COMPARISON OF RADIOGRAPHS, 2D-CT, 3D-CT WITH FRACTURE MAPPINIG IN ASSESSING

THE RELIABILITY OF 2018 AO/OTA CLASSIFICATION FOR INTERTROCHANTERIC

FEMORAL FRACTURES
Thesis Submitted for the Degree of
MASTER OF SURGERY
(ORTHOPAEDICS) UNIVERSITY OF
DELHI

2020-2023

Supervisor

Dr. Sumit Arora

Professor, Department of Orthopaedics, Maulana Azad Medical College &

associated hospitals, New Delhi

Co-Supervisor Co-Supervisor

Dr. Lalit Maini Dr. Abhishek Kashyap

Director Professor, Department of Professor, Department of Orthopaedics,

Orthopaedics, M A M Cand Maulana Azad Medical College &

, New Delhi associated hospitals,New Delhi

Co-Supervisor

Dr. Swati Gupta

Associate Professor,
Department of Radiodiagnosis,
Maulana Azad Medical College &

associated hospitals, New Delhi

Maulana Azad Medical College and associated L.N.H, G.N.E.C. and

G.I.P.M.E.R, New Delhi – 110002

2020-2023 Dr. Prajwal Gupta

 DECLARATION

I, Dr. Prajwal Gupta, hereby declare that the contents of this thesis entitled

“COMPARISON OF RADIOGRAPHS, 2D-CT, 3D-CT WITH FRACTURE

MAPPINIG IN ASSESSING THE RELIABILITY OF 2018 AO/OTA

CLASSIFICATION FOR INTERTROCHANTERIC FEMORAL

FRACTURES” has not been submitted earlier in the candidature of any degree in Delhi

University. The observations embodied in this thesis and the interpretations therein have

been done by me and the thesis fulfills the rules and regulations of Delhi University. I

hereby give my consent for permission of availability of the thesis for photocopying and

inter-library loan to other institutions.

Dr. Prajwal Gupta

 CERTIFICATE

We certify that this thesis entitled “COMPARISON OF RADIOGRAPHS, 2D-CT,

3D-CT WITH FRACTURE MAPPINIG IN ASSESSING THE RELIABILITY OF

2018 AO/OTA CLASSIFICATION FOR INTERTROCHANTERIC FEMORAL

FRACTURES” is a bonafide work of Dr. Prajwal Gupta, conducted in the

Department of Orthopaedics, Maulana Azad Medical College and associated L.N.H,

G.N.E.C and G.I.P.M.E.R, New Delhi, under our guidance and supervision.

Supervisor

Dr. Sumit Arora

Professor, Department of Orthopaedics,

MAMC and LNH, New Delhi

Co Supervisor Co Supervisor

Dr. Lalit Maini Dr. Abhishek Kashyap

Director Professor, Department of Professor, Department of

Orthopaedics, MAMC and LNH, Orthopaedics , MAMC and LNH,
New Delhi New Delhi

Co Supervisor

Dr. Swati Gupta,

Associate Professor, Department of Orthopaedics,

MAMC and LNH,
New Delhi
 DEDICATED

TO MY FAMILY AND TEACHERS

 ACKNOWLEDGEMENTS

Every mission needs a spirit of hard work and dedication to be put in the right path

to meet its destination and in my case, this credit goes to my guide, Dr Sumit Arora

It gives me utmost pleasure in expressing my words of gratitude for all the help I

received during this thesis work.I shall be forever indebted to my supervisor, Dr.

Lalit Maini, Director Professor, Department of Orthopaedics, Maulana Azad

Medical College, for his constant supervision and guidance throughout the course of

this study. I am highly obliged to him for suggesting me such an interesting,

worthwhile and educative subject for my thesis. It is my privilege to be under the

care of such a mentor who has always encouraged my endeavours, kept a constant

vigilance on my mistakes and helped me correct them at the same time.I also express

my deep sense of gratitude for my co-supervisors Dr. Abhishek Kashyap & Dr

Sumit Arora, Professor of Department of Orthopaedic Surgery, Maulana Azad

Medical College for their valuable suggestions, support and encouragement

throughout the post-graduation program.I take this opportunity to thank my co-

supervisor Dr. Sunil Jha, Professor, Department of Mechanical engineering, IIT

Delhi, for his valuable guidance and assistance in the technological aspect of my

thesis.I owe this thesis work to my parents Dr. Vilas Bagwe and Mrs. Chhaya

Bagwe, my sister Mrs. Tejal Bagwe, who have given me love and unconditional

support in all my endeavours. No words are sufficient enough, nor can truly express,

the feeling of gratitude and respect I have for them. I am extremely thankful to my

seniors Dr. Abhay Meena, Dr Siddharth Trivedi, Dr Prateek Goel, Dr. Palash Gupta,

Dr. Gaurang Agarwal, Dr. Shekhar Tomar and Dr. Raj Kumar for sharing their

experiences and providing a constant support and guidance.

I thank my colleagues, Dr. Lokesh Goyal, Dr Saurabh Garhial, Dr Mudit Sharma, Dr

Prajwal Arun Gupta, Dr. Nisha Yadav for being helpful throughout the course of

study. I would also like to thank Dr. Vaibhav Anand, from IIT Delhi for

technological assistance in making my AR application.A special thanks to Dr. Anil

and Dr. Piyush who helped me in statistical analysis of my thesis data. All this

would not have been possible if not for the co-operation and understanding of the

patients who agreed to be a part of this study, for whom I reserve my biggest share

of gratitude.

Dr. Prajwal Gupta

 TABLE OF CONTENTS

Sr. TITLE PAGE NO.

No.

1 INTRODUCTION 1-2

2 REVIEW OF LITERATURE 3-49

3 AIMS AND OBJECTIVES 50

4 MATERIALS AND METHODS 51-55

5 OBSERVATION AND RESULTS 56-87

6 DISCUSSION 88-100

7 CONCLUSION 101

8 INDEX OF REFERENCES 102-120

9 APPENDIX

✔ CONSENT FORM 121-124

✔ PATIENT PERFORMA 124-134

✔ PATIENT INFORMATION SHEET 135-138

139
✔ MASTER CHART

10 SUMMARY 140-142
 GLOSSARY OF ABBREVIATIONS

2 D: 2 Dimensional

3 D: 3 Dimensional

3DP: Three-dimensional printing

AIP: Anterior Intrapelvic

AR: Augmented Reality

A-P: Anteroposterior

AVN: Avascular

Necrosis

CAD: Computer Aided Design

DICOM: Digital Imaging and Communications in Medicine

FDM: Fused deposition modelling

HMD: Head mounted device

HUD: Heads Up Display

IL: Ilio-inguinal

LOM: Laminated object

manufacturing MJS: Multiphase jet

solidification MRI: Magnetic

Resonance Imaging

MRD: Maximum Residual displacement

NCCT: Non-Contrast Computed Tomography

PTA: Post-Traumatic Arthritis

Pre-op: Pre-operative

Post-op: Post-operative
QR code: Quick Response code

RP: Rapid Prototyping

SLA: Stereo lithography

apparatus SLS: Selective laser

Sintering SGC: Solid ground

curing

THR: Total Hip Replacement

VIRTOPS: Virtual Operation Planning in Orthopaedics Surgery

INTRODUCTION
 INTRODUCTION

The increase in the life expectancy in the past decades has led to a growing elderly population

across the world, substantially increasing the incidence of fragility fractures around the hip.

Intertrochanteric fractures are the most common type of hip fractures often resulting from simple

falls in elderly osteoporotic individuals. Since these patients are frail often having coexistent

comorbid conditions, these fractures are associated with increased morbidity and mortality and

pose a unique challenge to health systems worldwide. Internal fixation with early mobilisation is

a widely accepted method of treatment of both stable and unstable intertrochanteric fractures(1–

3). With an increasing shift towards operative management of these fractures the incidence of

complications like postoperative cut out of lag screws in unstable fractures have increased

leading to frequent revision surgeries and often hemiarthroplasty(4).

Stability of the fracture is an important predictor for the risk of implant cut out; therefore, pre-

operative evaluation using classification systems that accurately access the stability and

morphology of fracture patterns to determine the optimum choice of implant is an important step

to reduce the incidence of cut out(5). An extensive classification based preoperative assessment

is also essential to predict difficulty in achieving reduction, fracture patterns requiring open

reduction and to reduce the intra-operative time especially in elderly patients with coexistent

comorbidities who are at an increased risk for perioperative complications and subsequent

mortality.

A good classification should be simple enough to allow communication between surgeons while

being comprehensive enough to account for a majority of fracture patterns to guide the choice of

treatment, and should possess a high degree of inter- and intra-observer reliability. Radiographs
based classification systems like Boyd and Griffin(2), Evans(3), Jensen(6) and AO/ASIF(7)

(Arbeitsgemeinschaft für Osteosynthesefragen/ Association for the Study of Internal Fixation)

despite their routine use, have poor inter-observer reliability due to difficulty in evaluation of the

trajectory of fracture line (especially in the coronal plane), the degree of comminution and the

severity of involvement of the lateral wall in radiographs. However, this information is essential

due to its impact on the mechanical stability of the fracture and the choice of implant(8–11).

Because of the complex morphology of intertrochanteric fracture lines, radiograph based

classifications have limited accuracy and consistency.

AO/ASIF(7) is a standard classification system that is widely used in trauma settings. However,

studies by Crijns et al(11) and Van Emden et al(8) have shown a reduction in inter-observer

reliability at the subgroup level. In addition, it fails to take into account the instability of the

fracture due to lateral wall involvement. Lateral wall thickness is an important factor in

determining the stability of fracture and the choice of implant. A lateral wall thickness of less

than 20.5 mm is associated with a high risk of secondary fracture on placement of a sliding hip

screw(12). Recognition of lateral wall fracture is important as it is associated with high rates of

implant failure and re-operation following dynamic hip screw fixation due to uncontrolled

medialisation of the distal fragment(13,14). Coronal split extending into the greater trochanter

can lead to the loss of superolateral support and result in failure of fixation especially when a

sliding hip screw is being used as it is difficult to detect on radiographs and fractures which

might appear stable on plain radiographs with an adequate lateral wall thickness might in fact be

inherently unstable due to a undetected coronal split(15–17).

