Reliability and application of the new morphological classification system for chronic symptomatic osteoporotic thoracolumbar fracture

Abstract ObjectiveThis study proposed a new classification system for Chronic Symptomatic Osteoporotic Thoracolumbar Fracture (CSOTF) based on fracture morphology. Research on CSOTF has increased in recent years. However, the lack of a standard classification system has resulted in inconveniences regarding communication, research and treatment. Previous studies of CSOTF classification exhibit different defects, and none of these studies are widely accepted.MethodsWe collected 368 cases of CSOTF in our hospital from January 2010 to June 2017 and systematically analyzed the imaging data of all patients to develop a classification system. Imaging examinations included dynamic radiography, computed tomography scans and magnetic resonance imaging. Ten investigators systematically studied and fully understood the classification system grading 40 cases on two occasions, examined 1 month apart. Kappa coefficients (κ) were calculated to determine intraobserver and interobserver reliability.ResultsThe new classification system for CSOTF was divided into types I-V according to whether the CSOTF exhibited dynamic instability, spinal stenosis or kyphosis deformity. Intra- and interobserver reliability were excellent for all types (κ = 0.83 and 0.85, respectively).ConclusionsThe new classification system for CSOTF demonstrated excellent reliability in this initial assessment. The system is convenient for communication and research, but wide clinical application are needed to confirm its effectiveness and guide clinical treatment.

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The Comprehensive AO CMF Classification System for Mandibular Fractures: A Multicenter Validation Study

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0038-1677459 ◽

2019 ◽

Vol 12 (4) ◽

pp. 254-265 ◽

Cited By ~ 1

Author(s):

Paul A. Mittermiller ◽

Serena S. Bidwell ◽

Florian M. Thieringer ◽

Carl-Peter Cornelius ◽

Amber W. Trickey ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Fracture Morphology ◽

Mandibular Fractures ◽

Condylar Process ◽

Accuracy Study ◽

Level 3 ◽

Comprehensive Classification ◽

Level 2 ◽

Condylar Neck

The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss’ kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p < 0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p < 0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p < 0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p < 0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.

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Comprehensive classification system for multirod constructs across three-column osteotomies: a reliability study

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20678 ◽

2021 ◽

Vol 34 (1) ◽

pp. 103-109

Author(s):

Mostafa H. El Dafrawy ◽

Owoicho Adogwa ◽

Adam M. Wegner ◽

Nicholas A. Pallotta ◽

Michael P. Kelly ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Kappa Coefficient ◽

Intraobserver Reliability ◽

Osteotomy Site ◽

New Classification ◽

Good Reliability ◽

Kappa Value ◽

Comprehensive Classification ◽

High Degree

OBJECTIVEIn this study, the authors’ goal was to determine the intra- and interobserver reliability of a new classification system that allows the description of all possible constructs used across three-column osteotomies (3COs) in terms of rod configuration and density.METHODSThirty-five patients with multirod constructs (MRCs) across a 3CO were classified by two spinal surgery fellows according to the new system, and then were reclassified 2 weeks later. Constructs were classified as follows: the number of rods across the osteotomy site followed by a letter corresponding to the type of rod configuration: “M” is for a main rod configuration, defined as a single rod spanning the osteotomy. “L” is for linked rod configurations, defined as 2 rods directly connected to each other at the osteotomy site. “S” is for satellite rod configurations, which were defined as a short rod independent of the main rod with anchors above and below the 3CO. “A” is for accessory rods, defined as an additional rod across the 3CO attached to main rods but not attached to any anchors across the osteotomy site. “I” is for intercalary rod configurations, defined as a rod connecting 2 separate constructs across the 3CO, without the intercalary rod itself attached to any anchors across the osteotomy site. The intra- and interobserver reliability of this classification system was determined.RESULTSA sample estimation for validation assuming two readers and 35 subjects results in a two-sided 95% confidence interval with a width of 0.19 and a kappa value of 0.8 (SD 0.3). The Fleiss kappa coefficient (κ) was used to calculate the degree of agreement between interrater and intraobserver reliability. The interrater kappa coefficient was 0.3, and the intrarater kappa coefficient was 0.63 (good reliability). This scenario represents a high degree of agreement despite a low kappa coefficient. Correct observations by both observers were 34 of 35 and 33 of 35 at both time points. Misclassification was related to difficulty in determining connectors versus anchors.CONCLUSIONSMRCs across 3COs have variable rod configurations. Currently, no classification system or agreement on nomenclature exists to define the configuration of rods across 3COs. The authors present a new, comprehensive MRC classification system with good inter- and intraobserver reliability and a high degree of agreement that allows for a standardized description of MRCs across 3COs.

