Enhancing agreement in classification and surgical approach selection for tibial plateau fractures: The role of identifying metaphyseal fracture exit. - A Cross-sectional study

Objectives: To determine if identifying the metaphyseal exit can enhance intra- and inter-observer agreement in utilizing the Kfuri and Schatzker anatomical classification and selecting the appropriate surgical approach for tibial plateau fractures. Methods: Design: Cross-sectional observational study. Setting: Academic hospital with access to advanced imaging technologies. Patient Selection Criteria: Tibial plateau fracture cases from January 2019 to March 2021 with complete image sets (AP and lateral knee radiographs, CT scans). Exclusion criteria included periprosthetic, neglected, or pathological fractures. Outcome Measures and Comparisons: Primary outcome measures were intra- and inter-observer agreement in fracture classification and surgical approach selection, quantified using Cohen's and Fleiss Kappa coefficients. Results: The study analyzed 63 cases. Intra-observer agreement improved from moderate to 'very good,' especially in the third evaluation phase when the metaphyseal exit was identified alongside 3D CT imaging. Inter-observer agreement was generally low but improved when comprehensive image sets were available. Notably, the most experienced evaluator demonstrated significantly higher agreement in both fracture classification and surgical approach selection. Conclusions: The identification of metaphyseal exit points significantly enhances agreement in fracture classification and surgical approach selection, addressing limitations of traditional systems. While surgeon experience and imaging availability remain critical, incorporating the metaphyseal exit into the Kfuri and Schatzker classification offers a reproducible framework for guiding treatment decisions. Level of evidence: III Diagnostic Study.