Importance of radiological studies by means of computed tomography for managing fractures of the tibial plateau

Lopes, Clécio de Lima; Cândido Filho, Carlos Antônio da Rocha; Silva, Thiago Almeida de Lima e; Gonçalves, Marcelo Carvalho Krause; Oliveira, Ricardo Lyra de; Lima, Paulo Rogério Gomes de

doi:10.1016/j.rboe.2014.10.010

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Revista Brasileira de Ortopedia

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Original Articles • Rev. bras. ortop. 49 (6) • Nov-Dec 2014 • https://doi.org/10.1016/j.rboe.2014.10.010 copy

Importance of radiological studies by means of computed tomography for managing fractures of the tibial plateau^☆ ☆ Please cite this article as: de Lima Lopes C, da Rocha Cândido Filho CA, de Lima e Silva TA, Gonçalves MCK, de Oliveira RL, de LimaPRG. Importância do estudo radiológico por meio de tomografia computadorizada no manejo das fraturas do platô tibial. Rev Bras Ortop.2014;49:593–601. ,^☆☆ ☆☆ Work developed at the Orthopedics and Traumatology Service, Hospital Otávio de Freitas, Recife, PE, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objectives:

To evaluate the concordance among knee surgery specialists regarding the classification and surgical technique indicated in cases of tibial plateau fracture, using conventional radiographs and computed tomography.

Methods:

Forty-four patients with fractures of the tibial plateau shown on radiographic and tomographic images were selected. These were evaluated by specialists at two different times, with an interval of seven days. On the first occasion, the specialists only had access to the radiographs, while on the second occasion they had access to both radiographs and computed tomography images. Their concordance was evaluated by means of the kappa coefficient.

Results:

The interobserver reliability of the Schatzker classification on the first occasion was 0.36 and on the second occasion, 0.35. This was considered to present low reproducibility. In evaluating the intra-observer reproducibility of this classification, the mean kappa index was 0.42, which was classified as moderate. From evaluating the choice of surgical access, the inter-observer reliability was 0.55 on the first occasion and 0.50 on the second, which was considered to present moderate reproducibility. Evaluation on the implant chosen showed that the interobserver reliability was 0.01 on the first occasion and −0.06 on the second, which was considered to be poor and discordant. In evaluating the classification of the three columns, the inter-observer reproducibility was 0.47 (p< 0.0001), which was classified as moderate concordance.

Conclusion:

Use of computed tomography did not present any improvement in the inter-observer concordance, using the Schatzker classification, and did not produce any change in the preoperative planning.

Tibial fractures/classification; Tibial fractures/radiography; Computed tomography; Operative surgical procedures

Access	Implants
Double access (medial and anterolateral)	3.5 mm plate
Percutaneous	4.5 mm plate
Single access (medial or anterolateral or posterior)	7 mm cannulated screw

