SLR - September 2023 - Amin
Title: Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based ClassificationsReference: Morales, S., Massri-Pugin, J., Mery, P., Palma, J., Filippi, J., & Villa, A. (2023). Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications. JAAOS Global Research & Reviews, 7(1).
Level of Evidence: 3
Scientific Literature Review
Reviewed By: Suril Amin, DPM
Residency Program: Our Lady of Lourdes Memorial Hospital, Binghamton, NY
Podiatric Relevance: Posterior malleolar fractures are prevalent in 50% of all ankle fractures with several classifications systems to characterize them under CT. The three most common classification systems, Haraguchi, Bartonicek/Rammelt, and Mason do not completely report the level of agreement. This study aimed to compare the level of agreement of Haraguchi, Bartonicek/Rammelt, and Mason classifications among physicians with different levels of training using the Guidelines for Reporting Reliability and Agreement studies (GRRAS).
Methods: The inclusion criteria were patients 18 years and older with a posterior malleolar fracture and pre-operative ankle axial and sagittal CT scan. Exclusion criteria included history of ankle fractures, surgery, tumors, infections, and posterior pilon fractures. 94 fractures met the inclusion criteria. Three attendings orthopedic foot & ankle surgeons and three senior orthopedic residents evaluated the CT images. All images were reassessed three weeks later, and the kappa (k) coefficient was used to determine the interobserver and intraobserver agreement.
Results: A total of 564 assessments were completed for the 94 cases with each classification. The assessments were repeated three weeks later. About 69% of the cases had 3D reconstruction available for analysis. The interobserver agreement was moderate for Haraguchi, Bartonicek/Rammelt, and Mason classifications with a global k value of 0.52 (95% CI, 0.43 to 0.60), 0.53 (95% CI, 0.46 to 0.61), and 0.54 (95% CI, 0.47 to 0.62), respectively. The intraobserver agreement was substantial for Haraguchi, Bartonicek/Rammelt, and Mason classifications, with an overall k value of 0.70 (95% CI, 0.64 to 0.74), 0.73 (95% CI, 0.68 to 0.78), and 0.73 (95% CI, 0.69 to 0.78).
Conclusions: This study looked at the reliability of the three most common posterior malleolar ankle fracture classifications. It found good intraobserver agreement but only moderate interobserver agreement regardless of the experience of the evaluators. Ultimately neither of the three classification systems are superior to the other and it is recommended that another classification systems be devised for the posterior malleolus ankle.