The Unified Classification System (UCS) was introduced because of a growing need to have a standardised universal classification system of periprosthetic fractures. It combines and simplifies many existing classification systems, and can be applied to any fracture around any partial or total joint replacement occurring during or after operation. Our goal was to assess the inter- and intra-observer reliability of the UCS in association with knee replacement when classifying fractures affecting one or more of the femur, tibia or patella. We used an international panel of ten orthopaedic surgeons with subspecialty fellowship training and expertise in adult hip and knee reconstruction (‘experts’) and ten residents of orthopaedic surgery in the last two years of training (‘pre-experts’). They each received 15 radiographs for evaluation. After six weeks they evaluated the same radiographs again but in a different order. . The reliability was assessed using the Kappa and weighted Kappa values. The Kappa values for inter-observer reliability for the experts and the pre-experts were 0.741 (95% confidence interval (CI) 0.707 to 0.774) and 0.765 (95% CI 0.733 to 0.797), respectively. The weighted Kappa values for intra-observer reliability for the experts and pre-experts were 0.898 (95% CI 0.846 to 0.950) and 0.878 (95% CI 0.815 to 0.942) respectively. The UCS has substantial inter-observer reliability and ‘near perfect’ intra-observer reliability when used for periprosthetic fractures in association with knee replacement in the hands of experienced and inexperienced users. Cite this article: Bone Joint J 2014;96-B:1669–73

Interobserver reliability of the AO system of classification of fractures of the distal radius was assessed using plain radiographs and CT. Five observers classified 30 Colles’-type fractures using only plain radiographs; two months later they were reclassified using CT in addition. Interobserver reliability was poor in both series when detailed classification was used. By reducing the categories to five, interobserver reliability was slightly improved, but was still poor. When only two AO types were used, the reliability was moderate using plain radiographs and good to excellent with the addition of CT. The use of CT as well as plain radiographs brings interobserver reliability to a good level in assessment of the presence or absence of articular involvement, but is otherwise of minor value in improving the interobserver reliability of the AO system of classification of fractures of the distal radius

We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification. These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus

Cite this article: Bone Joint Res. 2020;9(2):79–81.

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

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra-and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used

Cite this article: Bone Joint Res. 2020;9(2):77–78.

We analysed 131 fractures of the tibial condyles in 130 patients, using a modification of the classification of Schatzker, McBroom and Bruce (1979). The patients were reviewed at an average of 7.6 years after the injury. Fifty-five (42%) fractures had been treated conservatively and 76 (58%) operatively. Medial unicondylar and medially tilted bicondylar fractures tended to redisplace into varus position and lateral unicondylar and laterally tilted bicondylar fractures into valgus. There were significant differences when the results were evaluated according to the methods of Hohl and Luck (1956) and Rasmussen (1973). Using our method in conservatively treated cases, the subjective results were acceptable in 49.1%, the functional results in 60.0% and the clinical results in 52.7%. In cases treated by operation the equivalent figures were 57.9%, 73.7% and 52.6%. The poorest results followed displaced medial condylar and medially tilted bicondylar fractures. Varus alignment of the tibial plateau was tolerated worse than valgus alignment

The objective of this study was to validate the efficacy of Takeuchi classification for lateral hinge fractures (LHFs) in open wedge high tibial osteotomy (OWHTO). In all 74 osteoarthritic knees (58 females, 16 males; mean age 62.9 years, standard deviation 7.5, 42 to 77) were treated with OWHTO using a TomoFix plate. The knees were divided into non-fracture (59 knees) and LHF (15 knees) groups, and the LHF group was further divided into Takeuchi types I, II, and III (seven, two, and six knees, respectively). The outcomes were assessed pre-operatively and one year after OWHTO. Pre-operative characteristics (age, gender and body mass index) showed no significant difference between the two groups. The mean Japanese Orthopaedic Association score was significantly improved one year after operation regardless of the presence or absence of LHF (p = 0.0015, p < 0.001, respectively). However, six of seven type I cases had no LHF-related complications; both type II cases had delayed union; and of six type III cases, two had delayed union with correction loss and one had overcorrection. These results suggest that Takeuchi type II and III LHFs are structurally unstable compared with type I. Cite this article: Bone Joint J 2015;97-B:1226–31

Radiographs of 100 randomly chosen femoral neck fractures were assessed by eight observers using Garden's classification. The radiographs were classified identically by all eight in only 22 cases. Another 45 cases were classified by some observers as undisplaced fractures (Stages 1 and 2) and by others as displaced fractures (Stages 3 and 4). Between the different observers the number of displaced fractures varied from 63 to 89. These results show that observers had a relatively poor ability to delineate the various stages of Garden's classification

We assessed the inter- and intraobserver variation in classification systems for fractures of the distal humerus. Three orthopaedic trauma consultants, three trauma registrars and three consultant musculoskeletal radiologists independently classified 33 sets of radiographs of such fractures on two occasions, each using three separate systems. For interobserver variation, the Riseborough and Radin system produced ‘moderate’ agreement (kappa = 0.513), but half of the fractures were not classifiable by this system. For the complete AO system, agreement was ‘fair’ (kappa = 0.343), but if only AO type and group or AO type alone was used, agreement improved to ‘moderate’ and ‘substantial’, respectively (kappa = 0.52 and 0.66). Agreement for the system of Jupiter and Mehne was ‘fair’ (kappa = 0.295). Similar levels of intraobserver variation were found. Systems of classification are useful in decision-making and evaluation of outcome only if there is agreement and consistency among observers. Our study casts doubt on these aspects of the systems currently available for fractures of the distal humerus

