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

Comparison of virtual reality and computed tomography in the preoperative planning of complex tibial plateau fractures

INTRODUCTION

Preoperative planning is a critical step in the success of any complex surgery. The pur-pose of this study is to evaluate the advantage of VR glasses in surgical planning of complex tibial plateau fractures compared to CT planning.

MATERIALS AND METHODS

Five orthopedic surgeons performed preoperative planning for 30 fractures using either conventional CT slices or VR visualization with a VR headset. Planning was performed in a randomized order with a 3-month interval between planning sessions. A standardized questionnaire assessed planned operative time, planning time, fracture classification and understanding, and surgeons' subjective confidence in surgical planning.

RESULTS

The mean planned operative time of 156 (SD 47) minutes was significantly lower (p < 0.001) in the VR group than in the CT group (172 min; SD 44). The mean planning time in the VR group was 3.48 min (SD 2.4), 17% longer than in the CT group (2.98 min, SD 1.9; p = 0.027). Relevant parameters influencing planning time were surgeon experience (-0.61 min) and estimated complexity of fracture treatment (+ 0.65 min).

CONCLUSION

The use of virtual reality for surgical planning of complex tibial plateau fractures resulted in significantly shorter planned operative time, while planning time was longer compared to CT planning. After VR planning, more surgeons felt (very) well prepared for surgery.

The effect of addition of 2DCT scans and 3DCT scans for the classification of tibial plateau fractures: a systematic review

PURPOSE

In this systematic review, we evaluate the effect of radiographs and 2D and 3D imaging techniques on the interobserver agreement of six commonly used classification systems for tibial plateau fractures.

METHODS

In accordance with PRISMA guidelines, PubMed, Cochrane, Embase and Web of Science were searched for studies regarding the effect of 2D and 3D imaging techniques on the interobserver agreement of tibial plateau classification systems. Studies validating new classification systems, not providing own data or only providing information on the interobserver agreement for radiographs were excluded. Studies were scored based on the ROBINS-I risk of bias tool.

RESULTS

Our review analysed 14 studies on different classification systems used for tibial plateau fractures in clinical practice, with the Schatzker classification being the most commonly used classification system. The results showed that the addition of 2D CT led to a significant improvement of interobserver agreement for one study. However, other included studies showed varying levels of interobserver agreement, ranging from fair to substantial according to the interpretation by Landis and Koch. The addition of 3D CT resulted in a significant deterioration in one study for the Schatzker classification. Similar to the addition of 2D CT, the interobserver agreement for the Schatzker classification with the addition of 3D CT were heterogeneous ranging from fair to almost perfect according to the interpretation by Landis and Koch.

CONCLUSIONS

The use of 2D CT can be recommended for classifying tibial plateau fractures with the Schatzker classification, AO/OTA classification and Hohl classification. The value of 3D CT on the interobserver agreement of commonly used classification systems remains uncertain and unproven. Therefore, we do not recommend the use of 3D CT for the classification of tibial plateau fractures. Overall, the advancement of imaging techniques is not in line with the advancement in interobserver agreement on fracture classification.

Does the Schatzker III Tibial Plateau Fracture Exist?

Background

The Schatzker classification system for tibial plateau fractures is one of the most commonly used systems. However, there has been controversy if a Schatzker III type fracture truly exists by their original definition. We aimed to correlate the radiographic and CT images of type III fractures, describe the additional propagating fracture patterns and determine if these fractures do exist by their original description.

Methods

This multicenter retrospective cohort observational study included patients with tibial plateau fractures across five trauma centers over 9 years were identified. All X-rays and CT scans were assessed. Two independent fellowship trained, Orthopaedic trauma surgeons reviewed all knee X-rays and classified them according to the Schatzker system. The CTs were subsequently reviewed and the fractures were reclassified based on CT findings.

Results

569 Tibial plateau fractures in 566 patients were analyzed. All X-ray classified Schatzker III fractures were reclassified to a Schatzker II type after review of CT scans by both assessors independently as there were always at least two or more fracture lines propagating from the depressed fragment to the lateral cortex in all cases. The interobserver variability as assessed by the kappa correlation coefficient (κ) for X-rays and CT-based classifications were κ = 0.274 and κ = 0.906, respectively. The majority of cases had two lateral cortical breaks (83.8%). In addition, the depression occurred mostly in the anterolateral and posterolateral positions (60.3%) of the lateral tibial plateau.

