The orthopaedic community began to move away from individual fracture classifications in the mid-1980s. The basis for that shift was the need for wider recognition that fractures represent a “continuous variable,” with infinite varieties of orientations and combinations of fracture lines. Trying to fit fractures into a narrow classification system can lead to confusion and misinformation. Furthermore, surgeons often disagree when determining a fracture’s classification and, therefore, which treatment is best.
To move away from individual classification systems, orthopaedic journals have generally moved toward the compendium of fracture classifications approved by the OTA and AO. Still, there are times when a new fracture classification seems appropriate, and in the June 5, 2019 issue of The Journal, Pieroh et al. have provided us with an example that classifies fragility fractures of the pelvis (FFP). The 4-group FFP classification is based on fracture morphology with different degrees of instability and includes treatment recommendations.
The authors collected the CT scans of 60 patients from 6 different hospitals who were ≥60 years old and had sustained a pelvic fracture from low-energy trauma. These CT scans were shown to 6 experienced surgeons, 6 inexperienced surgeons, and 1 surgeon who had direct experience/training with the FFP system. Each surgeon was asked to classify the pelvic fractures according to the FFP classification. Inter- and intra-rater reliabilities for the fracture classifications were calculated from these readings, and the overall inter-rater Kappa coefficient was found to be 0.53, while the overall intra-rater Kappa coefficient was 0.46 (Kappa coefficients of 0.61 to 0.41 constitute “moderate” reliability). In terms of percent agreement, there was greater agreement between surgeons when it came to classifying FFP Group 1 fractures than for FFP Group 2 and 3 fractures. This is noteworthy because Group 3 fractures are thought to require surgical treatment, while primary treatment for Group 2 fractures is usually nonoperative.
Pelvic fractures that are associated with low bone density and low-energy trauma are becoming increasingly frequent as our population continues to skew older. Having a validated, relatively straightforward classification system like the FFP to assist us in managing these patients will be of great assistance. The sound methodology used to develop the FFP classification system and its decent reliability, face validity, and construct and criterion validity can assure all of us about the usefulness of the FFP classification as the basis for future clinical investigations and to advance the care of these patients.
Marc Swiontkowski, MD
The contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.
Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.
Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.
This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.
So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.
Marc Swiontkowski, MD
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The common knowledge applied in managing open fractures (asepsis, irrigation and debridement, immobilization, and wound protection against infection) was obtained from the surgical experience accrued during World War I. Despite the overall improvement in outcomes from applying that knowledge, the varying severity of associated soft-tissue injuries created considerable ambiguity regarding optimal treatments during the years that followed.
”Prevention of Infection in the Treatment of 1,025 Open Fractures of Long Bones” by Ramon Gustilo and John Anderson in the June 1976 edition of JBJS classified open fractures into three types of increasing severity based on wound size, level of contamination, and osseous/soft-tissue injury. In general, more severe open fractures have a worse clinical prognosis for infection, nonunion, and other complications, although actual outcomes vary depending on numerous additional clinical factors. Also, high-energy Type III open fractures are not homogeneous, and in response to that variation, in 1984 Gustilo et al. further classified Type III open fractures into A, B, and C subtypes according to the severity of soft-tissue injury, the need for vascular reconstruction, and worsening prognosis.
However, the reliability of the Gustilo classification has been questioned in recent years. Clinical researchers have observed that the assessment of surface injuries does not always reflect deeper damage and does not account for tissue viability and tissue necrosis, which tends to develop with time after high-energy injuries. Also, a 1993 study found only moderate interobserver agreement among users of the classification. The limitless variety of injury patterns, mechanisms, and severities is almost impossible to be contained in a limited number of discrete categories.
As the management of open fractures continues to evolve, the 1976 Gustilo and Anderson treatment recommendation against primary internal fracture fixation for most Type III injuries due to high infection rates no longer represents the standard of care. Stabilization, even with internal fixation, for many of these fractures promotes healing, allows early rehabilitation, restores function, and reduces the risk of infection and malunion.
While “best practices” may have changed, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains an easy-to-use classification system that has formed the foundation for open fracture management during the last four decades, with good but imperfect prognostic and therapeutic implications. It remains widely accepted for research and training purposes, and it provides the preferred basic language for communicating about open fractures.
Konstantinos Malizos, MD, PhD
JBJS Deputy Editor