	Schatzker kappa (p-value)	Access kappa (p-value)	Implant kappa (p-value)
Observers	0.36 (<0.0001)	0.55 (<0.0001)	0.01 (0.676)
Observer 1 vs. Observer 2	0.47 (0.004)	0.64 (0.011)	−0.08 (0.742)
Observer 1 vs. Observer 3	0.39 (0.008)^a a Statistically significant.	0.84 (<0.0001)	−0.10 (0.679)
Observer 1 vs. Observer 4	0.75 (<0.0001)	0.68 (0.006)^a a Statistically significant.	−0.01 (0.740)
Observer 1 vs. Observer 5	0.54 (<0.0001)	0.52 (0.015)^a a Statistically significant.	−0.10 (0.511)
Observer 1 vs. Observer 6	0.19 (0.029)^a a Statistically significant.	0.69 (0.002)^a a Statistically significant.	0.12 (0.434)
Observer 1 vs. Observer 7	0.16 (0.123)	0.41 (0.056)	−0.13 (0.300)
Observer 1 vs. Observer 8	0.11 (0.378)	0.35 (0.149)	−0.02 (0.914)
Observer 1 vs. Observer 9	0.36 (0.031)^a a Statistically significant.	0.64 (0.010)	−0.19 (0.193)
Observer 1 vs. Observer 10	0.64 (<0.0001)	0.83 (0.002)^a a Statistically significant.	0.24 (0.127)
Observer 2 vs. Observer 3	0.59 (0.001)^a a Statistically significant.	0.50 (0.033)^a a Statistically significant.	0.50 (0.033)^a a Statistically significant.
Observer 2 vs. Observer 4	0.36 (0.027)^a a Statistically significant.	0.64 (0.010)	0.00 (1.000)
Observer 2 vs. Observer 5	0.50 (0.003)^a a Statistically significant.	0.44 (0.041)^a a Statistically significant.	−0.16 (0.214)
Observer 2 vs. Observer 6	0.37 (<0.0001)	0.66 (0.003)^a a Statistically significant.	−0.19 (0.125)
Observer 2 vs. Observer 7	0.27 (0.005)^a a Statistically significant.	0.28 (0.143)	−0.02 (0.898)
Observer 2 vs. Observer 8	0.31 (0.0255)^a a Statistically significant.	0.64 (0.010)	−0.12 (0.338)
Observer 2 vs. Observer 9	0.73 (<0.0001)	0.54 (0.072)	−0.12 (0.338)
Observer 2 vs. Observer 10	0.60 (<0.0001)	0.79 (0.007)^a a Statistically significant.	0.35 (0.019)^a a Statistically significant.
Observer 3 vs. Observer 4	0.38 (0.015)^a a Statistically significant.	0.69 (0.004)	−0.01 (0.740)
Observer 3 vs. Observer 5	0.50 (0.003)^a a Statistically significant.	0.55 (0.006)^a a Statistically significant.	0.15 (0.251)
Observer 3 vs. Observer 6	0.26 (0.004)	0.70 (0.001)^a a Statistically significant.	0.06 (0.658)
Observer 3 vs. Observer 7	0.32 (0.012)^a a Statistically significant.	0.37 (0.104)	0.09 (0.404)
Observer 3 vs. Observer 8	0.03 (0.822)	0.37 (0.124)	−0.04 (0.740)
Observer 3 vs. Observer 9	0.48 (0.008)^a a Statistically significant.	0.50 (0.033)^a a Statistically significant.	0.11 (0.376)
Observer 3 vs. Observer 10	0.47 (0.011)	0.67 (0.009)^a a Statistically significant.	0.23 (0.154)
Observer 4 vs. Observer 5	0.53 (<0.0001)	0.52 (0.015)^a a Statistically significant.	0.07 (0.087)
Observer 4 vs. Observer 6	0.16 (0.091)	0.69 (0.002)^a a Statistically significant.	0.06 (0.165)
Observer 4 vs. Observer 7	0.04 (0.731)	0.55 (0.009)^a a Statistically significant.	0.12 (0.026)^a a Statistically significant.
Observer 4 vs. Observer 8	0.21 (0.128)	0.68 (0.006)^a a Statistically significant.	0.08 (0.026)^a a Statistically significant.
Observer 4 vs. Observer 9	0.25 (0.134)	0.64 (0.010)	−0.02 (0.621)
Observer 4 vs. Observer 10	0.40 (0.011)	0.83 (0.002)^a a Statistically significant.	0.05 (0.428)
Observer 5 vs. Observer 6	0.54 (<0.0001)	0.84 (<0.0001)	0.38 (0.201)
Observer 5 vs. Observer 7	0.35 (0.003)^a a Statistically significant.	0.35 (0.035)^a a Statistically significant.	0.29 (0.091)
Observer 5 vs. Observer 8	0.29 (0.056)	0.52 (0.015)^a a Statistically significant.	0.74 (0.011)^a a Statistically significant.
Observer 5 vs. Observer 9	0.40 (0.007)^a a Statistically significant.	0.44 (0.041)^a a Statistically significant.	0.23 (0.425)
Observer 5 vs. Observer 10	0.88 (<0.0001)	0.31 (0.145)	−0.13 (0.072)
Observer 6 vs. Observer 7	0.28 (0.002)^a a Statistically significant.	0.45 (0.017)^a a Statistically significant.	0.19 (0.258)
Observer 6 vs. Observer 8	0.31 (0.022)^a a Statistically significant.	0.69 (0.002)^a a Statistically significant.	0.12 (0.658)
Observer 6 vs. Observer 9	0.30 (<0.0001)	0.31 (0.154)	0.12 (0.658)
Observer 6 vs. Observer 10	0.46 (<0.0001)	0.51 (0.025)^a a Statistically significant.	−0.10 (0.201)
Observer 7 vs. Observer 8	0.09 (0.493)	0.55 (0.009)^a a Statistically significant.	0.21 (0.193)
Observer 7 vs. Observer 9	0.25 (0.023)^b	0.28 (0.143)	0.02 (0.914)
Observer 7 vs. Observer 10	0.45 (<0.0001)	0.39 (0.071)	−0.20 (0.125)
Observer 8 vs. Observer 9	0.21 (0.081)	0.28 (0.264)	−0.22 (0.461)
Observer 8 vs. Observer 10	0.17 (0.247)	0.48 (0.068)	−0.05 (0.425)
Observer 9 vs. Observer 10	0.49 (0.003)^a a Statistically significant.	0.79 (0.007)^a a Statistically significant.	−0.17 (0.011)^a a Statistically significant.