Some drawbacks of the conventional AO/ASIF(7) classification have been addressed in the new

2018 AO/OTA(18) (Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma

Association) classification. It considers the lateral wall thickness while classifying the 31-A1 and

31-A2 groups, and classifies isolated trochanteric fractures that were not classified in the original

classification. The differentiation based on lateral wall thickness has implications on the choice

of implants. However, like the previous AO/ASIF(7) classification, it utilises only

anteroposterior radiographs and has similar problems with evaluation of fracture morphology,

detection of coronal split, lateral wall fracture and its effect on stability.

Posterior cortical integrity is essential to withstand the varus, retroversion stress transmitted by

the femoral neck, and to prevent varus displacement and retroversion of the proximal

fragment(9); however, the posterior cortex is thin and frequently comminuted and if bone on

bone impaction using sliding hip screw is applied on this, the fracture site may collapse.

Disruption of the calcar or posteromedial communition can lead to collapse with axial loading

leading to coxa vara, rotational instability and weakened abductors(19) .

The thicker anterior cortex is of utmost importance in these cases to provide stability; therefore,

any comminution at the anterior or posterior cortex can cause instability at the fracture site and

lead to failure of fracture fixation, making it necessary to detect pre-operatively(20–22). An

intact anteromedial fracture plane is essential in obtaining stable fixation for an unstable

intertrochanteric fracture as it limits the sliding of the head-neck fragment(21).

Flexion of the proximal fragment indicates a difficult close reduction and is a predictor for the

possible need of open reduction(23). Ikuta et al(24) defined a ‘subtype-p’ in their classification

system based on lateral radiographs in which they determined that posterior displacement of the

head-neck fragment with respect to the shaft is unstable leading to difficult reduction and
excessive sliding of the head-neck fragment along with collapse of the fracture in patients with

coexistent posterior wall comminution.

Coronal split with en block dissociation of the greater trochanter along with the lesser trochanter

posteriorly as a single fragment was labelled as the ‘Banana’ fragment by Futamura et al(25),

and was recognised by shoda et al(26) as an inherently unstable fracture fragment frequently

missed on plain radiographs.

Due to the complexity of intertrochanteric fractures it is easy to misinterpret the radiograph and

make an error in understanding the crucial points that help in deciding the stability and

formulating the plan of management.

With the advancement in technology, computed tomography (CT) is used to visualise the precise

morphology and trajectory of the fracture line. The process of 3-dimensional (3D) reconstruction

has the ability to detect fracture fragments that are not seen clearly on conventional radiographs.

Further, 3D reconstruction with segmentation and mapping of fracture lines can better detect the

involvement of the lateral wall, anterior and posterior comminution, flexion of the proximal

fragment, coronal plane fracture lines and the banana fragment. Fracture mapping can improve

our understanding of the morphology of fracture lines, which would facilitate the choice of

implant, improve pre-operative planning and help in determining the ease of reduction and risk

of fixation failure(21). These are of vital importance in the modality of fixation, intraoperative

reduction manoeuvres and prognostication.

Therefore, this study aims to assess the effect of addition of advanced imaging modalities like

2D-CT with multiplanar reconstruction and 3D reconstruction with segmentation on the inter-

and intra-observer reliability of the 2018 AO/OTA(18) classification, concurrently understanding

its influence on the detection of parameters that play a pivotal role in deciding the stability of

fracture and its management.

 REVIEW OF LITERATURE

Proximal femur fractures are the most common type of fractures in elderly with increasing

prevalence due to an increase in ageing population; intertrochanteric fractures contribute to

almost half of these fractures(8). The trochanteric region of the femur is enclosed by a line along

the intertrochanteric crest and another transverse line at the inferior border of the lesser

trochanter(figure1). Internal fixation with early mobilisation to restore the patient’s

independence and improve their quality of life is the preferred method of treatment.

Figure 1: Showing the trochanteric region

of the femur.

1) line along the intertrochanteric crest.

2) transverse line at the inferior border
of the lesser trochanter.

Classification systems are important for assessing the morphology, stability and the ease of

reduction of intertrochanteric fractures. This helps in clinical decision making, formulating a

plan for their management and ascertaining the type of implant to be used for fixation. An ideal

classification system should be able to guide the choice of treatment and predict its outcome. It
should possess a high degree of inter-observer and intra-observer reliability while being simple

enough to aid in communication in routine clinical practise and research.

Historically, various classification systems have been proposed based on the anatomical location

of the fracture lines and the stability of the fracture.

In 1939, Moore(27) classified them based on the anatomical location of the fracture lines into

fractures of the upper end of femur and fracture dislocations. Fractures of the upper end of femur

were further subdivided into fractures of the head, neck and trochanters.

Figure 2: Diagrammatic representation of the classification given by moore.

In 1946, Briggs and Keats(28) classified intertrochanteric fractures into five types in accordance

with the orientation of the fracture lines and the risk of coxa vara deformity due to impaction of

the base of neck of the femur.

However, since these classifications are based on the anatomical configuration of the fracture

lines, they provide very little practical information regarding further management and prognosis.

Classifications were also proposed on the basis of the stability of intertrochanteric fractures by

Evans(3), Boyd and Griffin(2), and Jensen’s modification of Evans classification(6).

In 1949, Boyd and Griffin(2) classified these fractures into four types considering the instability

of the fracture in the coronal and the sagittal planes along with the ease of achieving and

maintaining reduction.

In 1949, Evans(3) also proposed a classification based on the stability of fracture pattern, the

importance of calcar femorale and the propensity of the fracture to collapse leading to coxa vara.

He laid stress on the importance of the calcar to act as the medial cortical buttress and provide

post reduction stability.

In 1975, Jensen modified Evan’s classification(6) and based it on preoperative displacement of

fracture fragments, ability to achieve anatomical reduction in both planes along with the risk of

secondary fracture dislocation. He also used lateral radiographs for evaluation of the greater

trochanter and calcar femorale to predict the possibility of obtaining stable reduction and the risk

of secondary fracture dislocation. He classified it into three groups namely displaced or

undisplaced two part fractures that are stable, unstable 3-fragment fractures with greater or lesser

trochanter fracture and 4-fragment fractures.

The original AO/ASIF classification(7) (appendix 1) divided intertrochanteric fractures into three

major groups with each group being further divided into three subgroups based on the obliquity

of the fracture line and the degree of comminution. The A1 group having simple two fragment

fractures with oblique fracture line extending from the greater to the medial cortex. The A2
group includes multifragmentary fractures with posteromedial wall involvement along with

involvement of the adjacent medial cortex, the lateral cortex, however, remains intact. Fractures

in this group are generally unstable, depending on the size of the medial fragment. The A3 group

has the fracture line extending across both medial and lateral cortices, labelled as the reverse

oblique pattern. The differentiation in between the A1 and A2 groups and also in between the

various subgroups of the A2 group is based on the number of intermediate fragments.

In 2018, the original AO/ASIF(7) classification was modified with the differentiation between

the 31 A1 group and the 31 A2 based on the lateral wall thickness according to the method given

by Hsu et al(12). Thickness of greater than 20.5 mm has been classified as group A1 (competent

lateral wall) and less than 20.5 mm (incompetent lateral wall) as group A2. The A1 group was

also revised to include multiple fracture lines and the 31 A1.3 subgroup was modified to include

an independent lesser trochanteric fragment. The differentiation based on lateral wall thickness

has implications on the choice of implants. However, like the previous AO/ASIF(7)

classification, it utilises only anteroposterior radiographs and has similar problems with

evaluation of fracture morphology and stability. Despite these changes, the study by Chan et

al(29) and Zarie et al(30) did not demonstrate an adequate increase in reliability. The drawback

across the entire spectrum of radiographs based classifications is their inability to accurately

detect the fracture morphology, orientation of fragments, integrity of the lateral wall, flexion of

proximal fragment or posterior displacement of the head-neck fragment and severity of

comminution, which are critical factors for determining fracture stability and vital to the aspect

of clinical decision making.

The lateral wall of femur as defined by Gao et al(31) in 2017 is the area enclosed by the vastus

lateralis ridge and the intersection of the tangent along the inferior neck of femur to the lateral
wall of femur as shown in the figure 3. Both intra- and extra-medullary fixation devices are used

for fixation of intertrochanteric fractures. The choice of implant depends upon the stability of the

fracture and the integrity of the lateral wall with extra-medullary fixation (Dynamic Hip Screw)

being effective in stable fractures with an intact lateral wall and intra-medullary nail or

DHS(Dynamic Hip Screw) with modifications in unstable fractures(13,14). Fixed angle sliding

hip screws (Dynamic Hip Screw) that are commonly used in the fixation of these fractures,

function by allowing the controlled impaction of the proximal head-neck fragment with the distal

shaft fragment to achieve bone on bone stability. The use of a sliding hip implant, where the

lateral wall thickness is less than 20.5 mm, has a high risk of postoperative lateral wall fracture

which in turn may lead to fixation failure(12).

Figure 3: Showing the area of lateral wall enclosed by (1) tangent along the inferior border of the

neck, (2) vastus lateralis ridge.

Intact lateral femoral wall provides a lateral buttress for the proximal fragment and allows for

controlled fracture impaction which prevents varus malposition and collapse providing a
conducive environment for fracture healing by allowing cyclic loading and remodelling after

fixation with a Dynamic Hip Screw(32).

Recognition of lateral wall fracture is important as it is associated with high rates of implant

failure and re-operation following dynamic hip screw fixation due to uncontrolled medialisation

of the distal fragment(13,14). These fractures are better treated by augmentation with a

trochanteric buttress plate or using intra-medullary implants which can act like a lateral

prosthetic wall and prevent excessive collapse(33).

Coronal plane fracture line was first included in the classification given by Boyd and Griffin(2)

who in their original article described it as “One deceptive form of type II fracture is that which

on an AP roentgenogram appears to be a linear intertrochanteric fracture, or type I, but in the

lateral view reveals an additional fracture in the coronal plane.” In 2016, Cho et al(16) in their

article described the various morphological patterns of coronal splits originating from the ridge

on the most cephalic part of the trochanter labelled as the ‘trochanteric summit’ and exiting

through the intertrochanteric crest, through or adjacent to the lesser trochanter or through the

postero-medial cortex distal to the lesser trochanter(figure 4). Coronal splits involving the

trochanteric area are frequently missed on radiographic evaluation leading to the possibility of

failure of sliding hip screw if used in such fractures due to the loss of superolateral support.

