n Feature Article

New Classication System for Long-bone Fractures Supplementing the AO/OTA Classication
CHRISTOS GARNAVOS, MD, PHD; NIKOLAOS K. KANAKARIS, MD, PHD; NIKOLAOS G. LASANIANOS, MD, PHD, MSc; PARASKEVI TZORTZI, MD; ROBERT M. WEST, PHD

abstract
Full article available online at Healio.com/Orthopedics. Search: 20120426-26
This article describes a novel, clinically oriented classication system for long-bone fractures that is simple, reliable, and useful to predict treatment method, complications, and outcome. The reliability and memorability of the new classication were statistically tested and compared with the AO-Mller/Orthopaedic Trauma Association (AO/OTA) long-bone fracture classication. The proposed classication system was also clinically validated with a targeted pilot study designed for content and clinical outcome retrospectively reviewing 122 closed tibial shaft fractures, which were used as a representative paradigm of long-bone fractures. Statistical evaluation showed that the proposed classication system had improved inter- and intraobserver variation agreement and easier memorability compared with the AO/OTA classication system. The clinical validation study showed its predictive value regarding selection of treatment method, complication rate, and injury outcome. The proposed classication system proved simple, reliable, and memorable. Its clinical value appeared strong enough to justify the organization of larger studies for a complete assessment of its clinical usefulness for all long-bone fractures.

1
Figure 1: Topography of long-bone segments: D, distal; M, middle; MD, middle to distal; P, proximal; PM, proximal to middle).

2
Figure 2: Morphology of long-bone segments: St, simple-transverse; Ss, simple-spiral; I, intermediate; C, complex.

Drs Garnavos, Kanakaris, Lasanianos, and Tzortzi are from the Orthopaedic Department, Evangelismos General Hospital, Athens, Greece; Dr Kanakaris is also from the Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, and Dr West is from Leeds Institute of Health Sciences, Centre for Epidemiology & Biostatistics, University of Leeds, Leeds, United Kingdom. Drs Garnavos, Kanakaris, Lasanianos, Tzortzi, and West have no relevant nancial relationships to disclose. Correspondence should be addressed to: Christos Garnavos, MD, PhD, Orthopaedic Department, Evangelismos General Hospital, 5 Poseidonos Str, Glyfada 16674, Athens, Greece (cgarn@otenet.gr). doi: 10.3928/01477447-20120426-26

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ong-bone fractures are common trauma injuries. Compared with periarticular areas, where several fracture pattern classications have been described, long-bone fractures are classied exclusively according to the AO-Mller long-bone classication system and to its 1996 revision by the Orthopaedic Trauma Association (OTA) compendium.1,2 However, the revised version of the AO/OTA classication system has received criticism for being complicated and for having low inter- and intraobserver variation agreement and reliability. It has never been adequately tested for its usefulness regarding treatment selection and clinical outcomes.3-6 The necessity of a simple classication system for longbone fractures has been reported4,5,7-10 and is supported by numerous validation studies dealing with the existing AO/OTA system.3,4,6 Moreover, specic guidelines have been described on the optimal way to introduce a novel classication system or revise an existing classication system.10-12 This article proposes the simple Garnavos classication system for classifying long-bone fractures, oriented for everyday clinical use. It was tested and compared with the AO/OTA long-bone fracture classication system with inter- and intraobserver variation reliability studies. In addition, the current study provides the required evidence that the new classication system is applicable to a representative sample of long-bone shaft fractures for which it has been designed (face and content validation) and also assesses the correlation of the proposed classication to mechanisms of injury, various treatment options, complication rates, rehabilitation issues, and the main clinical endpoint of long-bone fracture treatment.

MATERIALS AND METHODS

Garnavos Classication System Denitions of Long-bone Segments. Femur: The bone segment between 2 paral-

