Thank you for the opportunity to present this work. My name is Jefet Masri, and today I'm going to talk about the shortcomings of posterior malleus fractor classifications and independent agreement study. We don't have any conflict of interest. Posterior malleus fractors are present in up to 50% of all ankle fractors. Its presence could produce poor functional outcomes, and several classification systems exist for these fractors under CT scan. The first one is the classification of Haraguchi, the other one is the classification of Bartonichek and Rammelt, and the last one, the classification of Mason, published five years ago. This is the Haraguchi classification with the type 1, a posterolateral fragment, the type 2, a fracture with medial extension, and the type 3, a small-shell fracture. Bartonichek and Rammelt classification with the type 1, extra-incisoral fragment, the type 2, a posterolateral fragment involving the incisora, the type 3, a posteromedial two-part fragment, the type 4, a posterolateral triangular fragment, and the type 5, an irregular osteoporotic fracture not classifiable in the other types. Finally, we have the Mason classification with the type 1, extra-articular fragment, the type 2a, a posterolateral fragment, the type 2b, a posterolateral and posteromedial fragment, and the type 3, a coronal plane fracture involving the posterior plafon. It's clearly known that current classifications don't report or report incompletely the level of agreement and reliability. Therefore, the aim of this study was to conduct an independent agreement study of these classifications among physicians with different levels of expertise in the management of these fractures. This was an observational study, and the guidelines for reporting reliability and agreement study was used as proposed by Kuttner. We included all the able patients with preparative CT scan and the presence of posteromodulus fracture under CT scan. We excluded patients with by-lung fractures, prior ankle surgeries, tumors, and infections. Three orthopedic surgeons and three orthopedic residents evaluated the image, and all CT images were reassessed in a random sequence three weeks later in order to void the recall bias. Coherent and place-kappa coefficients were calculated in order to detect the inter-observer and intra-observer agreement. These were the results. We evaluated 94 ankle fractures, being the most common the type 1 for Haraguchi, the type 2 for Bartoni-Tekon-Ramel, and the type 2b for Mason classification with near 40% of the cases. Regarding the intra-observer agreement, this was substantial for all classifications assessed without significant difference between them, as you can see here in the kappa coefficients. However, the inter-observer agreement was just moderate for all classifications assessed without significant difference between them. You can see here a kappa coefficient of 0.5 approximately for all classifications. Interestingly, we didn't find any significant difference in kappa coefficients among residents and orthopedic surgeons for the inter- and intra-observer agreement. According to the literature, this is the first study that compares the level of agreement of these classifications under CT scan and with the guidelines proposed by Kondner. This is the first study that compared the level of agreement among physicians with different levels of expertise in the management of these fractures. In conclusion, the intra-observer agreement was substantial. However, the inter-observer agreement was just moderate for all classifications. Current classification doesn't allow a reliable and reproducible communication both in clinical and research field, and it appears mandatory to generate a new classification that gives a higher level of reproducibility as well as treatment and prognosis orientation of these fractures. Thank you very much.

Jefet Masri

posterior malleolus fracture classifications

independent agreement study

ankle fractures

functional outcomes