	Schatzker kappa (p-value)	Access kappa (p-value)	Implant kappa (p-value)
Observers	0.35 (<0.0001)	0.50 (<0.0001)	−0.06 (0.023)^a a Statistically significant.
Observer 1 vs. Observer 2	0.55 (0.011)^a a Statistically significant.	1.00 (<0.0001)	−0.17 (0.258)
Observer 1 vs. Observer 3	0.28 (0.059)	0.21 (0.477)	−0.31 (0.303)
Observer 1 vs. Observer 4	0.13 (0.445)	0.49 (0.058)	0.06 (0.165)
Observer 1 vs. Observer 5	0.31 (0.108)	0.50 (0.049)^a a Statistically significant.	0.05 (0.428)
Observer 1 vs. Observer 6	−0.01 (0.915)	0.53 (0.019)^a a Statistically significant.	−0.04 (0.658)
Observer 1 vs. Observer 7	−0.11 (0.439)	0.38 (0.201)	0.02 (0.819)
Observer 1 vs. Observer 8	0.32 (0.014)^a a Statistically significant.	0.49 (0.058)	0.00 (1.000)
Observer 1 vs. Observer 9	0.49 (<0.0001)	0.49 (0.058)	−0.14 (0.462)
Observer 1 vs. Observer 10	0.22 (0.192)	0.61 (0.044)^a a Statistically significant.	−0.21 (0.132)
Observer 2 vs. Observer 3	0.40 (0.004)^a a Statistically significant.	0.21 (0.477)	−0.24 (0.111)
Observer 2 vs. Observer 4	0.48 (0.006)^a a Statistically significant.	0.49 (0.058)	−0.01 (0.740)
Observer 2 vs. Observer 5	0.71 (<0.0001)	0.50 (0.049)^a a Statistically significant.	0.00 (0.740)
Observer 2 vs. Observer 6	0.19 (0.017)^a a Statistically significant.	0.53 (0.019)^a a Statistically significant.	0.02 (0.621)
Observer 2 vs. Observer 7	0.27 (0.046)^a a Statistically significant.	0.38 (0.201)	0.05 (0.251)
Observer 2 vs. Observer 8	0.43 (<0.0001)	0.49 (0.058)	0.00 (1.000)
Observer 2 vs. Observer 9	0.61 (<0.0001)	0.49 (0.058)	−0.18 (0.120)
Observer 2 vs. Observer 10	0.60 (0.001)^a a Statistically significant.	0.61 (0.044)^a a Statistically significant.	0.58 (0.002)^a a Statistically significant.
Observer 3 vs. Observer 4	0.42 (0.003)^a a Statistically significant.	0.49 (0.058)	−0.04 (0.338)
Observer 3 vs. Observer 5	0.52 (<0.00001)	0.50 (0.049)^a a Statistically significant.	−0.08 (0.251)
Observer 3 vs. Observer 6	0.27 (0.016)^a a Statistically significant.	0.37 (0.099)	−0.01 (0.887)
Observer 3 vs. Observer 7	0.38 (0.011)^a a Statistically significant.	0.38 (0.201)	−0.03 (0.740)
Observer 3 vs. Observer 8	0.44 (0.001)^a a Statistically significant.	0.49 (0.058)	0.00 (1.000)
Observer 3 vs. Observer 9	0.66 (<0.0001)	0.49 (0.058)	0.43 (0.033)^a a Statistically significant.
Observer 3 vs. Observer 10	0.52 (<0.0001)	0.21 (0.477)	−0.15 (0.266)
Observer 4 vs. Observer 5	0.49 (0.005)^a a Statistically significant.	0.67 (0.008)^a a Statistically significant.	0.09 (0.064)
Observer 4 vs. Observer 6	0.26 (0.022)^a a Statistically significant.	0.55 (0.011)^a a Statistically significant.	−0.12 (0.073)
Observer 4 vs. Observer 7	0.28 (0.043)^a a Statistically significant.	0.35 (0.125)	−0.13 (0.441)
Observer 4 vs. Observer 8	0.32 (0.019)^a a Statistically significant.	1.00 (<0.0001)	0.00 (1.000)
Observer 4 vs. Observer 9	0.29 (0.057)	1.00 (<0.0001)	0.13 (0.137)
Observer 4 vs. Observer 10	0.50 (0.003)^a a Statistically significant.	0.49 (0.058)	−0.06 (0.402)
Observer 5 vs. Observer 6	0.27 (0.005)^a a Statistically significant.	0.41 (0.074)	−0.14 (0.621)
Observer 5 vs. Observer 7	0.36 (0.009)^a a Statistically significant.	0.33 (0.156)	−0.08 (0.251)
Observer 5 vs. Observer 8	0.29 (0.049)^a a Statistically significant.	0.67 (0.008)^a a Statistically significant.	0.00 (1.000)
Observer 5 vs. Observer 9	0.63 (<0.0001)	0.67 (0.008)^a a Statistically significant.	−0.08 (0.165)
Observer 5 vs. Observer 10	0.59 (0.002)^a a Statistically significant.	0.67 (0.008)^a a Statistically significant.	0.01 (0.740)
Observer 6 vs. Observer 7	0.39 (<0.0001)	0.20 (0.338)	0.13 (0.154)
Observer 6 vs. Observer 8	0.09 (0.480)^a a Statistically significant.	0.55 (0.011)^a a Statistically significant.	0.00 (1.000)
Observer 6 vs. Observer 9	0.27 (0.015)^a a Statistically significant.	0.55 (0.011)^a a Statistically significant.	−0.17 (0.038)^a a Statistically significant.
Observer 6 vs. Observer 10	0.36 (0.001)^a a Statistically significant.	0.53 (0.019)^a a Statistically significant.	0.02 (0.621)
Observer 7 vs. Observer 8	0.10 (0.371)	0.35 (0.125)	0.00 (1.000)
Observer 7 vs. Observer 9	0.31 (0.020)^a a Statistically significant.	0.35 (0.125)	−0.24 (0.106)
Observer 7 vs. Observer 10	0.37 (0.006)^a a Statistically significant.	−0.04 (0.898)	0.15 (0.087)
Observer 8 vs. Observer 9	0.33 (0.015)^a a Statistically significant.	1.00 (<0.0001)	0.00 (1.000)
Observer 8 vs. Observer 10	0.40 (0.013)^a a Statistically significant.	0.49 (0.058)	0.00 (1.000)
Observer 9 vs. Observer 10	0.28 (0.077)	0.49 (0.058)	−0.18 (0.183)

