Objective assessment of aesthetic outcome after breast conserving therapy: subjective third party panel rating and objective BCCT.core software evaluation

We analysed intra- and inter-rater agreement of subjective third party assessment and agreement with a semi-automated objective software evaluation tool (BCCT.core). We presented standardized photographs of 50 patients, taken shortly and one year after surgery to a panel of five breast surgeons, six breast nurses, seven members of a breast cancer support group, five medical and seven non-medical students. In two turns they rated aesthetic outcome on a four point scale. Moreover the same photographs were evaluated by the BCCT.core software. Intra-rater agreement in the panel members was moderate to substantial (k = 0.4-0.5; wk = 0.6-0.7; according to different subgroups and times of assessment). In contrast inter-rater agreement was only slight to fair (mk = 0.1-0.3). Agreement between the panel participants and the software was fair (wk = 0.24-0.45). Subjective third party assessment only fairly agree with objective BCCT.core evaluation just as third party participants do not agree well among each other.     

Aesthetics in Breast Conserving Therapy: Do Objectively Measured Results Match Patients’ Evaluations?

Background

To analyze the relationship of objective and subjective evaluation tools of breast aesthetics, we compare the results of the BCCT.core (breast cancer conservative treatment.cosmetic results) software, a semiautomated objective symmetry evaluation tool, with those of the Aesthetic Status of the BCTOS (Breast Cancer Treatment Outcome Scale) patient questionnaire.

Materials and Methods

We included 128 patients with one-sided, primary breast cancer, treated conservatively in a prospective, exploratory study in order to assess the inter-rater reliability of the BCCT.core and the agreement between the BCCT.core and the BCTOS preoperatively, shortly and 1 year after surgery. Therefore, we use agreement rates, multiple (mk), and weighted (wk) kappa coefficients as statistical methods. Furthermore, we analyzed patient-, tumor-, and therapy-related variables as possible covariates to explain agreement.

Results

The inter-rater reliability for the semiautomated BCCT.core is very good with agreement rates up to 84% (mk = 0.80). The agreement rates of the BCCT.core and the BCTOS Aesthetic Status range between 35 and 44% subject to the different times of assessment (wk = 0.34 at best). Moreover, the patients judge their aesthetic outcome more positively than the software. None of the considered patient-, tumor-, and therapy-related covariates turned out to explain agreement.

Conclusion

The BCCT.core is a reliable instrument that shows fair agreement with patient’s perspective.     

Evaluation of cosmetic outcome following breast‐conserving therapy in trials: panel versus digitalized analysis and the role of PROMs

Cosmetic outcome is an important quality of life‐related end point following breast‐conserving therapy (BCT). To advise on a gold standard, we compare cosmetic outcome evaluated by panel and an objective evaluation (BCCT.core software). Second, patient‐reported outcome measures (PROMs) are compared to cosmetic outcome evaluation by panel and BCCT.core. Sixty‐eight breast cancer patients were included following BCT between 2007 and 2012. Two independent 6‐member panels and two observers using the BCCT.core evaluated cosmetic outcome. First, reproducibility, repeatability, and relatedness of panel and BCCT.core were analyzed using the interclass correlation coefficient (ICC). Second, the association between panel/BCCT.core with PROMs (EORTC‐QLQ‐C30/BR23, EQ‐5D‐5L, and BREAST‐Q) was analyzed with a linear regression and the goodness of fit by the R². Both panel and BCCT.core evaluations showed “excellent” intraobserver agreement (ICC 0.93 [95% CI: 0.83; 0.97] and 0.93 [95% CI: 0.84; 0.97]) for respectively panel 1 and BCCT.core 1 and “excellent” interobserver agreement (ICC 0.94 [95% CI: 0.90; 0.96] and 0.85 [95% CI: 0.77; 0.91]) respectively for panel and BCCT.core. Association between panel and BCCT.core varied, ICC 0.59‐0.69. Only the PROM BREAST‐Q showed a significant association with both panel evaluations and BCCT.core observers (panel 1 and BCCT.core 1; R² of .157 [P = .002] and .178 [P = .001]). Both panel and BCCT.core showed comparable “excellent” intraobserver and interobserver agreement. For future trials evaluating cosmetic outcome following BCT, one of those can be chosen. Solely, the PROM BREAST‐Q showed a significant association with panel and/or BCCT.core evaluation. To enable standardized cosmetic outcome evaluation and corresponding patient satisfaction in future trials, at least the BREAST‐Q should be combined with a panel or BCCT.core evaluation.     

