Schatzker Ⅳ型胫骨平台骨折的分型及治疗

目的　探讨SchatzkerⅣ型胫骨平台骨折的损伤特点、疗效差的原因和改进的方法。方法　根据SchatzkerⅣ型胫骨平台骨折的骨折特点 ,将 1993～ 2 0 0 2年间诊治的 5 1例患者分为劈裂型、整髁型和塌陷型。对劈裂型和整髁型骨折 ,无关节面塌陷者 ,采用内侧切口 ;CT检查示有关节面塌陷者 ,采用正中切口纠正塌陷并植骨 ;劈裂型支撑钢板在内后侧固定 ,整髁型支撑钢板在内侧固定 ,或双侧支撑钢板固定。对塌陷型骨折 ,采用内侧切口 ,行复位、植骨、支撑钢板内侧固定。 33例患者术后平均随访 4 1个月 ,对影响骨折预后的因素进行分析。结果　随诊的 33例患者膝关节活动度为30°～ 14 7°(平均 110°) ;Lysholm评分平均为 83 2分 ,优 8例、良 9例、中 14例、差 2例。平台非解剖复位、平台增宽 >4mm、平台向外侧移位 >8mm是预后较差的相关因素 (χ2 值分别为 5 10、6 0 8、8 0 2 ,P<0 0 5、<0 0 5、<0 0 1) ,也易导致骨性关节炎的发生。结论　应根据分型和CT检查结果选择手术入路和固定方法 ,膝内翻畸形、平台增宽 >4mm或向外侧移位 >8mm是影响预后的因素。     

根据改良的Schatzker分型治疗复杂胫骨平台骨折

目的探讨改良的Schatzker分型对复杂胫骨平台骨折制定术前计划的指导作用,使术前计划更充分,减少术中误判。方法 2006年3月至2013年10月,对58例需要切开复位及内固定的常规SchatzkerⅤ型、Ⅵ型胫骨平台骨折,随机分成对照组及实验组,每组29例,对照组进行Schatzker分型,实验组进行改良的Schatzker分型,并分别确定手术入路、内固定物放置位置及数量,比较两种分型对手术进路、内固定物放置位置及数量的正确率,比较两种分型对指导治疗方案的满意度。结果根据改良的Schatzker分型,对SchatzkerⅤ型、Ⅵ型骨折患者进行手术入路选择,确定内固定物放置位置及数量,进行术前计划和术中观察,对关节面的复位及主要问题骨的显露和直接固定的正确率为100%,而根据常规Schatzker分型,对SchatzkerⅤ型、Ⅵ型胫骨平台骨折选择手术入路、内固定物放置位置及数量,正确率为86.36%,差异有统计学意义。结论根据改良的Schatzker分型,对需要切开复位及内固定的复杂胫骨平台骨折,选择手术入路及内固定物放置位置及数量更准确,使术前计划更充分,减少术中误判,术中证明对关节面及主要问题骨的复位更好,对主要问题骨的固定更直接,更准确。     

根据CT扫描及三维重建改良胫骨平台骨折的Schatzker分型

目的根据对胫骨平台骨折进行3D-CT检查,把Schatzker分型再分出若干亚型,方便制订治疗方案。方法选取265例胫骨平台骨折病例,所有病例均进行Schatzker分型,再行3D-CT检查。根据胫骨平台俯视图,把胫骨平台分为两柱四区,根据骨折累及各区情况,把Schatzker分型进一步分出亚型。对265例病例进行统计,分析各型及亚型的病例数和发病率。比较两种分型的漏诊率,比较两种分型对指导治疗方案的满意度。结果根据3D-CT检查,把Schatzker分型细分出亚型,我们称为改良的Schatzker分型。265例胫骨平台骨折有27例行CT检查后,常规Schatzker分型与改良的Schatzker分型结果不符合,不符合率为13.61%;两种分型正确率分别为86.4%和100%。所有265例患者中,2 8例根据常规Schatzker分型不需要手术,但根据改良的Schatzker分型需要手术,更改率为10.6%。结论根据3D-CT检查把Schatzker分型进行细分,使分型更详尽、直观,提高了胫骨平台骨折的检出率,减少了误判率,便于研究损伤机制、制订治疗方案以及评判预后。     

