Reliability of a four-column classification for tibial plateau fractures

A four-column classification system offers a different way of evaluating tibial plateau fractures. The aim of this study is to compare the intra-observer and inter-observer reliability between four-column and classic classifications. This is a reliability study, which included patients presenting with tibial plateau fractures between January 2013 and September 2015 in a level-1 trauma centre. Four orthopaedic surgeons blindly classified each fracture according to four different classifications: AO, Schatzker, Duparc and four-column. Kappa, intra-observer and inter-observer concordance were calculated for the reliability analysis. Forty-nine patients were included. The mean age was 39 ± 14.2 years, with no gender predominance (men: 51%; women: 49%), and 67% of the fractures included at least one of the posterior columns. The intra-observer and inter-observer concordance were calculated for each classification: four-column (84%/79%), Schatzker (60%/71%), AO (50%/59%) and Duparc (48%/58%), with a statistically significant difference among them (p = 0.001/p = 0.003). Kappa coefficient for intr-aobserver and inter-observer evaluations: Schatzker 0.48/0.39, four-column 0.61/0.34, Duparc 0.37/0.23, and AO 0.34/0.11. The proposed four-column classification showed the highest intra and inter-observer agreement. When taking into account the agreement that occurs by chance, Schatzker classification showed the highest inter-observer kappa, but again the four-column had the highest intra-observer kappa value. The proposed classification is a more inclusive classification for the posteromedial and posterolateral fractures. We suggest, therefore, that it be used in addition to one of the classic classifications in order to better understand the fracture pattern, as it allows more attention to be paid to the posterior columns, it improves the surgical planning and allows the surgical approach to be chosen more accurately.