Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Feb 18, 2021; 12(2): 82-93
Published online Feb 18, 2021. doi: 10.5312/wjo.v12.i2.82
Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models
Eran Keltz, Doron Keshet, Eli Peled, Yoav Zvi, Doron Norman, Yaniv Keren
Eran Keltz, Doron Keshet, Eli Peled, Doron Norman, Yaniv Keren, Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
Eran Keltz, Doron Keshet, Eli Peled, Doron Norman, Yaniv Keren, Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
Yoav Zvi, Department of Orthopaedic Surgery, Montefiore Medical Center, New York, NY 10461, United States
Author contributions: Keltz E drafted the manuscript; Keshet D participated in study design, data collection and analysis, and was the coordinator of this multicenter research; Keren Y initiated the study, designed it and supervised it; Peled E and Norman D contributed in collecting cases and providing consultation; Zvi Y assisted in coordinating the multicenter logistics and drafting the manuscript.
Institutional review board statement: The study was reviewed and approved by the Rambam Health Care Campus Institutional Review Board (Approval No. 0560-14-RMB).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All authors declare that they did not receive any funding in any form for this study and related topics. There is no conflict of interest what so ever.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at erankeltz@gmail.com. Participants consent for data sharing was not obtained but the presented data are anonymized and risk of identification is low.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Eran Keltz, MD, Attending Doctor, Surgeon, Division of Orthopedic Surgery, Rambam Health Care Campus, Ha'Aliya Ha'Shniya 8, Haifa 3525408, Israel. erankeltz@gmail.com
Received: August 6, 2020
Peer-review started: August 6, 2020
First decision: December 3, 2020
Revised: December 8, 2020
Accepted: December 16, 2020
Article in press: December 16, 2020
Published online: February 18, 2021
Processing time: 180 Days and 17.2 Hours
Abstract
BACKGROUND

Acetabular fractures pose diagnostic and surgical challenges. They are classified using the Judet-Letournel system, which is based solely on X-ray. However, computed tomography (CT) imaging is now more widely utilized in diagnosing these injuries. The emergence of 3-dimensional (3-D) printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan pre-operatively.

AIM

To evaluate the reliability of the Judet-Letournel classification system of acetabular fractures, when using either CT imaging or 3-D printed models.

METHODS

Seven patients with acetabular fractures underwent pelvic CT imaging, which was then used to create solid, 3-D printed models. Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach. The same questionnaire was completed using only CT imaging, and two weeks later, using only 3-D printed models. The inter- and intra-observer agreement rates were then analyzed.

RESULTS

Inter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification: κ = 0.44, κ = 0.55, respectively (P < 0.001) and fair for preferred surgical approach: κ = 0.34, κ = 0.29, respectively (P < 0.005). Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate: κ = 0.48, κ = 0.41, respectively. No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists.

CONCLUSION

The Judet-Letournel classification demonstrated only moderate rates of agreement. The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification, but decreased it with respect to the preferred surgical approach. This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries, thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.

Keywords: Acetabulum; Pelvic trauma; Acetabular fracture; Three-dimensional printing; Three-dimensional reconstruction; Judet-Letournel

Core Tip: Three-dimensional (3-D) imaging and printing is an emerging technique in the field of orthopedic surgery. This study highlights the utility of 3-D printing in the treatment of complex acetabular fractures, as it relates to the traditionally used Judet-Letournel classification and the accustomed surgical approaches.