Time 1 vs. Time 2	Schatzker kappa (p-value)	Access kappa (p-value)	Implant kappa (p-value)
Observer 1	0.35 (0.044)^a a Statistically significant.	0.36 (0.128)	0.36 (0.128)
Observer 2	0.85 (<0.0001)	0.35 (0.125)	−0.04 (0.707)
Observer 3	0.39 (0.012)^a a Statistically significant.	0.50 (0.049)^a a Statistically significant.	0.67 (0.011)^a a Statistically significant.
Observer 4	0.28 (0.075)	0.83 (0.002)^a a Statistically significant.	0.15 (0.464)
Observer 5	0.49 (0.005)^a a Statistically significant.	0.26 (0.202)	−0.16 (0.521)
Observer 6	0.28 (0.043)	0.44 (0.037)^a a Statistically significant.	0.12 (0.658)
Observer 7	0.28 (0.071)	0.02 (0.944)	0.11 (0.573)
Observer 8	0.31 (0.037)^a a Statistically significant.	0.48 (0.067)	0.00 (1.000)
Observer 9	0.38 (0.017)^a a Statistically significant.	0.79 (0.007)^a a Statistically significant.	−0.04 (0.658)
Observer 10	0.62 (<0.0001)	0.49 (0.058)	−0.10 (0.512)