Therefore, intertrochanteric fractures which might appear stable on plain radiographs with an

adequate lateral wall thickness might in fact be inherently unstable due to an undetected coronal

split(17). Coronal splits extending inferomedially and exiting through the posteromedial cortex

and lesser trochanter involve the lateral wall leading to an added element of instability.
Figure 4: Showing the various patterns of coronal split.

Calcar femorale is a region of dense compact bone which is vertically oriented and lies deep to

the lesser trochanter in the posteromedial part of the proximal femur (figure 5) which is involved

in the transmission of forces across the femoral neck to the shaft of the femur (34). The calcar is

oriented obliquely upwards and closely associated with both the principal tensile and

compressive trabeculae which helps in the re-distribution of the shear and rotatory stress that are

generated in the proximal femur(35). Disrupted calcar segment due to posteromedial

comminution will not be able to bear and redistribute the axial stress acting on it leading to the

collapse of the calcar with resultant rotational instability, coxa vara and weakening of the

abductor mechanism(19,36) (figure 6).

Figure 5: Showing the region of calcar femorale and the primary compressive and tensile

trabeculae.

Figure 6: Showing posteromedial comminution and the resulting varus collapse.

Anterior wall fracture is defined as an additional fracture line over the anterior aspect apart from

a primary fracture line, and the anterior wall is defined as comminuted if there is a third fracture

fragment along the main fragment line as shown in figure 7. An intact anteromedial cortical

support acts like a buttress allowing for controlled impaction of the head-neck fragment with the

shaft of femur, it becomes the primary stabilizer in cases where there is loss of the supporting

calcar(21). Anteromedial cortical apposition is necessary to arrest the excessive sliding of the

head-neck fragment, more so in cases with an incompetent lateral wall. Comminution along the

anterior cortex can lead to an increased risk of screw cut out, implant breakage and shaft

medialization(22).

Figure 7: Anterior wall comminution.

A single large fragment created by a coronal split involving the trochanter and exiting

posteroinferiorly below the lesser trochanter such that the posterior part of the greater trochanter

and the lesser trochanter are fractured en block was first described by Shoda et al(26) as an
occult fragment leading to instability undetected on radiographs in 40 percent of cases but

recognised on 3D reconstruction. This large separated fragment leading to posteromedial

instability was later labelled by Futamura et al(25) as the ‘banana fragment’ as shown in figure 8.

Figure 8: Showing the banana fragment.

Ikuta et al(24) in 2019 classified the fractures into 3 subtypes based on the relationship of the

head-neck fragment with the shaft and their association with difficulty in achieving closed

reduction preoperativetly. Subtype-A, where the head-neck fragment is located anterior to the

shaft (in flexion with respect to the axis of the shaft of femur) indicates a difficult closed

reduction and may be irreducible if associated with a displaced lesser trochanter often requiring

open reduction. The subtype-N, where the head-neck fragment lies in the axis of the femur can

be reduced easily with traction on the fracture table, while the third subtype; subtype-P

represents the posterior displacement(extension) of the head-neck fragment with respect to the

shaft indicating a difficult close reduction. Fractures of this subtype if associated with an intact

greater trochanter are considered irreducible by closed methods, therefore, the presence of
flexion or extension of the head-neck fragment serves as a predictor for the possible need of open

reduction(23). The subtypes ‘A’ and ‘P’ are shown in figure 9.

Figure 9: Showing flexion and extension of the head-neck fragment with respect to the shaft of

femur.

With the advancement in technology, computed tomography(CT) is used to visualise the precise

morphology and trajectory of the fracture line. The process of 3-dimensional (3D) reconstruction

with segementation has the ability to detect fracture fragments that are not seen clearly on

conventional radiographs. Further, mapping of fracture lines can better detect the involvement of

the lateral wall, anterior and posterior comminution, flexion or extension of the proximal

fragment and coronal plane fracture lines. Fracture mapping can improve our understanding of

the morphology of fracture lines, which would facilitate the choice of implant, improve pre-

operative planning and help in determining the ease of reduction and risk of fixation failure(21).

These are of vital importance in the modality of fixation, intraoperative reduction manoeuvres

and prognostication.
In order to address the limitations of the existing classifications based on radiographs, newer CT

based classifications were proposed. Kijima et al(37) in 2014 proposed the area classification for

proximal femoral fractures based on the anatomical location of the fracture lines to help in

identifying the “dangerous” variants that are associated with increased instability along with a

higher risk of failure of fixation and pseudoarthrosis. In 2017, Shoda et al(26) put forward a

fragment based classification system based on 3D-CT reconstruction that described various

instability patterns as a function of combination of these fragments. Wada et al(38) and Futamura

et al(25) further developed classifications including 5 fragments to more accurately represent the

various morphological patterns of fracture lines. However, these newer CT based classification

systems have not been tested clinically and there is paucity of literature on their inter- and intra-

observer reliability.

For our study we added advanced imaging modalities to evaluate their effect on the inter and

intra-observer reliability of an already established 2018 AO/OTA(18) classification,

concurrently understanding their influence on the detection of parameters that play a pivotal role

in deciding the stability of fracture and its management.

 METHODOLOGY

 STUDY DESIGN: It was a descriptive observational study and the subjects were enrolled to

participate in the study after approval from the Institutional Ethics Committee, Maulana

Azad Medical College.

 PLACE OF STUDY: The study was conducted in the Department of Orthopaedics, Maulana

Azad Medical College and associated Lok Nayak Hospital.

 Consents were obtained from all patients after explaining the procedure.

 STUDY POPULATION: All patients with intertrochanteric fracture of femur presenting to

the emergency and OPD and satisfying the below mentioned inclusion and exclusion criteria

were entitled to be enrolled in the study.

Inclusion criteria-

1. All patients with intertrochanteric fracture of the femur.

2. In the age group 18 - 80 years

3. Closed injury

Exclusion criteria-

1. Open intertrochanteric fractures

2. Pathological intertrochanteric fractures

3. Patients who have already undergone CT scans elsewhere and DICOM files of that

scan were not available.

4. History of prior hip surgery

 SAMPLE SIZE CALCULATION

At 95% confidence level and 80% power, taking inter-observer kappa agreement for

AO/OTA(18) classification of trochanteric femur fracture in conventional radiographs, 2D CT

and 3D CT as 0.28, 0.33 and 0.28 (Cavaignac et al(39)) and with an absolute error of 5%, the

maximum sample size estimated was 41 using the formula.

Where,

n = sample size

Zα = 1.96 value of the standard normal variate corresponding to level of significance

alpha 5%

1-β = power of study =80% = 0.84

R0=Value of inter-observer reliability for null hypothesis= 0

R1=Value of inter-observer reliability for alternate hypothesis- 0.28

k =no. of observer - 3

Total of 50 patients presenting to the emergency and OPD were enrolled in the study.
Step 1: Enrolment in the study

All patients of intertrochanteric femur fracture presenting to the orthopaedics emergemcy or

OPD of Lok Nayak Hospital were screened for their possible inclusion in the study using the

above-mentioned criteria.

Step 2: collection of data

Anteroposterior and lateral radiographs along with the CT scan of the hip with proximal femur

were done for each patient enrolled in the study. The CT scans were acquired using 128 slice

single source CT scanner (Erlangren, Germany). The images were acquired with the patient in

supine position and thin axial sections of 1 mm thickness were obtained for each patient. Thin

multiplanar images along coronal and sagittal planes were reconstructed from these axial set of

images. The acquired images were saved in the Digital Imaging and Communications in

Medicine (DICOM) format.

Step 3: 3D reconstruction to demonstrate the spatial topography of fractures

The DICOM files were imported into the InVesalius software (Version 3.0, Centro de

Tecnologia da Informação Renato Archer, Brazil) and 3D reconstruction of the fracture

fragments was done after thresholding and segmentation of the fracture fragments.

Thresholding and region growing:

The command of thresholding and region growing was used to attenuate and separate soft tissue

structures from the pelvis and the femur. The pelvis was subtracted for better visualization of the

proximal femur and the fracture fragments (as shown in figure 10 and 11).
Figure 10: Thresholding. Figure 11: Region growing.

Segmentation:

Fracture fragments were segmented using split mask feature, differentially coloured and saved as

independent entities using the segmentation function in the software (figure 12 and 13).

Figure 12: Split masking. Figure 13: fragments coloured differentially.

3D Reconstruction:

3D reconstruction of the fracture fragments were done by exporting the segmented parts in the

software (figure 14).

Figure 14: 3D reconstructed and segemnted fragments.

Step 3: organisation of the collected data

The collected and processed data was segregated into patient specific folders which were given a

unique code (the first digit of the code denotes the reading and the second digit denotes the

patient number) in order to hide the patient identity from the observers (figure 15).

Figure 15: Organisation of data into folders.

Step 4: selection of observers for the study

Two orthopaedic consultants (one senior orthopaedic surgeon and one junior orthopaedic

surgeon) and one consultant radiologist were chosen for the assessment, they were not provided

any clinical details regarding presentation or management of the patients presenting with these

fracture.

Step 5: Familiarising the observers with the evaluation method

A training session was conducted to familiarise the observers with the 2018 AO/OTA

classification system, lateral wall fracture, coronal split, anterior and posterior comminution,

flexion of the proximal fragment and the presence of the banana fragment with the help of a

diagrammatic scheme, written, and verbal description (annexure 3).

The examiners were also familiarised with the study design and the evaluation sheet which was

used to record their responses (annexure 4).

Step 6: Evaluation of the assorted folders by the observers

Assessment based on radiographs:

The observers were presented with the antero-posterior radiographs, lateral radiographs and were

asked to record the findings on the printed evaluation sheet provided to them. They were

provided as much time as needed to evaluate the radiographs independently, once each section of

the evaluation was complete they were not allowed to change their answers.

