Evaluation of Ankle Fracture Classification Systems in 193 Trimalleolar Ankle Fractures

Overview

Journal Eur J Trauma Emerg Surg

Specialties Critical Care
Emergency Medicine

Date 2022 Mar 29

PMID 35348840

Authors

Patrick Pfluger

Felix Harder

Karoline Muller

Peter Biberthaler

Moritz Cronlein

Affiliations

Soon will be listed here.

Abstract

Purpose: Different classification systems have been developed for ankle fractures. In recent years, the posterior malleolus has gained in importance and led to computed tomography (CT)-based classification systems. The aim of the study was to analyse their reliability, fracture patterns and influence on treatment strategy.

Methods: Patients with a trimalleolar ankle fracture treated between 2011 and 2020 with preoperative radiographs and CT images were included. The blinded images were independently classified by three reviewers according to the AO/OTA, Herscovici, Bartoníček, Mason and Haraguchi classifications. The interobserver reliability was calculated by Fleiss' kappa (κ). CT images were analysed to determine the dimensions of the posterior malleolus fragments. Patient registries were reviewed regarding the treatment data.

Results: A total of 193 patients were included. The AO/OTA classification showed almost perfect inter- and intraobserver reliability (Fleiss' κ = 0.86, 95% CI 0.82-0.90). Regarding the posterior malleolus, the Bartoníček classification demonstrated the highest reliability (Fleiss' κ = 0.78, 95% CI 0.73-0.83). The Herscovici classification only reached moderate reliability for medial malleolus fractures (Fleiss' κ = 0.59, 95% CI 0.54-0.65). There was a trend towards direct fixation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03-5.99).

Conclusion: In trimalleolar ankle fractures, the AO/OTA classification is a reliable system to characterize the type of fracture, but it fails to provide solid information about the posterior malleolus. Nowadays, treatment recommendations for trimalleolar ankle fractures focus on the configuration of the posterior malleolus; therefore, the results of this study advocate the use of the Bartoníček classification as a reliable tool to guide treatment.

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References

Verhage S, Hoogendoorn J, Krijnen P, Schipper I . When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg. 2018; 138(9):1213-1222. DOI: 10.1007/s00402-018-2949-2. View

Aitken S, Johnston I, Jennings A, Chua I, Buckley R . An evaluation of the Herscovici classification for fractures of the medial malleolus. Foot Ankle Surg. 2017; 23(4):317-320. DOI: 10.1016/j.fas.2016.10.003. View

Pfluger P, Braun K, Mair O, Kirchhoff C, Biberthaler P, Cronlein M . Current management of trimalleolar ankle fractures. EFORT Open Rev. 2021; 6(8):692-703. PMC: 8419795. DOI: 10.1302/2058-5241.6.200138. View

Meinberg E, Agel J, Roberts C, Karam M, Kellam J . Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2017; 32 Suppl 1:S1-S170. DOI: 10.1097/BOT.0000000000001063. View

Bartonicek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresl I . Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015; 135(4):505-16. DOI: 10.1007/s00402-015-2171-4. View

Maluta T, Samaila E, Amarossi A, Dorigotti A, Ricci M, Vecchini E . Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?. Foot Ankle Surg. 2021; 28(1):126-133. DOI: 10.1016/j.fas.2021.02.009. View

Mason L, Marlow W, Widnall J, Molloy A . Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle. Foot Ankle Int. 2017; 38(11):1229-1235. DOI: 10.1177/1071100717719533. View

Miller M, McDonald T, Graves M, Spitler C, Russell G, Jones L . Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation. Foot Ankle Int. 2017; 39(1):99-104. DOI: 10.1177/1071100717735839. View

Vacas-Sanchez E, Olaya-Gonzalez C, Abarquero-Diezhandino A, Sanchez-Morata E, Vila-Rico J . How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings. Int Orthop. 2020; 44(6):1177-1185. DOI: 10.1007/s00264-020-04481-5. View

10.

Haraguchi N, Haruyama H, Toga H, Kato F . Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006; 88(5):1085-92. DOI: 10.2106/JBJS.E.00856. View

11.

Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A . Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br. 2000; 82(3):345-51. DOI: 10.1302/0301-620x.82b3.10064. View

12.

Bartonicek J, Rammelt S, Tucek M . Posterior Malleolar Fractures: Changing Concepts and Recent Developments. Foot Ankle Clin. 2017; 22(1):125-145. DOI: 10.1016/j.fcl.2016.09.009. View

13.

Neumann A, Rammelt S . Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg. 2021; 142(8):1823-1834. PMC: 9296426. DOI: 10.1007/s00402-021-03875-3. View

14.

Herscovici Jr D, Scaduto J, Infante A . Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg Br. 2007; 89(1):89-93. DOI: 10.1302/0301-620X.89B1.18349. View

15.

Yang T, Tzeng Y, Wang C, Lin C, Chang M, Chiang C . Untreated small posterior fragment of ankle fracture with early removal of syndesmotic screw is associated with recurrent syndesmotic instability. Injury. 2020; 52(3):638-643. DOI: 10.1016/j.injury.2020.10.030. View

16.

Liu Y, Lu H, Xu H, Xie W, Chen X, Fu Z . Characteristics and classification of medial malleolar fractures. Bone Joint J. 2021; 103-B(5):931-938. DOI: 10.1302/0301-620X.103B5.BJJ-2020-1859.R2. View

17.

Elsoe R, Ostgaard S, Larsen P . Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018; 24(1):34-39. DOI: 10.1016/j.fas.2016.11.002. View

18.

Raeder B, Andersen M, Madsen J, Jacobsen S, Frihagen F, Figved W . Prognostic value of the Haraguchi classification in posterior malleolar fractures in A0 44-C type ankle fractures. Injury. 2021; 52(10):3150-3155. DOI: 10.1016/j.injury.2021.07.038. View

19.

Malek I, Machani B, Mevcha A, Hyder N . Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures. J Bone Joint Surg Br. 2006; 88(9):1204-6. DOI: 10.1302/0301-620X.88B9.17954. View

20.

Kennedy J, Johnson S, Collins A, DalloVedova P, McManus W, Hynes D . An evaluation of the Weber classification of ankle fractures. Injury. 1999; 29(8):577-80. DOI: 10.1016/s0020-1383(98)00116-8. View