Conclusion

This study did not support the existence of true Schatzker Type III fractures.

Modified gastrocnemius splitting anatomic approach to the tibial plateau. Medium-term evaluation

BACKGROUND

Posterior tibial plateau fractures, including avulsion fractures of the posterior cruciate ligament (PCL) insertion, represent a challenge for the orthopedic trauma surgeon. These injuries have gained a new perspective both diagnostically and therapeutically after the regular use of multiplanar computed tomography. In the herein study, we describe the outcome of patients sustaining a tibial plateau fracture with posterior articular involvement treated by open reduction and internal fixation (ORIF) using our modified gastrocnemius splitting anatomic approach.

METHODS

This observational retrospective descriptive study was conducted at Complejo Medico de la Policia Federal Argentina Churruca-Visca. All patients were treated by ORIF by our team through our modified gastrocnemius splitting anatomic approach, and followed-up for a minimum of 12 months.

RESULTS

A total of 18 patients sustaining plateau fracture were treated by this approach. Satisfactory tomographic reduction with articular gap and/or step-off <2 mm was achieved in 16. The mean time to the return to activities of daily living was 192.2 days.

CONCLUSION

The modified gastrocnemius splitting anatomic approach represents a good alternative for the management of tibial plateau fractures involving the posterior quadrants.

Depression fractures of the posterolateral tibial plateau: Treatment by lateral femoral epicondyle osteotomy approach

OBJECTIVE

The best surgical exposure and fixation method for fractures affecting the posterolateral corner of the tibial plateau remain debatable. This study describes a surgical approach to treat lateral depressions of the posterolateral tibial plateau with or without rim involvement by osteotomy of the lateral femoral epicondyle associated with osteosynthesis with a one-third tubular horizontal belt plate to stabilize the fracture fragment.

METHOD

We evaluated 13 patients with fractures of the tibial plateau affecting the posterolateral region. Assessments included the degree of the depression (in millimeters), quality of the reduction, complications, and function.

RESULTS

All fractures and osteotomies consolidated. The patients had a mean age of 48 years and were mostly men (n=8). Regarding the quality of the reduction, the mean reduction obtained was 15.8 mm, and 8 patients achieved anatomical reduction. The mean (± standard deviation) Knee Society Score was 92±13 (range 65-100), and the mean Function Score was 95±9.6 (range 70-100). The mean Lysholm Knee Score was 92±11.7 (range 66-100), and the mean International Knee Documentation Committee Score was 85±12.6 (range 63-100). All these scores reflect good results. None of the patients developed superficial or deep infection or presented healing disorders. Sensitive or motor complications of the fibular nerve were not observed.

CONCLUSIONS

In this series of patients with depression fractures of the posterolateral tibial plateau, a surgical approach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of the fractures without functional impairment.

High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF)

The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.

Preoperative Mixed-Reality Visualization of Complex Tibial Plateau Fractures and Its Benefit Compared to CT and 3D Printing

BACKGROUND

Various studies have shown the benefit of three-dimensional (3D) computed tomography (CT) reconstruction and especially 3D printing in the treatment of tibial plateau fractures (TPFs). This study aimed to investigate whether mixed-reality visualization (MRV) using mixed-reality glasses can provide a benefit for CT and/or 3D printing in planning treatment strategies for complex TPFs.

METHODS

Three complex TPFs were selected for the study and processed for 3D imaging. Subsequently, the fractures were presented to specialists in trauma surgery using CT (including 3D CT reconstruction), MRV (hardware: Microsoft HoloLens 2; software: mediCAD MIXED REALITY) and 3D prints. A standardized questionnaire on fracture morphology and treatment strategy was completed after each imaging session.

RESULTS

23 surgeons from 7 hospitals were interviewed. A total of 69.6% (n = 16) of those had treated at least 50 TPFs. A change in fracture classification according to Schatzker was recorded in 7.1% of the cases and in 78.6% an adjustment of the ten-segment classification was observed after MRV. In addition, the intended patient positioning changed in 16.1% of the cases, the surgical approach in 33.9% and osteosynthesis in 39.3%. A total of 82.1% of the participants rated MRV as beneficial compared to CT regarding fracture morphology and treatment planning. An additional benefit of 3D printing was reported in 57.1% of the cases (five-point Likert scale).

