gms | German Medical Science

Objectives: The Bartonícek/Rammelt classification is established for posterior malleolar fractures. It subdivides the fractures into 5 types and outlines treatment recommendations. This study aims to determine the intra- and interobserver reliability of the Bartonícek/Rammelt classification and investigates its applicability regarding treatment recommendations.

Methods: CT scans of 80 ankle fractures with a posterior malleolar fracture were analyzed by four observers at two different time points 30 days apart (d1 and d2). Intra- and interrater reliability was measured using kappa values. The corresponding surgery rates of the fracture subtypes were analyzed, and the surgery rates were correlated with fragment sizes and displacements.

Results and conclusion: A moderate interobserver reliability for d1 0.41 (CI 0.35–0.47) and d2 0.42 (CI 0.36–0.48) was detected. Intraobserver reliability was documented as perfect, with a mean kappa of 0.83. Type II fractures were operated on in 50% of cases. In 50% of type II cases, a non-operative treatment was chosen. Fragment size correlated strongly with the chosen therapy, and osteosynthesis was performed significantly more often when the fragment size exceeded 3 cm³ (p<0.01).

The Bartonícek/Rammelt classification system showed moderate interobserver reliability and perfect to substantial intraobserver reliability. Despite the recommendations in the literature, in clinical practice the size of the posterior malleolar fragment rather than the dislocation and joint impaction seems to influence the decision to operate on type II or III fractures. Existing treatment recommendations based upon the Bartonícek/Rammelt classification correspond to the therapy algorithm carried out in this cohort of patients.