Journal of clinical orthopaedics and trauma · 2025
Computed tomography versus plain radiography in the Mitsuzawa classification for severe proximal humeral fractures: Comparative agreement analysis and clinical implications.
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Mitsuzawa Sadaki, Takeuchi Hisataka, Yasuda Tadashi, Matsuda Shuichi
Аннотация
BACKGROUND: In a prior investigation, we demonstrated that the Mitsuzawa classification for dislocated and severely displaced proximal humeral fractures (PHFs) provided substantially higher reliability than the Neer or AO/OTA systems when applied to plain radiographs. The present study builds on that work by determining whether computed tomography (CT) alters classification outcomes or improves observer agreement.
METHODS: Four independent reviewers-two shoulder specialists and two orthopedic residents-classified 70 PHFs according to the Neer, AO/OTA, and Mitsuzawa systems. Each fracture fulfilled criteria for dislocation or severe displacement requiring arthroplasty. Evaluations were performed at two separate timepoints: first with radiographs and then with CT scans, including three-dimensional reconstructions. Changes between modalities were recorded. Intraobserver consistency was assessed with the Cohen κ statistic, while interobserver reliability was evaluated with the Fleiss κ statistic.
RESULTS: The incidence of axillary artery injury was 7.1 %. After CT review, classification changes occurred in 31 % of Neer, 29 % of AO/OTA, and 11 % of Mitsuzawa assessments. With radiographs alone, intraobserver reliability was moderate for Neer (κ = 0.52), substantial for AO/OTA (κ = 0.63), and substantial for Mitsuzawa (κ = 0.73). With CT imaging, the corresponding values were 0.55, 0.59, and 0.73. Interobserver agreement ranged from 0.43 to 0.45 (Neer), 0.49-0.52 (AO/OTA), and 0.68-0.68 (Mitsuzawa) with radiographs, and from 0.47 to 0.50, 0.57-0.57, and 0.67-0.69, respectively, after CT. Significant pairwise differences (p < 0.05) in interobserver agreement were observed among all combinations of the three systems for both modalities.
CONCLUSIONS: The Mitsuzawa classification was minimally influenced by imaging modality and consistently provided substantial agreement. For dislocated and displaced PHFs, CT appears to have only a minor influence on Mitsuzawa-based categorization, indicating that well-performed radiographs remain sufficient for reproducible classification. These findings have direct implications for clinical decision-making, imaging selection, and anticipating risks such as neurovascular compromise.
METHODS: Four independent reviewers-two shoulder specialists and two orthopedic residents-classified 70 PHFs according to the Neer, AO/OTA, and Mitsuzawa systems. Each fracture fulfilled criteria for dislocation or severe displacement requiring arthroplasty. Evaluations were performed at two separate timepoints: first with radiographs and then with CT scans, including three-dimensional reconstructions. Changes between modalities were recorded. Intraobserver consistency was assessed with the Cohen κ statistic, while interobserver reliability was evaluated with the Fleiss κ statistic.
RESULTS: The incidence of axillary artery injury was 7.1 %. After CT review, classification changes occurred in 31 % of Neer, 29 % of AO/OTA, and 11 % of Mitsuzawa assessments. With radiographs alone, intraobserver reliability was moderate for Neer (κ = 0.52), substantial for AO/OTA (κ = 0.63), and substantial for Mitsuzawa (κ = 0.73). With CT imaging, the corresponding values were 0.55, 0.59, and 0.73. Interobserver agreement ranged from 0.43 to 0.45 (Neer), 0.49-0.52 (AO/OTA), and 0.68-0.68 (Mitsuzawa) with radiographs, and from 0.47 to 0.50, 0.57-0.57, and 0.67-0.69, respectively, after CT. Significant pairwise differences (p < 0.05) in interobserver agreement were observed among all combinations of the three systems for both modalities.
CONCLUSIONS: The Mitsuzawa classification was minimally influenced by imaging modality and consistently provided substantial agreement. For dislocated and displaced PHFs, CT appears to have only a minor influence on Mitsuzawa-based categorization, indicating that well-performed radiographs remain sufficient for reproducible classification. These findings have direct implications for clinical decision-making, imaging selection, and anticipating risks such as neurovascular compromise.