lel lines that cross the long axis of the femur transversely. One passes just below the lesser trochanter and the other through the maximum diameter of the femoral condyles. Tibia: The bone segment between 2 parallel lines that cross the long 1 axis of the tibia transverseFigure 1: Topography of long-bone segments: D, distal; M, middle; ly. One passes just above the bular head or the MD, middle to distal; P, proximal; PM, proximal to middle). proximal end of the tibial tuberosity and the other just above the is located in the transition zone between base of the medial malleolus or the point the proximal and middle thirds of a longwhere the tibia separates from the bula. bone segment, it is described as PM. If it Humerus: The bone segment between is located in the transition zone between 2 parallel lines that cross the long axis the middle and distal thirds, it is described of the humerus transversely. One passes as MD. If a fracture extends to the whole through the surgical neck of the humeral bony segment, it is described as PMD. head and the other 1 cm above the proxiClassication is based on anteromal tip of the olecranon fossa. posterior (AP) and lateral radiographs. Radius and ulna: The bone segments However, additional imaging studies, between 2 parallel lines that cross the long such as oblique radiographs or computed axis of the radius and ulna transversely. tomography scan, may offer additional One passes through the base of the radial information about the extension or comneck and the other through the base of the minution of a fracture. Fractures must be ulnar head (Figure 1). described from the most proximal to the Garnavos Classication System. In the most distal extensions (ssure fracture new classication system, fractures are lines that extend proximally or distally rst described by their location (topog- must be included) and not in relation to raphy) and second by their pattern (mor- the center of comminution or to the main phology). location of the fracture. Fractures located Fracture topography: The long-bone mainly within the long-bone segments but segments are divided into 3 zones of equal extending toward the nearby joint, beyond length. The most proximal (head-to-foot the line dening the bone segment, should direction) zone is assigned the capital let- be described with the letters dening the ter P (for proximal), the middle zone is location within the shaft, followed by the assigned the capital letter M (for middle), small letter j (for joint) (Figure 1; Table 1). and the most distal zone is assigned the Fracture morphology: Fractures are capital letter D (for distal). The location morphologically described as simple (S), of a fracture is described by the appropri- intermediate (I), or complex (C), with ate capital letter (P, M, or D). The fracture these letters following the letter(s) denmust be completely contained within the ing the location. Simple fractures are those relevant zone to be described by only 1 ini- with no comminution (clear-cut fractures) tial. When a fracture extends to .1 zone and are further separated into transverse or occurs in the transition area between 2 or slightly oblique (t) and spiral (s). One zones, its location is described by 2 or 3 or 2 minor bony chips should not change initials from proximal to distal. If a fracture the denition of a fracture as simple. Inter-

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mediate fractures have 1 or 2 sizable bony fragments, whereas complex fractures have >3 sizable bony fragments or greater comminution (Figure 2; Table 1). A fracture located between the proximal and middle zones with 1 sizable bony fragment is described as PMI, whereas an oblique fracture with no comminution located at the distal zone is described as DSt. In cases where .1 fracture has occurred on the same bone with an intact bony fragment with complete canal separating the 2 fractures (segmental fracture), each must be described independently as if the other did not exist. The most proximal fracture is described rst, followed by the other fracture(s) in a proximal-to-distal order. If a long bone appears fractured at its proximal zone transversely and a second fracture exists at the middledistal transitional zone with 1 bony fragment, it is described as PSt, MDI. Intra- and Interobserver Variation Agreement Studies Radiological Material and Selection of Coders. Anteroposterior and lateral radiographs of 120 long-bone shaft fractures (40 femora, 40 tibiae, and 40 humeri) were randomly selected and shown to 6 orthopedic physicians of different seniority and experience (2 trainees in the last year of training and 4 qualied orthopedic trauma surgeons). None of these physicians was involved with the preparation or authorship of the current study. They agreed to participate in the study as independent observers and were blinded to the origin and identity of the creators of the new classication. All 6 doctors, already familiar with the AO/OTA long-bone fracture classication system, were introduced to the new classication system by the authors of the current study. They were provided with illustrated information for both classication systems and asked to apply either the AO/ OTA and the Garnavos classication system to each long-bone fracture presented as radiographs in a PowerPoint (Microsoft, Redmond, Washington) presentation.

The statistical analysis and evaluation process was based on the comparison of the classication systems by the observers; therefore, no correct answers were set by the authors. The time needed for complete classication of the fractures was recorded for every observer for each anatomical region (femur, tibia, and humerus). The same physicians were asked to repeat the procedure (with the same radiographs in the same sequence) 2 to 4 weeks later. Statistical Methodology. Data were analyzed using k value as a measure of inter- and intraobserver agreement.13,14 Results were dened as poor when k was ,0.20, fair when k was between 0.21 and 0.40, moderate when k was between 0.41 and 0.60, good when k was between 0.61 and 0.80, and very good between 0.81 and 1.00.13,14 All statistical tests were performed using SPSS version 10.0 statistical software (SPSS, Inc, Chicago, Illinois). Signicance was set at P,.05. Clinical Validation Study The authors retrospectively reviewed the clinical notes and radiographs of all consecutive patients older than 16 years (N5207) admitted to a Level I trauma center between January 2003 and December 2005 with the diagnosis of a diaphyseal tibial fracture. Inclusion criteria were isolated, closed injuries with mild soft tissue trauma (type 0 or 1 according to Tscherne and Gotzen classication15) and normal preinjury mobilization, with full documentation and radiograph series. Exclusion criteria were open fractures, fracture extension to the adjacent joint (knee or ankle), closed fractures with severe soft tissue injury (type 2 or 3 according to Tscherne and Gotzen classication15), and signicant comorbidities or coexisting injuries affecting postoperative rehabilitation. The fractures were treated individually by experienced trauma surgeons of different seniority, not involved with the preparation or authorship of the current study. At