GATA脊柱结核分型的可信度与可重复性研究

目的:对GATA脊柱结核分型的可信度及可重复性进行分析,为临床应用提供参考。方法:让4名脊柱外科医师以GATA脊柱结核分型为标准独立对100例脊柱结核患者进行两次分型(间隔1个月),通过计算两两医师之间及同一医师前后两次分型对最后分型、各指标判断相同的平均百分比,确定分型一致性,应用Kap-pa值和Spearman系数判定其可信度和可重复性,当Kappa值>0.5时有中度或中度以上的一致性,Spearman相关系数值>0.40时有中度或中度以上正性相关。结果:4名医师对各指标(椎体塌陷、椎旁脓肿、脊柱稳定性、脊柱后凸畸形、矢状面指数、椎间盘破坏)及最后分型判断相同的平均百分比分别为61.92%、91.83%、63.33%、60.08%、78.25%、82.00%、52.33%;可信度的Kappa值分别为0.430、0.519、0.317、0.380、0.536、0.531、0.343;Spearman相关系数分别为0.392、0.526、0.392、0.503、0.569、0.582、0.576。同一医师前后两次对各指标(椎体塌陷、椎旁脓肿、脊柱稳定性、脊柱后凸畸形、矢状面指数、椎间盘破坏)及最后分型判断相同的平均百分比分别为72.75%、91.00%、85.25%、70.75%、88.75%、81.75%、73.00%;可重复性的Kappa值分别为0.574、0.453、0.627、0.523、0.724、0.584、0.591;Spearman相关系数分别为0.748、0.473、0.632、0.660、0.730、0.613、0.762。结论:GATA脊柱结核分型具有较高的可重复性,但可信度较差。     

胫骨平台骨折的分型及进展

胫骨平台骨折是常见的关节内骨折，骨折的类型不同，其治疗方法及结果也不相同。同时，为了评估治疗效果，也需要分型的统一化、标准化，胫骨平台骨折常用的分型方法为AO分型和Schatzker分型。[第一段]     

胫骨平台骨折的Hohl分型与关节镜下内固定术

胫骨平台骨折为一种常见的关节内骨折,处理比较困难,常导致关节功能障碍,自2000～2002年治疗胫骨平台骨折共25例,术前行Hohl分型,对有手术指征的病例行关节镜下手术。现总结如下。     

SchatzkerⅣ型胫骨平台骨折及手术入路研究

SchatzkerⅣ型胫骨平台骨折为累及平台内髁的骨折,形态特殊,骨折线从内髁斜向外侧延伸,并常从后外侧平台关节面穿出。SchatzkerⅣ型胫骨平台骨折手术入路包括后正中入路、后内侧倒L形入路、前内侧长直入路、前外侧弧形入路、后内侧联合后外侧双直入路、后内侧联合后外侧双S形入路等。该文就SchatzkerⅣ型胫骨平台骨折及手术入路等研究进展作一综述。     

特发性脊柱侧凸PUMC分型的可重复性及可信度研究

目的:探讨特发性脊柱侧凸PUMC(协和)分型系统的一致性,并对影响分型一致性的因素进行分析.方法:随机选取南京鼓楼医院2004年～2006年治疗的80例特发性脊柱侧凸患者,其中男性15例,女性65例,平均年龄14.6岁(10～18岁),均有完整的术前站立位正侧位X线片及仰卧位左右Bending片共四张.由4名脊柱外科专科医生分别根据PUMC(协和)分型标准进行分型,2周后此4位医生分别对这些患者的X线片再次进行分型,收集分型结果分别作可信度和可重复性分析,计算Kappa值检验一致性并对影响分型一致性的因素进行统计分析,结果:80例患者均可用PUMC分型,分型可信度平均Kappa值为0.801,可重复性Kappa值为0.878.PUMC分型不一致中包括上胸弯的界定18次;胸弯明显时,代偿性与结构性腰弯的界定15次;腰弯明显时,代偿性与结构性胸弯的界定18次;单弯顶点的判断20次;测量角度的差异18次.结论:PUMC(协和)分型学习曲线相对较短,易于掌握且具有良好的可信度和可重复性.     