Turning subjective into objective: the BCCT.core software for evaluation of cosmetic results in breast cancer conservative treatment

Twelve expert observers from nine different countries convened in a workshop to evaluate the validity of the Breast Cancer Conservative Treatment. Cosmetic results (BCCT.core) software, an objective method for the aesthetic evaluation of breast cancer conservative treatment. Experts were initially asked to subjectively classify the aesthetic results of 30 photographed cases submitted to breast cancer conservative treatment according to the four-point Harris scale. It was pre-established that if at least two-thirds [Cardoso MJ, Cardoso J, Santos AC, Barros H, Oliveira MC. Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer. Breast 2005] of participants provided the same classification this would be considered a consensual evaluation for that case. For cases where such agreement was not reached, consensus was obtained using a nominal group technique. Experts then individually performed objective evaluation of the same set of photographs using the BCCT.core software. This provides an automatic rating of aesthetic results, once scale and reference points in the photograph have been chosen. Agreement between observers, between each observer and the consensus, for computer evaluation obtained by the different participants and between software and consensus was calculated using multiple kappa (k) and weighted kappa (wk) statistics. In the subjective assessment, first-round consensus was achieved in 17 (57%) cases. Overall interobserver agreement was fair to moderate (k=0.40, wk=0.57). In the objective assessment there was a higher level of concordance between participants (k=0.86, wk=0.90). Agreement between software and consensus classification was fair (k=0.34, wk=0.53), but was higher in the 17 cases that reached first-round consensus (k=0.60, wk=0.73). Merging the two middle classes of the Harris scale, to form a three-point scale, led to an improvement of all non-weighted measures of agreement. These results show that the BCCT.core software provides consistent evaluation of cosmesis. It has the potential to become a gold standard method for assessment of breast cosmesis in clinical trials, as it can be used simultaneously by a panel of observers from different parts of the world to provide more reliable assessments than has been possible previously.     

Nipple malposition after bilateral nipple‐sparing mastectomy with implant‐based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software

Nipple‐sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912‐0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.     

BCCT.core - can a computer program be used for the assessment of aesthetic outcome after breast reconstructive surgery?

Aesthetic outcome is as an important endpoint of breast cancer treatment and is associated with better psychological recovery and improved quality of life. Researchers in Portugal have developed a computerised program, BCCT.core, to objectively assess aesthetic outcome of conservation breast treatment photographs. This study aimed to investigate the correlation between the Harris Scale and the BCCT.core program in patients who have undergone mastectomy and reconstruction for breast cancer. 67 cases were assessed by five independent assessors using the Harris Scale and compared with BCCT.core software. Correlation between BCCT.core and the Harris Scale was significant for all cases (r = 0.66, p < 0.01, n = 67), unilateral cases (r = 0.70, p < 0.01, n = 50), implant reconstruction cases (r = 0.72 p < 0.01, n = 28) and latissimus dorsi flap reconstruction cases (r = 0.74, p < 0.01, n = 23). BCCT.core demonstrated correlation with the Harris Scale for measuring aesthetic outcome for unilateral surgery and suggests potential use for BCCT.core to measure aesthetics for breast reconstruction after mastectomy.     

