Reproducibility of the AO/ASIF and Gartland classifications for supracondylar fractures of the humerus in children r e v b r a s o r t o p . 2 0 1 5;5 0(3):266–269 w w w . r b o . o r g . b r Original Article Reproducibility of the AO/ASIF and Gartland classifications for supracondylar fractures of the humerus in children� Igor Tadeu Silveira Rocha ∗, André de Siqueira Faria, Carlos Fontoura Filho, Murilo Antônio Rocha Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil a r t i c l e i n f o Article history: Received 2 April 2014 Accepted 15 May 2014 Available online 28 May 2015 Keywords: Fractures of the humerus/classification Children Observer-dependent variations Reproducibility of results a b s t r a c t Objective: To evaluate the reproducibility of the radiographic classifications of Gartland and the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) for supracondylar fractures of the humerus in children. Methods: On two occasions, 50 radiographs in anteroposterior and lateral views were evalu- ated by three pediatric orthopedists in accordance with the Gartland and AO/ASIF pediatric classifications. Their responses were subjected to statistical analysis consisting of cal- culation of the � coefficient to assess the intra- and interobserver concordance, in both classifications. Results: The strength of the intraobserver concordance was high or near perfect for the three examiners in the two classification systems. The strength of the interobserver concordance was high in the two systems, with � coefficients of 0.756 for the Gartland classification and 0.766 for the AO/ASIF classification. Conclusion: The Gartland and AO/ASIF classification systems showed similar reproducibility and performance. High strength of concordance was seen in the intra- and interobserver analyses. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. Reprodutibilidade das classificações AO/ASIF e Gartland para fraturas supracondilianas de úmero em crianças r e s u m o Palavras-chave: Fraturas do úmero/classificação Criança Objetivo: Avaliar a reprodutibilidade das classificações radiográficas de Gartland e Associa- tion for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) para fraturas supracondilianas de úmero em crianças. � Work developed in the Discipline of Orthopedics and Traumatology, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil. ∗ Corresponding author. E-mails: igorsilveira2003@yahoo.com.br, doutorigorsilveira@hotmail.com (I.T.S. Rocha). http://dx.doi.org/10.1016/j.rboe.2015.05.001 2255-4971/© 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved. dx.doi.org/10.1016/j.rboe.2015.05.001 http://www.rbo.org.br http://crossmark.crossref.org/dialog/?doi=10.1016/j.rboe.2015.05.001&domain=pdf mailto:igorsilveira2003@yahoo.com.br mailto:doutorigorsilveira@hotmail.com dx.doi.org/10.1016/j.rboe.2015.05.001 r e v b r a s o r t o p . 2 0 1 5;5 0(3):266–269 267 Variações dependentes do observador Reprodutibilidade dos resultados Métodos: Em duas ocasiões foram avaliadas por três cirurgiões ortopedistas pediátricos 50 radiografias nas incidências anteroposteriores e perfil de acordo com as classificações de Gartland e AO/ASIF pediátrica. As respostas foram submetidas à análise estatística pelo cálculo do coeficiente � para avaliar a concordância intra- e interobservador, em ambas as classificações. Resultados: A força de concordância intraobservador foi grande ou quase perfeita para os três examinadores nos dois sistemas de classificação. A força de concordância interobservador foi grande nos dois sistemas, com coeficiente � de 0,756 para classificação de Gartland e de 0,766 para classificação AO/ASIF. Conclusão: Os sistemas de classificação de Gartland e AO/ASIF mostraram reprodutibili- dade e desempenho similar. Observou-se grande força de concordância nas análises intra- e interobservador. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados. I S f t c a f m a c r T h f m a s o M o t i s e c t ( t o l l M T o i the SPSS software, version 12.0 (Chicago, USA), in order to determine the � coefficient, which inferred the degree of con- cordance beyond what would be expected only by chance. The strength of the intra- and interobserver concordance of the Table 1 – Association between the � coefficient and the strength of concordance.14 � coefficient Strength of concordance Less than zero Poor 0–0.20 Negligible 0.21–0.40 Slight ntroduction upracondylar fractures are the commonest type of elbow ractures in children and the second commonest type of frac- ure during childhood, accounting for more than 60% of the ases.1–4 They occur most frequently between the ages of five nd ten years.5 The various classification systems proposed or these fractures have had the aims of guiding the treat- ent, estimating the prognosis and enabling standardization nd comparison among the many scientific studies. These lassifications need to be simple, easy to apply clinically and eproducible, with high concordance between surgeons.6–8 he Gartland classification for supracondylar fractures of the umerus is the one most used.9,10 In this classification system, ractures are grouped according to their degree of displace- ent. Although the LaGrange11 