DTS与DR技术应用于胫骨平台骨折Schatzker分型的效能比较

目的 比较X射线摄影系统(Digital radiography,DR)和数字断层融合技术(Digital tomosynthesis,DTS)用于胫骨平台骨折Schatzker分型的诊断效能.方法 纳入自2017-05-2018-11诊治的120例胫骨平台骨折,患者入院后常规进行DR和DTS成像技术检查,以术中Sch...     

退变性腰椎滑脱French分型和CARDS分型的可重复性与可信度研究

目的 :对退变性腰椎滑脱的French分型及CARDS分型进行可重复性与可信度的对比分析,探讨两种分型在退变性腰椎滑脱患者中的应用价值。方法:回顾性分析2012年1月~2016年6月期间118例腰椎退变性滑脱(L4/5 91例、L5/S1 27例)患者,其中男性26例,女性92例,平均年龄61.1±8.1岁。3名脊柱外科医师对患者术前X线片独自进行两次测量,分别使用French分型和临床与影像学分型(clinical and radiographic degenerative spondylolisthesis,CARDS分型)进行评估和分型,收集结果 ,作同一观察者间可重复性及不同观察者间可信度分析。应用Kappa值比较分析两种分型的差异性。结果:3位观察者使用French分型系统共进行708次(118例×3×2次)分型,包括1型261次,2型107次,3型83次,4型54次,5型203次,观察者内分型一致率80.5%~86.4%(Kappa值0.740~0.815),属于"基本可信";观察者间分型一致率为79.7%~82.2%(Kappa值0.728~0.758),属于"基本可信"。测量并分型单个患者平均花费时间约138s。CARDS分型系统共708次分型中,包括A型(A1)19次,B型(B1 90次,B2 59次)149次,C型(C1 291次,C2 108次)399次,D型(D1 98次,D2 43次)141次,观察者内总体一致率90.7%~93.2%(Kappa值0.878~0.911),属于"完全可信";观察者间总体一致率88.1%~94.1%(Kappa值0.844~0.921),属于"完全可信"。测量并分型单个患者平均花费时间约67s。结论 :两种分型系统具有较高的可重复性与可信度,CARDS分型可信度与可重复性优于French分型。     

Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures

Our aim was to assess the reproducibility and the reliability of the Weber classification system for fractures of the ankle based on anteroposterior and lateral radiographs. Five observers with varying clinical experience reviewed 50 sets of blinded radiographs. The same observers reviewed the same radiographs again after an interval of four weeks. Inter- and intra-observer agreement was assessed based on the proportion of agreement and the values of the kappa coefficient. For inter-observer agreement, the mean kappa value was 0.61 (0.59 to 0.63) and the proportion of agreement was 78% (76% to 79%) and for intra-observer agreement the mean kappa value was 0.74 (0.39 to 0.86) with an 85% (60% to 93%) observed agreement. These results show that the Weber classification of fractures of the ankle based on two radiological views has substantial inter-observer reliability and intra-observer reproducibility.     

Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures

IntroductionTibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT).Materials and MethodsEighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch.ResultsOverall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (k_Schatzker = 0.32 and k_Luo = 0.28, P = 0.021), however, ‘fair’ for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k_2DCT = 0.37 and k_2D+3DCT = 0.29, P < 0.001). The addition of 3DCT did not improve the overall interobserver reliability for the Luo classification as well, as kappa values were not significantly different on 2DCT and 2D- and 3DCT (k_2DCT = 0.31 and k_2D+3DCT = 0.25, P = 0.096).ConclusionsThe agreement between observers was significantly better for the Schatzker classification compared to Luo's Three Column classification, however agreement was fair for both classification systems. Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. Considering that new classification systems and 3DCT do not seem to improve agreement between surgeons, other efforts are needed that lead to more reliable diagnosis of complex tibial plateau fractures.     

Three-dimensional computed tomography imaging increases the reliability of classification systems for tibial plateau fractures

Objective

The purpose of this study was to determine whether three-dimensional reconstructed computed tomography (CT) images can improve intra-observer and inter-observer reliability for classification systems of tibial plateau fractures compared to plain radiographs and two-dimensional CT images.

