What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

Abstract

Background Fractures of the proximal fifth metatarsal are common, and often they are classified using a three-part scale first proposed by Lawrence and Botte. A clear consensus on prognosis and treatment for these fractures is lacking, particularly for fractures in the middle classification, Zone 2; the reliability of the classification scheme itself may be partly at fault for this. The intra-and interrater reliability of the classification itself has never been established, and it remains unclear whether the three-part Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

CORR Insights®: What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

“…The authors of this study [6] nicely show that simplifying the Lawrence and Botte classification from three zones to two zones markedly increased the interrater and intrarater reliability. Likewise, Morris et al [5] presented biomechanical data that revealed a distinctive change in stability between proximal fifth metatarsal fractures that were within the peroneal brevis insertional footprint (Lawrence and Botte Zone 1) compared with those proximal to the footprint (Lawrence and Botte Zones 2 and 3).…”

“…In the current study, Noori et al [6] appropriately challenged the validity and reliability of the commonly used Lawrence and Botte classification system for the treatment and prognosis of fifth metatarsal base fractures. They found that the Lawrence and Botte classification system demonstrated low interrater and intrarater reliability, even among surgeons specializing in foot and ankle surgery.…”

“…Classification systems such as the Lawrence and Botte system that are unable to reliably provide surgeons with appropriate guidance in determining treatment and prognosis are not helpful, and I agree with the authors [6] that it should be abandoned, at least in its current form. Their suggestion to simplify the classification, from a three-part to a two-part binary classification consisting of the Lawrence and Botte Zone 1 and a combination of Zones 2 and 3, makes a lot of sense.…”

“…The next study should take the good suggestion of Noori et al [6] and ensure the classification system’s reliability and validity in guiding treatment and predicting the likely outcome from treatment. Ideally, this would involve a new group of investigators using a different set of images of fifth metatarsal base fractures, and classifying them according to the revised—now two-group, instead of three—Lawrence and Botte classification.…”

“…Classification systems such as the Lawrence and Botte system that are unable to reliably provide surgeons with appropriate guidance in The fracture is either a stable avulsion fracture, typically within the peroneus brevis tendon insertion's footprint (Lawrence and Botte Zone 1), or it is an unstable fracture distal to the tendon footprint (Lawrence and Botte Zones 2 and 3), with a markedly increased risk of delayed union or nonunion often resulting in the need for internal fixation [5]. Noori et al [6] were right to ask questions about this classification, and their study suggests a way we can easily modify this commonly used but unreliable classification in a way that will better serve our patients and research needs.…”