title: High reliability of an algorithm for choice of implants in hip fracture patients.
abstract: OBJECTIVE
  Hip fracture treatment is controversial, with high complication rates. An algorithm for hip fracture surgery has shown reduced reoperation rates, but choice of implant is based on the commonly used fracture classifications, which were previously evaluated to be unreliable. The purpose of this study was to investigate the reliability of the algorithm.
  
  
  METHODS
  From two hospitals, four observers (orthopaedic consultant, fellow, resident and intern) used the algorithm to classify into 15 hip fracture types [Garden type I-IV femoral neck including posterior tilt, vertical femoral neck, basocervical and Arbeitsgemeinschaft für Osteosynthesefragen (AO)-31 A1.1 to A3.3 trochanteric fractures] and to choose between five surgical procedures [parallel implants, prosthesis, two-or four-hole sliding hip screw (SHS) and intermedullary (IM) nail]. After individual assessment, each hospital made a consensus decision. Observations were performed twice, ten weeks apart, on pelvic, anteroposterior (AP) and axial X-rays from 100 consecutive patients.
  
  
  RESULTS
  For fracture classification, mean kappa values were 0.60 for intra and 0.62 for interobserver variation, with interobserver variation between hospitals at 0.65. For posterior tilt, mean intraclass correlation coefficient was 0.91 for intra and 0.87 for interobserver variation. For choice of implant type, mean kappa values were 0.86 for both intra and interobserver variation. The two hospital consensus decisions chose same implant in 91 of 100 patients, giving a kappa value at 0.88.
  
  
  CONCLUSIONS
  Although hip fracture classification confirmed to be somewhat unreliable in this study, posterior tilt measurement and subsequent choice of implant type by the algorithm was found to be reliable, which opens up the possibility for a more standardized treatment of hip fracture patients between hospitals.
authors.affiliation: Department of Orthopaedic Surgery, Hvidovre Hospital, Copenhagen, Denmark. hpalm@dadlnet.dk
authors.forename: Henrik
authors.initials: H
authors.lastname: Palm
authors.forename: Eva
authors.initials: E
authors.lastname: Posner
authors.forename: Hans-Ulrik
authors.initials: HU
authors.lastname: Ahler-Toftehøj
authors.forename: Peter
authors.initials: P
authors.lastname: Siesing
authors.forename: Silas
authors.initials: S
authors.lastname: Gylvin
authors.forename: Tobias
authors.initials: T
authors.lastname: Aasvang
authors.forename: Kim
authors.initials: K
authors.lastname: Holck
authors.forename: Kenneth Brian
authors.initials: KB
authors.lastname: Holtz
mesh_terms: D000369:Aged, 80 and over; D000465:Algorithms; D001858:Bone Nails; D001863:Bone Screws; D003661:Decision Support Techniques; D005260:Female; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D008297:Male; D015588:Observer Variation; D009984:Orthopedic Fixation Devices; D019637:Orthopedic Procedures / Q000295:instrumentation* / Q000379:methods; D011859:Radiography; D015203:Reproducibility of Results