Assessment based on radiographs and 2D-CT with multiplanar reconstruction:

They were then presented with the 2D-CT scans of the patients (axial, coronal and sagittal

sections) and the findings were recorded on the second section of the evaluation sheet, taking

into consideration the radiographs along with the 2D-CT of the patient.

Assessment based on radiographs, 2D-CT and 3D reconstruction with segmentation :

The previous two modalities were augmented with the 3D reconstructed, segmented digital

model of the proximal femur and the findings were recorded. Once the findings were recorded

they could not be revisited or altered at a later stage.

After completion of all the 3 sections, the case was considered complete and the observer could

move onto the next folder.

Step 8: Re-evaluation of the folders

Following the first reading (assessment) the order of the patient folders was randomized to avoid

recall. The second evaluation was undertaken in the same manner as the first and the data

collected was organized in a tabular format and saved to a data bank for further statistical

evaluation.

Step 9: Creation of fracture maps:

A normal proximal femoral STL (stereolithography) file was imported into the software and

positioned in the four anatomical planes anterior, medial, lateral, posterior and exported as

separate files to act as templates for the creation of fracture lines (figure 16) .
Figure 16: Proximal femoral templates arranged in the four orthotropic views.

The 3D reconstructed fracture models were imported into the software, and with the help of its

move and rotate function the fragments were virtually reduced and aligned in the same

anatomical plane as the templates.

Figure 17: Virtually reduced fracture fragments arranged in the same orthotropic views as the

templates.
The image of the fracture model was imported into Adobe Photoshop (Version 20.0. 8, Adobe

Inc., United States of America) as the background layer as shown in figure 18 and the template

was imported on top of it.

Figure 18: Image imported in Adobe Photoshop cc 2019.

The opacity of the template layer was reduced to view the underlying fracture lines and using the

size adjustment tool the template was superimposed on the fracture model as shown in figure 19.

Once adequate superimposition was obtained, the fracture lines were marked on the template

layer and it was exported as the fracture map in the four orthotropic views as shown in figure 20.
.

Figure 19: Opacity of the template layer reduced and the underlying fracture line mapped onto

the template.

Figure 20: Showing the exported fracture map with four orthotropic views.

Flowchart depicting the steps of methodology is given below.

Intertrochanteric femoral fracture patients presenting to
the emergency and OPD of the orthopaedics department
of Lok Nayak Hospital.

Patients enrolled in the study following screening by the

inclusion and the exclusion criteria.

Anteroposterior and lateral radiographs along with the

CT scan of the hip with proximal femur done.

Thin multiplanar images along coronal and sagittal

planes were reconstructed from these axial set of images
and saved as DICOM files.

3D reconstruction and segemntation of the fracture

fragments done using software

The collected and processed data was segregated into

patient specific folders which were given a unique code.

Three observers (two orthopaedic consultants and one

consultant radiologist) selected and familiarized with the
classification system via a training session.

Evaluation of the assorted folders for classification and

assessment of lateral wall fracture, coronal split, banana
fragment, anterior and posterior comminution, and
flexion or extension of the head-neck fragment, done by
the observers independently on two occasions 4 weeks
apart.

Outcome assessed using the kappa coefficient evaluating

it via the Landis-Koch scale.
 RESULTS AND OBSERVATIONS:

The observations were recorded as a function of instances of evaluation, since 50 cases were

evaluated by 3 observers in 2 readings separated by an interval of 1 month; the total instances of

evaluation recorded were 300 for one radiological modality.

INTER-OBSERVER RELIABILITY:

OBSERVER 2 3

1 0.37 0.47

(0.17-0.56) (0.31-0.62)

2 0.48

(0.30-0.65)

Mean 0.44

Table 1: Inter-observer Kappa values at the end of first reading, when only radiographs were

available for evaluation.

OBSERVER 2 3

1 0.48 0.34

(0.28-0.67) (0.31-0.62)

2 0.37

(0.21-0.52)

Mean 0.39

Table 2: Inter-observer Kappa values at the end of first reading, when radiographs and 2D-CT

with multiplanar reconstruction were available for evaluation.

 OBSERVER 2 3

1 0.51 0.41

(0.33-0.68) (0.27-0.54)

2 0.46

(0.28-0.63)

Mean 0.46

Table 3: Inter-observer Kappa values at the end of first reading, when radiographs, 2D-CT with

multiplanar reconstruction and 3D reconstruction with segmentation were available for

evaluation.

OBSERVER 2 3

1 0.38 0.31

(0.20-0.55) (0.13-0.48)

2 0.36

(0.16-0.55)

Mean 0.35

Table 4: Inter-observer Kappa values at the end of second reading, when only radiographs were

available for evaluation.

 OBSERVER 2 3

1 0.41 0.28

(0.23-0.58) (0.08-0.47)

2 0.38

(0.18-0.57)

Mean 0.35

Table 5: Inter-observer Kappa values at the end of second reading, when radiographs and 2D-CT

with multiplanar reconstruction were available for evaluation.

OBSERVER 2 3

1 0.49 0.41

(0.29-0.68) (0.23-0.58)

2 0.44

(0.22-0.65)

Mean 0.44

Table 6: Inter-observer Kappa values at the end of first reading, when radiographs, 2D-CT with

multiplanar reconstruction and 3D reconstruction with segmentation were available for

evaluation.

The overall average kappa coefficient for inter-observer reliability = 0.40

Subgroup Analysis:
The inter-observer reliability of the 31 A 1 subgroup decreased slightly as compared to the inter-

observer reliability for AO grouping. However, for the 31 A 2 subgroup analysis revealed a

significant decrease in inter-observer reliability as shown in table 8.

OBSERVERS RADIOGRAPH 2D-CT 3D-CT

Kappa 95% CI Kappa 95% CI Kappa 95% CI

value value value
1 vs 2 0.48 0.20-0.75 0.21 -0.16 to 0.38 0.02-0.73
0.58
1 vs 3 0.37 0.09-0.64 0.20 -0.21 to 0.34 0.08-0.91
0.61
2 vs 3 0.40 0.22-1.0 0.42 0.10-0.73 0.41 0.17-0.88

Table 7: showing the inter-observer reliability of the 31 A1 subgroup.

The average kappa coefficient of inter-observer reliability in this subgroup was 0.356 (fair).

Inter-observer reliability of the 31 A2 subgroup:

OBSERVERS RADIOGRAPH 2D-CT 3D-CT

Kappa 95% CI Kappa 95% CI Kappa 95% CI

value value value
1 vs 2 0.22 -0.26 to 0.32 0.19 -0.28 to 0.30 0.18 -0.01 to 0.21

1 vs 3 0.23 0.01 to 0.44 0.14 -0.02 to 0.16 0.14 -0.02 to 0.16

2 vs 3 0.20 -0.03 to 0.43 0.18 -0.15 to 0.23 0.23 -0.06 t0 0.32

Table 8: showing the inter-observer reliability of the 31 A2 subgroup.

The average kappa coefficient for inter-observer reliability in this subgroup (A2) = 0.19

(slight)

The overall average kappa coefficient for inter-observer reliability of AO subgroups = 0.27 (fair)

INTRA-OBSERVER RELIABILITY:
 OBSERVER 2 3

1 0.53 0.42

(0.35-0.70) (0.22-0.61)

2 0.42

(0.22-0.61)

Mean 0.45

Table 9: Intra-observer Kappa values when only radiographs were available for evaluation.

OBSERVER 2 3

1 0.44 0.47

(0.26-0.61) (0.27-0.66)

2 0.38

(0.20-0.55)

Mean 0.43

Table 10: Intra-observer Kappa values when radiographs and 2D-CT with multiplanar

reconstruction were available for evaluation.

OBSERVER 2 3

1 0.57 0.53
 (0.39-0.74) (0.32-0.71)

2 0.42

(0.24-0.59)

Mean 0.51

Table 11: Intra-observer Kappa values when radiographs, 2D-CT with multiplanar reconstruction

and 3D reconstruction with segmentation were available for evaluation.

Overall average kappa value for intra-observer reliability = 0.46

Graph 1: Showing the comparison of inter- and intra-observer reliabilities on the three

radiological modalities.

OBSERVATIONS INTER-OBSERVER INTRA-OBSERVER

AO main grouping 0.41 (moderate) 0.46 (moderate)

 AO sub grouping 0.27 (fair) 0.32 (fair)

Table 12: Showing the values of kappa coefficient for AO group and subgroups.

Graph 2: Showing the comparison of the mean inter- and intra-observer reliabilities between AO

groups and subgroups.

OUTCOME ASSESSMENT
Kappa coefficient for intra- and inter-observer reliability was calculated and evaluated based on

the Landis and Koch scale(40). Reproducibility and agreement was considered better as the

coefficient approached the value of 1.

It was deemed:

 Slight (0-0.2)

 Fair (0.21-0.4)

 Moderate (0.41-0.6)

 Substantial (0.61-0.8)

 Almost perfect (>0.8)

Based on the Landis and Koch (40)scale.

Both the inter- and intra-observer reliability was moderate for AO main grouping (0.41 and 0.46

respectively) but decreased to fair for AO sub grouping (0.27 and 0.32 respectively). There was a

substantial decrease in the inter-observer reliability to slight (0.19) from moderate (0.41) for the

AO 31-A2 subgroup due to the difficulty in calculation of lateral wall thickness along with the

simultaneous recognition of non-classifiable patterns in this subgroup, which were classified as

matching the nearest described subgroup.

FLEXION OF PROXIMAL FRAGMENT:

Flexion of the proximal fragment was detected in 106 instances (35%) on radiographs, 163

instances (54%) on 2D-CT with multiplanar reconstruction and 180 instances (60%) on 3D

reconstruction with segmentation, as shown in the figure below.

Graph 3: Showing the number of instances of detection (out of 300) and its percentage of

detection of the flexion of proximal fragment.

EXTENSION OF PROXIMAL FRAGMENT:

Extension of the proximal fragment was detected in 06 instances (2%) on radiographs, 15

instances (5%) on 2D-CT with multiplanar reconstruction and 24 instances (8%) on 3D

reconstruction with segmentation, as shown in the graph below. The occurrence of extension of

the proximal fragment is a rare entity as compared to its flexion.