Table 1

Garnavos Long-bone Fracture Classication System

Topography P: Proximal Morphology S: Simple (no fragments) t: transverse or oblique s: spiral I: Intermediate (1 or 2 sizable fragments) C: Complex (>3 any size fragments or large comminution)

M: Middle

D: Distal

j: Extension toward the joint

2
Figure 2: Morphology of long-bone segments: St, simple-transverse; Ss, simple-spiral; I, intermediate; C, complex.

the time of initial treatment, the surgeons followed no specic protocol, and the chosen treatment was based on personal preference and experience. After applying the inclusion and exclusion criteria, 122 fractures remained and were classied according to the Garnavos classication system by 2 authors (C.G., N.K.K.). Recorded data were entered in a Microsoft Access database. The data included patient demographics, comorbidities, mechanism of injury, method of treatment, time to operation, length of hospital stay, rehabilitation scheme and mobilization progress, early and late complications, secondary interventions, time to union, and time to discharge from out-

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Table 2

Table 3

Interobserver Agreement
Parameter Femur Mean k Agreement strength Tibia Mean k Agreement strength Humerus Mean k Agreement strength 0.3 Fair 0.661 Good 0.242 Fair 0.44 Moderate 0.388 Fair 0.487 Moderate AO/OTA System Garnavos System

Intraobserver Agreement
Parameter Femur Mean k Agreement strength Tibia Mean k Agreement strength Humerus Mean k Agreement strength 0.38 Fair 0.562 Moderate 0.38 Fair 0.452 Moderate 0.38 Fair 0.574 Moderate AO-OTA System Garnavos System

Statistical Analysis Univariable and multivariable statistical analyses were performed to verify the original hypothesis that the Garnavos classication system can be related to clinical aspects regarding the management and outcome of long-bone fractures. For time to union, t test or 1-way analysis of variance was applied to compare grouped factors, and test for proportions or chi-square test was applied for complications. Univariable analysis was performed to identify the variables of interest. Any variable with a 10% signicance level was taken forward in a multivariable analysis to adjust for other factors.

RESULTS
Interobserver Variation Agreement Agreement strength improved with the Garnavos classication system compared with the AO/OTA classication system for all fractures assessed. Improvement occurred by 1 level (from fair to moderate) for femoral and tibial fractures and by 2 levels (from fair to good) for humeral fractures (Table 2). Intraobserver Variation Agreement When the same observer classied the same fractures with both classication systems 2 to 4 weeks after the rst attempt, 1 level of improvement occurred in agreement strength with the Garnavos classication system compared with the AO/OTA classication system (Table 3). Time Element Comparison of the time needed to classify fractures of the same long bone during 2 attempts revealed statistically signicant differences in favor of the Garnavos classication system (,.01 and ,.05, respectively). In addition, statistically signicantly less time was needed for the classication with the Garnavos classication system during the second attempt compared with the time needed for classication of the same fractures with the same classication system during the rst attempt

Abbreviation: AO/OTA, AO-Mller/ Orthopaedic Trauma Association classication.

Abbreviation: AO/OTA, AO-Mller/ Orthopaedic Trauma Association classication.

Table 4

Time Needed for Fracture Classication at 2 Sessions

Mean (Range) Session 1 2 P AO/OTA System 44 min 15 s (35 min 8 s to 51 min 50 s) 35 min 27 s (28 min 50 s to 64 min 48 s) .1 Garnavos System 22 min 44 s (13 min 30 s to 24 min 50 s) 15 min 57 s (11 min 25 s to 20 min) ,.05 P ,.01 ,.05

Abbreviation: AO/OTA, AO-Mller/ Orthopaedic Trauma Association classication.

