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Stulberg Classification System for Evaluation of Legg-Calvé-Perthes Disease: Intra-Rater and Inter-Rater Reliability*
JEROEN G. NEYT, M.D.†; STUART L. WEINSTEIN, M.D.†; KEVIN F. SPRATT, PH.D.†; LORI DOLAN, R.N., M.A.†; JOSÉ MORCUENDE, M.D., PH.D.†; FREDERICK R. DIETZ, M.D.†; GREG GUYTON, M.D.†; ROBERT HART, M.D.†; MICHELLE STEVENS KRAUT, M.D.†; GREGORY LERVICK, M.D.†; PETER PARDUBSKY, M.D.†; ANDREA SATERBAK, M.D.†, IOWA CITY, IOWA
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Investigation performed at the University of Iowa Hospitals and Clinics, Iowa City
J Bone Joint Surg Am, 1999 Sep 01;81(9):1209-16
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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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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