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A new classification of talocalcaneal coalitions based on computed tomography for operative planning

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04567-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Anhong Wang ◽

Weili Shi ◽

Lixiang Gao ◽

Linxin Chen ◽

Xing Xie ◽

...

Keyword(s):

Classification System ◽

Main Type ◽

Interobserver Reliability ◽

Weighted Kappa ◽

Type I ◽

Type Ii ◽

New Classification ◽

Type Iv ◽

Talocalcaneal Coalition ◽

Operative Planning

Abstract Background Current classifications emphasize the morphology of the coalition, however, subtalar joint facets involved should also be emphasized. Objective The objective of this study was to develop a new classification system based on the articular facets involved to cover all coalitions and guide operative planning. Methods Patients were diagnosed with talocalcaneal coalition using a CT scan, between January 2009 and February 2021. The coalition was classified into four main types according to the shape and nature of the coalition: I, inferiorly overgrown talus or superiorly overgrown calcaneus; II, both talus and calcaneus overgrew; III, coalition with an accessory ossicle; IV, complete osseous coalition (I-III types are non-osseous coalition). Then each type was further divided into three subtypes according to the articular facets involved. A, the coalition involving the anterior facets; M, the coalition involving the middle facets, and P, the coalition involving the posterior facets. Interobserver reliability was measured at the main type (based on nature and shape) and subtype (articular facet involved) using weighted Kappa. Results There were 106 patients (108 ft) included in this study. Overall, 8 ft (7.5%) were classified as type I, 75 ft (69.4%) as type II, 7 ft (6.5%) as type III, and 18 ft (16.7%) as type IV. Twenty-nine coalitions (26.9%) involved the posterior facets only (subtype-P), 74 coalitions (68.5%) involved both the middle and posterior facets (subtype-MP), and five coalitions (4.6%) simultaneously involved the anterior, middle, and posterior facets (subtype-AMP). Type II-MP coalition was the most common. The value of weighted Kappa for the main type was 0.93 (95%CI 0.86–0.99) (p<0.001), and the value for the subtype was 0.78 (95%CI 0.66–0.91) (p<0.001). Conclusion A new classification system of the talocalcaneal coalition to facilitate operative planning was developed.

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The Influence of Regional Differences on the Reliability of the AO Spine Sacral Injury Classification System

Global Spine Journal ◽

10.1177/21925682211068419 ◽

2022 ◽

pp. 219256822110684

Author(s):

Brian A. Karamian ◽

Gregory D. Schroeder ◽

Mark J. Lambrechts ◽

Jose A. Canseco ◽

Emiliano N. Vialle ◽

...

Keyword(s):

North America ◽

South America ◽

Classification System ◽

Interobserver Reliability ◽

Fracture Morphology ◽

Geographic Region ◽

Cross Sectional Survey ◽

Standard Type ◽

Cross Sectional ◽

Type C

Study Design Global cross-sectional survey. Objective To explore the influence of geographic region on the AO Spine Sacral Classification System. Methods A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart. Results A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k = .80) and North America (k = .86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 = .0000) and A3 (p1 = .0280), B2 (p1 = .0015), C0 (p1 = .0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean. Conclusions In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions.

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RELIABILITY OF LICHTMAN'S CLASSIFICATION FOR KIENBÖCK'S DISEASE IN 99 SUBJECTS

Hand Surgery ◽

10.1142/s0218810411005035 ◽

2011 ◽

Vol 16 (01) ◽

pp. 15-18 ◽

Cited By ~ 3

Author(s):

Masaki Shin ◽

Masahiro Tatebe ◽

Hitoshi Hirata ◽

Shukuki Koh ◽

Takaaki Shinohara

Keyword(s):

Classification System ◽

Wrist Joint ◽

Interobserver Reliability ◽

Clinical Settings ◽

X Rays ◽

New Classification ◽

Kienböck’S Disease ◽

Kienböck's Disease ◽

Kienbock’S Disease

Purpose: The objective of this research was to investigate the reliability of Lichtman's classification for Kienböck's disease. Methods: Interobserver reliability and intraobserver reproducibility were investigated by interpreting both anteroposterior and lateral X-rays of the wrist joint twice in 99 patients with Kienböck's disease using the modified Lichtman's classification system. Observers comprised three orthopaedic surgeons, and no information was exchanged between observers either before or during the study. Results: Intraobserver reliability was moderate (0.313–0.628), and interobserver reliability was fair (Siegel's kappa = 0.228). Conclusion: Low values were obtained regarding interobserver reliability for the modified Lichtman's classification of Kienböck's disease. This classification is thus inadequate for use in clinical settings. A new classification should be established.