patient clinic. Radiological fracture union was dened as callus formation on AP and lateral radiographs (presence of bridging callus in a minimum 3 of 4 cortices) and clinical fracture union as pain-free weight bearing or stressing at the fracture site according to the existing literature.16 Nonunion was dened as continued pain and motion at the fracture site and the absence of adequate callus formation on AP and lateral radiographs at least 8 months postinjury.16 Delayed union was dened as the absence of radiological progress of callus formation for .4 months postoper-

atively.17 Fracture malunion was dened as AP angulation or rotation of .10, varus/valgus deformity of .5, and shortening of .2 cm.18-20 All operative procedures performed after initial operative fracture xation were recorded as secondary interventions. These included nail dynamization, external xator pin removal, fasciotomies, exchange nailing, or change of the xation method. The clinical suspicion of compartment syndrome was investigated by intracompartmental pressure measurements as reported by Frink et al.21

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Table 5

General Parameters by Fracture Topography

Fracture Classication Variable Epidemiology No. (%) Median age (range), y No. men:women (ratio) Mechanism of injury, no. (%) Fall Sports Pedestrian accident Motorcycle accident Motor vehicle accident Treatment, no. (%) Conservativea Operative IMN External xation ORIF Median time to surgery (range), d Median hospital stay (range), d Rehabilitation and outcome, median (range) Time to union, wk Time of nonweight bearing, wk Time to partial weight bearing, wk Time to full weight bearing, wk Physiotherapy needed, wk Time to discharge, mo 22 (16-58) 4 (0-16) 6 (0-44) 12 (3-50) 8 (4-20) 7 (5-33) 18 (17-22) 1.5 (0-8) 4 (0-4) 8 (3-12) N/A 6.5 (6-7) 20 (16-58) 3 (0-16) 5.5 (0-44) 12 (4-50) 5 (4-12) 6 (5-26) 20.5 (17-44) 0 (0-10) 6 (4-12) 8 (4-20) 6 (4-10) 6.5 (5-18) 24 (17-56) 6 (0-12) 8 (0-44) 14 (4-48) 8 (4-20) 8 (5-33) 21 (18-28) 6 (0-12) 4 (1-16) 12 (7-16) 8 (6-12) 7 (5-16) 26 (18-30) 3 (3-4) 3 (0-4) 6 (3-8) N/A 11 (9-13) 18 (14.7) 104 (85.2) 82 (67.2) 19 (15.6) 3 (2.5) 1 (0-29) 7 (0-28) 0 6 4 2 0 0.5 (0-2) 5.5 (4-8) 1 17 11 6 0 1 (0-9) 7 (0-24) 0 16 16 0 0 2 (0-29) 9 (4-24) 14 51 47 4 0 1 (0-21) 7 (0-28) 3 14 4 7 3 0.5 (0-3) 5 (1-17) 0 3 3 0 0 3 (2-3) 6 (4-9) 61 (50) 31 (25.4) 16 (13.1) 9 (7.4) 5 (4.1) 3 1 2 0 0 8 3 3 2 2 6 4 2 3 1 35 18 8 3 1 9 5 1 1 1 2 0 1 0 0 122 (100) 32 (17-74) 89:33 (2.7) 6 (4.9) 33.5 (20-74) 5:1 (5) 18 (14.7) 28.5 (17-46) 14:4 (3.5) 16 (13.1) 28.5 (19-49) 14:2 (7) 65 (53.3) 34 (18-72) 46:19 (2.4) 17 (13.9) 33 (18-63) 10:7 (1.4) 3 (2.5) 34 (32-35) 3:0 (N/A) Total P PM M MD D Segmental

Abbreviations: D, distal; IMN, intramedullary nailing; M, middle; MD, middle to distal; N/A, not applicable; ORIF, open reduction and internal xation; P, proximal; PM, proximal to middle. a Some fractures initially treated conservatively underwent operative xation at a later stage.

(P,05). In contrast, no statistically signicant difference existed between the times needed for fracture classication with the AO/OTA classication system between the rst and second attempts (P5.1) (Table 4). Clinical Validation Tables 5 and 6 show demographic data, mechanism of injury, treatment method, and outcome in correlation with

the Garnavos classication system. Tables 7 and 8 show the distribution of complications within the subgroups of the Garnavos classication system. Univariable Analysis. For statistical methodological reasons, the classication categories were grouped. The fractures of a single zone (P, M, or D) were compared with fractures extending to multiple zones (PM, MD, and PMD). The same simpli-

cation was made for fracture morphology: simple fractures (Ss and St) were compared with multipart fractures (I and C). Univariable analysis identied the following as signicant negative factors related to time to union: age older than 35 years (P5.006), delay to partial or full weight bearing (P,.001), extension of the fracture in .2 zones (PM or MD) (P5.006), and presence of complex or intermediate

