Castiglia Marcello Teixeira, Nogueira-Barbosa Marcello Henrique, Messias Andre Marcio Vieira, Salim Rodrigo, Fogagnolo Fabricio, Schatzker Joseph, Kfuri Mauricio
Department of Biomechanics, Medicine and Rehabilitation of Locomotor System, São Paulo University, Ribeirão Preto Medical School, Ribeirão Preto, Sao Paulo, Brazil.
Division of Radiology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, Sao Paulo, Brazil.
J Knee Surg. 2018 Nov;31(10):1007-1014. doi: 10.1055/s-0038-1627464. Epub 2018 Feb 14.
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.
沙茨克（Schatzker）基于X线平片引入了一种应用最为广泛的胫骨平台骨折分类系统。计算机断层扫描使人们注意到冠状面骨折的重要性。我们研究的目的是确定增加计算机断层扫描是否会影响通常使用沙茨克分类法评估胫骨平台骨折的外科医生的决策。70例胫骨平台骨折患者的影像研究资料被上传至一个专用主页。每位患者都与一个文件夹相关联，该文件夹包含两张X线影像（前后位和侧位）、三段计算机断层扫描交互式视频（轴位、矢状位和冠状位）以及八张描绘胫骨平台三维重建的图片。10名不了解病例情况的骨科主治医生有权限访问该主页，并分两轮评估每组影像，两轮评估之间间隔2周。每个病例分三步进行评估，外科医生分别可以看到X线片、计算机断层扫描二维视频和三维重建图像。每一步之后，都会要求外科医生说明他们会如何使用沙茨克系统对病例进行分类以及哪种手术入路合适。我们使用卡帕一致性系数评估沙茨克分类法的观察者间和观察者内可靠性，并通过卡方检验和似然比评估计算机断层扫描对每个病例手术入路决策的影响。每个评估步骤后的观察者间一致性卡帕系数分别为0.58、0.62和0.64。对于观察者内分析，系数分别为0.76、0.75和0.78。计算机断层扫描改变了沙茨克II型、V型和VI型骨折的手术入路选择（P<0.01）。在X线平片基础上增加计算机断层扫描可提高沙茨克分类法的观察者间可靠性。计算机断层扫描对胫骨外侧平台手术入路的选择有统计学显著影响。
