![]() In clinical practice AO/OTA classification is usually simplified considering only the three categories (B1, B2, B3). Each of these types has a subclassification. Fractures of the femoral head have been classified as subcapital with minimal or no displacement (Type B1), transcervical (Type B2), or displaced subcapital fractures (Type B3). The AO/OTA classification system is organized into hierarchies of severity as the descriptions generally proceed from simple to multifragmentary fractures. A type IV fracture is a complete fracture with total displacement of the fracture fragments, allowing the femoral head to rotate back to an anatomic position. A type III fracture is a complete fracture with partial displacement of fracture fragments. A type II fracture is a complete fracture without displacement of the fracture fragments. A type I fracture is an incomplete or valgus-impacted fracture. Garden classified femoral neck fractures into four types based on displacement on the anteroposterior radiograph. These classification systems are based on 2-dimensional X-ray images. The most common classification used for intracapsular FNF are the Garden Classification and the AO/OTA classification. Radiographic FNF classification helps with clinical decision making, communication, and research on prognosis and treatment. For unstable FNF the treatment of choice is hip replacement (total hip arthroplasty or hemiarthroplasty) instead for stable FNF, the most used treatment is the internal fixation with cannulated screws or with other hip implants. The choice of a specific treatment option is based on the stability and orientation of the fracture and patient factors such as age, function, and bone quality. The treatment of choice, in almost all of the cases, is surgical. For this reason it is important to reach a fast and correct diagnosis and perform an adequate and prompt treatment to reduce post-operative complications and mortality. Furthermore hip fractures affect the quality of life of patients. This leads to an increasing number of hospital admission and hospitalization costs. In Italy, hip fractures occurred in people over 65 years increased from 89,601 to 94,525 during the period from 2007 to 2014. The incidence of femoral neck fractures (FNF) is approximately equal to the incidence of pertrochanteric fractures, in combination making up over 90% of all proximal femur fractures. In fact, the global number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. The incidence of proximal femur fracture has raised worldwide in the last two decades along with the increase in the average age of the population. It is caused by accidental falls in elderly patients, due to osteoporosis. It occurs in 18% of women and in 6% of men worldwide. Proximal femur fracture is one of the most common type of fracture in the elderly. No classification has been shown to be superior in terms of reliability. The experience of the surgeons seems not to improve reliability. The simplified AO/OTA classification show a reliability similar to Garden classification, with a moderate interobserver reliability. The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. Simplified AO/OTA classification showed a reliability from 0,4 to 0,75 with an average of 0,61. AO classification showed reliability from 0,2 to 0,64 with an average of 0,5. The values of intra observer reliability for Garden classification was from 0,48 to 0,79 with an average of 0,63. Simplified AO/OTA classification showed a reliability from 0,38 to 0,58 with an average of 0,48. AO classification showed reliability from 0,2 to 0,42, with average of 0,30. The k values of interobserver reliability for Garden classification was from 0,28 to 0,73 with an average of 0,49. Fleiss’ Kappa was used to determine multi-rater agreement. Cohen’s Kappa was calculated to determine intra and inter observer reliability. The Kappa statistical analysis was used to determine the reliability of the classifications. One month later, the radiographs were renumbered and then each observer performed a second evaluation of the radiographs. Six Orthopaedic surgeons, divided in three groups based on trauma experience, evaluated 150 blinded antero-posterior and latero-lateral radiography of FNF using Garden classification, 2018 AO/OTA and simplified AO/OTA classification. This study aims to evaluate reliability of 2018 AO/OTA Classification, AO/OTA simplified and Garden classification. A valid radiographic classification system is mandatory to perform the correct treatment and to allow surgeons to facilitate communication. Femoral neck fractures (FNF) are one of the most common injury in the elderly.
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