Observers	kappa (p-value)	Observers	kappa (p-value)	Observers	kappa (p-value)
1 × 2	0.29 (0.118)	2 × 9	0.52 (0.022)^a a Statistically significant.	5 × 6	0.32 (0.131)
1 × 3	0.21 (0.249)	2 × 10	0.53 (0.011)^a a Statistically significant.	5 × 7	1.00 (<0.0001)
1 × 4	0.58 (0.003)^a a Statistically significant.	3 × 4	0.55 (0.011)^a a Statistically significant.	5 × 8	0.57 (0.023)^a a Statistically significant.
1 × 5	0.26 (0.145)	3 × 5	0.53 (0.009)^a a Statistically significant.	5 × 9	0.66 (0.002)^a a Statistically significant.
1 × 6	0.17 (0.394)	3 × 6	0.41 (0.064)	5 × 10	0.67 (0.001)^a a Statistically significant.
1 × 7	0.26 (0.145)	3 × 7	0.53 (0.009)^a a Statistically significant.	6 × 7	0.32 (0.131)
1 × 8	0.12 (0.460)	3 × 8	0.17 (0.478)	6 × 8	0.31 (0.154)
1 × 9	0.58 (0.003)^a a Statistically significant.	3 × 9	0.55 (0.011)^a a Statistically significant.	6 × 9	0.39 (0.079)
1 × 10	0.44 (0.028)^a a Statistically significant.	3 × 10	0.30 (0.129)	6 × 10	0.40 (0.064)
2 × 3	0.37 (0.104)	4 × 5	0.66 (0.002)^a a Statistically significant.	7 × 8	0.57 (0.023)^a a Statistically significant.
2 × 4	0.52 (0.022)^a a Statistically significant.	4 × 6	0.39 (0.079)	7 × 9	0.66 (0.001)^a a Statistically significant.
2 × 5	0.43 (0.064)	4 × 7	0.66 (0.002)^a a Statistically significant.	7 × 10	0.67 (0.001)^a a Statistically significant.
2 × 6	0.84 (<0.0001)	4 × 8	0.31 (0.154)	8 × 9	0.31 (0.154)
2 × 7	0.43 (0.064)	4 × 9	1.00 (<0.0001)	8 × 10	0.34 (0.066)
2 × 8	0.41 (0.108)	4 × 10	0.70 (0.001)^a a Statistically significant.	9 × 10	0.70 (0.001)^a a Statistically significant.

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[1] *Corresponding author. E-mail: cleciolimopes@yahoo.com.br (C. de Lima Lopes).