Inadequate Annotation and Its Impact on Pelvic Tilt Measurement in Clinical Practice

Background: Accurate pre-surgical templating of the pelvic tilt (PT) angle is essential for hip and spine surgeries, yet the reliability of PT annotations is often compromised by human error, inherent subjectivity, and variations in radiographic quality. This study aims to identify challenges leading to inadequate annotations at a landmark dimension and evaluating their impact on PT. Methods: We retrospectively collected 115 consecutive sagittal radiographs for the measurement of PT based on two definitions: the anterior pelvic plane and a line connecting the femoral head’s centre to the sacral plate’s midpoint. Five annotators engaged in the measurement, followed by a secondary review to assess the adequacy of the annotations across all the annotators. Results: The outcomes indicated that over 60% images had at least one landmark considered inadequate by the majority of the reviewers, with poor image quality, outliers, and unrecognized anomalies being the primary causes. Such inadequacies led to discrepancies in the PT measurements, ranging from −2° to 2°. Conclusion: This study highlights that landmarks annotated from clear anatomical references were more reliable than those estimated. It also underscores the prevalence of suboptimal annotations in PT measurements, which extends beyond the scope of traditional statistical analysis and could result in significant deviations in individual cases, potentially impacting clinical outcomes.