Methods

Twenty-one tibial plateau fractures were classified independently by four attending orthopaedic trauma surgeons using the AO/ASIF and Schatzker classification systems. First, a combination of plain radiographs and two-dimensional (2D) CT images were evaluated. Second, 4 weeks later, plain radiographs and three-dimensional (3D) CT images were assessed. Then, 4 weeks later, these two rounds of evaluation were repeated. The intra-observer and inter-observer reliability were assessed using kappa statistics.

Results

Three-dimensional CT images can improve the inter-observer and intra-observer reliability regarding both AO/ASIF and Schatzker classification systems of tibial plateau fractures compared to 2D CT images. The degree of agreement of the inter-observer and intra-observer reliability among four surgeons increased from ‘substantial’ to ‘almost perfect’.

Conclusion

Three-dimensional CT is a more reliable radiographic modality than 2D CT in evaluation of fracture patterns in tibial plateau fractures. This finding seems to show that more sophisticated imaging techniques can improve the reliability of fracture classification systems.     

Comparison between reliability of Schatzker's classification and CT based four quadrant classification for tibial plateau fractures

IntroductionConventionally used Schatzker and AO/OTA classification, do not identify posterior column injuries in tibial plateau fractures. CT based Four quadrant classification, has been proposed to identify fractures of tibial plateau and help in surgical planning of treatment. However, to assess its validity, there is scanty literature about its reliability (inter and intra-observer variation) and comparison of its reliability with that of the more popular Schatzker classification in classifying tibial plateau fracture.Material and methodsX-rays and CT scans of 35 patients (18–65 years) of closed tibial plateau fractures were assessed by 5 Orthopaedic surgeons and classified by both Schatzker's and Four Quadrant Classification. A similar observation was recorded after 2 months. All observers were blinded for the demographic and clinical details of the patients. Their responses were noted and interobserver and Intraobserver variation was calculated. Kappa Test of Cohen was used to determine the level of agreement, as per Landis and Koch's criteria. The reliability of four quadrant classification was also compared with that of Schatzker's classification.ResultsThere was a moderate agreement in interobserver variation in observations for Schatzker's classification (on X-rays) which improved to substantial agreement when the observations were recorded after showing both CT and X-rays. The intraobserver variation had substantial agreement. On the other hand, there was a perfect agreement in both intra- and interobserver variation for Four Quadrant Classification. This difference between the reliability of both classifications was statistically significant (p < 0.001).ConclusionsFour Quadrant classification is a more reliable classification having a better agreement on interobserver and intraobserver variation.     

Two column classification of tibial plateau fractures; description,clinical application and reliability

PurposeIn this era of life highly comminuted and multi planar tibial plateau fractures involving the posterior corners are more commonly seen and addressed in the literature than before. Among these several types have not been described in the currently used classification systems. In fact simple classification systems ignore several fracture types and leniently grouped the fractures with different mechanism, morphology, treatment modalities and prognosis in same category. On the other hand, more extensive nature classifications with detailed subdivisions are difficult to remember for clinicians. The clinical reliability of these classifications is another problem. All these issues demand the potential need of a new classification. The aim of this study was to describe a quadrant specific two column classification of tibial plateau fractures and to analyse its inter-observer and intra-observer reliability, clinical assessment and application.Materials and methodsFrom January 2009 to December 2015, 44 patients with tibial plateau fractures were studied retrospectively. The antero-posterior (AP), lateral X-rays and computed tomography (CT) with axial transverse, sagittal, coronal and three dimensional (3D) reconstruction images were performed for all the patients. All of the fractures were categorized according to quadrant specific two column classification and the traditional Schatzker’s classification. The comparative analysis for inter-observer and intra-observer reliability of the new classification and the Schatzker’s classification was conducted by four observers.ResultsThree cases didn’t match any type in the Schatzker’s classification. While on the other hand, all cases were classified by two column classification. The mean kappa values for inter-observer reliability by using the Schatzker’s classification was 0.723 (range, 0.674-0.823), representing substantial agreement, whereas the mean kappa value was 0.939 (range: 0.897-0.974), representing almost perfect agreement according to two column classification. The mean kappa values for intra-observer reliability using the Schatzker’s classification and two column classification were 0.789 (range: 0.590-0.864) and 0.955 (range:0.923-0.948) showing substantial agreement and almost perfect agreement.ConclusionThe quadrant specific two column classification is anatomically oriented, CT based and clinically valid. The different fracture types according to anatomic location are represented alphanumerically so that treatment matched to specific fracture type (quadrant specific anatomic fixation) for optimal outcomes. Furthermore, it demonstrates higher inter-observer and intra-observer reliability. This classification can be adopted to strengthen the traditional Schatzker’s classification, particularly in the multi planar and posteriorly extended plateau fractures. It can be used as a reliable research tool. The database can be used to distinguish different fracture types, individual type incidences, specific treatment and also prognosis. Authors suggest a large multi-centre study.     

