• Philipp Pieroh, Andreas Höch, Tim Hohmann, Florian Gras, Sven Märdian, Alexander Pflug, Silvan Wittenberg, Christoph Ihle, Notker Blankenburg, Kevin Dallacker-Losensky, Tanja Schröder, Steven C Herath, Daniel Wagner, Hans-Georg Palm, Christoph Josten, and Fabian M Stuby.
• Department of Orthopedics, Trauma, and Plastic Surgery, University of Leipzig, Leipzig, Germany.
• J Bone Joint Surg Am. 2019 Jun 5; 101 (11): 987-994.

BackgroundThe fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking.MethodsSix experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references.ResultsThe intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III.ConclusionsThe FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities.Clinical RelevanceWith moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.

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