The ICI classification for calcaneal injuries: a validation study

IntroductionThe integral classification of injuries (ICI), by Zwipp et al. has been developed as a classification system for injuries of the bones, joints, cartilage and ligaments of the foot. It follows the principles of the comprehensive classification of fractures by Müller et al. The ICI was developed for ‘everyday use’ and scientific purposes. Our aim was to perform a validation study for this classification system applied to the calcaneal injuries.MethodsA panel of five experienced trauma and orthopaedic surgeons evaluated the ICI score in 20 calcaneal injuries. After 2 months, a second classification was performed in a different order. Inter- and intra-observer variability were evaluated by kappa statistics.ResultsPanel members were not able to evaluate capsule and ligamental injuries based on X-ray and computed tomography (CT) films. Two injuries were excluded for logistical reasons. The inter-observer agreement based on 18 injuries of bone and joints was slight; kappa 0.14 (90% confidence interval (CI): 0.05–0.22). The intra-observer agreement was fair; kappa 0.31 (90% CI: 0.22–0.41). Overall, the panel rated the system as very complicated and not practical.ConclusionThe ICI is a complicated classification system with slight to fair inter- and intra-observer variabilities. It might not be a practical classification system for calcaneal injuries in ‘everyday use’ or scientific purposes.     

Assessment of interobserver variation in Garden classification and management of fresh intracapsular femoral neck fracture in adults

Objective： To assess the interobserver agreement on Garden classification of fresh femoral neck fracture and management plan based on anteroposterior （AP） view and also assess if the addition of lateral view changes the classification and management plan. Methods： Ten orthopaedic surgeons were asked to classify 35 femoral neck fractures on AP view only and propose the management plan. Then the same films were reshown in conjunction with their lateral view after 10 days. Results were compared with respect to the classification and management plan between two groups. Interobserver agreement was calculated using Fleiss＇ kappa. Results： There was only a fair interobserver agreement （kappa value 0.39） on Garden classification on AP view only which improved to moderate agreement （kappa value 0.52） after adding a lateral view. While there was only a slight improvement in the interobserver agreement on the management plan on AP view only （kappa value 0.50） and AP combined with lateral views （kappa value 0.52）. Supplementation of the lateral view changed the classification in 15.42% of the cases and altered the management plan in 23.14% of the cases. Conclusion： We conclude that lateral view should be obtained routinely on all patients with suspected femoral neck fracture as it definitely has a role in planning treatment of femoral neck fracture.     

Objective breast symmetry evaluation using 3-D surface imaging

This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910^® scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice.     

The acetabulum in Perthes’ disease: Inter-observer agreement and reliability of radiographic measurements

Background and purpose — Perthes’ disease leads to radiographic changes in both the femoral head and the acetabulum. We investigated the inter-observer agreement and reliability of 4 radiographic measurements assessing the acetabular changes.

Patients and methods — We included 123 children with unilateral involvement, femoral head necrosis of more than 50%, and age at diagnosis of 6 years or older. Radiographs were taken at onset, and 1 year and 5 years after diagnosis. Sharp’s angle, acetabular depth-width ratio (ADR), lateral acetabular inclination (LAI), and acetabular retroversion (ischial spine sign, ISS) were measured by 3 observers. Before measuring, 2 of the observers had a consensus meeting.

Results — We found good agreement and moderate to excellent reliability for Sharp’s angle for all observers (intra-class correlation coefficient (ICC) > 0.80 with consensus, ICC = 0.46–0.57 without consensus). There was good agreement and substantial reliability for ADR between the observers who had had a consensus meeting (ICC = 0.62–0.89). Low levels of agreement and poor reliability were found for observers who had not had a consensus meeting. LAI showed fair agreement throughout the course of the disease (kappa = 0.28–0.52). The agreement between observations for ISS ranged from fair to good (kappa = 0.20–0.76).

Interpretation — Sharp’s angle showed the highest reliability and agreement throughout the course of the disease. ADR was only reliable and showed good agreement between the observers when landmarks were clarified before measuring the radiographs. Thus, we recommend both parameters in clinical practice, provided a consensus is established for ADR. The observations for LAI had only fair agreement and ISS showed inconclusive agreement in our study. Thus, LAI and ISS can hardly be recommended in clinical practice.     

Is the Robinson classification of clavicle fractures accurate enough within the setting of the Swedish Fracture Register?

