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Tibial Plateau Fractures: Reproducibility of Three Classifications (Schatzker, AO, Duparc) and A Revised Duparc Classification
Tibial Plateau Fractures: Reproducibility of Three Classifications (Schatzker, AO, Duparc) and A Revised Duparc Classification
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ORIGINAL ARTICLE
a
Service d’orthopédie-traumatologie, hôpital Pontchaillou, 2, rue Le Guilloux, 35033 Rennes, France
b
Service d’orthopédie-traumatologie, CHU de Poitiers, 86000 Poitiers, France
KEYWORDS Summary
Tibial plateau Introduction: Since the reproducibility of the Schatzker and AO tibial plateau fracture classi-
fractures; fication systems has already been assessed, the goal of this study was to evaluate the Duparc
Classification system; classification system and compare it to the other two.
Reproducibility; Hypotheses: CT scan is better than X-rays for analyzing and classifying tibial plateau fractures.
CT scan The Duparc classification system is more effective than the other two systems but could be
improved by adding elements of each.
Materials and methods: Six observers analyzed images from 50 fractures and then classified
them. Each fracture was evaluated on X-rays. Two weeks later, these same fractures were
evaluated on X-rays and CT scans. The same process was repeated four weeks later. The Kappa
coefficient () was used to measure agreement and contingency tables were built.
Results: The interobserver reproducibility for the X-ray analysis was poor for the Duparc
and AO classifications (Duparc = 0.365; AO = 0.357) and average for the Schatzker classification
(Schatzker = 0.404). The reproducibility was improved overall when CT scans were also analyzed
(Duparc = 0.474; AO = 0.479; Schatzker = 0.476). A significantly greater number of fractures could
not be classified in the Schatzker system than in the others (14.3% versus 2% for Duparc and
7.33% for AO). Review of the contingency tables revealed that the Schatzker and AO classifica-
tion systems did not take certain fracture types into account. Seventy-one percent (71%) of the
lateral unicondylar split fractures were found to be combined fractures when CT scan analysis
was added.
Discussion: Our results showed CT scan to be better at analyzing and classifying fractures. We
also found the Duparc classification to be advantageous because it allowed more fractures to
be classified than in other classification systems, while having similar reproducibility. Based on
our study findings, the Duparc classification was revised by adding elements of the other two.
We propose using the modified Duparc classification system to analyze tibial plateau fractures
going forward.
Level of evidence: Level IV. Retrospective study.
© 2013 Published by Elsevier Masson SAS.
intraobserver correlation was substantial with XR and XR/CT intraobserver correlation was moderate with XR (XR = 0.582)
(XR = 0.663; XR/CT = 0.784). When the ‘‘simplified’’ classifi- and substantial with XR/CT (XR/CT = 0.694). Use of the
cation with five types was used, the inter- and intraobserver ‘‘simplified’’ AO classification (7 types only) did not improve
correlations improved to substantial and excellent, respec- these correlations. With the XR files, 5.7% of fractures could
tively (XR = 0.647; XR/CT = 0.736; XR =0.821; XR/CT = 0.889). not be classified; with the XR/CT files, 7.3% could not.
With the XR files, 3.3% of fractures could not be classified;
with the XR/CT files, 2% could not.
Contribution of CT scan
Schatzker classification
Use of CT scan significantly (p < 0.01) improved the inter-
observer reproducibility in every classification system and
The interobserver correlation was moderate for both XR
the intraobserver reproducibility of the simplified Duparc
(XR = 0.404) and XR/CT (XR/CT = 0.476) (Table 2). The
classification.
intraobserver correlation was substantial for XR and XR/CT
(XR = 0.626; XR/CT =0.660). With the XR files, 11.7% of frac-
tures could not be classified; with the XR/CT files, 14.3% Comparison of classification systems
could not.
The simplified Duparc classification was more reproducible
AO classification (p < 0.01) than the Schatzker and AO (even in its simplified
version) classification systems. Use of the Schatzker system
The interobserver correlation was fair with XR (XR = 0.357) resulted in significantly higher number of fractures not being
and moderate with XR/CT (XR/CT = 0.479) (Table 2). The classified (p < 0.01).
