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European Journal of Trauma and Emergency Surgery
Published in: European Journal of Trauma and Emergency Surgery 1/2023

Open Access 09-08-2022 | Computed Tomography | Original Article

The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures

Authors: Tobias Dust, Maximilian J. Hartel, Julian-Elias Henneberg, Alexander Korthaus, Tobias Malte Ballhause, Johannes Keller, Malte Ohlmeier, Kai-Jonathan Maas, Karl-Heinz Frosch, Matthias Krause

Published in: European Journal of Trauma and Emergency Surgery | Issue 1/2023

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Abstract

Purpose

Tibial plateau fractures continue to be a challenging task in clinical practice and current outcomes seem to provide the potential for further improvement. Especially presurgical understanding of the orientation of fracture lines and fracture severity is an essential key to sufficient surgical treatment. The object of this study was to evaluate the reliability of modern axial CT-based classification systems for tibial plateau fractures. In addition, the diagnostic-added value of 3D printing on the classification systems was investigated.

Methods

22 raters were asked to classify 22 tibial plateau fractures (11 AO B- and 11 AO C-fractures) with the AO, the 10-Segment and the Revisited Schatzker classification in a three-step evaluation: first only using CT scans, second with 3D volumetric reconstructions and last with 3D-printed fracture models. Inter- and intraobserver agreement and the subjective certainty were analyzed. Statistics were done using kappa values, percentage match and a univariant one-way analysis of variance.

Results

The AO classifications interobserver percentage match and kappa values improved for all raters and recorded an overall value of 0.34, respectively, 43% for the 3D print. The 10-Segment classification interobserver agreement also improved with the 3D-printed models and scored an overall kappa value of 0.18 and a percentage match of 79%. Equally the Revisited Schatzker classification increased its values to 0.31 and 35%. The intraobserver agreement showed a moderate agreement for the AO (0.44) and Revisited Schatzker classification (0.42) whereas the 10-Segment classification showed a fair agreement (0.27). Additionally, the raters changed their classification in 36% of the cases after evaluating the fracture with the 3D-printed models and the subjective certainty regarding the decisions improved as categories of self-reliant diagnostic choices were selected 18% (p < 0.05) more often after using the 3D-printed models.