IntroductionIn the Swedish Fracture Register (SFR) clavicle fractures are classified according to the Robinson classification. This study aimed to evaluate the accuracy of the classification of clavicle fractures in the SFR. A secondary aim was to assess inter- and intraobserver agreement.Materials and MethodsClavicle fractures (n = 132) were randomly selected from the SFR and radiographs were requested for each patient from their treating departments. Not all radiographs could be acquired, and after exclusion, 115 fractures were independently classified by three expert raters blinded to patient information. The 115 fractures were classified on two occasions, 3 months apart. The raters’ consensus classification was used as a gold standard that was compared to the classification registered in the SFR. The accuracy, defined as the degree of agreement between the gold standard and SFR classifications, was reported, as was the inter- and intraobserver agreement for the expert raters.ResultsAgreement between the classification in the SFR and the gold standard classification was fair (kappa = 0.35). Fractures with only partial displacement were often incorrectly classified as fully displaced in the SFR (n = 31 of 78 displaced fractures in the SFR). The inter- and intraobserver agreement among the expert raters was almost perfect (interobserver kappa = 0.81–0.87, intraobserver kappa = 0.84–0.94).ConclusionsThe accuracy of the classification of clavicle fractures in the SFR was only fair, whereas the inter- and intraobserver agreement among the expert raters was almost perfect. Accuracy in the SFR may be improved if the classification instructions in the SFR are updated by incorporating the original classification displacement criteria, both in text and in illustrated form.     

3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures

The Neer and AO fracture classifications for fractures of the proximal humerus have shown poor reproducibility based on plain radiography. We wanted to investigate whether the addition of 3-dimensional (3D) reconstructions would increase the reproducibility of classification. 7 observers independently classified 24 fractures of the proximal humerus using both plain radiographs, CT and 3D and the classification was repeated 2 months later. There was a moderate interobserver agreement when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a mean kappa value of 0.44 and the AO had a value of 0.32 for the first assessment. In the second assessment, the mean kappa values were 0.49 and 0.34, respectively. Intraobserver reproducibility was fair to substantial agreement for Neer (kappa range 0.27-0.73) and for AO (kappa range 0.29-0.74). In conclusion, the addition of CT and 3D to plain radiographs did not improve the reproducibility of the classifications of Neer and AO of the proximal humerus.     

Improved Interobserver Reliability of the Sanders Classification in Calcaneal Fractures Using Segmented Three-Dimensional Prints

We examined the added value of 3-dimensional (3D) prints in improving the interobserver reliability of the Sanders classification of displaced intraarticular calcaneal fractures. Twenty-four observers (radiologists, trainees, and foot surgeons) were asked to rate 2-dimensional (2D) computed tomography images and 3D prints of a series of 11 fractures, selected from cases treatment at our level I trauma center between 2014 and 2016. The interobserver reliability for the Sanders classification was assessed using kappa coefficients. Three versions of the Sanders classification were considered: Sanders classification with subclasses, Sanders classification without subclasses, and the combination of Sanders types III and IV because of the high incidence of comminution in both types. The reference standard for classification was the perioperative findings by a single surgeon. The 3D print always yielded higher values for agreement and chance-corrected agreement. The Brennan-Prediger–weighted kappa equaled 0.35 for the 2D views and 0.63 for the 3D prints for the Sanders classification with subclasses (p?=?.004), 0.55 (2D) and 0.76 (3D) for the classification without subclasses (p?=?.003), and 0.58 (2D) and 0.78 (3D) for the fusion of Sanders types III and IV (p?=?.027). Greater agreement was also found between the perioperative evaluation and the 3D prints (88% versus 65% for the 2D views; p?<?.0001). However, a greater percentage of Sanders type III-IV were classified with 2D than with 3D (56% versus 32%; p?<?.0001). The interobserver agreement for the evaluation of calcaneal fractures was improved with the use of 3D prints after “digital disarticulation.”     