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Table 6

General Parameters by Fracture Morphology

Fracture Classication Variable Epidemiology No. (%) Median age (range), y No. men:women (ratio) Mechanism of injury, no. (%) Fall Sports Pedestrian accident Motorcycle accident Motor vehicle accident Treatment, no. (%) Conservativea Operative IMN External xation ORIF Median time to surgery (range), d Median hospital stay (range), d Rehabilitation and outcome, median (range) Time to union, wk Time of nonweight bearing, wk Time to partial weight bearing, wk Time to full weight bearing, wk Physiotherapy needed, wk Time to discharge, mo 22 (16-58) 4 (0-16) 6 (0-44) 12 (3-50) 8 (4-20) 7 (5-33) 24 (17-58) 4 (0-12) 5 (4-44) 13 (4-50) 6 (4-12) 8.5 (5-26) 22 (17-54) 2.5 (0-8) 4 (0-44) 10 (4-48) 8 (8-8) 7 (5-24) 22 (16-48) 6 (0-16) 6 (0-22) 12 (4-24) 8 (4-20) 7 (5-25) 28 (18-56) 6 (3-12) 8 (0-36) 20 (3-48) 18 (15-20) 11 (6-33) 18 (14.7) 104 (85.2) 82 (67.2) 19 (15.6) 3 (2.5) 1 (0-29) 7 (0-28) 0 24 18 3 3 2 (0-29) 9 (5-17) 8 26 28 2 0 1 (0-18) 6 (0-24) 10 46 28 14 0 1 (0-21) 6.5 (0-28) 0 8 8 0 0 1 (0-3) 7.5 (4-9) 61 (50) 31 (25.4) 16 (13.1) 9 (7.4) 5 (4.1) 10 7 2 3 2 19 11 3 1 0 26 12 10 5 3 6 1 1 0 0 122 (100) 32 (17-74) 89:33 (2.7) 24 (19.7) 28.5 (18-46) 19:5 (3.8) 34 (27.9) 32 (18-74) 29:5 (5.8) 56 (45.9) 32 (17-72) 36/20 (1.8) 8 (6.6) 36.5 (23-49) 5/3 (1.7) Total St Ss I C

Abbreviations: C, complex; I, intermediate; IMN, intramedullary nailing; ORIF, open reduction and internal xation; Ss, simple spiral; St, simple transverse. a Some fractures initially treated conservatively underwent operative xation at a later stage.

fracture morphology (P5.03). Notably, smoking status lay just outside the limit of statistical signicance (P,.05), but because smoking delays time to union,22-24 it was included in the parameters of the subsequent multivariable analysis (Table 9). Multivariable Analysis. The multivariable analysis focused on 2 targets: time to union and complications. To make a suitable adjustment for multiple factors, a multivariable regression was used. The

continuous variables of age and time to full weight bearing were grouped in the univariable analyses for simplicity, but were regarded as continuous for multivariable analysis. Regarding the correlation between Garnavos classication system categories and the occurrence of complications, multivariable analysis identied that the fracture extension in .1 zone increased the risk of complications (odds ratio53.64). Similarly, a complex mor-

phology doubled the risk of complications (odds ratio52.26), with signicance at the 7% level. The time to full weight bearing was included as a grouped variable because the effect on the complication rate was nonlinear. Thus, the subgroup of cases that progressed to full weight bearing between weeks 8 and 15 had a high risk of complications (odds ratio514.07) when compared with the early mobilization subgroup (Table 10).

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Further Notable Findings. Detailed analysis of the results revealed ndings indicating that the Garnavos classication system can be related to additional clinical parameters than those previously described. However, a larger sample of fractures is needed to prove the statistical strength of these ndings.
Mechanism of Injury: The majority of tibial shaft fractures related to sports, falls, and pedestrian injuries occurred in the MD zone, whereas fractures resulting from motor vehicle injuries were more evenly distributed in 3 zones (PM, M, MD). Six of 8 complex fractures resulted from a fall. l Treatment Method: Eleven of 14 fractures that occurred in the MD zone and were treated conservatively underwent operative xation at a later stage. Intramedullary nailing was the operative treatment of choice for all fractures that occurred in M zone, for 92.2% of fractures in the MD zone, and for all segmental fractures. External xation was used for half of the fractures that occurred in the D zone and for the majority of fractures with an intermediate morphology. l Rehabilitation Parameters: The median time of nonweight bearing was signicantly less (P,.05) for patients who sustained Ss fractures than those who sustained I and C fractures (2.5 vs 6 weeks, respectively). The time to full weight bearing was almost double for C fractures compared with St and Ss fractures (20 weeks vs 13 and 10 weeks, respectively). The duration of physiotherapy was signicantly prolonged for C fractures compared with St, Ss, and I fractures. l Complications: Sixteen of 19 delayed unions and all malunions occurred in MD fractures. In addition, delayed union occurred more often in St fractures (10/22). Half of the infections (6/12) occurred in the PM zone, whereas all pulmonary embolisms (n53) and fat embolisms (n53) were associated with M fractures. All proximal prominences of intramedullary nails occurred in D fractures.
l

