Computed tomography-based classifications of posterior malleolar fractures and their inter- and intraobserver reliability: a comparison of the Haraguchi, Bartoníček/Rammelt, and Mason classifications

Kleinertz, Holger; Mueller, Elena; Tessarzyk, Marlon; Frosch, Karl‐Heinz; Schlickewei, Carsten

doi:10.1007/s00402-021-04315-y

Cited by 10 publications

(15 citation statements)

References 28 publications

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“…It is thus reasonable to state that whilst a correct diagnosis is possible, at acceptable rates, this is only possible to achieve once a unanimous diagnosis is made. In contrast to recent literature which notes substantial reliability and agreement to all three of the commonly utilized classification systems, our study observed “poor” interobserver reliability [ 37 , 38 ]. The general poor agreement may be due to the complexity of the classifications themselves, clinical difficulties in recognizing these variables, or both.…”

Section: Discussioncontrasting

confidence: 99%

The reliability of posterior malleolar ankle fracture assessment: a unique perspective

Fűzy,

Ferreira,

Brown

et al. 2023

Eur J Orthop Surg Traumatol

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Aim This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. Methods A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. Results A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18–78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. Conclusion A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. Level of evidence Level III.

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Section: Discussioncontrasting

confidence: 99%

The reliability of posterior malleolar ankle fracture assessment: a unique perspective

Fűzy,

Ferreira,

Brown

et al. 2023

Eur J Orthop Surg Traumatol

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“…Another paper by Morales et al also showed moderate interobserver reliability for the M&M classification with a global κ value of 0.54 (95% CI: 0.47-0.62), rated by six evaluators [18]. It is also worth mentioning a study by Kleinertz et al with four raters which presented Fleiss' κ value of 0.724 (95% CI: 0.674-0.774) [19].…”

Section: Discussionmentioning

confidence: 89%

Enhancing Consistency in Posterior Malleolus Fracture Classification: A Comprehensive Interobserver Reliability Study With 20 Raters Using the Mason & Molloy Classification

Theyvan Balakrishnan,

Bilal,

Fitzpatrick

et al. 2023

Cureus

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Introduction: Over the past decade, there has been a growing interest in the identification and treatment of posterior malleolus fragments, driven by a better understanding of their significance. The Mason & Molloy (M&M) classification system has emerged as a valuable tool for systematically categorizing these fractures and assisting clinicians in formulating treatment. We aim to assess the interobserver reliability of the M&M classification for posterior malleolus fracture by using 20 raters.Methodology: The study was conducted at a major foot and ankle referral center in Wythenshawe, Manchester, UK. Thirty-eight Computed Tomography (CT) scans were evaluated by 20 independent raters: 15 general orthopedic and trauma surgeons plus five foot and ankle surgeons. Each rater classified the posterior malleolus fracture according to M&M classification into type 1, 2A, 2B, 3, or not classifiable. Statistical analysis was done with the R software package and SPSS (v26; IBM Corp., Armonk, NY). Fleiss kappa (κ) coefficient with a 95% confidence interval (CI) was applied.Results: The interobserver agreement was moderate with a global κ value of 0.531 (95% CI: 0.518, 0.544). There were good agreements for identifying type 3 M&M (κ=0.785) and those that are not applicable for M&M classification (κ=0.785). There was a strong correlation between all raters in using M&M classification (T b =0.53-0.59) except for Rater 12.Conclusion: M&M classification remains a valuable tool to guide the management of patients with these subsets of ankle fractures.

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“…Kleinertz et al, 11 recently published on this subject with the same classifications. They used four observers and showed substantial, if not perfect, interobserver and intraobserver reliabilities independent of the observer's level of expertise.…”

Section: Discussionmentioning

confidence: 93%

“…None of these classifications showed superiority over the others in the interobserver and intraobserver agreement. To the best of our knowledge, this is the first study that independently assessed the most used classifications for posterior malleolus ankle fractures under a CT scan using the GRRAS, proposed by Kottner et al 9 Kleinertz et al, 11 recently published on this subject with the same classifications. They used four observers and showed substantial, if not perfect, interobserver and intraobserver reliabilities independent of the observer's level of expertise.…”

Section: Discussionmentioning

confidence: 99%

Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications

Morales

Massri-Pugin²,

Mery³

et al. 2023

JAAOS Glob Res Rev

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Background: Posterior malleolus fractures occur in up to 50% of all ankle fractures. Several classification systems exist for their characterization, especially under CT. However, those classifications do not report the level of agreement or do it incompletely. This study aims to independently assess three posterior malleolus fracture classifications (Haraguchi, Bartonı ´ cek/Rammelt, and Mason). Methods: This study was designed according to the Guidelines for Reporting Reliability and Agreement Studies. Ninety-four CT scans of patients with ankle fractures that had posterior malleolus fractures were included. Posterior malleolus fractures were assessed by six evaluators (three attending foot and ankle surgeons and three orthopaedic surgery residents) according to Haraguchi, Bartonı ´ cek/Rammelt, and Mason classifications. All images were reassessed by the same evaluators in a random sequence 3 weeks later. The kappa (k) coefficient was used to determine the interobserver and intraobserver agreement. Statistical significance was established using P , 0.05 with a 95% confidence interval (CI). Results: The interobserver agreement was moderate for Haraguchi, Bartonı ´ cek/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, Bartonı ´ cek/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), respectively. Interobserver and intraobserver agreement among orthopaedic surgeons and residents had no significant difference. Conclusion:The current classifications for posterior malleolus fractures showed a substantial intraobserver agreement.

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Computed tomography-based classifications of posterior malleolar fractures and their inter- and intraobserver reliability: a comparison of the Haraguchi, Bartoníček/Rammelt, and Mason classifications

Cited by 10 publications

References 28 publications

The reliability of posterior malleolar ankle fracture assessment: a unique perspective

The reliability of posterior malleolar ankle fracture assessment: a unique perspective

Enhancing Consistency in Posterior Malleolus Fracture Classification: A Comprehensive Interobserver Reliability Study With 20 Raters Using the Mason & Molloy Classification

Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications

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