We have devised a combined pillar score (CPS) system, based on the lateral pillar (LP) and the posterior pillar (PP) classifications, together with the age at onset of Perthes’ disease, and examined its correlation with prognosis. The correlation coefficient of the Catterall classification, LP, PP, and CPS systems with the Stulberg system was 0.39, 0.52, 0.50, and 0.70, respectively. Overall 21 of the 22 hips (95.4%) with a CPS of 0 to 1 point had a good outcome and 12 of the 13 hips (92.3%) with a CPS of 3 points or more had a fair or poor outcome. None with a CPS of 2 points, had a poor outcome. The study shows that an accurate prediction of the prognosis is not possible with the LP classification alone for patients classified as belonging to group B (LP height 50% to 100% of contralateral height). The CPS system does allow accurate prediction of outcome

The Unified Classification System (UCS) emphasises the key principles in the assessment and management of peri-prosthetic fractures complicating partial or total joint replacement. We tested the inter- and intra-observer agreement for the UCS as applied to the pelvis and femur using 20 examples of peri-prosthetic fracture in 17 patients. Each subtype of the UCS was represented by at least one case. Specialist orthopaedic surgeons (experts) and orthopaedic residents (pre-experts) assessed reliability on two separate occasions. For the pelvis, the UCS showed inter-observer agreement of 0.837 (95% confidence intervals (CI) 0.798 to 0.876) for the experts and 0.728 (95% CI 0.689 to 0.767) for the pre-experts. The intra-observer agreement for the experts was 0.861 (95% CI 0.760 to 0.963) and 0.803 (95% 0.688 to 0.918) for the pre-experts. For the femur, the UCS showed an inter-observer kappa value of 0.805 (95% CI 0.765 to 0.845) for the experts and a value of 0.732 (95% CI 0.690 to 0.773) for the pre-experts. The intra-observer agreement was 0.920 (95% CI 0.867 to 0.973) for the experts, and 0.772 (95% CI 0.652 to 0.892) for the pre-experts. This corresponds to a substantial and ‘almost perfect’ inter- and intra-observer agreement for the UCS for peri-prosthetic fractures of the pelvis and femur. We hope that unifying the terminology of these injuries will assist in their assessment, treatment and outcome. Cite this article: Bone Joint J 2014;96-B:1472–7

Injuries to the tarsometatarsal (Lisfranc) joint are not common, and the results of treatment are often unsatisfactory. Since no individual is likely to see many such injuries, we decided to make a retrospective study of patients from five different centres. In this way 119 patients with injuries of the Lisfranc joint have been collected. This paper classifies these injuries and describes their incidence, mechanism of production, methods of treatment, results and complications. Sixty-nine of the patients attended for review: 35 of these had been treated by closed methods, 27 had had an open reduction and seven patients had had no treatment. On the basis of our study we suggest that these injuries should be classified according to the type of injury rather than the nature of the deforming force and that their treatment be based upon this classification. It seems that, whatever the severity of the initial injury, prognosis depends on accurate reduction and its maintenance

A new dynamic classification of Paget's disease is proposed, incorporating both the radiographic phases of bone remodelling and the scintigraphic findings. Osteolytic, mixed and osteoblastic phases are associated with increased scintigraphic activity, while the osteosclerotic phase of remodelling is associated with normal or diminished activity and an osteoblastic radiographic appearance. Abnormal modelling of bone leading to deformity is produced by accelerated apposition or absorption at the periosteal and endosteal envelopes of the bone. In 112 patients with symptoms from Paget's disease, 527 lesions were classified. The most frequent remodelling phase was the mixed one and the most common modelling state was bone expansion with endosteal and periosteal apposition. Of 88 patients treated medically, 12 had lesions which progressed to increased bone formation without a change in modelling, and the active lesions in seven patients became inactive. Prolonged treatment with disodium etidronate led to progressive osteopenia in 11 patients

We reviewed the radiographs of 49 patients with Perthes' disease at the stage of fragmentation and also after the end of skeletal growth to assess the value of the lateral pillar classification of Herring. The average age of the patients at diagnosis was 7 years 6 months and the mean follow-up was 24 years. Ten of the 11 Herring group-A hips showed good reconstruction of the femoral head. There were good results in group-B hips when the patients were less than nine years of age at diagnosis. All 11 group-C patients showed hip deformity at follow-up. The Herring classification provides a valid long-term prognosis in Perthes' disease, although age at diagnosis is also an important prognostic factor. The classification is relatively easy to apply, is reliable, and requires only an anteroposterior radiograph taken during the fragmentation stage of the disease

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers

Five children with atlanto-axial rotatory fixation (AARF) in association with fractures of the clavicle are described. It is postulated that the rotary fixation is a direct result of the trauma which produces the fracture. The importance of early diagnosis is stressed, since delayed diagnosis may lead to chronic deformity. Early diagnosis depends on awareness of the possibility of AARF, and either fluoroscoping the patient in order to take appropriate spot films or imaging the atlanto-axial joint by CT. A simple classification of AARF is proposed based on distinct radiological features which differentiate subluxation from dislocation

Aims

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user’s cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma.

Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199–206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.