Reproducibility of the stability-based classification for ankle fractures

  • Bjarke VibergEmail author
  • Tamim A. Haidari
  • Jesper Stork-Hansen
  • Roland Knudsen
  • Rune Dueholm Bech
Original Article • ANKLE - FRACTURES



Classification of ankle fracture is important when deciding for operative or conservative treatment. This study rates the reproducibility of ankle stability assessment and compares it with the classification by Lauge-Hansen and Arbeitsgemeinschaft für Osteosyntesefragen (AO) in adult patients with primary ankle fractures.


A total of 496 consecutive ankle fractures were included, and the X-ray images were reviewed 2 times by 2 medical students, 2 residents, and 1 consultant in orthopedic traumatology. The raters were blinded to each other and to their own results. Unweighted Kappa statistics were used to assess reproducibility.


Overall mean (95% CI) interrater Kappa results were 0.65 (0.64; 0.68) for Lauge-Hansen, 0.62 (0.60; 0.63) for AO and 0.61 (0.57; 0.62) for the stability assessment. The intrarater results ranged from a mean Kappa of 0.64–0.80 for the medical students, 0.65–0.81 for the residents and 0.82–0.84 for the consultant.


The stability assessment has substantial to almost-perfect agreement which is comparable to the Lauge-Hansen and AO classifications.


Reproducibility Stability Ankle fracture Classification 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury 37(8):691CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Biant L, Bugler KE, McQueen MM (2014) Changing epidemiology of adult fractures in Scotland. Scott Med J 59(1):30CrossRefGoogle Scholar
  3. 3.
    Elsoe R, Ostgaard SE, Larsen P (2018) Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg 24(1):34CrossRefGoogle Scholar
  4. 4.
    Toth MJ, Yoon RS, Liporace FA, Koval KJ (2017) What’s new in ankle fractures. Injury 48(10):2035CrossRefGoogle Scholar
  5. 5.
    Broos PL, Bisschop AP (1991) Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury 22(5):403CrossRefGoogle Scholar
  6. 6.
    Lauge-Hansen N (1950) Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60(5):957CrossRefGoogle Scholar
  7. 7.
    Müller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, BerlinCrossRefGoogle Scholar
  8. 8.
    Fonseca LLD, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI (2018) Reproducibility of the Lauge-Hansen, Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop 53(1):101CrossRefGoogle Scholar
  9. 9.
    Alexandropoulos C, Tsourvakas S, Papachristos J, Tselios A, Soukouli P (2010) Ankle fracture classification: an evaluation of three classification systems: Lauge-Hansen, A.O. and Broos-Bisschop. Acta Orthop Belg 76(4):521Google Scholar
  10. 10.
    Verhage SM, Rhemrev SJ, Keizer SB, Quarles van Ufford HM, Hoogendoorn JM (2015) Interobserver variation in classification of malleolar fractures. Skelet Radiol 44(10):1435CrossRefGoogle Scholar
  11. 11.
    Pakarinen HJ, Flinkkil TE, Ohtonen PP, Ristiniemi JY (2011) Stability criteria for nonoperative ankle fracture management. Foot Ankle Int 32(2):141CrossRefGoogle Scholar
  12. 12.
    Michelson JD (2013) Using decision analysis to assess comparative clinical efficacy of surgical treatment of unstable ankle fractures. J Orthop Trauma 27(11):642CrossRefGoogle Scholar
  13. 13.
    Kottner J, Audige L, Brorson S, Donner A, Gajewski BJ, Hrobjartsson A, Roberts C et al (2011) Guidelines for reporting reliability and agreement studies (GRRAS) were proposed. J Clin Epidemiol 64(1):96CrossRefGoogle Scholar
  14. 14.
    EpiData Association. Available at: Accessed 1 Jan 2010
  15. 15.
    Sim J, Wright CC (2005) The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 85(3):257Google Scholar
  16. 16.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159CrossRefGoogle Scholar
  17. 17.
    Cordova CB, Dunn JC, Kusnezov N, Bader JM, Waterman BR, Orr JD (2018) Comparing clinician use of three ankle fracture classifications. JAAPA 31(2):36CrossRefGoogle Scholar
  18. 18.
    Thomsen NO, Overgaard S, Olsen LH, Hansen H, Nielsen ST (1991) Observer variation in the radiographic classification of ankle fractures. J Bone Joint Surg Br 73(4):676CrossRefGoogle Scholar
  19. 19.
    Viberg B, Bartholin ML, Weber K, Bech RD, Palm H, Schultz-Larsen M (2016) High reliability of a scoring system for implant position in undisplaced femoral neck fractures. J Orthop Trauma 30(8):432CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and TraumatologyOdense University HospitalOdenseDenmark
  2. 2.Department of Orthopaedic Surgery and TraumatologyKolding Hospital – part of Hospital LillebaeltKoldingDenmark
  3. 3.Institute for Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark

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