classification is more descriptive nd detailed in cases of greater displacement, it is not the ystem most used. In turn, the system adopted by the AO group12 for fractures f the long bones in children combines the classification of uller et al.13 for adults with an additional description focused n the immature skeleton.8 This is an alphanumeric system hat includes the bone affected, the location and the sever- ty, along with the peculiarities of the growing bone. Thus, upracondylar fractures would be described as 13-/9.1 with an nding of I, II, III or IV, according to whether the fracture was omplete or incomplete, and with or without contact between he fragments. In this manner, only the exception component I–IV) of the morphological segment of the AO/ASIF classifica- ion was taken into consideration in the present study. The objective of this study was to assess the reproducibility f the Gartland and AO/ASIF classifications for supracondy- ar fractures of the humerus in children, by investigating the evels of intra- and interobserver concordance. ethods his study was conducted in a referral hospital that attends rthopedic trauma cases, after receiving approval from the nstitution’s ethics committee. Fifty conventional radiographs (anteroposterior and lateral views) originating from initial attendance of patients with supracondylar fractures of the humerus, produced between January and June 2013, were selected for evaluation. The radiographic images for the study were obtained by means of high-resolution digital photography, with preserva- tion of the original characteristics of the film. The selection did not take into consideration the quality of the radiography. Images from patients over the age of 16 years, from those who presented a closed growth plate line and from those presenting multiple fractures on radiographs were excluded. The images were evaluated by three pediatric orthopedists who had had previous access to the classifica- tion systems. Seven days of training before the analysis was permitted. The examiners evaluated the 50 images over a maximum time of two hours and made a second evaluation with the same duration, two weeks later. The order of the 50 images was varied through randomization. The examiners did not have access to the responses of their peers or to their own responses given on the previous occasion. The responses given by each examiner to the radiographic evaluations were written on a printed chart that was handed out to each participant, together with a free and informed consent statement. The results were gathered and analyzed with the aid of ® 0.41–0.60 Moderate 0.61–0.80 High 0.81–1.00 Almost perfect 268 r e v b r a s o r t o p . 2 0 Table 2 – Intraobserver concordance level according to the � coefficient, in relation to the Gartland and AO classifications for supracondylar fractures of the humerus in children. Gartland AO Examiner 1 0.781 0.767 Examiner 2 0.859 1 Examiner 3 0.719 0.782 Table 3 – Interobserver analysis on � coefficient for Gartland classification. Gartland I Gartland II Gartland III � 0.945 0.535 0.677 p-Value of � <0.001 <0.001 <0.001 95% confidence interval of � Upper: 1.0 Upper: 0.695 Upper: 0.837 Lower: 0.785 Lower: 0.375 Lower: 0.517 two classification systems was then determined, as detained in Table 1.14 Results The intraobserver concordance according to the � coeffi- cient, relating to the Gartland classification for supracondylar fractures of the humerus in children and the AO/ASIF clas- sification for fractures in children, as presented in Table 2, was high or almost perfect for all the examiners in relation to both classifications. For two of the three examiners, the concordance for the AO/ASIF system was slightly higher. Tables 3 and 4 present the interobserver analyses for the Gartland and AO classifications, respectively. It can be seen that the interobserver concordance decreased with regard to category II, in both classification systems. As shown in Table 5, the interobserver evaluation showed � of 0.756 for the Gartland classification and 0.766 for the AO/ASIF classification, which thus shows high concordance between the two systems. Table 4 – Interobserver analysis on � coefficient for AO classific AO I � 0.865 p-Value of � <0.001 95% confidence interval of � Upper: 1.0 Lower: 0.705 Table 5 – General � coefficient for interobserver evaluation, acco Number of radiographs General � Gartland 50 0.756 AO/ASIF 50 0.766 1 5;5 0(3):266–269 Discussion The diversity of classification systems for a group of fractures that is published over the course of time may give rise to inter- pretational conflicts. Thus, the validity, reproducibility and correlations of well- established classifications need to be verified, given that comparisons between different evaluations, with exclusion of causality and personal bias, can demonstrate the qualities or weaknesses of a given system under examination. According to Audigé et al.,6 for these objective to be attained, the clas- sification system needs to go through three research phases before it is validated for clinical use.6,14 To know whether a given characterization or classification for an object is reliable, this object needs