Interobserver
XR 0.404 (0.262-0.525) 0.365 (0.219-0.498) 0.647 (0.566-0.747) 0.357 (0.203-0.480) 0.319 (0.153-0.443)
XR/CT 0.476 (0.329-0.565) 0.474 (0.346-0.617) 0.736 (0.637-0.913) 0.479 (0.410-0.616) 0.433 (0.299-0.574)
Intraobserver
XR 0.626 (0.449-0.717) 0.663 (0.441-0.877) 0.821 (0.739-0.885) 0.582 (0.499-0.902) 0.571 (0.461-0.918)
XR/CT 0.660 (0.545-0.809) 0.784 (0.599-0.975) 0.889 (0.824-0.972) 0.694 (0.635-0.900) 0.677 (0.594-0.881)
808 T. Gicquel et al.
Relationship between classification systems after Schatzker classification and 44% in the OA classification
XR/CT (Table 3);
• Schatzker type IV fractures were classified as spinocondy-
• Of the posteromedial fractures identified in the lar (74%), unicondylar (19%), posteromedial (5%) or
Duparc system, 72% were not classified in the bicondylar (2%) in the Duparc classification and B3 (53%),
Classification of tibial plateau fractures 809
Duparc
Schatzker
I 6 0 0 0 0 0 6
II 111 0 0 1 0 0 112
III 18 0 0 0 0 0 18
IV 0 8 1 32 2 0 43
V 0 0 34 2 3 2 41
VI 1 0 33 1 0 2 37
NC 1 7 13 7 13 2 43
Total 137 15 81 43 18 6 300
AO
A 0 0 0 0 0 0 0
B1 7 5 0 15 1 0 28
B2 18 0 0 0 0 0 18
B3 112 10 4 21 5 0 152
C1 0 0 12 0 0 0 12
C2 0 0 29 0 0 1 30
C3 0 0 32 2 4 0 38
NC 0 0 4 5 8 5 22
Total 137 15 81 43 18 6 300
NC: not classified.
810 T. Gicquel et al.
Figure 3 AO Classification.
were labeled ‘‘combined’’ after CT evaluation and 58.3% of The Schatzker and AO classification systems have previ-
the ‘‘depressions’’ were labeled ‘‘combined’’. ously been compared in multiple published studies [8—15]
(Table 5). Kappa coefficients were improved when CT
scans were added and were a bit better than ours for
the AO system, but similar for the Schatzker system.
Discussion These discrepancies probably stem from having various
levels of experience with the classification system and
The three classification systems (Duparc, Schatzker, AO) had using different methodology [19]. Our poor results with
the same reproducibility when CT scans were used, which the AO classification system could be due to our lack of
is now an essential imaging modality [12—15] (Fig. 4). The experience with this system. Various groups have demon-
Duparc classification had the advantage of being more repro- strated the contribution of 3D reconstructions [12,15] and
ducible in its simplified five-type format and allowing a MRI [20,21], which also allows soft tissue injuries to be
greater number of fractures to be classified. assessed.
Classification of tibial plateau fractures 811
Lateral plateau
Fracture linea 0.387 Fair 0.522 Moderate
Displacement 0.285 Fair 0.287 Fair
Comminution 0.387 Fair 0.372 Fair
Depression location 0.333 Fair 0.360 Fair
Dislocation/sublux 0.573 Moderate 0.524 Moderate
Medial plateau
Fracture linea 0.378 Fair 0.496 Moderate
Displacement 0.433 Moderate 0.454 Moderate
Comminution 0.523 Moderate 0.468 Moderate
Depression location 0.383 Fair 0.374 Fair
Dislocation/sublux 0.235 Fair 0.171 Slight
Intercondylar eminence fracture
Fracture line 0.432 Moderate 0.455 Moderate
Displacement 0.435 Moderate 0.478 Moderate
TT fracture 0.432 Moderate 0.345 Fair
Ligament insertions 0.229 Fair 0.158 Slight
Tibial shaft fracture 0.596 Moderate 0.433 Moderate
Fibula fracture 0.812 Excellent 0.689 Substantial
Subcondylar area
Fracture linea 0.726 Substantial 0.817 Excellent
Displacement 0.608 Substantial 0.621 Substantial
Comminution 0.504 Moderate 0.590 Moderate
Spinocondylar line
Fracture line 0.571 Moderate 0.549 Moderate
Displacement 0.633 Substantial 0.515 Moderate
Comminution 0.518 Moderate 0.392 Fair
a Significantly better with CT scan (p < 0.01).