CONCLUSIONS

Preoperative MRV of complex TPFs leads to improved fracture understanding, better treatment strategies and a higher detection rate of fractures in posterior segments, and it thus has the potential to improve patient care and outcomes.

The symmetry of the left and right tibial plateau: a comparison of 200 tibial plateaus

PURPOSE

This study aims to investigate the symmetry of the left and right tibial plateau in young healthy individuals to determine whether left-right mirroring can be reliably used to optimize preoperative 3D virtual planning for patients with tibial plateau fractures.

METHODS

One hundred healthy subjects, without previous knee surgery, severe knee trauma, or signs of osteoarthritis were included for a previous dynamic imaging study of the knee. The subjects underwent a CT scan, scanning the left and right knee with a slice thickness of 0.8 mm. 3D surface models of the femur, patella, and tibia were created using a convolutional neural network. The 3D models of the left and right tibias were exported to MATLAB © and the tibias were mirrored. The mirrored tibias were superimposed on the contralateral tibia using a coherent point drift surface matching algorithm. Correspondence points on both surfaces were established, the mean root squared distance was calculated and visualized in a boxplot and heatmaps.

RESULTS

The overall mean difference between correspondence points on the left and right tibial plateau is 0.6276 ± 0.0343 mm. The greatest differences between correspondence points were seen around two specific surfaces on the outside of the tibial plateau; where the distal tibia was cut 15 mm below the tibial plateau and around the tibiofibular joint.

CONCLUSIONS

The differences between the left and right tibial plateau are small and therefore, we can be confident that the mirrored contralateral, unfractured, tibial plateau can be used as a template for 3D virtual preoperative planning for young patients without previous damage to the knee.

Systematic Review of Current Approaches to Tibia Plateau: Best Clinical Evidence

If not treated adequately, tibia plateau fractures result in premature osteoarthritis and lifelong disability. The advent of newer implants and techniques to improve outcomes has necessitated the development of different surgical approaches. A Medline and EMBASE search (June 2020) was conducted to identify publications during the last 10 years that focused on surgical approaches for proximal tibia fractures/ tibia plateau management. A total of 2107123 and 2715399 articles were found related to fractures in this area with 133 and 103 review articles looking at the approach on MEDLINE and EMBASE, respectively. This article reviews the continued development of the surgical approaches to aid understanding for surgeons and identify areas for future research to help improve outcomes. Although the anterolateral approach is the most commonly applied surgical technique, having the knowledge of newer approaches (medial, posteromedial, posterolateral, or direct posterior) in the armamentarium is necessary to treat the vast array of fracture patterns. There has been a shift amongst trauma surgeons of using a combination of approaches for complex tibia plateau fractures. 

Are 3D-printed Models of Tibial Plateau Fractures a Useful Addition to Understanding Fractures for Junior Surgeons?

BACKGROUND

Tibial plateau fractures are often complex, and they can be challenging to treat. Classifying fractures is often part of the treatment process, but intra- and interobserver reliability of fracture classification systems often is inadequate to the task, and classifications that lack reliability can mislead providers and result in harm to patients. Three-dimensionally (3D)-printed models might help in this regard, but whether that is the case for the classification of tibial plateau fractures, and whether the utility of such models might vary by the experience of the individual classifying the fractures, is unknown.

QUESTIONS/PURPOSES

(1) Does the overall interobserver agreement improve when fractures are classified with 3D-printed models compared with conventional radiology? (2) Does interobserver agreement vary among attending and consultant trauma surgeons, senior surgical residents, and junior surgical residents? (3) Do surgeons' and surgical residents' confidence and accuracy improve when tibial plateau fractures are classified with an additional 3D model compared with conventional radiology?