to be evaluated sev- eral times, by more than one examiner. For this, in the present study, the � coefficient was used. This infers the degree of con- cordance beyond what would be expected purely by chance. It is based on the number of concordant responses, i.e. the number of cases for which the result is the same among the examiners.15,16 In the present study, the examiners seemed to be “well calibrated”, both within themselves and with the others. The interobserver concordance values were within the 95% con- fidence interval, with p < 0.001 in both classification systems. Therefore, these values presented statistical significance. As also found by Brandão et al.,14 our interobserver concordance index was no greater than 0.8, even though the observers were all pediatric orthopedists. The concordance found between the Gartland and AO/ASIF classification systems was satisfactory (high or almost per- fect). These systems had similar performance, despite the greater complexity of the AO/ASIF system and the examiners’ lower degree of familiarity with this system. In the present study, the lowest strength of concordance (moderate) in the interobserver analysis was found in type II of the Gartland and AO/ASIF classifications. However, according 10 to Heal et al., the lowest level of interobserver concordance for the Gartland classification occurred in type I. It was observed that variations in the degree of concord- ance in the interobserver analysis of different studies10,14 did ation. AO II AO III AO IV 0.435 0.75 1.0 <0.001 <0.001 <0.001 Upper: 0.595 Upper: 0.91 Upper: 1.0 Lower: 0.275 Lower: 0.59 Lower: 0.84 rding to classification system. General p-value 95% confidence interval of � <0.001 Upper: 0.874 Lower: 0.637 <0.001 Upper: 0.868 Lower: 0.665 0 1 5 n c o t a c h s t C T i s t c C T r 1 1 1 1 1 1 r e v b r a s o r t o p . 2 ot invalidate the constant observation that the two classifi- ations have good reproducibility. Evaluation of the reproducibility of these classifications is f importance insofar as they guide the type of treatment insti- uted for these fractures (conservative versus surgical). They lso enable standardization of the orthopedic language for omparing studies from different centers. Now that the reproducibility of these classification systems as been verified, it becomes necessary to conduct further tudies to ascertain whether one of them might be superior o the other and thus to determine a standard system. onclusion he Gartland and AO/ASIF classification systems showed sim- lar reproducibility and the intra- and interobserver analyses howed high strength of concordance, even though use of he AO/ASIF system remains limited among orthopedists and, onsequently, their familiarity with this method is lower. onflicts of interest he authors declare no conflicts of interest. e f e r e n c e s 1. Lins RE, Simovitch RW, Waters PM. Pediatric elbow trauma. Orthop Clin North Am. 1999;30(1):119–32. 2. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3350 children. J Orthop Trauma. 1993;7(1):15–22. 3. Blount WP. Fractures in children. Baltimore: Williams and Wilkins; 1955. 1 ;5 0(3):266–269 269 4. Smith FM. Children’s elbow injuries: fractures and dislocations. Clin Orthop Relat Res. 1967;(50):7–30. 5. Kasser JR, Beaty JH. Supracondylar fractures of the distal humerus. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 577. 6. Audigé L, Bhandari M, Kellam J. How reliable are reliability sudies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004;75(3):184–94. 7. Garbuz DS, Marsi BA, Esdaile J, Duncan CP. Classification systems in orthopaedics. J Am Acad Orthop Surg. 2002;10(4):290–7. 8. Slongo T, Audigé L, Schlickewei W, Clavert J, Hunter J. Development and validation of the AO paediatric comprehensive classification of long-bone fractures. J Pediatr Orthop. 2006;26(1):43–9. 9. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109(2):145–54. 0. Heal J, Boud M, Livingstone J, Blewitt N, Blom AW. Reproducibility of the Gartland classification for supracondylar humeral fractures in children. J Orthop Surg (Hong Kong). 2007;15(1):12–4. 1. LaGrange JRP. Fractures supracondyleennes. Rev Chir Orthop. 1962;48:337–414. 2. Slongo T, Audigé L, Clavert JM, Lutz N, Frick S, Hunter J. AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study. J Pediatr Orthop. 2007;27(2):171–80. 3. Müller ME, Nazarian S, Koch P. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990. 4. Brandão G, Teixeira L, Américo L, Soares C, Caldas L, Azevedo A, et al. Reprodutibilidade da classificação da AO/Asif para fraturas dos ossos longos na criança. Rev Bras Ortop. 2010;45 Suppl.:37–9. 5. Siegel S, Castellan N. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill; 1988. 6. Fleiss JL. The measurement of interrater agreement. In: Statistical methods for rates and proportions. 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http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 http://refhub.elsevier.com/S2255-4971(15)00062-2/sbref0160 Reproducibility of the AO/ASIF and Gartland classifications for supracondylar fractures of the humerus in children Introduction Methods Results Discussion Conclusion Conflicts of interest References