Reliability of the modified lateral pillar classification for legg calvé perthes disease performed by a large group of international paediatric orthopaedic surgeons

Purpose: The modified lateral pillar classification (mLPC) is used for prognostication in the fragmentation stage of Legg Calvé Perthes disease. Previous reliability assessments of mLPC range from fair to good agreement when evaluated by a small number of observers with pre-selected radiographs. The purpose of this study was to determine the inter-observer and intra-observer reliability of mLPC performed by a group of international paediatric orthopaedic surgeons. Surgeons self-selected the radiograph for mLPC assessment, as would be done clinically. Methods: In total, 40 Perthes cases with serial radiographs were selected. For each case, 26 surgeons independently selected a radiograph and assigned mLPC and 21 raters re-evaluated the same 40 cases to establish intra-observer reliability. Rater performance was determined through surgeon consensus using the mode mLPC as ‘gold standard’. Inter- observer and intra-observer reliability data were analysed using weighted kappa statistics. Results: The weighted kappa for inter-observer correlation for mLPC was 0.64 (95% confidence interval: 0.55 to 0.74) and was 0.82 (range: 0.35 to 0.99) for intra-observer correlation. Individual surgeon’s overall performance varied from 48% to 88% agreement. Surgeon mLPC performance was not influenced by years of experience (p = 0.51). Radiograph selection did not influence gold standard assignment of mLPC. There was greater agreement on cases of mild B hips and severe C hips. Conclusions: mLPC has low good inter-observer agreement when performed by a large number of surgeons with varied experience. Surgeons frequently chose different radiographs, with no impact on mLPC agreement. Further refinement is needed to help differentiate hips on the border of group B and C. Level of evidence III.