Evaluation of inter- and intra-observer reliability of current classification systems for subtrochanteric femoral fractures

  • Ahmet İmerci
  • Nevres Hurriyet Aydogan
  • Kursad Tosun
Original Article • HIP - FRACTURES



To evaluate the inter- and intra-observer reliability of the Russell Taylor, Seinsheimer and AO classification systems, and to investigate whether or not the experience of the surgeon had any effect on the classification.

Patients and methods

All the radiographs of 35 patients with subtrochanteric femur fracture were classified by 16 observers using the Russell Taylor, Seinsheimer and 31-AO classifications. Two groups of observers were formed of eight orthopedic surgeons, each with at least five-year experience and eight orthopedic assistants, from six different hospitals, who were invited to participate in the study. All the observers reviewed all the X-rays at this first evaluation. At 6 weeks after the first evaluation, the same radiographs were presented to each observer again in a random order and all the observers were requested to classify the fractures again. To evaluate the inter- and intra-observer reliability, the Fleiss kappa and Cohen’s kappa values were used.


In the inter-observer reliability, the mean values of the two evaluations for the Russell Taylor classification were determined to be κ:0.724 (substantial) for the specialists and κ:0.722 (substantial) for the assistants. Using the Seinsheimer classification, the mean values were κ:0.691 (substantial) for the specialists and κ:0.629 (substantial) for the assistants, and for the AO classification, the mean values were κ:0.279 (fair) for the specialists and κ:0.291 (fair) for the assistants. In the intra-observer reliability, the median values for the Russell Taylor classification were determined to be κ:0.955 (almost perfect) for the specialists and κ:0.855 (almost perfect) for the assistants. Using the Seinsheimer classification, the median values were κ:0.915 (almost perfect) for the specialists and κ:0.900 (almost perfect) for the assistants, and for the AO classification, the median values were κ:0.665 (substantial) for the specialists and κ:0.695 (substantial) for the assistants.


As both the Russell Taylor and Seinsheimer classifications were found to be more reliable and reproducible than the AO classification for subtrochanteric femoral fractures, they can be considered to be more valuable in clinical practice and communication. The experience of the surgeons was not found to have any significance in the evaluation of these three classification systems in these types of fractures.


Subtrochanteric femoral fractures Agreement study Inter-observer and intra-observer reliability Classification 


Compliance with ethical standards

Conflict of interest

No conflicts declared.


No funds were received in support of this study. All authors have approved the manuscript and agree with its submission to “European Journal of Orthopaedic Surgery & Traumatology”.


  1. 1.
    Burstein AH (1993) Fracture classification systems: do they work and are they useful? J Bone Joint Surg Am 75(12):1743–1744CrossRefPubMedGoogle Scholar
  2. 2.
    Roberts CS, Nawab A, Wang M, Voor MJ, Seligson D (2002) Second generation intramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion. J Orthop Trauma 16(4):231–238CrossRefPubMedGoogle Scholar
  3. 3.
    Russell TA, Taylor JC (1992) Subtrochanteric fractures of the femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG (eds) Skeletal trauma. Fractures, dislocations, ligamentous injuries, 1st edn. Saunders, Philadelphia, pp 1485–1524Google Scholar
  4. 4.
    Seinsheimer F (1978) Subtrochanteric fractures of the femur. J Bone Joint Surg Am 60(3):300–306CrossRefPubMedGoogle Scholar
  5. 5.
    Muller ME, Nazarian S, Koch P, Schatzker J (1990) The AO classification of fractures of long bones. Springer, BerlinCrossRefGoogle Scholar
  6. 6.
    Gehrchen PM, Nielsen JO, Olesen B, Andresen BK (1997) Seinsheimer’s classification of subtrochanteric fractures. Poor reproducibility of 4 observers’ evaluation of 50 cases. Acta Orthop Scand 68(6):524–526CrossRefPubMedGoogle Scholar
  7. 7.
    Loizou CL, McNamara I, Ahmed K, Pryor GA, Parker MJ (2010) Classification of subtrochanteric femoral fractures. Injury 41(7):739–745CrossRefPubMedGoogle Scholar
  8. 8.
    Urrutia J, Zamora T, Besa P, Zamora M, Schweitzer D, Klaber I (2015) Inter and intra-observer agreement evaluation of the AO and the Tronzo classification systems of fractures of the trochanteric area. Injury 46(6):1054–1058CrossRefPubMedGoogle Scholar
  9. 9.
    Jin WJ, Dai LY, Cui YM, Zhou Q, Jiang LS, Lu H (2005) Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons. Injury 36(7):858–861CrossRefPubMedGoogle Scholar
  10. 10.
    Pervez H, Parker MJ, Pryor GA, Lutchman L, Chirodian N (2002) Classification of trochanteric fracture of the proximal femur: a study of the reliability of current systems. Injury 33(8):713–715CrossRefPubMedGoogle Scholar
  11. 11.
    Schipper IB, Steyerberg EW, Castelein RM, van Vugt AB (2001) Reliability of the AO/ASIF classification for pertrochanteric femoral fractures. Acta Orthop Scand 72(1):36–41CrossRefPubMedGoogle Scholar
  12. 12.
    van Embden D, Rhemrev SJ, Meylaerts SA, Roukema GR (2010) The comparison of two classifications for trochanteric femur fractures: the AO/ASIF classification and the Jensen classification. Injury 41(4):377–381CrossRefPubMedGoogle Scholar
  13. 13.
    Guyver PM, McCarthy MJ, Jain NP, Poulter RJ, McAllen CJ, Keenan J (2014) Is there any purpose in classifying subtrochanteric fractures? The reproducibility of four classification systems. Eur J Orthop Surg Traumatol 24(4):513–518CrossRefPubMedGoogle Scholar
  14. 14.
    R Core Team (2016) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0.
  15. 15.
    Fleiss JL, Cohen J (1973) The equivalence of weighted kappa and intraclass correlation coefficient as measures of reliability. Educat Psychol Measurement 33:613–619CrossRefGoogle Scholar
  16. 16.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174CrossRefPubMedGoogle Scholar
  17. 17.
    Robinson CM, Houshian S, Khan LA (2005) Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am 87(10):2217–2226PubMedGoogle Scholar
  18. 18.
    Mun˜oz-Mahamud E, Garcıa-Oltra J, Ferna´ndez-Valencia A, Zumbado JA, Rıos J, Suso S, Bori G (2011) Subtrochanteric femoral fractures: a comparative study of the long proximal femoral nail and the long trochanteric fixation nail. Eur J Orthop Surg Traumatol 21:511–516CrossRefGoogle Scholar
  19. 19.
    Kristek D, Lovrić I, Kristek J, Biljan M, Kristek G, Sakić K (2010) The proximal femoral nail antirotation (PFNA) in the treatment of proximal femoral fractures. Coll Antropol 34(3):937–940PubMedGoogle Scholar
  20. 20.
    Johnstone DJ, Radford WJ, Parnell EJ (1993) Interobserver variation using the AO/ASIF classification of long bone fractures. Injury 24(3):163–165CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS 2017

Authors and Affiliations

  • Ahmet İmerci
    • 1
  • Nevres Hurriyet Aydogan
    • 1
  • Kursad Tosun
    • 2
  1. 1.Department of Orthopaedics and Traumatology, Faculty of MedicineMugla Sitki Kocman UniversityMuglaTurkey
  2. 2.Department of Biostatistics, Faculty of MedicineMugla Sitki Kocman UniversityMuglaTurkey

Personalised recommendations