Table 7

Complications by Fracture Topography

Fracture Classication, No. Complication Delayed unions Nonunion Malunion Infection Pulmonary embolism Fat embolism Compartment syndrome Loss of reduction, displacement Joint stiffness Anterior knee pain Proximal prominence Total No. (%) 19 (15.6) 3 (2.5) 8 (65.6) 12 (9.8) 3 (2.5) 3 (2.5) 12 (9.8) 15 (12.3) 3 (2.5) 15 (12.3) 3 (2.5) P 0 0 0 1 0 0 1 0 0 0 0 PM 2 2 0 6 0 0 3 1 0 5 0 M 1 0 0 0 3 1 3 0 1 2 0 MD 16 1 8 1 0 2 5 11 1 8 0 D 0 0 0 4 0 0 0 3 1 0 3 Segmental 2 0 0 2 0 0 1 0 0 0 0

Abbreviations: D, distal; M, middle; MD, middle to distal; P, proximal; PM, proximal to middle.

Table 8

Complications by Fracture Morphology

Fracture Classication, no. Complication Delayed union Nonunion Malunion Infection Pulmonary embolism Fat embolism Compartment syndrome Loss of reduction, displacement Joint stiffness Anterior knee pain Proximal prominence Total No. (%) 19 (15.6) 3 (2.5) 8 (65.6) 12 (9.8) 3 (2.5) 3 (2.5) 12 (9.8) 15 (12.3) 3 (2.5) 15 (12.3) 3 (2.5) St 8 2 0 3 0 0 3 0 0 0 0 Ss 5 1 0 2 3 0 0 3 0 2 0 I 4 0 5 5 0 3 6 12 3 13 3 C 2 0 3 2 0 0 3 0 0 0 0

Abbreviations: C, complex; I, intermediate; Ss, simple spiral; St, simple transverse.

DISCUSSION
Since its publication, the AO/OTA long-bone fracture classication system2 has been adopted by the majority of orthopedic surgeons and has gained worldwide acceptance for its usefulness in research. However, numerous studies agree that the

AO/OTA long-bone fracture classication system has signicant drawbacks, such as complexity and low reliability.3-6,8,9 Newey et al4 reported that the AO classication system is unnecessarily complicated and often falls short of playing a useful role in planning and management.

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Table 9

Univariable Analysis of Results

Time to Union, wk Variable Sex Male Female Age group, y 17-34 35-74 Smoking status Nonsmoker Smoker Initial treatment Conservative Surgical Treatment type Conservative External xation IMN ORIF Time to full weight bearing, wk 0-7 8-15 16-50 Fracture topography P PM M MD D P, M, or D PM or MD Fracture morphology I or C Ss or St 23.066.7 26.5610.5 t52.15 .03 32/5850.55 48/6450.75 z52.30 .02 19.062.0 24.6612.1 22.466.9 27.069.4 21.863.7 21.665.2 26.4610.1 t52.82 .006 F52.38 .06 1/650.17 13/1950.68 9/1750.53 46/6350.73 11/1750.65 21/4050.525 59/8250.72 z52.12 .03 x2(4)59.18 .06 22.464.0 22.265.6 30.6612.5 F513.63 ,.001 7/2150.33 52/6350.83 21/3850.55 x2(2)519.49 ,.001 23.162.8 26.9612.3 24.568.7 23.460.9 F50.53 .66 16/2250.73 59/8850.67 2/550.40 x2(3)53.63 .30 3/750.43 22.462.0 25.369.7 t51.25 .21 12/1850.66 68/10450.65 z50.11 .92 24.167.9 27.2611.8 t51.62 .11 59/9350.63 21/2950.72 z50.89 .37 23.067.5 27.6610.5 t52.81 .006 48/7450.65 32/4850.67 z50.02 .84 24.268.5 26.7610.4 t51.36 .18 32/8950.70 10/3350.64 z50.58 .56 Mean6SD Test P Proportion Complications Test P

Abbreviations: C, complex; D, distal; I, intermediate; IMN, intramedullary nailing; M, middle; MD, middle to distal; ORIF, open reduction and internal xation; P, proximal; PM, proximal to middle; Ss, simple spiral; St, simple transverse.

