Predicting epiphyseal stability of slipped capital femoral epiphysis with preoperative CT imaging

Background We analyzed preoperative CT scans of hips with slipped capital femoral epiphysis (SCFE) for characteristics that could be predictive of intraoperative epiphyseal stability and developed a set of imaging criteria for stable and unstable SCFE. We then compared this grading system with the Loder classification. Methods We reviewed preoperative CT imaging to develop a SCFE stability classification system. Three orthopaedic surgeons used the classification system to grade stability on a series of SCFE hips. Kappa was used to evaluate intra- and interobserver reliability among the observers. A series of SCFE hips treated with open procedures in which intraoperative stability was determined under direct visualization was evaluated. Intraoperative stability was compared with stability ratings as determined by the CT classification system and the Loder classification system. Results Interobserver reliability among our three observers was κ = 0.823 (95% confidence interval (CI) 0.414 to 1.0; p < 0.001). Intraobserver reliability was κ = 0.901 (95% CI 0.492 to 1.31; p < 0.001). In all, 27 hips were used in the comparison of intraoperative stability with the Loder and CT classification systems. CT-predicted stability exhibited 78% concordance with intraoperative stability. The sensitivity and specificity of CT-predicted stability was 75% and 82%, respectively, versus Loder sensitivity of 69% and specificity of 91%. Conclusion The CT evaluation method provided is easy to use and can help to improve the accuracy in determining preoperative epiphyseal stability, which may lead to improved treatment outcomes for this population. Level of Evidence III

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Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee

The American Journal of Sports Medicine ◽

10.1177/0363546516637175 ◽

2016 ◽

Vol 44 (7) ◽

pp. 1694-1698 ◽

Cited By ~ 24

Author(s):

James L. Carey ◽

Eric J. Wall ◽

Nathan L. Grimm ◽

Theodore J. Ganley ◽

Eric W. Edmonds ◽

...

Keyword(s):

Osteochondritis Dissecans ◽

Classification System ◽

Interobserver Reliability ◽

Intraclass Correlation ◽

Intraobserver Reliability ◽

Classification Systems ◽

Future Research ◽

Multicenter Studies ◽

Level Of Evidence ◽

Surgical Evaluation

Background: Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems. Purpose: To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories—3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC). Results: The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good. Conclusion: The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD.

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The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System

Aesthetic Surgery Journal ◽

10.1093/asj/sjy325 ◽

2018 ◽

Vol 39 (9) ◽

pp. 979-988 ◽

Cited By ~ 4

Author(s):

Madison A Hesse ◽

Jacqueline S Israel ◽

Nikita O Shulzhenko ◽

Ruston J Sanchez ◽

Catharine B Garland ◽

...

Keyword(s):

Surgical Treatment ◽

Classification System ◽

Recurrent Infection ◽

Well Being ◽

Classification Systems ◽

Penile Skin ◽

Level Of Evidence ◽

Excess Skin ◽

Wound Breakdown ◽

Buried Penis

Abstract Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

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Classification and Nomenclature: Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950722 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1271-1276 ◽

Cited By ~ 1

Author(s):

Mark S. Myerson ◽

David B. Thordarson ◽

Jeffrey E. Johnson ◽

Beat Hintermann ◽

Bruce J. Sangeorzan ◽

...

Keyword(s):

Classification System ◽

Consensus Statement ◽

Classification Systems ◽

Posterior Tibial Tendon ◽

Foot Deformity ◽

New Classification ◽

Level Of Evidence ◽

3 Dimensional ◽

Posterior Tibial ◽

Consensus Statements

Recommendation: The historical nomenclature for the adult acquired flatfoot deformity (AAFD) is confusing, at times called posterior tibial tendon dysfunction (PTTD), the adult flexible flatfoot deformity, posterior tibial tendon rupture, peritalar instability and peritalar subluxation (PTS), and progressive talipes equinovalgus. Many but not all of these deformities are associated with a rupture of the posterior tibial tendon (PTT), and some of these are associated with deformities either primarily or secondarily in the midfoot or ankle. There is similar inconsistency with the use of classification schemata for these deformities, and from the first introduced by Johnson and Strom (1989), and then modified by Myerson (1997), there have been many attempts to provide a more comprehensive classification system. However, although these newer more complete classification systems have addressed some of the anatomic variations of deformities encountered, none of the above have ever been validated. The proposed system better incorporates the most recent data and understanding of the condition and better allows for standardization of reporting. In light of this information, the consensus group proposes the adoption of the nomenclature “Progressive Collapsing Foot Deformity” (PCFD) and a new classification system aiming at summarizing recent data published on the subject and to standardize data reporting regarding this complex 3-dimensional deformity. Level of Evidence: Level V, consensus, expert opinion. Consensus Statements Voted: CONSENSUS STATEMENT ONE: We will rename the condition to Progressive Collapsing Foot Deformity (PCFD), a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT TWO: Our current classification systems are incomplete or outdated. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: MRI findings should be part of a new classification system. Delegate vote: agree, 33% (3/9); disagree, 67% (6/9); abstain, 0%. (Weak negative consensus) CONSENSUS STATEMENT FOUR: Weightbearing CT (WBCT) findings should be part of a new classification system. Delegate vote: agree, 56% (5/9); disagree, 44% (4/9); abstain, 0%. (Weak consensus) CONSENSUS STATEMENT FIVE: A new classification system is proposed and should be used to stage the deformity clinically and to define treatment. Delegate vote: agree, 89% (8/9); abstain, 11% (1/9). (Strong consensus)

