What is the value of 3D virtual reality in understanding acetabular fractures?

  • Lars BrouwersEmail author
  • Albert F. Pull ter Gunne
  • Mariska A. de Jongh
  • Thomas J. J. Maal
  • Rinaldo Vreeken
  • Frank H. W. M. van der Heijden
  • Luke P. H. Leenen
  • Willem R. Spanjersberg
  • Sven H. van Helden
  • Diederik O. Verbeek
  • Mike Bemelman
  • Koen W. W. Lansink
Original Article • PELVIS - ANATOMY



Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns.


A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet–Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss’ kappa statistics (κ).


Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42).

Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000).


The Judet–Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.


Virtual reality 3D printing Acetabular surgery Judet–Letournel classification Inter-observer 





Virtual reality


Surface Tessellation Language


Kappa statistics




Computed tomography


Human subjects act


Digital imaging and communications in medicine


Confidence intervals



We would like to thank Mark van Baal, Ivar de Bruin, Pascal Buijs, Joppe Drop, Birgit van Gerwen, Mark van Heijl, Erik Hermans, Ludo van Hout, Henk A. Formijne Jonkers, Tijmen Koëter, Irene Fleur Kramer, Joost Kuipers, Mhan Fei Lam, Romy Lamers, Jacky Luiten, Siegrid de Meer, Sander Stigt, Arno Teutelink, Siward de Vries and Raoul van Vugt for the study participation. We would also like to thank Barbera Bröhrmann and Johan Stokkermans for the technical support.

Authors’ contributions

LB analyzed and interpreted the data. APtG analyzed the data and was a major contributor in writing the manuscript. MdJ and KL performed revisions of the manuscript. All authors read and approved the final manuscript.


Project was supported by the Royal Dutch Medical Association stimulus fund (KNMG). Project no AOTEU-R-2016-050 was supported by AOTRAUMA Switzerland. This project was financially supported by the Royal Dutch Medical Association stimulus fund ( and AOTRAUMA Switzerland (Project no AOTEU-R-2016-050, LB received both grants. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Consent for publication

The published video contains individual person’s data of Lars Brouwers.

Ethics approval and consent to participate

This study was exempted from the scope of the Medical Research Involving Human Subjects Act (WMO) according to our institutional ethics committee (METC Brabant).

Supplementary material

Movie 1 Example of head movements to rotate the hemi-pelvic model using the Samsung Gear VR. (MP4 4657 kb)


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Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  • Lars Brouwers
    • 1
    • 2
    Email author
  • Albert F. Pull ter Gunne
    • 3
  • Mariska A. de Jongh
    • 1
    • 2
  • Thomas J. J. Maal
    • 4
  • Rinaldo Vreeken
    • 4
  • Frank H. W. M. van der Heijden
    • 5
  • Luke P. H. Leenen
    • 6
  • Willem R. Spanjersberg
    • 7
  • Sven H. van Helden
    • 7
  • Diederik O. Verbeek
    • 8
  • Mike Bemelman
    • 5
  • Koen W. W. Lansink
    • 1
    • 2
    • 5
  1. 1.Brabant Trauma Registry, Network Emergency Care BrabantElisabeth-Tweesteden HospitalTilburgThe Netherlands
  2. 2.Department of SurgeryRadboudUMCNijmegenThe Netherlands
  3. 3.Department of SurgeryRijnstate HospitalArnhemThe Netherlands
  4. 4.3D Lab, Department of Oral- and Maxillofacial SurgeryRadboudUMCNijmegenThe Netherlands
  5. 5.Department of SurgeryElisabeth-Tweesteden HospitalTilburgThe Netherlands
  6. 6.Department of SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
  7. 7.Department of SurgeryIsala HospitalZwolleThe Netherlands
  8. 8.Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands

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