Enhancing orthopaedic resident competency in calcaneal fracture evaluation with Sanders classification: A comparative study of computed tomography, 3D printing and virtual reality.

BACKGROUND: Interpretation of intra-articular calcaneal fractures using the Sanders classification remains challenging because of complex three-dimensional morphology. This study compared CT, 3D printing, and virtual reality (VR) for Sanders classification.

METHODS: Thirty-three calcaneal fractures were assessed by 25 orthopaedic residents using CT, 3D-printed models, and VR. Interobserver agreement and within-observer cross-modality concordance were analysed using Cohen's kappa (κ) and intraclass correlation coefficients (ICC). Accuracy was compared with a composite reference standard.

RESULTS: Interobserver agreement was highest with 3D printing (κ = 0.26; ICC = 0.90). CT showed the highest overall classification accuracy (p < 0.001). Agreement and accuracy were not affected by training level or session. VR was the preferred modality (80%).

CONCLUSIONS: 3D visualization improved interobserver agreement, whereas CT remained the most accurate modality. VR showed strong perceived educational value. Modality-dependent differences suggest that 3D methods may complement and refine CT-based Sanders classification.

LEVEL: Level II diagnostic evidence.