The Influence of Computerized Tomography Imaging on Treatment of Periprosthetic Proximal Femur Fractures

Introduction Periprosthetic femur fractures (PPFF) are increasing in incidence and management of such injuries requires a specialized skill set combined with detailed knowledge of component design. To assist with planning, computed tomography (CT) can be used pre-operatively to give a surgeon more information. No study to date has shown the utility of obtaining preoperative CT. The goal of this study is to show that CT is a useful diagnostic adjunct and report any differences in how subspecialties such as orthopedic traumatologists and arthroplasty surgeons use it. Methods Seventeen PPFF cases met our inclusion criteria. They were shown to six faculty, three trauma and three arthroplasty surgeons. They viewed the plain radiographs and then CTs. After each they filled out the same questionnaire that included their assessment of diagnosis and proposed treatment plan both before and after access to CT imaging. Fleiss and Cohen kappa were used to compare inter- and intra-observer reliability. Results The interobserver kappa values (k) in diagnosis were 0.348 pre- and 0.371 post-CT, while trauma and arthroplasty were 0.328 to 0.260 and 0.821 to 0.881 respectively. The interobserver reliability in treatment was 0.336 pre- and 0.254 post-CT, while trauma and arthroplasty were 0.323 to 0.288 and 0.688 to 0.519. For intraobserver the average k for diagnosis and treatment were 0.818 and 0.671. Broken down by subspecialty they were 0.874 and 0.831 and 0.762 and 0.510 for trauma and arthroplasty. There were 11 diagnostic and 24 treatment changes. Conclusion CT provides diagnostic changes 10% and treatment changes 24% of the time. However, it does not lead to greater agreement among the surgeons on either. Arthroplasty uses CT more to guide both their treatment and the diagnosis, and they agree more than trauma surgeons. Most of the treatment changes come from adding or removing a plate, and the most common diagnostic change was shared by A to B1 and B2 to B3. This suggests fracture extension and bone stock are better evaluated by CT.