METHODS

Between 2012 and 2020, 113 patients with tibial plateau fractures were treated at a Level 1 trauma center. Forty-four patients were excluded based on the presence of bone diseases (such as osteoporosis) and the absence of a CT scan. To increase the chance to detect an improvement or deterioration and to prevent observers from losing focus during the classification, we decided to include 40 patients with tibial plateau fractures. Nine trauma surgeons, eight senior surgical residents, and eight junior surgical residents-none of whom underwent any study-specific pretraining-classified these fractures according to three often-used classification systems (Schatzker, OA/OTA, and the Luo three-column concept), with and without 3D-printed models, and they indicated their overall confidence on a 10-point Likert scale, with 0 meaning not confident at all and 10 absolutely certainty. To set the gold standard, a panel of three experienced trauma surgeons who had special expertise in knee surgery and 10 years to 25 years of experience in practice also classified the fractures until consensus was reached. The Fleiss kappa was used to determine interobserver agreement for fracture classification. Differences in confidence in assessing fractures with and without the 3D-printed model were compared using a paired t-test. Accuracy was calculated by comparing the participants' observations with the gold standard.

RESULTS

The overall interobserver agreement improved minimally for fracture classification according to two of three classification systems (Schatzker: κconv = 0.514 versus κ3Dprint = 0.539; p = 0.005; AO/OTA:κconv = 0.359 versus κ3Dprint = 0.372; p = 0.03). However, none of the classification systems, even when used by our most experienced group of trauma surgeons, achieved more than moderate interobserver agreement, meaning that a large proportion of fractures were misclassified by at least one observer. Overall, there was no improvement in self-assessed confidence in classifying fractures or accuracy with 3D-printed models; confidence was high (about 7 points on a 10-point scale) as rated by all observers, despite moderate or worse accuracy and interobserver agreement.

CONCLUSION

Although 3D-printed models minimally improved the overall interobserver agreement for two of three classification systems, none of the classification systems achieved more than moderate interobserver agreement. This suggests that even with 3D-printed models, many fractures would be misclassified, which could result in misleading communication, inaccurate prognostic assessments, unclear research, and incorrect treatment choices. Therefore, we cannot recommend the use of 3D-printed models in practice and research for classification of tibial plateau fractures.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Revisiting the management of tibial plateau fractures

Three-dimensional imaging has changed the understanding and management of tibial plateau fractures. In the 1970s, Schatzker proposed a classification for tibial plateau fractures, which highlighted the morphology of the six principal types. More recently, this original classification was complimented by an extended one underscoring the importance of understanding where the split wedge fragment(s) is/are located in three dimensions. The extended classification introduced the split wedge fragment and the continuity of the rim as the determinants of joint stability and the critical role that this plays in the management of tibial plateau fractures. The current manuscript re-emphasizes contemporary concepts of tibial plateau stability and depicts key issues which must be considered when planning the definitive surgical fixation of tibial plateau fractures.

Avaliação da reprodutibilidade da classificação de Schatzker revisada por Kfuri para as fraturas do planalto tibial

Objective  The Schatzker classification is the most used for tibial plateau fractures. Kfuri et al. 12 reviewed Schatzker's initial classification describing in more detail the involvement of the tibial plateau in the coronal plane, allowing a better understanding of the fracture pattern and a more accurate surgical planning. The objectives of the present study are to evaluate the interobserver agreement of these classifications and to evaluate the influence of the experience of the observer on the reproducibility of the instruments.

Methods  An observational and retrospective study was conducted by evaluating the radiological study of 20 adult individuals with tibial plateau fractures, including radiographs and computed tomography (CT). The fractures were classified once by 34 examiners with varied experience (24 specialists and 10 residents in Orthopedics and Traumatology), according to the Schatzker classification and to the modification proposed by Kfuri. The Fleiss Kappa index was used to verify interobserver agreement.

Results  The interobserver agreement index was considered moderate for the Schatzker classification (κ = 0.46) and mild for the Kfuri modification (κ = 0.30). The Schatzker classification showed moderate agreement, with κ = 0.52 for residents and κ = 0.45 among specialists. The Kfuri classification showed mild agreement, with Kappa values for residents and specialists of 0.39 and 0.28, respectively.

Conclusion  The Schatzker classification and the classification modified by Kfuri presented moderate and mild interobserver agreement, respectively. In addition, the residents presented higher agreement than the specialists for the two systems studied.

