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The Journal of Bone and Joint Surgery (American) 83:1040-1046 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.

Reliability and Intraoperative Validity of Preoperative Assessment of Standardized Plain Radiographs in Predicting Bone Loss at Revision Hip Surgery

Khaled J. Saleh, MD, MSc(Epid), FRCSC, Jeremy Holtzman, MD, MS, Amiram Gafni, PhD, Lena Saleh, BScN, RN, Aileen Davis, PhD, Scott Resig, MD and Allan E. Gross, MD, FRCSC

Investigation performed at the University of Toronto, Toronto, Ontario, Canada; the University of Minnesota, Minneapolis, Minnesota; and the Hospital for Special Surgery, Cornell Medical Center, New York, NY
Khaled J. Saleh, MD, MSc(Epid), FRCSC
Scott Resig, MD
Department of Orthopedics, University of Minnesota, Clinical Outcome Research Center, 492-420 Delaware Street SE, Minneapolis, MN 55455. E-mail address for K.J. Saleh: saleh002{at}tc.umn.edu

Jeremy Holtzman, MD, MS
Department of Medicine and Division of Health Services Research and Policy, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455

Amiram Gafni, PhD
Health Economics and Policy Analysis, Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada

Lena Saleh, BScN, RN
Aileen Davis, PhD
Allan E. Gross, MD, FRCSC
Division of Orthopedics, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 476A, Toronto, Ontario M5G 1X5, Canada

One or more of the authors has received or will receive benefits for personal or professional use from a commercial party (Smith and Nephew) related directly or indirectly to the subject of this article. K.J. Saleh is supported by a career health services research award from the Orthopaedic Research and Education Foundation, and A. Davis is supported by a career health award from the Canadian Institute of Health Research. No funds were received in support of this study.

Background: The most challenging aspect of revision hip surgery is the management of bone loss. A reliable and valid measure of bone loss is important since it will aid in future studies of hip revisions and in preoperative planning. We developed a measure of femoral and acetabular bone loss associated with failed total hip arthroplasty. The purpose of the present study was to measure the reliability and the intraoperative validity of this measure and to determine how it may be useful in preoperative planning.

Methods: From July 1997 to December 1998, forty-five consecutive patients with a failed hip prosthesis in need of revision surgery were prospectively followed. Three general orthopaedic surgeons were taught the radiographic classification system, and two of them classified standardized preoperative anteroposterior and lateral hip radiographs with use of the system. Interobserver testing was carried out in a blinded fashion. These results were then compared with the intraoperative findings of the third surgeon, who was blinded to the preoperative ratings. Kappa statistics (unweighted and weighted) were used to assess correlation. Interobserver reliability was assessed by examining the agreement between the two preoperative raters. Prognostic validity was assessed by examining the agreement between the assessment by either Rater 1 or Rater 2 and the intraoperative assessment (reference standard).

Results: With regard to the assessments of both the femur and the acetabulum, there was significant agreement (p < 0.0001) between the preoperative raters (reliability), with weighted kappa values of >0.75. There was also significant agreement (p < 0.0001) between each rater’s assessment and the intraoperative assessment (validity) of both the femur and the acetabulum, with weighted kappa values of >0.75.

Conclusions: With use of the newly developed classification system, preoperative radiographs are reliable and valid for assessment of the severity of bone loss that will be found intraoperatively.


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