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The reliability of the AOSpine Thoracolumbar Spine Injury Classification System in children: an international validation study

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.15.200188 ◽

2021 ◽

pp. 1-7

Author(s):

Andrew Z. Mo ◽

Patricia E. Miller ◽

Javier Pizones ◽

Ilkka Helenius ◽

Michael Ruf ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Thoracolumbar Spine ◽

Paediatric Population ◽

Spine Injury ◽

Level Of Evidence ◽

Orthopaedic Surgeons ◽

Intraobserver Reproducibility ◽

Paediatric Orthopaedic ◽

Injury Classification

Purpose To evaluate the AOSpine Thoracolumbar Spine Injury Classification System and if it is reliable and reproducible when applied to the paediatric population globally. Methods A total of 12 paediatric orthopaedic surgeons were asked to review MRI and CT imaging of 25 paediatric patients with thoracolumbar spine traumatic injuries, in order to determine the classification of the lesions observed. The evaluators classified injuries into primary categories: A, B and C. Interobserver reliability was assessed for the initial reading by Fleiss’s kappa coefficient (kF) along with 95% confidence intervals (CI). For A and B type injuries, sub-classification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff’s alpha (αk) along with bootstrapped 95% CIs. A second round of classification was performed one-month later. Intraobserver reproducibility was assessed for the primary classifications using Fleiss’s kappa and sub-classification reproducibility was assessed by Krippendorff’s alpha (αk) along with 95% CIs. Results In total, 25 cases were read for a total of 300 initial and 300 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF = 0.74; 95% CI 0.71 to 0.78) across all observers. Sub-classification reliability was substantial (αk= 0.67; 95% CI 0.51 to 0.81), Adjusted intraobserver reproducibility was almost perfect (kF = 0.91; 95% CI 0.83 to 0.99) for both primary classifications and for sub-classifications (αk = 0.88; 95% CI 0.83 to 0.93). Conclusion The inter- and intraobserver reliability for the AOSpine Thoracolumbar Spine Injury Classification System was high amongst paediatric orthopaedic surgeons. The AOSpine Thoracolumbar Spine Injury Classification System is a promising option as a uniform fracture classification in children. Level of Evidence III

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A Radiographic Healing Classification for Osteochondritis Dissecans of the Knee Provides Good Interobserver Reliability

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117740846 ◽

2017 ◽

Vol 5 (12) ◽

pp. 232596711774084 ◽

Cited By ~ 2

Author(s):

David E. Ramski ◽

Theodore J. Ganley ◽

James L. Carey

Keyword(s):

Osteochondritis Dissecans ◽

Classification System ◽

Femoral Condyle ◽

Interobserver Reliability ◽

Intraclass Correlation ◽

Level Of Evidence ◽

Patient Age ◽

Lesion Location ◽

Patient Âgé ◽

Treatment Type

Background: Recent studies have examined radiographic factors associated with healing of osteochondritis dissecans (OCD) lesions of the knee. However, there is still no gold standard in determining the healing status of an OCD lesion. Purpose: We examined temporally associated patterns of healing to (1) evaluate the practicality of a classification system and (2) elucidate any associations between healing pattern and patient age, sex, lesion location, treatment type, and physeal patency. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: We retrospectively screened 489 patients from 2006 to 2010 for a total of 41 consecutive knee OCD lesions that met inclusion criteria, including at least 3 consecutive radiographic series (mean patient age, 12.8 years; range, 7.8-17.1 years; mean follow-up, 75.1 weeks). Radiographs were arranged in sequential order for ratings by 2 orthopaedic sports medicine specialists. Healing patterns were rated as boundary resolution, increasing radiodensity of progeny fragment, combined, or not applicable. Repeat ratings were conducted 3 weeks later. Results: Patients were most commonly adolescent males aged 13 to 17 years, with a medial femoral condyle lesion that was treated operatively. Interobserver reliability of the healing classification was good (intraclass correlation coefficient, 0.67; 95% CI, 0.55-0.79). Boundary and radiodensity healing was observed for all ages, sexes, lesion locations, treatment types, and physeal patency states. Conclusion: This study evaluated a valuable radiographic paradigm—boundary resolution, increasing radiodensity of progeny fragment, or combined—for assessment of OCD lesion healing. The proposed system of healing classification demonstrated good inter- and intraobserver reliability. Healing patterns were not significantly associated with any particular age, sex, lesion location, treatment type, or physeal patency status. The development of a classification system for knee OCD may eventually improve clinical assessment and management of OCD lesions.