Johnstone et al3 reported that a high incidence of errors may occur when fractures are coded on an individual basis using this comprehensive system and variabil-

ity may exist when retrieving data from a computer for research purposes and for surgical audit. Martin and Marsh8 reported that the observer agreement for this sys-

tem drops to unacceptable standards at the group and subgroup levels and that further study is warranted to determine how this agreement can be improved. Garbuz et al9

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Table 10

Multivariable Analysis of Results

Variable Time to union Age Smoking status Time to full weight bearing PM or MD topography I or C morphology Complications Time to full weight bearing PM or MD topography I or C morphology 14.07 3.64 2.26 9.09 1.85 1.02 4.10 2.54 1.81 .000 .011 .07 3.97 to 49.88 1.35 to 9.84 0.93 to 5.46 0.084 2.82 0.731 1.8 0.14 0.044 1.36 0.071 1.26 1.18 1.92 2.07 10.35 1.43 0.12 .057 .04 .000 .156 .904 20.003 to 0.171 0.12 to 5.52 0.59 to 0.87 20.7 to 4.29 22.2 to 2.48 Coefcient Standard Error t P.(t) 95% CI

Abbreviations: C, complex; CI, condence interval; I, intermediate; MD, middle to distal; PM, proximal to middle.

identied classication systems in orthopedics that have been properly tested for their reliability, but the AO-Mller and AO/OTA classications for long-bones fractures were not included. They reported that many classication systems have been published and widely adopted in orthopedics without enough information available on their reliability.9 Revisions of the AO-Mller fracture classication system introduced by the compendium of the OTA consisted of the reorganization of the alphanumeric codes to offer a universal system for classifying different anatomical sites.2-7,9,10 Nonetheless, the original concept of the AO-Mller system is maintained, along with its weaknesses. Audige et al12 described a comprehensive staged concept for validating a classication system before its general clinical application. The rst phase of the validation pathway included the classication proposal and pilot agreement studies, and the next 2 phases consisted of multicenter agreement studies and clinical studies to assess the clinical relevance and usefulness of the proposed system.12 The recent compendium of the OTA committee of experts reafrmed this staged approach of introducing any novel classication

system under the contemporary demand for evidence-based medicine.10 Following these suggestions, the current study introduces the new classication system by describing, statistically testing, and clinically validating it. Statistical analysis revealed improved inter- and intraobserver variation agreement (constant improvement of at least 1 level), and therefore better reliability, of the Garnavos classication system compared with the AO/OTA classication system. Use of the k value for assessment of inter- and intrarater agreement is well established in the medical literature. A difference by 1 level of the k value is considered signicant, as well as the consistency of this nding in all pairs that were compared.13,14 No statistically signicant differences existed between trained and trainee observers regarding the agreement of each classication system. The time needed for classifying the fractures with the Garnavos classication system during both attempts separated by at least 2 weeks was signicantly less compared with the time needed for classifying the same fractures during the same sessions with the AO/OTA classication system, a strong indication that the new

system is less complicated and easier to memorize. This nding is of signicant importance in the routine clinical practice of modern trauma. A reliable and easyto-remember classication system helps communication signicantly. For clinical validation, the Garnavos classication system was applied to a representative sample of long-bone diaphyseal fractures. The application was easy and swift due to its descriptive nature. This characteristic is well recognized in the literature as an advantage of all descriptive classication systems when compared with hierarchical enumeration coding systems. The univariable and multivariable analyses of clinical data revealed signicant statistical correlation of the Garnavos classication system with important clinical parameters, such as time to union and complication rates. It has been shown that time to union and general complication rates are related to specic groups of the new classication system. Furthermore, strong evidence existed that more clinical parameters are related to the new classication system, but a larger dataset is required for statistical conrmation. According to this evidence, conservative treatment may not be a good option for fractures occurring in