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Cystic Duct Carcinoma: A New Classification System and the Clinicopathological Features of 62 Patients

Frontiers in Oncology ◽

10.3389/fonc.2021.696714 ◽

2021 ◽

Vol 11 ◽

Author(s):

Lingxi Nan ◽

Changcheng Wang ◽

Yajie Dai ◽

Jie Wang ◽

Xiaobo Bo ◽

...

Keyword(s):

Cystic Duct ◽

Survival Data ◽

Classification System ◽

Vascular System ◽

Type I ◽

Type Ii ◽

Imaging Data ◽

New Classification ◽

Duct Carcinoma ◽

Cystic Duct Carcinoma

BackgroundCystic duct carcinoma (CDC) is a rare biliary malignancy with a low incidence and poor prognosis. However, the clinical landscape of the disease has not been clarified and no widely applicable classification system has been developed.MethodsSixty-two patients with CDC were included in this retrospective study, and a new classification system was established using imaging data. Blood indices, radiological characteristics, pathological features, surgical procedures, and overall survival data were collected. The efficacy of the new classification in predicting resectability was evaluated using receiver operating characteristic (ROC) curves, and K-means clustering and t-distributed stochastic neighbor embedding were applied to verify the conclusion.ResultsThe pT stage of patients with type II CDC was significantly worse than that of type I. Patients with type II CDC were more likely to experience distant metastasis and invasion of the nervous system, vascular system, and liver. The resectability of patients with type II CDC was significantly worse than that of patients with type I CDC. Patients with type II CDC had worse prognoses. ROC curve analysis and K-means clustering revealed that the new classification could better categorize patients with CDC than currently available systems.ConclusionPatients with type II CDC have significantly worse clinicopathological outcomes. The new classification system has better accuracy in grouping patients with CDC.

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Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/10711007211058154 ◽

2021 ◽

pp. 107110072110581

Author(s):

Hee Young Lee ◽

Nacime Salomao Barbachan Mansur ◽

Matthieu Lalevee ◽

Kevin N. Dibbern ◽

Mark S. Myerson ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Joint Involvement ◽

Posterior Tibial Tendon ◽

Diagnostic Study ◽

Foot Deformity ◽

New Classification ◽

Posterior Tibial Tendon Dysfunction ◽

Level Of Evidence ◽

Radiographic Findings

Background: Historical concept of flatfoot as posterior tibial tendon dysfunction (PTTD) has been questioned. Recently, the consensus group published a new classification system and recommended renaming PTTD to Progressive Collapsing Foot Deformity (PCFD). The new PCFD classification could be effective in providing comprehensive information on the deformity. To date, there has been no study reporting intra- and interobserver reliability and the frequency of each class in PCFD classification. Methods: This was a single-center, retrospective study conducted from prospectively collected registry data. A consecutive cohort of PCFD patients evaluated from February 2015 to October 2020 was included, consisting of 92 feet in 84 patients. Classification of each patient was made using characteristic clinical and radiographic findings by 3 independent observers. Frequencies of each class and subclass were assessed. Intraobserver and inteobserver reliabilities were analyzed with Cohen kappa and Fleiss kappa, respectively. Results: Mean sample age was 54.4, 38% was male and 62% were female. 1ABC (25.4%) was the most common subclass, followed by 1AC (8.7%) and 1ABCD (6.9%). Only a small percentage of patients had isolated deformity. Class A was the most frequent component (89.5%), followed by C in 86.2% of the cases. Moderate interobserver reliability (Fleiss kappa = 0.561, P < .001, 95% CI 0.528-0.594) was found for overall classification. Very good intraobserver reliability was found (Cohen kappa = 0.851, P < .001, 95% CI 0.777-0.926). Conclusion: Almost half (49.3%) of patients had a presentation dominantly involving the hindfoot (A) with various combinations of midfoot and/or forefoot deformity (B), (C) with or without subtalar joint involvement (D). The new system may cover all possible combinations of the PCFD, providing a comprehensive description and guiding treatment in a systematic and individualized manner, but this initial study suggests an opportunity to improve overall interobserver reliability. Level of Evidence: Level III, retrospective diagnostic study.

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A new and reliable classification system for fractures of the navicular and associated injuries to the midfoot

The Bone & Joint Journal ◽

10.1302/0301-620x.100b2.bjj-2017-0879.r1 ◽

2018 ◽

Vol 100-B (2) ◽

pp. 176-182 ◽

Cited By ~ 4

Author(s):

M. J. Petrie ◽

C. M. Blakey ◽

C. Chadwick ◽

H. G. Davies ◽

C. M. Blundell ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Subsequent Treatment ◽

The Body ◽

Associated Injuries ◽

New Classification ◽

Lateral Column ◽

Fracture Dislocations ◽

Reliable Classification ◽

Patterns Of Injury

Aims Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot. Patients and Methods We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot. Results In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively. Conclusion We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176–82.

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