Graph 4: Showing the number of instances of detection (out of 300) and its percentage of

detection of the flexion of proximal fragment.

Extension of the proximal fragment which indicates a difficult closed reduction is relatively less

common as compared to the flexion of the head and neck fragment as shown in graph 4. While

the detection of both these entities is difficult on radiographs, as it requires an adequate lateral

view which is difficult to obtain in emergency settings, they are better detected on 2D-CT and

3D reconstruction which has almost similar percentages of detection.

Graph 5: Showing the comparison of instances of detection between the extension and flexion of

the proximal head-neck fragment.

ANTERIOR WALL COMMINUTION:

Anterior wall comminution was detected in 67 instances (22%) on radiographs, 201 instances

(67%) on 2D-CT with multiplanar reconstruction and 206 instances (68%) on 3D reconstruction

with segmentation, as shown in the graph below. Radiographs could detect comminution in a

majority of cases, however, the differentiation between the anterior and posterior comminution

and ascertaining its severity was challenging for observers. Higher modalities significantly

increased the detection of anterior and posterior wall comminution and helped in gauging its

severity.

Graph 6: Showing the number of instances of detection (out of 300) and its percentage of

detection of anterior wall comminution.

POSTERIOR WALL COMMINUTION:

Posterior wall comminution was detected in 125 instances (41%) on radiographs, 247 instances

(82%) on 2D-CT with multiplanar reconstruction and 255 instances (85%) on 3D reconstruction

with segmentation, as shown in the graph below.

Graph 7: Showing the number of instances of detection (out of 300) and the percentage of

detection of posterior wall comminution.

Postero-medial comminution has been recognised as the most common form of instability noted

in intertrochanteric fractures which can lead to varus collapse it is more frequently observed than

anterior wall comminution.

Graph 8: Showing the comparison of instances of detection between the anterior and posterior

wall comminution.

CORONAL PLANE FRACTURE LINE:

Coronal split was detected in 113 instances (37%) on radiographs, 189 instances (63%) on 2D-

CT with multiplanar reconstruction and 242 instances (80%) on 3D reconstruction with

segmentation, as shown in the graph below. Detection of coronal plane fracture lines is essential

for the assessment of stability of intertrochanteric fractures since they play an important role in

providing supero-lateral support when DHS implant is used for fixation, failure to detect them

can lead to catastrophic consequences.

Graph 9: Showing the number of instances of detection (out of 300) and its percentage of

detection of coronal plane fracture line.

LATERAL WALL FRACTURE:

Lateral wall fracture was detected in 45 instances (15%) on radiographs, 80 instances (26%) on

2D-CT with multiplanar reconstruction and 138 instances (46%) on 3D reconstruction with

segmentation, as shown in the graph below.

Graph 10: Showing the number of instances of detection (out of 300) and its percentage of

detection of lateral wall fracture.

BANANA FRAGMENT:

Banana fragment was detected in 5 instances (1%) on radiographs, 16 instances (5%) on 2D-CT

with multiplanar reconstruction and 83 instances (27%) on 3D reconstruction with segmentation.

Banana fragment occurs on the posterior aspect when the coronal split involves the greater

trochanter and exits postero-inferiorly to form a fragment having the posterior part of greater

trochanter and the lesser trochanter, this banana fragment represents a highly unstable type of

fracture pattern which is essential to detect. However, it is very difficult to detect on radiographs

and 2D-CT as shown in the graph below.

Graph 11: showing the number of instances of detection (out of 300) and its percentage of

detection of the banana fragment.

The graph given below demonstrates the occurrence of the banana fragment in comparison to

coronal split.
Graph 12: showing the relative instances of detection of the coronal splits and banana fragment.

PATIENT DEMOGRAPHICS:

Gender distribution:

The gender distribution of the patients and their percentages are represented in the table 13 and

graph 13.

Gender Number of patients Percentaage

Male 34 68%

Female 16 32%

TOTAL 50 100%

Table 13: Showing the gender distribution of the patients in various groups along with their

percentages.
Graph 13: Showing the gender distribution in the study.

Age distribution:

The age distribution of the patients enrolled in the study is represented in table 14 and graph 14.

Age group Number of patients Percentage of patients

<30 YEARS 1 2%

31-40 YEARS 9 18.4%

41-50 YEARS 8 16.3%

51-60 YEARS 7 14.3%

>60 YEARS 17 34.7%

TOTAL 50 100%

Table 14: Showing the age distribution of the patients in various groups along with their

percentages.
Graph 14: Showing the age distribution of the patients in various age groups along with their

percentages.

Mode of injury:

The majority of injuries occurring in the elderly group were osteoporotic fractures secondary to

low energy trivial trauma like fall from bed or slip and fall on the floor. Fall from stairs was also

a common mode of injury in elderly patients, in younger individuals the most common mode of

injury was high energy road traffic accidents (RTA).

Graph 15: pie chart representing the distribution of various modes of injury in the study shown

below. (RTA- road traffic accidents, bed-fall from bed, floor-slip and fall on floor, stairs-fall

from stairs)
Graph 16: Line graph showing the comparison of instances of detection of all the seven

independent entities on the three radiological modalities (on the next page).

Graph 17: Bar graph showing the comparison of percentage of instance detection of all the seven

independent entities on the three radiological modalities.

 DISCUSSION

With an increasing elderly population, the incidence of fragility fractures around the hip has also

increased with intertrochanteric fractures of femur forming a bulk of these patients. These

patients often have multiple coexistent conditions that require multidisciplinary optimization

followed by prompt fixation and early mobilization as an attempt to decrease the morbidity and

mortality associated with these fractures. Detailed pre-operative planning is essential for the

reduction of intra-operative time and decreasing peri-operative complications. Classification

systems help surgeons in the recognition and prediction of the challenges associated with various

fracture types.

The original 1990 AO/ASIF(7) classification was based primarily upon the integrity of the

posteromedial cortical buttress and the various fracture patterns were classified in accordance of

increasing severity of comminution involving this region. Studies by Van embden et al(8) and

Crijns et al(11) demonstrated moderate agreement on inter- and intra-observer reliability at the

subgroup level which increased substantially when only groups were considered. Pervez et al(41)

in his study in 2002, also demonstrated moderate and fair agreement of inter- and intra-observer

reliability respectively. Cavaignac et al(39) in his study demonstrated a fair agreement which did

not improve substantially even with the use of 2D-CT with multiplanar reconstruction and 3D

reconstruction. While the original AO classification helps in differentiating between stable and

unstable fracture patterns based on posteromedial comminution, it fails to take into account the

other entities contributing to instability including the lateral wall thickness that has emerged as

an important factor in determining the choice of implant for allowing controlled impaction of

fracture fragments.
Some of the shortcomings of the original AO classification were addressed in the new 2018

AO/OTA(18) classification system. Lateral wall thickness is an important determinant in making

the choice of implant and classifying fractures according to the 2018 AO/OTA(18) classification

which differentiates between the A1 group and A2 group based upon the competency of the

lateral wall. Thickness of greater than 20.5 mm has been classified as type A1 (competent lateral

wall) and less than 20.5 mm (incompetent lateral wall) as type A2. The A1 group was also

revised to include multiple fracture lines and the 31-A1.3 subgroup was modified to include an

independent lesser trochanteric fragment. However, like the previous AO/ASIF(7) classification,

it utilises only anteroposterior radiographs and has similar problems with detection of coronal

plane fracture lines, evaluation of fracture morphology and stability.

An ideal classification system should be:

 Comprehensive enough to accommodate the various types of fracture morphologies.

 Simple enough to allow for better communication and clinical application.

 It should help with the choice of implant.

 Help with prognostication following operative intervention.

 Should have a high degree of inter- and intra observer reliability.

This study evaluated the 2018 AO/OTA(18) classification along these lines also assessing the

effect of application of higher imaging modalities (2D-CT with multiplanar reconstruction and

3D reconstruction and segmentation of fracture fragments) on its inter- and intra-observer

reliability and also evaluating their impact on the detection of the seven independent entities

described above.
Some variants that were actually not classifiable as per the existing described subgroupss:

Although the 2018 AO/OTA(18) classification is more comprehensive, topographically more

descriptive and specific of the fracture patterns as compared to other classifications described

previously, certain patterns of fractures and their variations have not been accounted for in this

classification system. In this study we recognised four such types that have been summarised in

the table 15.

Type 1:

An ‘epsilon-reverse epsilon’ variant has been described in literature as a potential irreducible

type of two part intertrochantreic fracture which is very difficult to reduce by either closed or

open means due to the interposition of the capsule and the iliopsoas ligament between the

fracture fragments(42). This is a two part fracture with extension of the fracture line lateral to the

pyriform fossa with a long posterior spike and the lesser trochanter being majorly a part of the

proximal fragment leading to its external rotation and valgus displacement due to the attachment

of the external rotators of the hip. Fractures lateral to the pyriform fossa had the attachment of

the external rotators to the proximal fragment and such fractures were termed as ‘extradigital’ by

Ottolenghin and needed to be reduced in external rotation. Typically intertrochanteric fractures

are reduced by axial traction with adduction and internal rotation, however, this particular type of

intertrochanteric facture is highly unstable and not amenable to reduction by routine manoeuvre

or closed reduction, they require open reduction with retraction of the interposed iliopsoas

tendon and the capsule. Although they are suitable for fixation using the dynamic hip screw

system due to an adequate lateral wall thickness, If classified by the AO classification they

would fall under the A1.2 subgroup and be labelled as ‘simple’ two part fracture which might
mislead the surgeon in failing to recognise the instability and challenges associated with this

complex pattern.

Figure 21: Case of epsilon variant in this study which is potentially irreducible by closed means.

Type 2:

The A 1.3 subgroup is represented as a fracture having an independent lesser trochanteric

fragment with a competent lateral wall, however, in our study, we came across several fracture

patterns where the lesser trochanter was intact and independent facture fragments were present

along the fracture line over the intertrochanteric crest or a greater trochanter fragment associated

with a competent lateral wall, which created a dilemma in classification for the observer as such

a pattern could not be classified under the A 1.2 subgroup since it includes only two part

fractures and neither under the A 1.3 subgroup which includes an independent lesser trochanter

fragment with competent lateral wall; but fractures with fragments along the superior aspect of
the fracture line with competent lateral wall have not been described in the classification system.

