肩胛盂骨折Bartonícek分型的观察者间和观察者内的一致性分析

doi:10.3877/cma.j.issn.2095-5790.2023.01.008

目的

通过与Ideberg分型和OTA/AO分型比较，评估新的Bartonícek分型在临床实践中的可靠性。

方法

共纳入2015年1月至2022年1月于首都医科大学附属北京朝阳医院诊治的68例肩胛盂骨折患者治疗前的X线片和3DCT资料，4名观察者（2名骨科医生、2名影像科医生）根据Ideberg分型、OTA/AO分型和Bartonícek分型分别对上述两种影像资料进行分类。4周后将所有原始资料重新编号，4名观察者再次使用相同的方法对骨折进行分类。通过使用Chron Kappa和组内相关系数（intraclass correlation coefficient，ICC）来确定三种分型的观察者间和观察者内一致性。

结果

本研究共纳入68例患者，其中男52例、女16例；平均年龄为41岁（20~76岁）。Bartonícek分型、OTA/AO分型和Ideberg分型基于3DCT的观察者间平均Kappa值分别为0.75±0.03、0.70±0.03、0.57±0.03，基于X线的观察者间平均Kappa值分别为0.52±0.02、0.46±0.02、0.51±0.01，基于3DCT的观察者内平均ICC值分别为0.78±0.04、0.72±0.02、0.68±0.02，基于X线的观察者内平均ICC值分别为0.56±0.02、0.51±0.02、0.55±0.02。不论是基于X线片或3DCT，Bartonícek分型的观察者间kappa值和观察者内ICC值均显著高于OTA/AO分型和Ideberg分型（P<0.05）。

结论

与OTA/AO分型和Ideberg分型相比，Bartonícek分型的可靠性更具优势。

关键词: 肩胛盂骨折, 骨折分型, 三维CT, 可信度

Background

Subscapular glenoid fracture is rare, accounting for only 0.11% of total body fractures and about 16.2% of scapular fractures. A comprehensive and reliable classification system for subscapular glenoid fractures is necessary. There are many classification systems to describe subscapular glenoid fractures, among which the most commonly used is the Ideberg classification based on X-ray films. However, there are still some shortcomings in fracture morphology, diagnostic accuracy, and completeness. In addition, OTA/AO classification and Bartoníclassification based on 3DCT have been proposed, which significantly improve the diagnostic accuracy and value for treatment decision-making. However, no studies have investigated the reliability of these three classifications in clinical practice. Objective The reliability of the new Bartoní classification in clinical practice was evaluated by comparison with Ideberg and OTA/AO classification.

Methods

Sixty-eight patients with scapular glenoid fractures diagnosed and treated in Beijing Chaoyang Hospital, Capital Medical University from January 2015 to January 2022 were enrolled with pre-treatment X-ray and 3DCT data. Four observers (2 orthopedic surgeons and 2 radiologists) classified the two images according to the classifications of Ideberg, OTA/AO, and Bartoní. After 4 weeks, all the original data were renumbered, and the fractures were again classified using the same method by 4 observers. Chron Kappa and intraclass correlation coefficient (ICC) were used to determine inter-observer and intra-observer consistencies for the three classifications.

Results

Sixty-eight patients with a mean age of 41 (20 to 76) were enrolled in this study, including 52 males (76.5%). The mean inter-observer Kappa values of Bartoni, OTA/AO, and Ideberg classification based on 3DCT were 0.75±0.03, 0.70±0.03, and 0.57±0.03, respectively. The mean inter-observer Kappa values based on X-ray were 0.52±0.02, 0.46±0.02, 0.51±0.01, and the mean intra-observer ICC values based on 3DCT were 0.78±0.04, 0.72±0.02, 0.68±0.02, respectively. The mean intraobserver ICC values based on X-ray were 0.56±0.02, 0.51±0.02, and 0.55±0.02, respectively. The interobserver kappa values and intraobserver ICC values of Bartoni were significantly higher than those of OTA/AO and Ideberg (P < 0.05), whether based on radiographs or 3DCT.

Conclusion

Compared with OTA/AO classification and Ideberg classification, the Bartoní classification has more advantages in reliability.

Key words: Glenoid fractures, Fracture classification, Three-dimensional CT, Reliability

表1 本研究纳入和排除患者的人口统计学和骨折特征的比较

患者	例数	年龄（岁，±s）	性别[例（%）]		伤侧[例（%）]		受伤机制[例（%）]		孤立性骨折[例（%）]
患者	例数	年龄（岁，±s）	男	女	左	右	高能量创伤	中低能量创伤	是	否
纳入患者	68	41±15	52（76.5）	16（23.5）	39（57.4）	29（42.6）	59（86.8）	9（13.2）	7（10.3）	61 （89.7）
排除患者	17	39±14	10（58.8）	7（41.2）	11（64.7）	6（35.3）	16（94.1）	1（5.9）	3 （17.6）	14 （82.4）
检验值		t=0.52	x²=1.345		x²=0.304		x²=0.177		x²=0.177
P值		0.604	0.246		0.582		0.674		0.674

