The MRI Effect in Clinical Decision Process in Perthes' Disease: "More Complex Imaging, More Complicated Surgeries".

PURPOSE OF THE STUDY Radiographs are preferred for understanding the deformity and containment in Legg-Calvé-Perthes disease (LCPD), as well as for treatment planning, but plain radiographs provide only static information and are inadequate for dynamic assessment of the joint. Magnetic resonance imaging (MRI) has been shown to be superior to other diagnostic modalities. The aim of this study was to determine the importance of hip MRI in LCPD treatment decision-making processes between pediatric orthopedic surgeons and orthopedic surgery residents. MATERIAL AND METHODS Eight orthopedic surgery residents and eight pediatric orthopedic surgeons were invited to retrospectively evaluate hip radiography images and MRI sections of 34 patients with LCPD. The treatment choices were divided into two groups as conservative and surgical. Gwet's AC1 analysis was used to establish the relative level of intra-observer agreements. The correlation between the professional experience and the agreement parameters was also evaluated using the Pearson correlation coefficient. ANOVA was used to compare multiple groups. p ≤ 0.05 was statistically significant. RESULTS For both groups most preferred treatment method was conservative approaches based on plain radiography and MRI. The resident group showed a significant shift from conservative treatment to surgical treatment choices after MRI evaluation. The difference between the frequencies of each treatment choice for pediatric orthopedic surgeons was not statistically significant among different imaging modalities, but a comparison of the changes in surgical treatment revealed a significant difference between the imaging modalities, with a trend towards more complicated treatment choices. DISCUSSION Conservative methods were the most preferred treatment choice in the study, as it is common. It was observed that treatment choices changed when patients were evaluated together with MRI. Compared to plain radiographs, MRI provides sufficient and particular information for evaluating the structures of the hip joint components. CONCLUSIONS We found that consideration of MRI data in LCPD patients changed treatment recommendations substantially towards more complicated surgical procedures. We consider this to be an 'MRI effect' where using a more complex imaging modality leads surgeons to more complicated treatment modalities in LCPD. Key words: imagnetic resonance imaging, reliability, MRI effect, Perthes disease, children.

Reliability of Evaluation of the Surgeon-Dependent Factors Affecting Mechanical Failure after Intertrochanteric Femur Fracture Treatment.

PURPOSE OF THE STUDY The intertrochanteric femur fractures seen in the elderly population are usually treated surgically. Mechanical failure of this treatment is a serious complication and to prevent this, many assessment factors have been described such as tip-apex distance, reduction quality etc. The aim of this study is to evaluate the intra- and inter-observer reliability of modifiable factors evaluated after the treatment of intertrochanteric fractures. MATERIAL AND METHODS The early post-operative radiographs of sixty-two patients treated with PFN-A were evaluated. Six observers with 8 to 27 years of experience in hip trauma surgery were asked to measure tip apex distance (TAD), calcar referenced TAD (calTAD), collo-diaphyseal angle (CDA) and evaluate the position of helical blade and also fracture reductions according to Baumgaertner and Chang criteria on these radiographs. Fleiss kappa and intra-class correlation coefficient (ICC) values were calculated for inter-observer and intra-observer reliability assessment, respectively. RESULTS Inter-observer reliability values for both evaluations were moderate (fleiss κ: 0.417-0.455) for TAD measurements, moderate (fleiss κ: 0.418-0.458) for calTAD measurements, fair (fleiss κ: 0.302-0.288) for CDA measurements, substantial (fleiss κ: 0.606-0.631) for antero-posterior zone evaluation, moderate (fleiss κ: 0.550-0.546) for lateral zone assessment, fair-moderate (fleiss κ: 0.353-0.453) for Baumgaertner reduction quality assessment, and fair-moderate (fleiss κ: 0.365- 0.456) for Chang reduction quality assessment. Intra-observer reliabilities were found to be moderate to good for TAD and calTAD measurements, moderate for CDA measurements, good to excellent for AP and lateral zone and Baumgaertner reduction quality criteria assessments and good for Chang reduction quality criteria assessment. DISCUSSION There is no large data on the subject of the present study in the literature. There is a single article evaluating the reliability of more than one evaluation criteria in which only two observers' findings were evaluated in the literature. As in our study, more accurate inferences can be made with the increase in the number of observers. Unlike the literature, the inter-observer reliabilities of TAD and calTAD which have a very important place in the postoperative evaluation of these fractures were found as "moderate'' instead of "excellent'' in our study, CONCLUSIONS It was determined that only the inter-observer reliability of antero-posterior zone evaluation was substantial. The inter-observer reliability of all other measurements and evaluations were fair to moderate. Key words: Intertrochanteric fractures, reliability, measurements, reduction quality; TAD, calTAD.