Inter-rater reliability of an arthritic glenoid morphology classification system

To our knowledge, no independent analysis of the inter-rater agreement of the widely used Walch classification for osteoarthritic glenoid morphology has been performed. The computed tomography scans of 24 shoulders with primary osteoarthritis were used by 4 experienced shoulder surgeons to classify the glenoids independently according to Walch et al. The weighted kappa statistic was calculated to determine the inter-rater and intrarater agreement among observers. The overall inter-rater agreement for the Walch classification was fair (kappa = 0.37) when classified into the 5 types (A1, A2, B1, B2, and C). Agreement for the various subclassifications was as follows: A1, kappa = 0.22; A2, kappa = 0.33; B1, kappa = 0.17; B2, kappa = 0.32; and C, kappa = 0.86. When the classification system was simplified to just the 3 major types (A, B, and C), overall agreement was moderate (kappa = 0.44). Agreement for each type was moderate for A (kappa = 0.59) and B (kappa = 0.59) and almost perfect for C (kappa = 0.89). Overall intrarater agreement was fair (kappa = 0.37). We conclude that only fair agreement was found among experienced shoulder surgeons when classifying arthritic shoulders using the classification system of Walch et al. A glenoid classification scheme that relies more upon glenoid morphology and less upon humeral head position may demonstrate greater observer agreement and, therefore, may offer greater value.     

Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures

IntroductionTibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT).Materials and MethodsEighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch.ResultsOverall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (k_Schatzker = 0.32 and k_Luo = 0.28, P = 0.021), however, ‘fair’ for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k_2DCT = 0.37 and k_2D+3DCT = 0.29, P < 0.001). The addition of 3DCT did not improve the overall interobserver reliability for the Luo classification as well, as kappa values were not significantly different on 2DCT and 2D- and 3DCT (k_2DCT = 0.31 and k_2D+3DCT = 0.25, P = 0.096).ConclusionsThe agreement between observers was significantly better for the Schatzker classification compared to Luo's Three Column classification, however agreement was fair for both classification systems. Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. Considering that new classification systems and 3DCT do not seem to improve agreement between surgeons, other efforts are needed that lead to more reliable diagnosis of complex tibial plateau fractures.     

External validation of the recommendations of the multidisciplinary consensus about inhaled therapies

The understanding of physicians and the skill of patients in the use of inhalers continues to be inadequate.ObjectiveThe external validation, by an expert panel, of practical clinical recommendations that had been developed in order to improve the knowledge and understanding of correct inhaled therapy use.MethodsAfter a bibliographic review about inhaled therapies, 40 clinical recommendations were proposed. A two-round modified Delphi consensus was used to compare the opinions of a panel of 59 experts about the recommendations, which were grouped into 8 areas: general aspects (4), inhaled drugs (9), pressurized metered-dose and spacer inhalers (6), powder inhalers (4), nebulizers (3), devices for mechanical ventilation (3), inhalers for children (5) and issues related with compliance and education (6).ResultsAfter the first round of the consensus panel, 35 of the 40 recommendations analyzed were accepted. At the end of round 2, agreement was reached in 39 (97.5%). In 8 (20%), the consensus was unanimous (100%). Item 14 was deleted from the recommendations as consensus was not reached.ConclusionsThe external validation by experts in inhaled therapy found a high level of agreement with the clinical recommendations proposed. This consensus provides a tool that could contribute to the improved use of inhalers in our country in the future.     

Management of Patients with Advanced Prostate Cancer. Part I: Intermediate-/High-risk and Locally Advanced Disease,Biochemical Relapse,and Side Effects of Hormonal Treatment: Report of the Advanced Prostate Cancer Consensus Conference 2022

