Study on the consistency of trauma orthopedic surgeons in applying the 2007 and 2018 AO/OTA classifications for intertrochanteric femoral fractures_West China Medical Journal

Authors：

BAO Quanwei ¹ , SHI Huanyu ¹ , HUA Xiang ² , REN Yongchuan ² , GUO Qingshan ² ,  LI Yang ¹

1. Department of Emergency Medicine, Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, State Key Laboratory of Trauma and Chemical Poisoning, Chongqing 400042, P. R. China;
2. Department of Trauma, Medical Center of Trauma and War Injury, Daping Hospital, Army Medical University, Chongqing 400042, P. R. China;

Corresponding?author：

LI Yang, Email: dpliyang@tmmu.edu.cn

Keywords：

Intertrochanteric fractures; AO/OTA classification; consistency; accuracy

DOI：

10.7507/1002-0179.202510104

Video：

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Objective To compare the inter-observer agreement, consistency with the gold standard, and accuracy of the 2007 and 2018 versions of the AO/OTA classification in femoral intertrochanteric fractures, and to identify easily confused fracture types. Methods X-ray images of patients with femoral intertrochanteric fractures at Daping Hospital, Army Medical University between 2017 and 2021 were retrospectively collected. Three senior orthopedic trauma surgeons independently classified the fractures using both the 2007 and 2018 AO/OTA versions. A committee of five experts established the gold standard. Kappa coefficients were used to evaluate inter-observer agreement and consistency with the gold standard, while a confusion matrix was used to analyze accuracy and confusion points. Results A total of 236 patients were included. Regarding inter-observer agreement, the 2007 version was superior to the 2018 version at the subtype level [Kappa value: (0.473-0.739) vs. (0.322-0.658)], with no significant difference at the subgroup level [Kappa value: (0.234-0.453) vs. (0.204-0.442)]. Regarding consistency with the gold standard, the 2018 version was slightly better than the 2007 version [Kappa value: (0.332-0.629) vs. (0.269-0.581)] at the subgroup level. In terms of accuracy, the 2007 version showed higher accuracy at the subtype level (72.50% vs. 70.11%), whereas the 2018 version demonstrated better accuracy at the subgroup level (59.04% vs. 51.99%). The most easily confused subtypes in both versions were A1 and A2. At the subgroup level, A2.2 was the most easily confused type in both versions. Conclusions There is inconsistency in the application of both classification versions by surgeons. The 2007 version demonstrates slightly better inter-observer agreement at the subtype level, while the 2018 version shows better accuracy at the subgroup level. The A2.2 subgroup is a major point of confusion, suggesting that clinical attention should be focused on this type or that auxiliary tools may be needed to improve accuracy.

Citation： BAO Quanwei, SHI Huanyu, HUA Xiang, REN Yongchuan, GUO Qingshan, LI Yang. Study on the consistency of trauma orthopedic surgeons in applying the 2007 and 2018 AO/OTA classifications for intertrochanteric femoral fractures. West China Medical Journal, 2025, 40(11): 1777-1782. doi: 10.7507/1002-0179.202510104 Copy

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4.	Agarwal N, Feng T, Maclullich A, et al. Early mobilisation after hip fracture surgery is associated with improved patient outcomes: a systematic review and meta-analysis. Musculoskeletal Care, 2024, 22(1): e1863.
5.	Wu S, Qian G, Huang Q, et al. Clinical evaluation of femoral head fractures: which classification systems have the best universality, reliability, and reproducibility?. Clin Orthop Relat Res, 2024, 482(1): 76-86.
6.	Lin CL, Liao CD, Lee YH, et al. Delphi-based consensus to determine core aspects of post-hip-fracture surgery rehabilitation based on the international classification of functioning, disability, and health. Int J Environ Res Public Health, 2022, 19(23): 15988.
7.	Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(Suppl 10): S1-133.
8.	Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32(Suppl 1): S1-S170.
9.	Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics, 1977, 33(1): 159-174.
10.	Vallon F, Gamulin A. Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature. EFORT Open Rev, 2020, 5(2): 118-125.
11.	Zhang C, Xu B, Liang G, et al. Optimizing stability in AO/OTA 31-A2 intertrochanteric fracture fixation in older patients with osteoporosis. J Int Med Res, 2018, 46(5): 1767-1778.
12.	Hoffmann MF, Khoriaty JD, Sietsema DL, et al. Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures. J Orthop Surg Res, 2019, 14(1): 360.
13.	吳克儉, 湯俊君. 準確理解股骨轉子間骨折“外側壁”. 中國修復重建外科雜志, 2019, 33(10): 1210-1215.
14.	Jiamton C, Sayan P, Rungchamrussopa P, et al. Traction-internal rotation radiograph can improve agreement in AO/OTA classification system for intertrochanteric fracture. Indian J Orthop, 2022, 56(11): 1998-2005.
15.	Crijns TJ, Janssen SJ, Davis JT, et al. Reliability of the classification of proximal femur fractures: does clinical experience matter?. Injury, 2018, 49(4): 819-823.

1. Zhu Y, Xing X, Liu S, et al. Epidemiology of low-energy wrist, hip, and spine fractures in Chinese populations 50 years or older: a national population-based survey. Medicine (Baltimore), 2020, 99(5): e18531.
2. Peeters CM, Visser E, Van de Ree CL, et al. Quality of life after hip fracture in the elderly: a systematic literature review. Injury, 2016, 47(7): 1369-1382.
3. Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl J Med, 2017, 377(21): 2053-2062.
4. Agarwal N, Feng T, Maclullich A, et al. Early mobilisation after hip fracture surgery is associated with improved patient outcomes: a systematic review and meta-analysis. Musculoskeletal Care, 2024, 22(1): e1863.
5. Wu S, Qian G, Huang Q, et al. Clinical evaluation of femoral head fractures: which classification systems have the best universality, reliability, and reproducibility?. Clin Orthop Relat Res, 2024, 482(1): 76-86.
6. Lin CL, Liao CD, Lee YH, et al. Delphi-based consensus to determine core aspects of post-hip-fracture surgery rehabilitation based on the international classification of functioning, disability, and health. Int J Environ Res Public Health, 2022, 19(23): 15988.
7. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(Suppl 10): S1-133.
8. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32(Suppl 1): S1-S170.
9. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics, 1977, 33(1): 159-174.
10. Vallon F, Gamulin A. Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature. EFORT Open Rev, 2020, 5(2): 118-125.
11. Zhang C, Xu B, Liang G, et al. Optimizing stability in AO/OTA 31-A2 intertrochanteric fracture fixation in older patients with osteoporosis. J Int Med Res, 2018, 46(5): 1767-1778.
12. Hoffmann MF, Khoriaty JD, Sietsema DL, et al. Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures. J Orthop Surg Res, 2019, 14(1): 360.
13. 吳克儉, 湯俊君. 準確理解股骨轉子間骨折“外側壁”. 中國修復重建外科雜志, 2019, 33(10): 1210-1215.
14. Jiamton C, Sayan P, Rungchamrussopa P, et al. Traction-internal rotation radiograph can improve agreement in AO/OTA classification system for intertrochanteric fracture. Indian J Orthop, 2022, 56(11): 1998-2005.
15. Crijns TJ, Janssen SJ, Davis JT, et al. Reliability of the classification of proximal femur fractures: does clinical experience matter?. Injury, 2018, 49(4): 819-823.

West China Medical Journal

Study on the consistency of trauma orthopedic surgeons in applying the 2007 and 2018 AO/OTA classifications for intertrochanteric femoral fractures

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