Inter-observer reliability of alternative diagnostic methods for proximal humerus fractures: a comparison between attending surgeons and orthopedic residents in training

Abstract

BackgroundProximal humerus fractures are frequent, and several studies show low diagnostic agreement among the observers, as well as an inaccurate classification of these lesions. The divergences are generally correlated with the experience of the surgeons as well as the diagnostic methods used. This paper challenges these problems including alternative diagnostic methods such as 3D models and augmented reality (holography) and including the observers’ period of medical experience as a factor.MethodsTwenty orthopedists (ten experts in shoulder surgery and ten experts in traumatology) and thirty resident physicians in orthopedics classified nine proximal humerus fractures randomly distributed as x-ray, tomographies, 3D models and holography, using AO/ASIF and Neer’s classification. In the end, we evaluated the intra- and inter-observer agreement between diagnostic methods and whether the experience of the observers interfered in the evaluations and the classifications used.ResultsWe found overall kappa coefficients ranging from 0.241 (fair) to 0.624 (substantial) between the two classifications (AO / ASIF and Neer), concerning the diagnostic methods used. We identified image modality differences (p = 0.017), where 3D models presented an average kappa coefficient value superior to that of tomographies. There were no differences between kappa scores for x-ray and holography compared to the others. The kappa scores for AO / ASIF classification and Neer classification and subdivided by observer period of experience showed no differences concerning the diagnostic method used.Conclusions3D models can substantially improve diagnostic agreement for proximal humerus fractures evaluation among experts or resident physicians. The holography showed good agreement between the experts and can be a similar option to x-ray and tomography in the evaluation and classification of these fractures. The observers’ period of experience did not improve the diagnostic agreement between the image modalities studied.Trial registrationRegistered in the Brazil Platform under no. CAAE 88912318.1.0000.5487.

Three-dimensional models increase the interobserver agreement for the treatment of proximal humerus fractures

“…The 3D-models as a diagnostic method showed the highest agreement among interobservers for the treatment of proximal humerus fractures (overall Kappa coefficient), both among experts and residents. Higher concordance based on proximal humerus fractures classification was found using 3D-models in our previous work, when compared to x-ray, tomography or holography [ 13 ]. Although 3D-models were the diagnostic method with a higher agreement in the choice of treatment among all interobservers, experts showed overall higher agreement when compared to residents.…”

“…The classifications proposed by Charles Neer, 1970 [5] and the AO / OTA group -Arbeit Gemeinschaft für Osteosynthesefragen [6], the most widespread and used worldwide, were not able to find a relevant reproducibility for diagnosis of proximal humerus fractures [21][22][23]. It seems logical, therefore, that the best choice to treat patients has uncertainties [2,3,13]. Handoll et al [2] state that there is not enough evidence that surgical treatments are superior to conservative ones.…”

“…Although the prevalence of proximal humerus fractures is relevant and growing worldwide [ 20 ], we still have problems with diagnosis and definitions about the best treatment [ 2 , 3 , 7 , 8 , 13 , 21 – 28 ]. With these findings presented here, we believe that surgeons, while still in training, are influenced by tactile rather than exclusively visual aspects to understand shoulder fractures.…”

“…et al [ 12 ], using the same three-dimensional models to present acetabular fractures to resident physicians, reported an improvement in the understanding of the particularities of this fracture. In a recent publication from our group [ 13 ], we suggested a relevant improvement in the diagnostic agreement among specialists and residents in orthopedics utilizing 3D-models for proximal humerus fractures compared to x-rays and tomographies. In addition, we presented the use of augmented reality (holography) as a diagnostic method to find a way to reproduce the characteristics of these fractures reliably.…”

Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems

“…Future developments in diagnostic imaging include alternative tools such as 3D models and augmented reality (holography) [35]. Recently, Cocco et al reported better inter-and intraobserver agreement when 3D-printed models of the fractures were used to classify according to the Neer and the AO/OTA systems, compared with traditional CT scans and 3D reconstruction [36,37].…”