowest kappa values were seen for type B fractures (0.095 to 0.360). The mean intraobserver reliability kappa value was 0.672 (0.447 to 0.867), indicating substantial agreement. Validity percentage agreement was 65.7% and the mean kappa value was 0.300 (0.160 to 0.4400) indicating only fair agreement. Conclusion. This study demonstrates that the UCS is unsatisfactory for the classification of PFFs around PTS stems, and that it has considerably lower reliability and validity than previously described for other stem types. Radiological PTS stem loosening in the presence of PFF is poorly defined and formal intraoperative testing of stem stability is recommended. Cite this article: Bone Joint J 2021;103-B(8):1339–1344

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3. The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures

Identifying and restoring alignment is a primary aim of total knee arthroplasty (TKA). In the coronal plane, the pre-pathological hip knee angle can be predicted using an arithmetic method (aHKA) by measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (aHKA=MPTA - LDFA). The aHKA is shown to be predictive of coronal alignment prior to the onset of osteoarthritis; a useful guide when considering a non-mechanically aligned TKA. The aim of this study is to investigate the intra- and inter-observer accuracy of aHKA measurements on long leg standing radiographs (LLR) and preoperative Mako CT planning scans (CTs). Sixty-eight patients who underwent TKA from 2020–2021 with pre-operative LLR and CTs were included. Three observers (Surgeon, Fellow, Registrar) measured the LDFA and MPTA on LLR and CT independently on three separate occasions, to determine aHKA. Statistical analysis was undertaken with Bland-Altman test and coefficient of repeatability. An average intra-observer measurement error of 3.5° on LLR and 1.73° on CTs for MPTA was detected. Inter-observer errors were 2.74° on LLR and 1.28° on CTs. For LDFA, average intra-observer measurement error was 2.93° on LLR and 2.3° on CTs, with inter-observer errors of 2.31° on LLR and 1.92° on CTs. Average aHKA intra-observer error was 4.8° on LLR and 2.82° on CTs. Inter-observer error of 3.56° for LLR and 2.0° on CTs was measured. The aHKA is reproducible on both LLR and CT. CT measurements are more reproducible both between and within observers. The difference between measurements using LLR and CT is small and hence these two can be considered interchangeable. CT may obviate the need for LLRs and may overcome difficulties associated with positioning, rotation, body habitus and flexion contractures when assessing coronal alignment

Aims. The evidence demonstrating the superiority of early MRI has led to increased use of MRI in clinical pathways for acute wrist trauma. The aim of this study was to describe the radiological characteristics and the inter-observer reliability of a new MRI based classification system for scaphoid injuries in a consecutive series of patients. Methods. We identified 80 consecutive patients with acute scaphoid injuries at one centre who had presented within four weeks of injury. The radiographs and MRI scans were assessed by four observers, two radiologists, and two hand surgeons, using both pre-existing classifications and a new MRI based classification tool, the Oxford Scaphoid MRI Assessment Rating Tool (OxSMART). The OxSMART was used to categorize scaphoid injuries into three grades: contusion (grade 1); unicortical fracture (grade 2); and complete bicortical fracture (grade 3). Results. In total there were 13 grade 1 injuries, 11 grade 2 injuries, and 56 grade 3 injuries in the 80 consecutive patients. The inter-observer reliability of the OxSMART was substantial (Kappa = 0.711). The inter-observer reliability of detecting an obvious fracture was moderate for radiographs (Kappa = 0.436) and MRI (Kappa = 0.543). Only 52% (29 of 56) of the grade 3 injuries were detected on plain radiographs. There were two complications of delayed union, both of which occurred in patients with grade 3 injuries, who were promptly treated with cast immobilization. There were no complications in the patients with grade 1 and 2 injuries and the majority of these patients were treated with early mobilization as pain allowed. Conclusion. This MRI based classification tool, the OxSMART, is reliable and clinically useful in managing patients with acute scaphoid injuries. Cite this article: Bone Jt Open 2022;3(11):913–920

Aims. Besides conventional radiographs, the use of MRI, CT, and bone scintigraphy is frequent in the diagnosis of a fracture of the scaphoid. However, which techniques give the best results remain unknown. The investigation of a new imaging technique initially requires an analysis of its precision. The primary aim of this study was to investigate the interobserver agreement of high-resolution peripheral quantitative CT (HR-pQCT) in the diagnosis of a scaphoid fracture. A secondary aim was to investigate the interobserver agreement for the presence of other fractures and for the classification of scaphoid fracture. Methods. Two radiologists and two orthopaedic trauma surgeons evaluated HR-pQCT scans of 31 patients with a clinically-suspected scaphoid fracture. The observers were asked to determine the presence of a scaphoid or other fracture and to classify the scaphoid fracture based on the Herbert classification system. Fleiss kappa statistics were used to calculate the interobserver agreement for the diagnosis of a fracture. Intraclass correlation coefficients (ICCs) were used to assess the agreement for the classification of scaphoid fracture. Results. A total of nine (29%) scaphoid fractures and 12 (39%) other fractures were diagnosed in 20 patients (65%) using HR-pQCT across the four observers. The interobserver agreement was 91% for the identification of a scaphoid fracture (95% confidence interval (CI) 0.76 to 1.00) and 80% for other fractures (95% CI 0.72 to 0.87). The mean ICC for the classification of a scaphoid fracture in the seven patients diagnosed with scaphoid fracture by all four observers was 73% (95% CI 0.42 to 0.94). Conclusion. We conclude that the diagnosis of scaphoid and other fractures is reliable when using HR-pQCT in patients with a clinically-suspected fracture. Cite this article: Bone Joint J 2020;102-B(4):478–484