Three-dimensional computed tomography reconstruction improves the reliability of tibial pilon fracture classification and preoperative surgical planning

Purpose In the present study, we aimed to evaluate the impact of two-dimensional multi-planar computed tomography (2D-MP-CT) scans and three-dimensional surface rendering computed tomography reconstruction (3D-SR-CT) on the inter- and intra-observer reliability of four commonly used classification systems for tibial pilon fractures, and on the reliability and validity of surgical treatment planning for fracture fixation. Methods Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for bone graft augmentation. Fractures were first evaluated using 2D-MP-CT, followed by 3D-SR-CT. We calculated the Kappa values for the correlation between the fracture classifications, types of surgical approaches, implant positions, and bone graft recommendations by the observers. Furthermore, we assessed the correlation between the treatment plans recommended by the observers and the actual surgical procedure performed. Results All classifications showed poor inter-observer reliability and moderate intra-observer reliability with 2D-MP-CT scans. The inter-observer reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications improved to moderate, whereas the intra-observer reliability of the AO/OTA classification improved to good with additional 3D-SR-CT. The correlation between the suggested and the actually performed surgical approaches was poor with 2D-MP-CT, but improved to moderate with 3D-SR-CT. The suggested plate positions showed a moderate correlation with the actually performed plating; although the correlation improved significantly, it remained moderate with 3D-SR-CT. Conclusion The use of 3D-SR-CT reconstruction can improve the reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications. Furthermore, three-dimensional imaging enables a more valid planning of the surgical approach and implant position.