title: Stulberg classification system for evaluation of Legg-Calvé-Perthes disease: intra-rater and inter-rater reliability.
abstract: BACKGROUND
  Researchers and clinicians commonly use the classification system of Stulberg et al. as a basis for treatment decisions during the active phase of Legg-Calvé-Perthes disease because of its putative utility as a predictor of long-term outcome. It is generally assumed that this system has an acceptable degree of reliability. This assumption, however, is not convincingly supported by the literature.
  
  
  METHODS
  The purpose of the present study was to assess the inter-rater and intra-rater reliability of the classification system of Stulberg et al. with use of a pre-test, post-test design. During the pre-test phase, nine raters independently used the system to evaluate the radiographs of skeletally mature patients who had been managed for Legg-Calvé-Perthes disease. The intervention between the pre-test and post-test phases consisted of a consensus-building session during which all raters jointly arrived at standardized definitions of the various joint structures that are assessed with use of the classification system. The effect of these definitions on reliability then was assessed by reevaluating the radiographs during the post-test phase.
  
  
  RESULTS
  The pre-test intra-rater reliability coefficients ranged from 0.709 to 0.915, and the post-test coefficients ranged from 0.568 to 0.874. The pre-test inter-rater reliability coefficients ranged from 0.603 to 0.732, and the post-test coefficients ranged from 0.648 to 0.744. Contributing to the variance was a lack of agreement concerning the assessment of joint structures and the way in which the raters translated these evaluations into a classification according to the system of Stulberg et al.
  
  
  CONCLUSIONS
  Although intra-rater reliability was marginally acceptable, the degree of variability between the classifications assigned by different raters even after the intervention - calls into question the reliability of the system of Stulberg et al.; consequently, the validity of any treatment decisions, outcome evaluations, or epidemiological studies based on this system is also in question.
authors.affiliation: Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City 52242-1009, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Neyt
authors.forename: S L
authors.initials: SL
authors.lastname: Weinstein
authors.forename: K F
authors.initials: KF
authors.lastname: Spratt
authors.forename: L
authors.initials: L
authors.lastname: Dolan
authors.forename: J
authors.initials: J
authors.lastname: Morcuende
authors.forename: F R
authors.initials: FR
authors.lastname: Dietz
authors.forename: G
authors.initials: G
authors.lastname: Guyton
authors.forename: R
authors.initials: R
authors.lastname: Hart
authors.forename: M S
authors.initials: MS
authors.lastname: Kraut
authors.forename: G
authors.initials: G
authors.lastname: Lervick
authors.forename: P
authors.initials: P
authors.lastname: Pardubsky
authors.forename: A
authors.initials: A
authors.lastname: Saterbak
mesh_terms: D000077:Acetabulum / Q000000981:diagnostic imaging; D000465:Algorithms; D005270:Femur Head / Q000000981:diagnostic imaging; D005272:Femur Neck / Q000000981:diagnostic imaging; D006801:Humans; D007396:Internship and Residency; D007873:Legg-Calve-Perthes Disease / Q000145:classification* / Q000000981:diagnostic imaging / Q000601:surgery; D015588:Observer Variation; D009985:Orthopedics / Q000193:education; D011859:Radiography; D015203:Reproducibility of Results