Direct Radiography Following Fracture Reduction Improves the Reliability of Pauwels Classification.

PURPOSE OF THE STUDY Pauwels classification system is widely used to classify the femoral neck fractures. Even its widely usage there are severals debates about its reliability. After the femoral neck fracture occured the lower extremity rotates externally and this external rotation deformity could lead to misevaluation of Pauwels angle at the initial radiographs. The purpose of our study is to investigate whether the reliability of Pauwels classification increases after reduction of femoral neck fractures. MATERIAL AND METHODS Two power point presentation was prepared with 117 slides that include antero-posterior radiographs of each femoral neck fracture. The first one included preoperatively taken radiographs and the second one included early postoperatively taken radiographs. Eight observers evaluated these radiographs and they classified the fractures according to Pauwels classification system. After 3 months, the order of the slides were changed for each presentation and the observers were asked to evaluate the radiographs again. Intraclass correlation coefficient values were calculated for evaluation of inter- and intra-observer reliability. RESULTS The mean intra-observer agreement of preoperative evaluation was 0.406 (0.071-0.626) and the interobserver agreements were 0.263 (0.197-0.342) and 0.359 (0.287-0.447), respectively. The intra-observer agreement of postoperative evaluation was 0.508 (0.393-0.757), inter-observer agreements were 0.427 (0.353-0.509) and 0.431 (0.356-0.513), respectively. According to preoperative and postoperative evaluations, 6 of 8 observers' intra-observer agreements were found to be increased and the remaining 2 decreased. Interobserver reliability was improved from poor to fair-good values after evaluating the reducted fracture radiographs. DISCUSSION Femoral neck fractures(FNF) are common and anatomical reduction and internal fixation are preferred as a treatment option in young people and patients have good bone quality. Pauwels classification system is used for classify the FNF based on the shearing angle of the fracture line. As this angle increases, the fracture becomes unstable and nowadays stronger fixation devices are preferred for unstable fractures. Therefore, misevaluation of the fracture can lead to wrong treatment method selection. Non-optimal X-rays taken in the emergency rooms may cause misinterpretation of femoral neck fractures according to Pauwels classification system. We hypothized that the reliability of this classification system could be improved after reduction of the fracture. CONCLUSIONS Our study showed that classifying the femoral neck fracture according to Pauwels classification system is more confidential after the reduction, however we can not state that it's reliability is adequate. Key words: femoral neck fracture, Pauwels classification, reliability, inter-observer, intra-observer.

Remodelling of Humeral Fracture in a Child with Osteopetrosis Tarda following Conservative Management - A 7-year Follow-up: A Case Report.

Osteopetrosis (OP) is a rare hereditary sclerosing bone dysplasia characterised by generalised hard and brittle bone secondary to defective osteoclastic function. Osteopetrotic bone is brittle, thus these subjects are prone to frequent fractures, particularly of the long bones. Due to defective osteoclastic function, remodeling is also defective in OP. This report is a case of humeral fracture in a 9 years old girl who was followed seven years. The fracture had remodeled totally similar to healthy bone at the final follow-up. Conservative treatment should be kept in mind in the management of fractures in children with OP, and fractures within acceptable angulations and/or translations should be treated conservatively without hesitation.

Remodelling of Humeral Fracture in a Child with Osteopetrosis Tarda following Conservative Management -A 7-year Follow-up: A Case Report

@#Osteopetrosis (OP) is a rare hereditary sclerosing bone dysplasia characterised by generalised hard and brittle bone secondary to defective osteoclastic function. Osteopetrotic bone is brittle, thus these subjects are prone to frequent fractures, particularly of the long bones. Due to defective osteoclastic function, remodeling is also defective in OP. This report is a case of humeral fracture in a 9 years old girl who was followed seven years. The fracture had remodeled totally similar to healthy bone at the final follow-up. Conservative treatment should be kept in mind in the management of fractures in children with OP, and fractures within acceptable angulations and/or translations should be treated conservatively without hesitation.