SLR - August 2013 - Jacqueline M. Tulodzieski
Reference : Agel, J, Evans, AR, Marsh, JL, DeCoster, TA, Lundy, DW, Kellam, JF, Jones, CB, and DeSilva, GL. The OTA Open Fracture Classification: A Study of Reliability and Agreement. The Journal of Orthopedic Trauma, 2013; 27: 379-385.
Scientific Literature Review
Reviewed by: Jacqueline M. Tulodzieski, DPM
Residency Program: Inova Fairfax Hospital; Falls Church, Virginia
Podiatric Relevance: Open fractures are not an uncommon occurrence in the foot and ankle, and treatment for over 30 years has been guided by the Gustilo-Anderson classification. Modifications over time have developed the classification to fit certain subsets of injuries, but still with room for debate amongst physicians. With the advent of new medical treatments, this classification system has become somewhat outdated. The newest addition to describing open fractures, namely the OTA classification, utilizes five different categories with three severities for a particular region of the body. This study reflects a higher rate of interobserver agreement of differing types of injuries by use of this system. The article also includes areas within the system for which there is room for improvement in the future. As this may, and very well likely, be the classification utilized most by physicians across varying specialties, including orthopaedics, vascular, infectious disease, and plastic surgery, it is important to understand this classification. The OTA classification for open fractures is yet another tool in a podiatric physician's armament for description of these injuries which will be beneficial in guiding best practice and treatment for patients.
Methods: Video material of six different types of open fractures of differing injury and anatomy were chosen. Along with descriptions of the history and physical, the videos were presented to members of the Classification and Outcomes Committee at the annual meeting of the Orthopedic Trauma Association. One-hundred and thirty-six raters, 91 of which were attending orthopaedic surgeons and the remainder being orthopaedic residents, completed a classification form for the different cases presented. Kappa scores were used to evaluate agreement among the observers.
Results: The multicenter cohort study confirms a higher interrater reliability of the OTA classification as compared with the consistency of the Gustilo-Anderson classification. Of the differing subsets described, arterial injury was found to have the highest reliability. Skin damage, bone loss, and contamination were also found to have very high levels of agreement and muscular injury was found to be the lowest. All subsets were still found to be more reliable than the Guistilo-Anderson classification.
Conclusions: The OTA Open Fracture Classification is shown to have moderate to excellent reliability among attending and resident orthopaedic observers. Future studies should be aimed at patient outcomes and shortcomings of the system in general.