Conclusion

Based on the measured outcomes it was concluded that the new classification systems show an overall slight to fair reliability and the use of 3D printing proved to be beneficial for the preoperative diagnostics of tibial plateau fractures. The 10-Segment classification system showed the highest percentage match evaluation of all classification systems demonstrating its high clinical value across all levels of user experience.
Literature
1.
Eggli S, Hartel MJ, Kohl S, Haupt U, Exadaktylos AK, Röder C. Unstable bicondylar tibial plateau fractures: a clinical investigation. J Orthop Trauma. 2008;22:673–9.PubMed
2.
Manidakis N, Dosani A, Dimitriou R, Stengel D, Matthews S, Giannoudis P. Tibial plateau fractures: functional outcome and incidence of osteoarthritis in 125 cases. Int Orthop. 2010;34:565–70.PubMed
3.
Kraus TM, Martetschläger F, Müller D, Braun KF, Ahrens P, Siebenlist S, et al. Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up. Am J Sports Med. 2012;40:2845–52.PubMed
4.
Wasserstein D, Henry P, Paterson JM, Kreder HJ, Jenkinson R. Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-population-based cohort study. J Bone Jt Surg Am. 2014;96:144–50.
5.
Frosch K-H, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg. 2020;46:1211–9.PubMedPubMedCentral
6.
Krause M, Alm L, Berninger M, Domnick C, Fehske K, Frosch K-H, et al. Bone metabolism is a key factor for clinical outcome of tibial plateau fractures. Eur J Trauma Emerg Surg. 2020;46:1227–37.PubMedPubMedCentral
7.
8.
Schatzker J. Compression in the surgical treatment of fractures of the tibia. Clin Orthop Relat Res. 1974;105:220–39.
9.
Doornberg JN, Rademakers MV, van den Bekerom MP, Kerkhoffs GM, Ahn J, Steller EP, et al. Two-dimensional and three-dimensional computed tomography for the classification and characterisation of tibial plateau fractures. Injury. 2011;42:1416–25.PubMed
10.
Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018;49:2252–63.PubMed
11.
Luo C-F, Sun H, Zhang B, Zeng B-F. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24:683–92.PubMed
12.
Krause M, Preiss A, Müller G, Madert J, Fehske K, Neumann MV, et al. Intra-articular tibial plateau fracture characteristics according to the “ten segment classification.” Injury. 2016;47:2551–7.PubMed
13.
Millar SC, Arnold JB, Thewlis D, Fraysse F, Solomon LB. A systematic literature review of tibial plateau fractures: what classifications are used and how reliable and useful are they? Injury. 2018;49:473–90.PubMed
14.
Krause M, Müller G, Frosch K-H. Surgical approaches to tibial plateau fractures. Unfallchirurg. 2018;121:569–82.PubMed
15.
Weidert S, Andress S, Suero E, Becker C, Hartel M, Behle M, et al. 3D printing in orthopedic and trauma surgery education and training. Possibilities and fields of application. Unfallchirurg [Internet]. 2019 [cited 2019 Jun 2]; Available from: http://​link.​springer.​com/​https://​doi.​org/​10.​1007/​s00113-019-0650-8
16.
Krause M, Hubert J, Deymann S, Hapfelmeier A, Wulff B, Petersik A, et al. Bone microarchitecture of the tibial plateau in skeletal health and osteoporosis. Knee. 2018;25:559–67.PubMed
17.
18.
Meinberg E, Agel J, Roberts C, Karam M, Kellam J. Fracture and dislocation classification compendium—2018. J Orthop Trauma. 2018;32:S1-10.PubMed
19.
Krause M, Preiss A, Meenen NM, Madert J, Frosch K-H. “Fracturoscopy” is superior to fluoroscopy in the articular reconstruction of complex tibial plateau fractures-an arthroscopy assisted fracture reduction technique. J Orthop Trauma. 2016;30:437–44.PubMed
20.
Berger-Groch J, Thiesen DM, Grossterlinden LG, Schaewel J, Fensky F, Hartel MJ. The intra- and interobserver reliability of the tile AO, the young and burgess, and FFP classifications in pelvic trauma. Arch Orthop Trauma Surg [Internet]. 2019 [cited 2019 Apr 2]; Available from: http://​link.​springer.​com/​https://​doi.​org/​10.​1007/​s00402-019-03123-9
21.
Frandsen PA, Andersen E, Madsen F, Skjødt T. Garden’s classification of femoral neck fractures. An assessment of inter-observer variation. J Bone Joint Surg Br. 1988;70:588–90.PubMed
22.
Rauer T, Boos M, Neuhaus V, Ellanti P, Kaufmann RA, Pape H-C, et al. Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups. Patient Saf Surg. 2020;14:4.PubMedPubMedCentral
23.