表1 本研究纳入和排除患者的人口统计学和骨折特征的比较

患者	例数	年龄（岁，±s）	性别[例（%）]		伤侧[例（%）]		受伤机制[例（%）]		孤立性骨折[例（%）]
患者	例数	年龄（岁，±s）	男	女	左	右	高能量创伤	中低能量创伤	是	否
纳入患者	68	41±15	52（76.5）	16（23.5）	39（57.4）	29（42.6）	59（86.8）	9（13.2）	7（10.3）	61 （89.7）
排除患者	17	39±14	10（58.8）	7（41.2）	11（64.7）	6（35.3）	16（94.1）	1（5.9）	3 （17.6）	14 （82.4）
检验值		t=0.52	x²=1.345		x²=0.304		x²=0.177		x²=0.177
P值		0.604	0.246		0.582		0.674		0.674

图1 Ideberg分型示意图注：Ia为前侧盂缘骨折；Ib为后侧盂缘骨折；II为关节孟窝下部横行或斜行骨折,波及肩胛骨外侧缘；III为关节孟上半横行骨折，骨折线向内上方延伸，伴有肩峰、喙突、锁骨等；IV为关节盂中央横行骨折,骨折线延伸至肩胛骨内缘,常有关节对应关系改变；Va为II型与IV型的复合型；Vb为II型与IV型的复合型；Vc为II型、III型与IV型的复合型；VI为关节孟严重粉碎性骨折

图2 OTA/AO分型（关节盂骨折）示意图注：F1为累及关节盂的骨折，具有简单的边缘、横断或斜型骨折模式；F1.1为单纯的前关节缘或斜型骨折；F1.2为单纯的后关节缘或斜型骨折；F1.3为单纯横断或短斜型骨折；F2为累及关节窝的多块关节骨折，有3个或更多关节碎片；F2.1为边缘出口多于1处骨折线的粉碎骨折；F2.2为不伴有边缘出口的关节盂中央型粉碎骨折；r为赤道线以下，单象限；f为赤道线以上，2个象限；t为赤道线以下，2个象限；i为赤道以下；e为位于赤道线；p为赤道线以上

图3 Bartonícek分型示意图注：I为上关节盂骨折，Ia仅累及上缘，喙突完整；Ib为分离喙突基底；Ic为骨折线延伸至肩胛骨上缘，几乎达到上角顶点；Id为上角为独立碎片；Ie为上缘、上角和肩胛冈均受累；II为前关节盂骨折；IIa为外周型（环形骨折）；IIb为悬垂型（占关节面20%~25%）；IIc为分裂型（占关节面30%~50%）；III为后关节盂骨折；IIIa为后盂缘骨折；IIIb为后下盂缘骨折；IV为下关节盂骨折；IVa为关节盂的1/4撕裂；IVb为关节盂的1/3撕裂；IVc为关节盂的1/2撕裂；IVd为关节盂的2/3撕裂；V为关节盂完全骨折；Va为关节面分为两个大骨折碎片；Vb为关节盂分为三个大骨折碎片；Vc为一个大骨折碎片与关节面其余部分粉碎；Vd为两个大骨折碎片与关节面其余部分粉碎

表2 各分型系统的观察者间、观察者内的kappa值和ICC值比较

观察者	3DCT					X线
观察者	Bartonícek分型	OTA/AO分型	Ideberg分型	F值	P值	Bartonícek分型	OTA/AO分型	Ideberg分型	F值	P值
观察者间	0.75±0.03	0.70±0.03^a	0.57±0.03^a，b	68.271	<0.001	0.52±0.02	0.46±0.02^a	0.51±0.01^b	16.986	<0.001
观察者内	0.78±0.04	0.72±0.02^a	0.68±0.02^a	10.804	<0.001	0.56±0.02	0.51±0.02^a	0.55±0.02^b	7.926	<0.001

表2 各分型系统的观察者间、观察者内的kappa值和ICC值比较

观察者	3DCT					X线
观察者	Bartonícek分型	OTA/AO分型	Ideberg分型	F值	P值	Bartonícek分型	OTA/AO分型	Ideberg分型	F值	P值
观察者间	0.75±0.03	0.70±0.03^a	0.57±0.03^a，b	68.271	<0.001	0.52±0.02	0.46±0.02^a	0.51±0.01^b	16.986	<0.001
观察者内	0.78±0.04	0.72±0.02^a	0.68±0.02^a	10.804	<0.001	0.56±0.02	0.51±0.02^a	0.55±0.02^b	7.926	<0.001

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Intra- and interobserver reliability of Bartonícek classification of subscapular glenoid fractures

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Intra- and interobserver reliability of Bartonícek classification of subscapular glenoid fractures