Keltz E, Keshet D, Peled E, Zvi Y, Norman D, Keren Y. Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models. World J Orthop 2021; 12(2): 82-93 [PMID: 33614427 DOI: 10.5312/wjo.v12.i2.82]
Corresponding Author of This Article
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
Research Domain of This Article
Orthopedics
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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/
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
ARTICLE HIGHLIGHTS
Research background
There are numerous studies examining the reliability of the Judet-Letounel classification system for acetabular fractures using traditional radiographs and computed tomography (CT). However, 3-dimensional (3-D) printing is an emerging technology that hasn't been thoroughly investigated in the field of orthopedics in terms of imaging and pre-operative planning.
Research motivation
We evaluated the intra and inter-observer reliability of the Judet-Letournel classification system, with respect to fracture classification and preferred surgical approach. We compared the use of 3-D printed models of acetabular fractures to the current standard use of CT scans.
Research objectives
The study aims to illustrate the added value of 3-D printed models as a reliable method to more accurately characterize a patient’s acetabular fracture, and aid in the decision regarding the preferred surgical approach.
Research methods
Seven patients with acetabular fractures underwent a CT scan with 3-D reconstructions. We then created 3-D printed models of the fractured acetabula. Eighteen trauma surgeons were surveyed to classify each fracture and identify their preferred surgical approach, on two separate occasions, using one of each imaging modality alone.
Research results
The inter-observer agreement regarding fracture classification based on CT and 3-D printed models was moderate for both: κ = 0.44 (SE range: 0.0-0.24), and κ = 0.55 (SE range: 0.0-0.22), respectively; this difference was statistically significant (P < 0.001). The inter-observer agreement regarding the preferred surgical approach based on CT and 3-D printed models was fair for both: κ = 0.34, and κ = 0.29 (SE range: 0.0-0.39), respectively; this difference was statistically significant (P < 0.005). The intra-observer agreement regarding fracture classification among all 18 surgeons when comparing the two imaging modalities was moderate: κ = 0.48, as for the preferred surgical approach: κ = 0.41.
Research conclusions
3-D printed models improve the inter-observer reliability of the Judet-Letournel classification system, when compared to the use of standard CT scans. However, the inter-observer agreement regarding the surgical approach was decreased, likely due to the added perspective and visualization of the fractures.
Research perspectives
3-D printed models improve visuospatial understanding of complex fractures. Its utility and contribution for better patient outcomes should be investigated in future prospective randomized controlled trials.