Howells NR, Hughes AW, Jackson M, Atkins RM, Livingstone JA. Interobserver and intraobserver reliability assessment of calcaneal fracture classification systems. J Foot Ankle Surg. 2014;53:47–51.PubMed
24.
Cohen J. A coefficient of agreement for Nominal Scales. Educ Psychol Measur. 1960;20:37–46.
25.
Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull. 1971;76:378–82.
26.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–74.PubMed
27.
Wirtz MA, Caspar F. Beurteilerübereinstimmung und Beurteilerreliabilität: Methoden zur Bestimmung und Verbesserung der Zuverlässigkeit von Einschätzungen mittels Kategoriensystemen und Ratingskalen. Göttingen Bern: Hogrefe, Verl. für Psychologie; 2002.
28.
Burstein AH. Fracture classification systems: do they work and are they useful? J Bone Joint Surg Am. 1993;75:1743–4.PubMed
29.
Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78:726–31.PubMed
30.
Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop Relat Res. 1984;182:193–9.
31.
Charalambous CP, Tryfonidis M, Alvi F, Moran M, Fang C, Samarji R, et al. Inter- and intra-observer variation of the Schatzker and AO/OTA classifications of tibial plateau fractures and a proposal of a new classification system. Ann R Coll Surg Engl. 2007;89:400–4.PubMedPubMedCentral
32.
Brunner A, Horisberger M, Ulmar B, Hoffmann A, Babst R. Classification systems for tibial plateau fractures; does computed tomography scanning improve their reliability? Injury. 2010;41:173–8.PubMed
33.
Walton NP, Harish S, Roberts C, Blundell C. AO or Schatzker? How reliable is classification of tibial plateau fractures? Arch Orthop Trauma Surg. 2003;123:396–8.PubMed
34.
Rasmussen S, Madsen PV, Bennicke K. Observer variation in the Lauge–Hansen classification of ankle fractures. Precision improved by instruction. Acta Orthop Scand. 1993;64:693–4.PubMed
35.
Sidor ML, Zuckerman JD, Lyon T, Koval K, Cuomo F, Schoenberg N. The neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Jt Surg Am. 1993;75:1745–50.
36.
Yao P, Liu Y, Shan L, Zhao Y, Wang D, He Y, et al. Intra- and inter-observer reliability assessment of widely used classifications and the “ten-segment classification” of tibial plateau fractures. Knee. 2022;35:149–56.PubMed
37.
Solomon LB, Stevenson AW, Lee YC, Baird RPV, Howie DW. Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury. 2013;44:1561–8.PubMed
38.
Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The classification systems for tibial plateau fractures: how reliable are they? Injury. 2008;39:1216–21.PubMed
39.
Brouwers L, Teutelink A, van Tilborg FAJB, de Jongh MAC, Lansink KWW, Bemelman M. Validation study of 3D-printed anatomical models using 2 PLA printers for preoperative planning in trauma surgery, a human cadaver study. Eur J Trauma Emerg Surg. 2019;45:1013–20.PubMed
40.
Brouwers L, Pull TerGunne AF, de Jongh MA, Maal TJJ, Vreeken R, van der Heijden FHWM, et al. What is the value of 3D virtual reality in understanding acetabular fractures? Eur J Orthop Surg Traumatol. 2020;30:109–16.PubMed
41.
Ersan F, Aktürk E, Ciraci S. Stable, one-dimensional suspended and supported monatomic chains of pnictogens: a metal-insulator framework. Phys Chem Chem Phys. 2019;21:14832–45.PubMed
42.
Brouwers L, Pull terGunne AF, de Jongh MAC, van der Heijden FHWM, Leenen LPH, Spanjersberg WR, et al. The value of 3D printed models in understanding acetabular fractures. 3D Print Addit Manuf. 2018;5:37–46.
43.
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005;19:448–55.PubMed
44.
Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2016;1:225–32.PubMedPubMedCentral
45.
Li KHC, Kui C, Lee EKM, Ho CS, Wong SH, Wu W, et al. The role of 3D printing in anatomy education and surgical training: a narrative review. MedEdPublish. 2017;6:92.
46.
Wainwright AM, Williams JR, Carr AJ. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Jt Surg Br. 2000;82:636–42.
Metadata
Title
The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures
Authors
Tobias Dust
Maximilian J. Hartel
Julian-Elias Henneberg
Alexander Korthaus
Tobias Malte Ballhause
Johannes Keller
Malte Ohlmeier
Kai-Jonathan Maas
Karl-Heinz Frosch
Matthias Krause
Publication date
09-08-2022
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Trauma and Emergency Surgery / Issue 1/2023
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-022-02055-1

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