3D reconstruction images of some cases with this pattern are shown in figure 22 .

Since the AO classification is based solely on antero-posterior radiographs and fails to consider

coronal splits, some cases in the study with coexistent posteromedial comminution in the coronal

plane could not be classified under A1 subgroup even though the lateral wall was adequate on

calculation.

Figure 22: Showing 3D reconstruction with segemntation of some cases in this study with an

intact lesser trochanteric fragment but other fragments present along the fracture line over the

intertrochanteric crest or greater trochanter.

Type 3:

In this study we encountered several fractures which had both intertrochanteric and reverse

obliquity elements which are not described in the classification and hence, could not be

conclusively classified into either 31-A2 or 31-A3 subgroups. Figure 23 shows the particular

pattern observed in this study on 3D reconstruction and segmentation with both intertrochanteric

and reverse oblique fracture lines creating a dilemma for the observer whether to classify these

as A2 group or A3 group.
Figure 23: Fracture patterns having both intertrochanteric and reverse oblique fracture lines.

Type 4:

During the course of our study we also came across a few cases where there were multiple

fragments along the intertrochanteric line with an incompetent lateral wall but the lesser

trochanteric fragment was intact, thus, creating a predicament on classifying these fractures as all

the patterns included under the A2 group have an associated lesser trochanteric fragment.

Figure 24: Showing example cases in this study with incompetent lateral wall and intermediate

fragments without the involvement of the lesser trochanter.

 In all these situations where the observers encountered potentially unclassifiable patterns the

closest pattern matching them in the classification was marked. The various non-classifiable

patterns and their relative instances observed in this study are summarised in table 15 given

below. Fractures with both reverse oblique and intertrochanteric fracture lines had the highest

instance of detection on all 3 modalities.

Types of non Reason for being non classifiable Instances on Instances Instances on 3D

classifiable Radiographs on 2D-CT reconstruction

fractures (Out of total (Out of (Out of total

=300) total =300) =300)

1. Two part fracture with Epsilon- 09 09 11

Reverse Epsilon variant as

explained above

2 Competent lateral wall with intact 12 28 34

lesser trochanter but independent

fragments present along the

fracture line.

3 Fractures with both reverse oblique 46 65 66

and intertrochanteric components

4 Fracture with incompetent lateral 10 22 23

wall and multiple fragments but

lesser trochanter intact

TOTAL 77 124 134

Table 15: Showing the types of non-classifiable patterns and their instances of detection on

various radiological modalities.

Graph 18: Comparing the detection of instances of non-classifiable patterns on the various

imaging modalities.
Graph 19: Showing the different proportions of detection of non classifiable patterns on the three

imaging modalities.

Inherent complexity and difficulty in communication:

While the AO system provides an anatomical classification which is useful for collecting and

presenting information for research and audit purposes, it’s inherent complexity and

alphanumeric nature lacks the ease of application and communication required in routine

clinical practise, thus falling short of playing a useful role in planning and management of

patients(43). The AO compendium has an anatomical basis for deciding the long bone involved,

the location of the fracture (proximal end, diaphyseal or distal end), the type of involvement

(extraarticular, partial articular or complete articular), the group of classification based on

fracture specific topographical characteristics, and the subgroup which is based on the various

fracture morphologies, it also recommends the use of universal modifiers after the classification

for better representation of the patient’s condition Although these factors improve the

comprehensiveness of the classification system it renders the classification process more

complex, difficult to memorize and reproduce in clinical situations thus hindering

communication in between clinicians. Furthermore, study by Johnstone et al(44) reported a high

incidence of error due to complexity when the fractures were coded on individual basis.

Similarly Martin and Marsh(45) in their study noted that the overall inter- and intra-observer

reliability of the classification drops to unacceptable levels at the group level in some instances

and the subgroup level in almost all fractures. In this research study, we provided the observers

with evaluation sheets depicting the various fracture patterns in order to factor out these

difficulties in classifying the fractures to better gauge the classification method objectively on its

inherent properties.
Figure 25: Showing the complex alphanumeric hierarchy of the AO/OTA classification.

Choice of implant and prognostication:

In 2012 Hsu et al(12) conducted a study to determine the relationship between the thickness of

the lateral wall and the incidence of post-operative lateral wall fractures when DHS was used for

fixation in 208 patients with intertrochanteric fractures. They concluded that the risk of lateral

wall fracture increased substantially if DHS was used in patients with lateral wall thickness less

than 20.5mm. Intact lateral wall plays an integral role in preventing the excessive sliding of the

head-neck fragment by acting like a lateral buttress preventing varus collapse and allowing a

controlled impaction by cyclic loading and remodelling after fixation. This concept was utilized

by the new AO classification in differentiating between the A1 and A2 groups, and postulating a

probable choice of implant to be applied in each group. However, this requires a clear distinction

to be made in between the groups as any ambiguity in this differentiation can mislead the

surgeon in choosing the wrong implant for the fracture type leading to postoperative lateral wall

fractures.
Chan et al(29) and Klaber et al(46) in their studies attributed the decrease in reliabilities among

observers, and the disparity of reliabilities between consultants and residents, to the difficulty in

calculation of the lateral wall thickness which plays an important part in deciding groups in the

2018 AO/OTA(18) classification system.

In this study too, the observers faced multiple challenges while trying to calculate the lateral

wall thickness by the method given by Hsu et al(12) which utilizes the innominate tubercle as the

proximal point for the 3cm vertical drop as shown in the figure 26. Firstly, there is ambiguity on

the location of the innominate tubercle as a anatomically discernable landmark on plain

radiographs thus creating an impediment in choosing the proximal reference point. Furthermore,

since the innominate tubercle is situated on the intertrochanteric crest, which is frequently

comminuted in intertrochanteric fractures, it creates a unique predicament in its identification for

subsequent calculation of the lateral wall thickness.

Secondly, in the method described by Hsu et al(12), lateral wall thickness is taken from the

midpoint in between the anterior and the posterior cortex, during the course of our study we

encountered various instances where the posterior cortex thickness was reduced substantially due

to a coronal fracture line extending posterior-inferiorly to involve to involve the lesser trochanter

or the posteromedial cortex, often associated with a large banana fragment, however, the

majority of these cases had a thick anterior wall which could be misinterpreted as a fracture

pattern amenable for sliding screw fixation.

Thirdly, for better delineation and accurate measurement of the lateral wall thickness AO

recommends traction view with leg in neutral rotation, however, this is not always feasible in

acute cases due to the pain and distress faced by the patient along with the lack of facilities in the
emergency radiology suite for obtaining traction views. Similar challenges are faced while trying

to obtain lateral views which may often end up being inadequate due to improper positioning as a

result of pain and muscular spasms, repeated attempts to obtain proper lateral views can

exaggerate the discomfort faced by the patient.

Figure 26: Showing the method described by Hsu et al for calculation of lateral wall thickness.

The evaluation sheet had a field where the observer entered if they faced difficulty while trying

to calculate the lateral wall thickness; these observations are presented in table 16. The observers

also faced difficulty while trying to calculate the lateral wall thickness on 2D-CT with

multiplanar reconstruction when there was associated comminution with the fracture line

extending across it. In all these cases the innominate tubercle was localised by approximation

using the contra lateral side as reference.

 Radiographs 2D-CT with MPR 3D-reconstruction

Instances in which the observers 267 234 206

faced difficulty in localisation of

the innominate tubercle

Table 16: Showing the number of instances (out of 300) when the observers faced difficulty in

localisation of the innominate tubercle on the three radiological modalities.

These problems were reflected in our study as decreased inter- and intra-observer reliability on

subgroup analysis of the A1.3, A2.2 and A2.3 subgroups. We suggest a three-fold approach to

tackle these problems, these methods to localise the innominate tubercle are enumerated in the

order of preference that we recommend:

Firstly, use of vastus lateralis ridge instead of the innominate tubercle as the proximal

landmark:

Vastus lateralis ridge is a clear and prominent landmark easily recognizable on radiographs and

rarely involved in intertrochanteric fractures. It may be involved in reverse oblique fractures,

however, since these fractures are classified as highly unstable injuries with coexistent lateral

wall fracture, lateral wall thickness is of little significance. We calculated the distance between

the vastus lateralis ridge anad the innominate tubercle in 2D-CT of the 50 subjects enrolled in the

study and found the mean (for both males and females) to be 10.02 mm (see table 17 for the

average distance in between the vastus lateralis ridge and the innominate tubercle for patients

enrolled in the study with varying heights). In the method published by Hsu et al(12) the

reference point is taken 3 cm below the innominate tubercle (figure 27), after due corrections for

changing the proximal landmark we can take the reference point from the vastus lateralis ridge.
Calculation of the distance in between the innominate tubercle and the vastus laterlais ridge:

Step 1: On the axial sections of 2D-CT the mid axial section showing the innominate tubercle

was identified.

Figure 27: Arrow pointing towards the innominate tubercle.

Step 2: A plane was created along the X and Y axis enclosing the axial mid section showing the

innominate tubercle.

Figure 28: The innominate tubercle is marked within the plane drawn along the X and Y axis.
Step 3: on the coronal sections the mid coronal section showing the vastus lateralis ridge in full

profile is selected and a line drawn across its most distal point, the distance between this line and

the plane visible as a line on the representative coronal section is calculated.

Figure 29: Showing the calcuation of difference in between the innominate tubercle and vastus

lateralis ridge.