The three classification systems only overlap for Duparc Posteromedial fractures (Fig. 5), either isolated or
lateral unicondylar fractures, which correspond to Schatzker associated with another fracture, were a challenge for
Types I, II and III and AO types B1.1, B2.1, B2.2 and B3.1 observers to classify because they are not described in
(separating them instead of grouping them). The Duparc and the Schatzker (Type IV?) or AO (Type B1.2?) classification
AO systems have other common aspects: systems. First described by Postel et al. in 1974 [23] and
later included in the Duparc classification [3], these frac-
• rare medial unicondylar fracture: B1.2, B2.3 or tures lead to specific problems in terms of approach and
B3.2; fixation [24—28].
• medial spinocondylar fracture [3,22]: B1.3. or Schatzker type IV fractures, which are fractures treated
B3.3; through a medial approach, were classified randomly in the
• simple bicondylar fractures, which resemble AO Types other classification systems, suggesting that they encom-
C1 and C2 but the AO takes metaphyseal comminu- pass different fractures. In the Schatzker classification,
tion into consideration (C2). Conversely, the Duparc the medial fragment can be split or split and depressed,
classification better handles articular comminution which could correspond to medial unicondylar fractures.
with ‘‘complex’’ (split-depression of lateral plateau) His diagrams suggest the intercondylar eminence can
and ‘‘comminuted’’ (includes posteromedial fracture) be involved; this could be interpreted as a spinocondy-
types. lar fracture line (Fig. 6), but the displacement of this
812
Table 5 Published studies.
Classification Imaging Method Average Interobserver Kappa () Average Intraobserver Kappa ()
systems
Rx Rx/TDM2D Rx/TDM3D Rx Rx/TDM2D Rx/TDM3D
T. Gicquel et al.
Classification of tibial plateau fractures 813
Figure 4 a: simple bicondylar fracture viewed on X-Ray; b—d: comminuted bicondylar fracture viewed on CT scan (combined
lateral condyle + posteromedial fracture).
fracture has not been taken into account. In addition, it captures the greatest number of fractures. However, uni-
is hard to relate them with posteromedial fractures hav- condylar fractures could be classified in the same order as
ing a frontal fracture line. Yang had the same observation Schatzker did to harmonize them, and certain features of
[29]. both the AO and Schatzker system can be added to the
Schatzker type V fractures are bicondylar fractures revised Duparc classification:
that do not take into account potential comminution
(metaphyseal and/or articular). In the Schatzker classifi- • metaphyseal comminution of simple bicondylar fractures
cation, they are characterized by metaphysis and diaphysis (from the AO system);
continuity, which is not correct in many cases. His diagrams • index D is a diaphyseal fracture associated with another
show a fracture-split of the two condyles, which we have fracture (taken from Schatzker). Similarly, the index P can
never observed. be added to fractures associated with a posteromedial
Schatzker type VI fractures have the advantage of captur- fracture.
ing a potential association with diaphysis fracture, which is a
challenging scenario for fixation. Nevertheless, this does not Based on our results, these changes find us proposing
allow tibial plateau fractures themselves to be described. a revised Duparc classification (Fig. 7), with acronyms for
Thus it would seem logical to use the Duparc classifica- each fracture (UL1 for Type 1 lateral unicondylar fractures,
tion as a basis for an improved classification system, as it etc.).
814 T. Gicquel et al.
Figure 6 Medial spinocondylar fracture: a: Type II fracture or even Type I on X-ray; b and c: subluxation and depression of lateral
plateau (Type III) on CT scan.
Classification of tibial plateau fractures 815
Figure 7 Revised Duparc classification. Lateral (UL1, UL2, UL3) or medial (UM1, UM2, UM3) unicondylar fractures. Bicondylar
(BI) fractures: simple articular BI1 or with metaphyseal comminution: BI2; complex articular (with lateral plateau depression): BI3.
Spinocondylar (SC) fractures: medial or lateral. Posteromedial fractures: PM isolated or associated with another fracture (index P);
associated with diaphyseal fracture (index D).
Conclusion evaluated has their pros and cons. We believe that a sin-
gle classification system (revised Duparc) is sufficient for
classifying nearly all tibial plateau fractures (Fig. 7).
The simplified Duparc classification was the most repro-
ducible system evaluated and was able to capture the great-
est number for fractures. Furthermore, it classifies types of Disclosure of interest
fractures and/or displacements that are not described in any
other classification system (spinocondylar fracture, postero- The authors declare that they have no conflicts of interest
medial fracture). Each of the three classifications systems concerning this article.
816 T. Gicquel et al.
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