The Impact of Computed Tomography on Decision Making in Tibial Plateau Fractures

Abstract

Schatzker introduced one of the most used classification systems for tibial plateau fractures, based on plain radiographs. Computed tomography brought to attention the importance of coronal plane-oriented fractures. The goal of our study was to determine if the addition of computed tomography would affect the decision making of surgeons who usually use the Schatzker classification to assess tibial plateau fractures. Image studies of 70 patients who sustained tibial plateau fractures were uploaded to a dedicated homepage. Every patient was linked to a folder which contained two radiographic projections (anteroposterior and lateral), three interactive videos of computed tomography (axial, sagittal, and coronal), and eight pictures depicting tridimensional reconstructions of the tibial plateau. Ten attending orthopaedic surgeons, who were blinded to the cases, were granted access to the homepage and assessed each set of images in two different rounds, separated to each other by an interval of 2 weeks. Each case was evaluated in three steps, where surgeons had access, respectively to radiographs, two-dimensional videos of computed tomography, and three-dimensional reconstruction images. After every step, surgeons were asked to present how would they classify the case using the Schatzker system and which surgical approaches would be appropriate. We evaluated the inter- and intraobserver reliability of the Schatzker classification using the Kappa concordance coefficient, as well as the impact of computed tomography in the decision making regarding the surgical approach for each case, by using the chi-square test and likelihood ratio. The interobserver concordance kappa coefficients after each assessment step were, respectively, 0.58, 0.62, and 0.64. For the intraobserver analysis, the coefficients were, respectively, 0.76, 0.75, and 0.78. Computed tomography changed the surgical approach selection for the types II, V, and VI of Schatzker ( < 0.01). The addition of computed tomography scans to plain radiographs improved the interobserver reliability of Schatzker classification. Computed tomography had a statistically significant impact in the selection of surgical approaches for the lateral tibial plateau.

Revisiting the Schatzker classification of tibial plateau fractures

“…the management of tibial plateau has been reported as beneficial for the understanding of associated soft tissues injuries. In fact, all image modalities when used together provide a complete assessment to the extent of the damage [24][25][26][27]. The most significant impact and contribution of three-dimensional imaging in the assessment of tibial plateau injuries was the recognition and characterization of fractures in the coronal plane.…”

Diagnostik – Indikationen für CT und MRT bei Tibiaplateaufrakturen

“…Das Außenband zeigt sich in bis zu 29 % der Fälle rupturiert, während sich das Innenband in 32 % der Tibiaplateaufrakturen affiziert zeigt [7]. [3,19,24].…”

“…Die so angefertigten Einzelaufnahmen erlauben jedoch keine exakte Beurteilung des 3-dimensionalen Frakturcharakters und eine entsprechende Planung der operativen Strategie, insbesondere bei komplexen Frakturen. Die Reliabilität der nativradiologisch klassifizierten Tibiaplateaufrakturen wurde als schlecht oder mäßig bewertet [3,4]. Die a.p.…”

“…Moderne Klassifikationssystemen nutzen die CT-Aufnahmen in drei Ebenen inklusive 3-D-Rekonstruktionen für eine verbesserte Planung des operativen Vorgehens und des Nachbehandlungsregimes [14,21]. Das Hinzuziehen von CT-Bildern mit entsprechenden 3-D-Rekonstruktionen erhöht entsprechend nicht nur die Reliabilität der Klassifikationssysteme, sondern nützt vor allem dem chirurgischen Team hinsichtlich der Auswahl des korrekten operativen Zugangs und der Patientenlagerung maßgeblich [3,14].…”

Tibia plato ve proksimal tibia metafiz kaynamamaları

“…Ayrıca 3D tomografi görüntülemeleri de yaygın olarak kullanılmaktadır. [15] Sınıflamada, Schatzker ve AO/ASIF sınıflamaları yaygın olarak kullanılır. [5] Kaynama, dört korteksten en az üçünde kortikal devamlılığın görülmesi olarak kabul edilir.…”