Sagittal deformity of Garden type I and II geriatric femoral neck fractures is frequently misclassified by lateral radiographs

Madeline S Tiee; Andrew G Golz; Andrew Kim; Joseph B Cohen; Hobie D Summers; Anup J Alexander; William D Lack

doi:10.1097/OI9.0000000000000273

Sagittal deformity of Garden type I and II geriatric femoral neck fractures is frequently misclassified by lateral radiographs

OTA Int. 2023 Apr 18;6(2):e273. doi: 10.1097/OI9.0000000000000273. eCollection 2023 Jun.

Authors

Madeline S Tiee¹, Andrew G Golz^{1

2}, Andrew Kim³, Joseph B Cohen¹, Hobie D Summers¹, Anup J Alexander⁴, William D Lack⁵

Affiliations

¹ Department of Orthopaedics and Rehabilitation, Loyola University Medical Center, Maywood, IL.
² Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, CA.
³ Loyola University Chicago Stritch School of Medicine, Maywood, IL.
⁴ Department of Radiology and Medical Imaging, Loyola University Medical Center, Maywood, IL; and.
⁵ Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.

Abstract

The objective of this study was to determine the validity and inter-rater reliability of radiographic assessment of sagittal deformity of femoral neck fractures.

Design: This is a retrospective cohort study.

Setting: Level 1 trauma center.

Patients/participants: Thirty-one patients 65 years or older who sustained low-energy, Garden type I/II femoral neck fractures imaged with biplanar radiographs and either computed tomography or magnetic resonance imaging were included.

Main outcome measurements: Preoperative sagittal tilt was measured on lateral radiographs and compared with the tilt identified on advanced imaging. Fractures were defined as "high-risk" if posterior tilt was ≥20 degrees or anterior tilt was >10 degrees.

Results: Of 31 Garden type I/II femoral neck fractures, advanced imaging identified 10 high-risk fractures including 8 (25.8%) with posterior tilt ≥20 degrees and 2 (6.5%) with anterior tilt >10 degrees. Overall, there was no significant difference between sagittal tilt measured using lateral radiographs and advanced imaging (P = 0.84), and the 3 raters had good agreement between their measurements of sagittal tilt on lateral radiographs (interclass correlation coefficient 0.79, 95% confidence interval [0.65, 0.88], P < 0.01). However, for high-risk fractures, radiographic measurements from lateral radiographs alone resulted in greater variability and underestimation of tilt by 5.2 degrees (95% confidence interval [-18.68, 8.28]) when compared with computed tomography/magnetic resonance imaging. Owing to this underestimation of sagittal tilt, the raters misclassified high-risk fractures as "low-risk" in most cases (averaging 6.3 of 10, 63%, range 6 - 7) when using lateral radiographs while low-risk fractures were rarely misclassified as high-risk (averaging 1.7 of 21, 7.9%, range 1 - 3, P = 0.01).

Conclusions: Lateral radiographs frequently lead surgeons to misclassify high-risk sagittal tilt of low-energy femoral neck fractures as low-risk. Further research is necessary to improve the assessment of sagittal plane deformity for these injuries.

Level of evidence: Level IV diagnostic study.

Keywords: advanced imaging; biplanar radiographs; femoral neck fractures; geriatric trauma; sagittal angulation.