Secondly, use of a line intersecting the inferior aspect of the head of femur of the contralateral

side for localisation of the innominate tubercle:

In undisplaced or mildly displaced intertrochanteric fractures, a line drawn from the inferior most

part of the head of femur of the contralateral side approximately intersects with the position of

the innominate tubercle on the affected side. We evaluated 50 bilateral hip 2D-CT with

multiplanar reconstruction by identifying the innominate tubercle on the axial sections bilaterally

and creating planes to mark them on the corresponding coronal section as explained in the
method below. After marking the corresponding position of the innominate tubercle on the

coronal section, a line drawn between the two markings intersected the inferior-most point of the

head of femur on both sides within a range of 0-2 mm depending upon the height of the patient

and the femur length as shown in the table 17. Therefore, in undisplcaed or marginally displaced

intertrochanteric fractures the innominate tubercle on the affected side may be localised with

considerable accuracy on plain radiographs as the point of intersection of the line drawn from the

from the inferior-most point of the head of femur of the unaffected side and the intertrochanteric

crest of the involved side provided there is no abduction or adduction at the hip bilaterally which

could then change the relative orientation of the innominate tubercle with respect to the

contralateral side, considering this limitation we recommend that the preference should be given

to the first method described above.

Calculation of distance in between the line intersecting the inferior most point of the head of

femur bilaterally and the innominate tubercle:

Steps 1 and 2 of recognizing the mid axial section of the innominate tubercle and marking it on

the coronal plane will remain the same as described above. However, this method should only be

used when both the hips are in neutral coronal alignment (no adduction or abduction at bilateral

hip joints), which should be checked before proceeding with this method.

Step 3: selecting the coronal section showing the inferior most part of the head of femur and

making a line intersecting it bilaterally, followed by calculation of the distance in between this

line and the plane of the innominate tubercle.

Figure 30: Showing the calcuation of distance in between the innominate tubercle and the line

intersecting the inferior most part of the head of femur bilaterally. Also note the orientation of

the pelvis with the tip of both the teardrops at the same level and both the hips in neutral position

with respect to adduction and abduction.

Thirdly, use of the inter-teardrop line of pelvis for localization of the innominate tubercle:

This method also helps with the localisation of the innominate tubercle by using the inter-

teardrop line as a landmark, However, similar to the second method the prerequisite for

application of this method is the neutral orientation of the pelvis (the inter-tear drop line should

be horizontal with both the tear drops approximately at similar levels) and bilateral hips also in

neutral coronal plane orientation. In this study we evaluated the 2D-CT with multiplanar

reconstruction of 50 patients and found the mean overall distance to be 8.4 mm (the average

distance for the various height groups of patients is given in table 17).
Calculation of distance in between the line intersecting the inter-teardrop line and the innominate

tubercle:

Steps 1 and 2 of recognizing the mid axial section of the innominate tubercle and marking it on

the coronal plane will remain the same as described above. However, this method should only be

used when both the hips and the pelvis are in neutral coronal alignment (no adduction or

abduction at bilateral hip joints), which should be checked before proceeding with this method.

Step 3: selecting the coronal section showing the teardrop in full profile bilaterally and making

an intertear drop line, followed by calculation of the distance in between this line and the plane

of the innominate tubercle.

Figure 31: Showing the calcuation of distance in between the innominate tubercle and the inter-

teardrop line. Also note the orientation of the pelvis with the tip of both the teardrops at the same

level and both the hips in neutral position with respect to adduction and abduction.

As already mentioned we recommend the use of ipsilateral vastus lateralis ridge followed by the

other two methods in the order that they have been described.
 HEIGHT NUMBER FEMUR Distance from Distance from Distance from

BRACKET OF LENGTH vastus the line the inter-tear

CASES (from the lateralis ridge intersecting drop line with

superior most (Average) inferior part of the pelvis at

aspect of head the head of level

to the distal femur with the (Average)

most aspect of limb in neutral

the medial position in the

condyle of coronal plane.

femur)

(Average)

< 4 FEET 1 30 cm 9.2 mm 0-1 mm 6.3 mm

4-5 FEET 13 34.5 cm 9.7 mm 0-1 mm 7.2 mm

5-6 FEET 33 40.8 cm 10.4 mm 0-1.5 mm 9.8 mm

>6 FEET 3 46 cm 11 mm 0-2 mm 10.4 mm

MEAN 37.8 cm 10.02 mm 8.4 mm

Table 17: Showing the various methods of localisation of the innominate tubercle and the

measurnements with respect to the height and femur length of the patients.

Inter- and intra observer reliability:

After the publication of the new AO classification in 2018, various studies were performed to

evaluate its inter- and intra-observer reliability. In 2020, Chan et al(29) conducted a multicentre
observational study for assessment of the inter- and intra-observer reliability of the new AO

classification. Radiographs of 150 patients were classified by six orthopaedic surgeons (two

consultants and four residents) on 2 occasions 3 months apart. It demonstrated a mean inter- and

intra-observer reliability of 0.479 and 0.661 at the group level, 0.376 and 0.587 at the subgroup

level respectively. Consultants had better reliabilities than residents. The finding of inter-

observer reliability was in tune with our study which also demonstrated a moderate inter-

observer reliability (0.41) at the group level which decreased to slight (0.27) on subgroup

analysis. However, the intra-observer reliabilities were not concurrent to those observed in our

study, 0.46 for the groups which decreased to 0.32 on subgroup analysis.

Klaber et al(46) in 2020 conducted a study for comparison of inter- and intra-observer reliability

of the 2018 AO/OTA and original AO/ASIF classification. Radiographs of 67 patients were

evaluated by 6 observers (3 specialists and 3 residents of orthopaedics). The overall inter-

observer agreement as inferred from this study was 0.128 (slight) for the original AO/ASIF

classification and 0.250 (fair) for the new AO/OTA system. Intra-observer agreement for the

original AO/ASIF and new AO/OTA classification system was 0.350 (fair) and 0.295 (fair)

respectively. However, this study showed a greater reliability among residents as compared to

specialists. These findings did not co-relate with the findings observed in our study where the

inter-observer and intra-observer reliability was moderate (0.41 and 0.46) respectively.

In the study conducted by Zarie et al(30) in 2020, 96 plain radiographs were evaluated by four

observers on two occasions at an interval of one month. Their results showed substantial mean

inter- and intra-observer reliability 0.61 and 0.56 respectively for the AO groups while the

agreements were fair 0.321 and 0.314 for the AO subgroups. The findings of mean inter- and

intra- observer reliability for the AO groups were in contrast to those observed in this study,
which were moderate 0.41 and 0.46 respectively. However, the findings of inter- and intra-

observer reliability regarding AO subgroups were in conjunction to the findings of our study

which also demonstrated a decrease in the inter- and intra-observer reliabilities in AO sub

groupings to 0.27 and 0.32 (fair).

Bo Yin et al(47) in 2021 conducted a study comparing the inter- and intra-observer reliability of

the Evans(3), Jensen(6), 2018 AO/OTA(18) and Tang(48) classification systems on radiographs

and 2D-CT scans of 258 patients. The evaluation was done by six orthopaedic surgeons on two

occasions one month apart. It showed moderate agreement of inter- and intra observer reliability

0.46

and 0.45 respectively on radiographs, 0.44 and 0.41 on 2D-CT with multiplanar reconstruction

respectively. This was in contrast to this study which had an inter- and intra-observer of 0.39 and

0.37 for radiographs and 2D-CT with multiplanar reconstruction respectively, however, the intra-

observer reliabilities for both the studies were similar with the intra-observer reliability in this

study being 0.45 and 0.43 for radiographs and 2D-CT with multiplanar reconstruction

respectively . According to their study only the Tang classification showed substantial agreement

in inter- and intra-observer reliability on both radiographs and 2D-CT. However, they did not

include 3D reconstruction and subgroup analysis in their study.

Another study by Yildrim et al(49) in 2022 conducted a retrospective analysis of the radiographs

of 60 patients by five residents and five orthopaedic surgeons, who classified them according to

the Evans(3), Boydd-Griffin(2), Evans-Jensen(6), 2018 AO/OTA(18), and Tronzo(50)

classification systems. It demonstrated substantial inter- and intra-observer agreement (0.669 and

0.744 respectively) for AO grouping between both the residents and the surgeons, however, the

agreement decreased to moderate (0.444 and 0.516 respectively) when AO subgroups were
considered the classification having the most inter- and intra-observer agreement was the 2018

AO/OTA(18) when only the main groups were considered, however, the findings were in

contrast to the findings of our study which only demonstrated a moderate inter- and intra-

observer reliability (0.41 and 0.46 respectively) when considering AO main grouping which

decreased to fair for AO sub grouping (0.27 and 0.32 respectively) as shown in table 12.

The decrease in inter-observer reliability noted in the subgroup analysis reflects the difficulty

faced by observers in calculating the lateral wall thickness, which is the key determinant in

classifying fractures between the subgroup A1 and A2, and in classifying the patterns that have

not been described in the AO/OTA classification (the four types have been described above) and

were therefore, marked as the subgroup described by the AO classification which most closely

resembled the non classifiable pattern at hand.

Table 18 provides a brief summary and reiterates the salient features of the inter- and intra-

observer reliability studies discussed above.

Radiographs vs higher modalities (2D-CT with multi-planar reconstruction and 3D

reconstruction with segmentation of fracture fragments):

As shown on the graphs 16 and 17, the instances of detection of flexion or extension of proximal

fragment, anterior or posterior wall comminution, coronal plane fracture lines, lateral wall

fractures and the banana fragment increased substantially on application of higher modalities.

Since the AO classification only utilizes plain antero-posterior radiographs it fails to recognise

lateral wall fractures and instabilities created by large posteromedial coronal splits involving the

posterior part of the lateral wall rendering it incompetent. The integrity of the posteromedial

hinge is essential to prevent varus displacements and retroversion of the proximal fragments.

Plain radiographs not only underestimate the complexity of the fracture and the degree of

comminution they pose a challenge in localisation of intermediate fragments and their

categorization as anterior wall or posterior wall comminution. Furthermore, lateral view is

essential for the distinction of superimposed intermediate fragments along the primary fracture

line for differentiation in between the A2.2 and A2.3 subgroups for better assessment of stability

and prognostication. Adequate lateral views are essential for the detection of flexion or extension

of the head-neck fragment with respect to the shaft; however, it is a herculean task in an acute

traumatic setting, often requiring multiple radiographic exposures, due to the pain and distress

caused to the patient while trying to achieve an appropriate position for these radiographs.

Higher imaging modalities offer an easier, faster and a more patient friendly alternative for

detection of these unstable fracture patterns.