BackgroundInnovations in imaging and molecular characterisation and the evolution of new therapies have improved outcomes in advanced prostate cancer. Nonetheless, we continue to lack high-level evidence on a variety of clinical topics that greatly impact daily practice. To supplement evidence-based guidelines, the 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed experts about key dilemmas in clinical management.ObjectiveTo present consensus voting results for select questions from APCCC 2022.Design, setting, and participantsBefore the conference, a panel of 117 international prostate cancer experts used a modified Delphi process to develop 198 multiple-choice consensus questions on (1) intermediate- and high-risk and locally advanced prostate cancer, (2) biochemical recurrence after local treatment, (3) side effects from hormonal therapies, (4) metastatic hormone-sensitive prostate cancer, (5) nonmetastatic castration-resistant prostate cancer, (6) metastatic castration-resistant prostate cancer, and (7) oligometastatic and oligoprogressive prostate cancer. Before the conference, these questions were administered via a web-based survey to the 105 physician panel members (“panellists”) who directly engage in prostate cancer treatment decision-making. Herein, we present results for the 82 questions on topics 1–3.Outcome measurements and statistical analysisConsensus was defined as ≥75% agreement, with strong consensus defined as ≥90% agreement.Results and limitationsThe voting results reveal varying degrees of consensus, as is discussed in this article and shown in the detailed results in the Supplementary material. The findings reflect the opinions of an international panel of experts and did not incorporate a formal literature review and meta-analysis.ConclusionsThese voting results by a panel of international experts in advanced prostate cancer can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers prioritise areas for future research. Diagnostic and treatment decisions should always be individualised based on patient and cancer characteristics (disease extent and location, treatment history, comorbidities, and patient preferences) and should incorporate current and emerging clinical evidence, therapeutic guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2022 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.Patient summaryThe Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with health care providers and patients worldwide. At each APCCC, a panel of physician experts vote in response to multiple-choice questions about their clinical opinions and approaches to managing advanced prostate cancer. This report presents voting results for the subset of questions pertaining to intermediate- and high-risk and locally advanced prostate cancer, biochemical relapse after definitive treatment, advanced (next-generation) imaging, and management of side effects caused by hormonal therapies. The results provide a practical guide to help clinicians and patients discuss treatment options as part of shared multidisciplinary decision-making. The findings may be especially useful when there is little or no high-level evidence to guide treatment decisions.     

What is the value of 3D virtual reality in understanding acetabular fractures?

Background

Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns.

Methods

A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet–Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss’ kappa statistics (κ).

Results

Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42).

Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000).

Conclusions

The Judet–Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

     

Three dimensional (3D) modelling and surgical planning in trauma and orthopaedics

IntroductionThree dimensional (3D) modelling facilitates visualization, manipulation, and analysis of image data, the three dimensional format of such image, allows a better appreciation of the geometry, size, and exact relationship between diseased and normal tissue. The role in orthopaedic surgical planning is highlighted.DiscussionSurgical procedures in orthopaedics and trauma rely on imaging, which in addition to making the diagnosis also assist in planning the elected surgical procedure through to a successful execution.In the area of trauma management, the use of 3D modelling eases the execution of fracture operative approach, reduction and appropriate fixation, especially in complex fractures, like in the acetabulum. Post trauma correction of deformities is made easier using 3D modelling in the preoperative surgical planning.For the purposes of tumour excision, a more acceptable margin of excision can be planned and successfully implemented.There is an increasing role for computer assisted procedures in arthroplasty, the use of a 3D image for preoperative planning promises to deliver patient specific bone cut in dimensions that will allow less of inappropriate loading thereby promoting longevity of the implant especially in younger patients.ConclusionThe processes for acquiring 3D images need to be made simpler and easier to gain more widespread use in orthopaedics and trauma.     

Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery

BackgroundSanders classification, based on the number of displaced fractured fragments of posterior facet, can predict the prognosis of calcaneal intraarticular fractures. The aim of the study was assessing not only intraobserver reproducibility and interobserver reliability of Sanders classification but also the agreement between preoperative reported types based on computed tomography (CT) scan and direct observation during the surgery.MethodsIn this cross-sectional study, preoperative CT scans of 100 patients with intra-articular calcaneal fracture operated by a single surgeon were studied by two orthopedic and trauma surgeons (A & B), twice with an interval of three weeks. Their result were compared with each other and with the number of displaced fractured fragments recorded in the operation notes. Quadratic weighted kappa test was used to check the agreement between two observers and between the observers and the surgeon.ResultsIntraobserver reproducibility for Sanders classification of intraarticular calcaneal fractures was found to be good to excellent (A1–A2: 0.91 and B1–B2: 0.75). There was a moderate agreement between the two observers (A1–B1: 0.56, A1–B2:0.58, A2–B1:0.48, and A2–B2:0.51). The agreement between reported types of Sanders classification and the number of displaced fractured fragments seen during the surgery was fair (A1-surgeon: 0.27, A2-surgeon: 0.29, B1-surgeon: 0.38, and B2-surgeon: 0.50).ConclusionsAgreement between Sanders classification and what is real during surgery is fair. Hence, Sanders classification as determined in the widest cut of coronal CT scan extended posteriorly should be cautiously interpreted for surgery.