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the MD zone because 11 of 14 fractures in this zone that were treated conservatively underwent operative treatment at a later stage. Intramedullary nailing was the operative treatment of choice for all fractures in the M zone and most fractures in the MD zone, a nding that likely reects the current treatment policy of the specic trauma center, which is consistent with the contemporary literature.20 Problems with vascularity and poor soft tissue envelope in the MD zone may be responsible factors for .80% of delayed unions (16/19) and all malunions (8) occurring in this zone. This nding is consistent with other reports that relate these complications mostly with the middle area of the tibial shaft. Moreover, delayed union appears to be more associated with the St fracture morphology (10/22), which may be due to the limited contact surface of bony fragments. Half of the infections (6/12) occurred in the PM zone, which also could be associated with the specic vascular or anatomic features of this zone, the application of external xation pins, or the development of compartment syndrome and subsequent fasciotomies. Another interesting nding is that all proximal prominences of an intramedullary nail occurred in D fractures. A logical explanation is that in distal fractures, the surgeon uses the longest nail that can go as distal as possible to secure the fracture. Therefore, the nail may be prominent at the knee immediately postoperatively or postdynamization. All pulmonary embolisms (n53) and all fat embolisms (n53) were associated with M fractures. Conrmation of this nding with a larger dataset could dictate a change in future anticoagulant strategy. Finally, 6 of 8 complex fractures happened after a fall and not after a motor collision or road trafc accident. However, open fractures or fractures with severe soft tissue damage were excluded from the study. A major limitation of the current study is the relative small sample size for clinical validation. However, this sample, includ-

ing all consequent tibial shaft fractures admitted in a large Level I trauma center over 3 years, constituted the material for a pilot study according to the criteria set by Audige et al.12 A validation study with an adequate number of cases is warranted. The current study does not represent an effort to describe and assess all treatment options and outcome patterns of closed tibial diaphyseal fractures and has the weaknesses of all retrospective studies. Moreover, fractures extending to adjacent joints, open fractures, polytrauma patients, and injuries with signicant compromise of the soft tissues or associated injuries that would potentially inuence the outcome of the tibial fractures were excluded. Thus, the indications of using the proposed classication system were not exhausted. The exclusion of open fractures and cases with signicant soft tissue injury was dictated by the fact that the new classication system refers strictly to the element of bony injury. It aims to aid communication between clinicians, indicate treatment options, and predict the outcomes of long-bone fractures. For a more comprehensive description of bony and soft tissue injury, the Garnavos classication system should be combined with the well-established classication systems introduced by Gustilo and Anderson25 and Gustilo et al26 for open fractures or by Tscherne and Gotzen15 for closed fractures. Simple transformation of the investigated clinical parameters, such as square root or logarithm, were attempted to improve variance stability. However, interpretation of the coefcient became more complicated. This led to the use of broader topographic and morphologic categories for multivariable analysis. The overall occurrence of complications was considerably high due to the fact that even minor complications were included. In addition, some patients experienced .1 complication. With these concessions, the topography and morphology of the tibial shaft

fractures, as described by the Garnavos classication system, were proven to be signicant predictors of complication rates and time to union, together with patient age and smoking status. A larger, multicenter prospective study is justied and may reveal the comprehensive statistical signicance of the new classication system. It has been suggested that 2 classication systems are needed for long-bone fractures: 1 for clinical use and 1 for research purposes.27 This will provide access to all data required for research without burdening the clinician with details he or she cannot use. If the AO/OTA classication of long-bone fractures provides the basis for a general classication for research, the Garnavos classication system may meet the need for a clinically oriented classication system with a high degree of reliability, memorability, and clinical relevance.

CONCLUSION
The Garnavos classication system for diaphyseal long-bone fractures was found to be easily applicable in a clinical setting. Further research should be conducted in the form of prospective, multicenter, observational agreement studies for the completion of the validation process, something that, to our knowledge, has never been undertaken for any existing classication systems.

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22. Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop Relat Res. 1999; 36(5):184-200. 23. Harvey EJ, Agel J, Selznick HS, Chapman JR, Henley MB. Deleterious effect of smoking on healing of open tibia-shaft fractures. Am J Orthop (Belle Mead NJ). 2002; 31(9):518-521. 24. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM. Impact of smoking on fracture healing and risk of complications in limbthreatening open tibia fractures. J Orthop Trauma. 2005; 19(3):151-157. 25. Gustilo RB, Anderson JT. Prevention of in fection in the treatment of one thousand and twenty-ve open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58(4):453-458. 26. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classication of type III open fractures. J Trauma. 1984; 24(8):742-746. 27. Bernstein J, Monaghan BA, Silber JS, DeLong WG. Taxonomy and treatmenta classication of fracture classications. J Bone Joint Surg Br. 1997; 79(5):706-707.

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