2D-CT with multi-planar reconstruction vs 3D-CT reconstruction with segmentation of fracture

fragments:

As shown in graphs 16 and 17, significant increase was observed in detection of instances of

coronal plane fracture line, lateral wall fracture and especially the banana fragment in between

the two modalities. The presence or absence of banana fragments could also not be commented

upon conclusively on plain radiographs or 2D-CT with multiplanar reconstruction, while it was

clearly visualised and consistently detected on 3D reconstruction with segmentation.

2D-CT with multiplanar reconstruction was comparatively better in detection of location and

severity of anterior and posterior comminution as compared to 3D reconstruction with

segmentation, since very small fragments could not be segmented leading to an underestimation

of severity of comminution on reconstruction; small fragments either in contact with the parent

fragment or in very close proximity to it, could not be differentially segmented and appeared in a

similar colour as the parent fragment on 3D reconstruction leading to downstaging of

classification in some cases. Similarly, in cases where the fracture lines are closely apposed to

one another they often coalesced on 3D reconstruction.

Axial and coronal sections of 2D-CT were most informative regarding the location and severity

of comminution, coronal splits and lateral wall fractures. Flexion-extension of the head-neck

fragment was better detected on the sagittal sections by 2D-CT and on lateral and medial

representative sections of 3D reconstruction and segmentation. However, evaluation of 3D

reconstruction of fracture fragments is easier, faster, with better and consistent detection of the

banana fragments that are mostly undetected on plain radiographs and 2D-CT as shown in figure.
This study demonstrated a moderate and fair overall interobserver reliability for the new

AO/OTA group and sub-group classification of intertrochanteric hip fractures, with moderate to

substantial intraobserver reliability for both group and sub-group classifications.

Fracture mapping:

Fracture mapping allows for detailed visualisation and evaluation of the morphology of fracture

lines, it provides a ‘Bird’s-eye view’ for observing the distribution of the fracture lines. On

plotting the fracture lines of the cases in this study, we were able to appreciate the diverse

morphology of the fracture lines with different variations that were far wider than the existing

AO classification could include. Plotting fracture maps with four orthotropic planes provides

more information about the characteristics of the fracture and its morphology which can be used

in future to describe other fracture patterns and understand fracture mechanisms. The method for

plotting the fracture lines is explained in detail in the methodology section. The figure shows the

fracture map of the fifty cases enrolled in this study.

 CONCLUSION

The 2018 AO/OTA classification system is more comprehensive, topographically more

descriptive, accommodating several fracture morphologies than other previously described

radiograph based classification systems. It also takes into account the thickness of lateral wall

which is a key determinant for the choice of implant, risk of post-operative lateral wall fracture

and screw cut out. It utilizes the lateral wall thickness for differentiation in between the A1 and

A2 groups, and for postulating a probable choice of implant in these groups. However, this

requires a clear distinction to be made in between the groups as any ambiguity in this

differentiation

Various studies evaluating the classification demonstrated only moderate agreement of inter- and

intra-observer reliability which decreased substantially when subgroup analysis was performed.

Similar finding were echoed in our study as a reflection of the multiple challenges faced by the

observers for classification, namely, difficulty in recognition of the location of the innominate

tubercle as a anatomically discernable landmark on plain radiographs for calculation of lateral

wall thickness as per the method described by Hsu et al(12) and recommended by the

classification; four types of fracture patterns were encountered during the course of our study

which did not match the fracture morphologies described in the classification. This ambiguity in

the method of calculation of lateral wall thickness has serious clinical implications as it can

mislead the surgeon in choosing the wrong implant for the fracture type leading to postoperative

lateral wall fracture or screw cut out. To tackle this problem, we proposed the use of vastus

lateralis ridge which is a clearly visible landmark rarely involved in inter-trochanteric fractures,

for calculation of lateral wall thickness. We also proposed the use of a line intersecting the

inferior-most aspect of the head of femur with the intertrochanteric crest bilaterally and distance
from the inter teardrop line as accessory beacons for helping the localization of the innominate

tubercle.

Plain radiographs not only underestimate the complexity of the fracture and the degree of

comminution they pose a challenge in localisation of intermediate fragments and their

categorization as anterior wall or posterior wall comminution. Adequate lateral views are

essential to comment upon the flexion or extension of the head-neck fragment, which are

difficult to obtain in acute trauma setting and repeated attempts can lead to significant patient

distress and pain. Even when adequate lateral views are obtained, it is difficult to detect coronal

splits, lateral wall fractures, and especially the banana fragment.

This study clearly showed the advantages of application of higher imaging modalities like 2D-

CT with multiplanar reconstruction and 3D reconstruction with segmentation for better detection

of flexion or extension of the head-neck fragment, anterior or posterior wall comminution,

coronal plane fracture line, lateral wall fracture and the banana fragment. While 2D-CT with

MPR was able to better detect the location and severity of comminution, 3D reconstruction and

segmentation was most useful for detection of Banana fragments which were missed on both

radiographs and 2D-CT.

Fracture mapping allows for better evaluation of the morphology and distribution of fracture

lines enabling a better understanding of fracture mechanisms that can be used to describe other

fracture patterns in further research studies.

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 ANNEXURE-1

1990 AO/ASIF Classification

 ANNEXURE-2

2018 AO/OTA Classification

 MEASUREMENT OF LATERAL WALL THICKNESS

The method of measurement of lateral wall thickness as mentioned in the 2018 AO/OTA 18
classification.

The differentiation between groups is defined by the lateral wall height (d) of the greater
trochanter. Lateral wall height or thickness is defined as the distance in millimeters (mm) from a
reference point 3 cm below the innominate tubercle of the greater trochanter angled 135° upward
to the fracture line on the anteroposterior x-ray. The thickness (d) must be less than 20.5 mm for
the fracture to be considered an A2 fracture. It is recommended that the measurement for the
lateral wall be taken using the traction view with the leg in neutral rotation.
 ANNEXURE-3

TRAINING SESSION.

The first group has simple per–trochanteric fractures : 31A1

31A 1.1 : Isolated fracture of one of the trochanter.

fracture of either the greater trochanter(1) or lesser trochanter(2) As shown in figure below.

31A1.2 : This subgroup has simple two part fracture.

With a thick lateral wall that is amenable for fixation with DHS as shown in the figure below.

31A1.3: Intertrochanteric fracture line along with an independent lesser trochanter

fragment with a competent lateral wall of thickness greater than 20.5 mm.

The lateral wall thickness is defined as the distance in millimetres from the midpoint of both the

fractured cortices along a line that is angled 135 degrees upwards to the fracture line from a

reference point that lies 3 cm below the inominate tubercle of the greater trochanter. B – is the

midpoint of both the cortices. A – point on the lateral wall. AB – lateral wall thickness
31 A2 : This subgroup consists of multifragmentary intertrochanteric fractures with

intermediate fragments at the trochanteric region along with an incompetent lateral wall of

thickness less than 20.5 mm.

31 A 2.1 Does not exist in the description.

31 A 2.2 There is one intermediate fragment.

31 A2.3 Two or more than two intermediate fragments.

 31 A2.3 31 A2.3

31 A3 : This subgroup consists of reverse oblique intertrochanteric fractures.

Reverse oblique fractures are highly unstable fractures due to the propensity of

medialisation of the distal fragment as a result of the strong pull of medial fiber bundles of

the iliofemoral ligament, adductors, and/or iliopsoas.

These fractures are associated with difficulty in achieveing and maintaining reduction and

often require open reduction.

31 A 3.1 – Simple reverse oblique fracture

31 A 3.2 – simple transverse fracture

31 A 3.3 – reverse oblique fracture with wedging or multi fragmentary morphology

LATERAL WALL FRACTURE: Intact lateral femoral wall provides a lateral buttress for the

proximal fragment and allows for controlled fracture impaction which prevents varus

malposition and collapse and provides a conducive environment for fracture healing by allowing

cyclic loading and remodelling after fixation with a Dynamic Hip Screw.
Recognition of lateral wall fracture is important as it is associated with high rates of implant

failure and re-operation following dynamic hip screw fixation due to uncontrolled medialisation

of the distal fragment.

Even when other intramedullary implants are used the blade or screw used for fixation may pass

through the fracture line leading to the separation of the fractured fragments.

POSTERIOR COOMINUTION: Disruption of the calcar or posteromedial communition can

lead to collapse with axial loading leading to coxa vara, rotational instability and weakened

abductors.
CORONAL SPLIT: oronal split extending into the greater trochanter can lead to the loss of the

superolateral support and result in failure of fixation especially when a sliding hip screw is being

used as the coronal split is difficult to detect on radiographs and the instability due to this

fracture pattern has not been described by the AO classification.

ANTERIOR WALL COMMINUTION: Anterior wall fracture is defined as an additional

fracture line over the anterior aspect apart from a primary fracture line and the anterior wall is

defined as comminuted if there is a third fracture fragment along the main fragment line.An
intact anteromedial fracture plane is essential in obtaining stable fixation for an unstable

intertrochanteric fracture as it limits the sliding of the head neck fragment.Anterior comminution

is also associated with increased screw cut out.

Anterior wall comminution Flexion of the proximal fragment

FLEXION OR EXTENSION OF THE PROXIMAL FRAGMENT :Flexion or extension of the

proximal fragment indicates a difficult close reduction and is a predictor for the possible need of

open reduction

BANANA FRAGMENT: In a study done by Shoda et al approx. 40 percent of the

intertrochanteric fractures classified as stable by the AO classification were found to be

inherently unstable after 3D-CT reconstruction due to the involvement of the trochanteric region

which is frequently missed on plain radiographs as it lies posteriorly.

Shoda classified the fractures involving the posterior part of grater trochanter with the lesser

trochanter as a single fragment are considered unstable. This pattern of fracture was labelled as

the ‘Banana’ fragment by Futumura et al.

ANNEXURE-4

CASE EVALUATION SHEET

Lateral wall height or thickness is defined as the distance in millimeters (mm) from a reference point 3

cm below the innominate tubercle of the greater trochanter angled 135° upward to the fracture line on

the anteroposterior x-ray. The thickness (d) must be less than 20.5 mm for the fracture to be considered

an A2 fracture. It is recommended that the measurement for the lateral wall be taken using the traction

view with the leg in neutral rotation.6,7