Tibial plateau fracture: does fracture classification influence the choice of surgical approach? A retrospective multicenter analysis

PURPOSE

The role of classification systems for the choice of surgical approach and the management of tibial plateau fractures remains unclear. The purpose of this study was to investigate the potential of classification systems to choose the appropriate operative approach. Current surgical management strategies were investigated in a large multicenter assessment.

METHODS

In this study, we retrospectively analyzed all patients with tibial plateau fractures that have received surgical treatment in one of the five Level I trauma facilities between 2012 and 2015. Fractures were classified in each center by a senior orthopedic surgeon using the AO/OTA and the Luo classification. Demographics, trauma mechanism, as well as the surgical approach were recorded.

RESULTS

538 patients (46.1% male, 53.9% female) were included. The anterolateral approach was used most frequently with 54.8% of all single approaches; 76.2% of all combined approaches used anterolateral as part of the approach. Combined approaches were used in 22.5% of the cases; a combination of the anterolateral and medial (10%), anterolateral, and posteromedial approach (5.8%) were used most frequently. The lowest number was found for the posterolateral (1.3%) and the combined approaches dorsal/anterolateral and medial/dorsal (1.7%, 1.1%). The AO/OTA classification showed a peak for 41.B2 (21.9%) and B3 (35.5%) fractures. Regarding the Luo classification, the dorsal column was involved in 45.7%. In contrast, only 14.7% of the surgical approaches used were able to address the dorsal tibial plateau potentially.

CONCLUSION

The use of dorsal approach seems to be of minor importance than expected in daily clinical practice in this multicenter study. It was not possible to specify whether the AO/OTA or the Luo classification can reliably predict the choice of surgical approach. The operative treatment strategy of tibial plateau fractures seems to rather rely on the surgeons' experience, education, and preferences.

Evolution of imaging in surgical fracture management

Intraoperative imaging has been advanced substantially over the last decades. It supports localization of the region of interest, verification of the preoperatively classified fracture pattern, identification of correct insertion point of the implant, placement of instruments and fixation material, and verification of correct fracture reduction and implant positioning. While conventional fluoroscopic 2D imaging remains the gold standard in intraoperative imaging, critical anatomical regions are predestined for intraoperative 3D imaging. Additional options such as perioperative virtual planning, simulation, and surgical training, 3D printing techniques and 3D augmented reality visualization may potentially open new windows to improve surgical results in fracture care. This manuscript presents an update on current and upcoming imaging techniques in orthopaedic and trauma surgery focusing on technical advances for decreasing malreduction, malalignment, and malposition, as well as tips and tricks for daily surgical practice in order to improve clinical outcomes and patients' and surgeons' safety.

Value of three-dimensional computed tomography reconstruction in the treatment of posterior tibial plateau fractures

BACKGROUND

Indication for surgical treatment of posterior tibial plateau fractures (TPFs) remains up for debate. Three-dimensional computed tomography (3D-CT) reconstruction can provide insight into fracture morphology and could improve treatment strategy and surgical planning. In this study, we investigated the value of 3D-CT reconstruction in the treatment of posterior TPF and evaluated the influence on surgical decision-making.

METHODS

CT images of 34 cases with a TPF involving the posterior column were included and digitally presented to a panel of five international observers at two intervals. At the first evaluation, only coronal, axial and sagittal images were shown. After an interval of at least three weeks, 3D-CT reconstruction images were added. During both surveys, observers were asked to classify the TPF according to the revised three-column classification (rTCC), as well as to define operative strategy.

RESULTS

When using 2D images, overall multirated kappa value was 0.48, with an average pairwise agreement of 68%. After adding 3D images, overall multirated kappa value was 0.43, with average pairwise agreement of 67%. Hierarchical logistic regression of decision to operate on image condition (3D vs. 2D) shows an odds ratio of 2.01 (95% confidence interval, 1.11-3.67), P = .022. Increase in operative indication was seen mainly in posterolateral fractures.

CONCLUSION

This study investigated the value of 3D classification in the treatment of posterior column TPF. Contrary to expectations, the addition of 3D images to the assessment did not reduce but rather appeared to increase operative indications, especially in fractures involving the posterolateral region.