三柱固定理论在胫骨平台骨折治疗中的价值

目的评价三柱固定理论在胫骨平台骨折治疗中的应用价值。方法将32例胫骨平台骨折患者按内固定方法分为符合三柱固定理论组（符合组,21例）和不符合三柱固定理论组（不符合组,11例）。采用Ras-mussen评分评价复位固定效果,改良HSS评分评价术后功能恢复情况。比较两组间复位固定效果和术后功能恢复情况。结果 32例均获随访,时间6~46个月。术后初期与末次随访时Rasmussen评分：符合组差异无统计学意义（P〉0.05）,不符合组差异有统计学意义（P〈0.05）。Rasmussen评分和末次随访改良HSS评分两组各时期比较差异均有统计学意义（P〈0.05）。结论三柱固定理论用于指导手术治疗能够获得更优良的复位和更稳定的固定,有利于膝关节功能的恢复。     

Revisiting the Schatzker classification of tibial plateau fractures

Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.     

胫骨平台骨折三柱分型的可信度评价

 目的 研究胫骨平台骨折三柱分型不同观察者间的可信度,并与传统Schatzker分型进行比较,证实三柱分型的可靠性。方法 2004年12月至2007年3月,对胫骨平台骨折患者进行三柱分型,根据分型选择手术切口和治疗。采用随机数表法从304例（323膝）胫骨平台骨折中抽取50例,选择4位未参与该项手术的工作人员,在规定时间内完成对每例胫骨平台骨折的三柱分型和Schatzker分型的评估。评估结束后使用Kappa值计算4组相关度,以比较评价三柱分型和Schatzker分型的可信度差别。结果 323膝胫骨平台骨折中,0柱骨折4膝（1.2%）,单柱骨折181膝（56.0%）,双柱骨折108膝（33.4%）,三柱骨折30膝（9.3%）。在单柱骨折中,外侧柱114膝（63.0%）,内侧柱53膝（29.3%）,后侧柱14膝（7.7%）。在双柱骨折中,外侧柱合并内侧柱36膝（33.3%）,内侧柱合并后侧柱34膝（31.5%）,外侧柱合并后侧柱38膝（35.2%）。三柱分型的可信度Kappa值为0.766（0.706～0.890),属于基本可信程度;Schatzker分型的可信度Kappa值为0.567（0.513～0.589）,属于中度可信程度。结论 基于CT和三维重建的胫骨平台骨折三柱分型直观明了,具有较高可信度,建议作为新的分型系统在临床推广和应用。     

Inter-observer and intra-observer reliability in the radiographic measurements of paediatric forefoot alignment

BackgroundFoot bones in children have more rounded shapes in radiograms than adults. Thus, the goal of this work was assessing inter- and intra-observer reliability in paediatric forefoot angle measurements.Material and methodsSix forefoot angles in 34 AP standing paediatric foot radiographs were measured by 5 researchers. A classic statistical analysis with use of IBM SPSS Statistics 25 was performed and a new method with two-way analysis of variance was applied.ResultsResults of statistical analysis revealed the properties of a subjective assessment related to specific angles. Kilmartin’s angle, calcaneus-fifth metatarsal angle and first ray angle are the most reliable; metatarsus adductus angle should be used with great caution in pediatric population. Engel’s angle is the most difficult for measuring and measurement error is the highest.ConclusionThe power of paediatric forefoot measurements is various. Several angles are reliable, while Engle’s angle is the most doubtful.