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INTEROBSERVER RELIABILITY OF A COMPREHENSIVE LATERAL DISCOID MENISCUS CLASSIFICATION SYSTEM: A MULTICENTER ARTHROSCOPIC VIDEO ANALYSIS STUDY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00244 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0024

Author(s):

R. Jay Lee ◽

Jeffrey J. Nepple ◽

Gregory A. Schmale ◽

Emily Niu ◽

Jennifer J. Beck ◽

...

Keyword(s):

Classification System ◽

Sports Medicine ◽

Interobserver Reliability ◽

Surgical Techniques ◽

Classification Systems ◽

Fair Agreement ◽

Consensus Method ◽

Significant Heterogeneity ◽

Discoid Meniscus ◽

Stability And Instability

Introduction/Background: Lateral discoid meniscus (LDM) is the most common congenital anomaly of the knee. Due to the significant heterogeneity in pathomorphology, LDM treatment remains challenging. Treatment approaches and surgical techniques vary widely among surgeons and different types of LDM. Current classification systems inadequately describe the spectrum of pathology or dictate treatment. Hypothesis/Purpose: The Pediatric Research in Sports Medicine (PRISM) meniscal study group developed and tested the reliability of a novel classification system designed to comprehensively capture the intricacies of LDM pathomorphology and guide treatment decisions. Methods: The PRISM LDM Classification System was developed through an initial review of existing classification systems followed by group consensus method by pediatric meniscal surgeons from 20 tertiary academic centers. Four factors were evaluated: (1) meniscal width (surface area), (2) meniscal height (thickness, +/- horizontal delamination), (3) peripheral stability (and instability pattern), and (4) tearing (and tear location)(Table 1). A stepwise arthroscopic exam utilizing two standard anterior viewing portals was established for optimizing diagnosis of LDM features. From a set of 101 arthroscopic videos submitted for review, 41 were selected for quality by 3 of the authors (non-’readers’). Five ‘readers’ then performed assessments using the classification system. Interobserver reliability of the primary and secondary rating factors was assessed using the Fleiss kappa coefficient (K, 95% CI), designed for multiple readers with nominal variables (Reliability Classification: Fair 0.21-0.40 fair, Moderate 0.41-0.60, Substantial 0.61-0.80, and Excellent 0.80-1.00). Results: The majority of the primary and secondary rating factors demonstrated ‘substantial’ reliability, such as meniscal width (complete vs. incomplete, K 0.609; 0.512-0.706) and posterior horn stability (stable vs. unstable, K 0.693; 0.594-0.792), or ‘moderate’ reliability, such as meniscal height (normal vs. abnormal, K 0.444; 0.347-0.541), overall stability, (stable vs. unstable, K 0.569; 0.472-0.666), and tear presence (tear vs. no tear, K 0.541; 0.444-0.638). Several features demonstrated only ‘fair’ agreement, including anterior horn stability (stable vs. unstable, K 0.358; 0.258-0.457), meniscal body stability (stable vs. unstable, K 0.314; 0.214-0.413), and tear type (no tear, radial, vertical, complex, K 0.386; 0.325-0.446). Conclusion/Discussion: A novel classification system that more comprehensively and descriptively characterizes the spectrum of LDM pathology demonstrated moderate or substantial agreement in most diagnostic categories analyzed. Specific features demonstrating fair agreement may warrant investigation of alternative steps in the arthroscopic exam or descriptors to improve agreement. A comprehensive classification system is critical to advance LDM research from single-center, level 4 studies to prospective multicenter efforts that will enhance improve communication, research, and evidence-based treatment of LDM pathology.

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Comparison of the CO-RADS and the RSNA chest CT classification system concerning sensitivity and reliability for the diagnosis of COVID-19 pneumonia

Insights into Imaging ◽

10.1186/s13244-021-00998-4 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Mohamed Abdel-Tawab ◽

Mohammad Abd Alkhalik Basha ◽

Ibrahim A. I. Mohamed ◽

Hamdy M. Ibrahim ◽

Mohamed M. A. Zaitoun ◽

...

Keyword(s):

Classification System ◽

Intraclass Correlation ◽

Final Diagnosis ◽

Chest Ct ◽

Classification Systems ◽

Kappa Statistics ◽

Radiological Society ◽

Dutch Association ◽

Ct Classification ◽

Chest Ct Scan

Abstract Background The Radiological Society of North America (RSNA) recently published a chest CT classification system and Dutch Association for Radiology has announced Coronavirus disease 2019 (COVID-19) reporting and data system (CO-RADS) to provide guidelines to radiologists who interpret chest CT images of patients with suspected COVID-19 pneumonia. This study aimed to compare CO-RADS and RSNA classification with respect to their sensitivity and reliability for diagnosis of COVID-19 pneumonia. Results A retrospective study assessed consecutive CT chest imaging of 359 COVID-19-positive patients. Three experienced radiologists who were aware of the final diagnosis of all patients, independently categorized each patient according to CO-RADS and RSNA classification. RT-PCR test performed within one week of chest CT scan was used as a reference standard for calculating sensitivity of each system. Kappa statistics and intraclass correlation coefficient were used to assess reliability of each system. The study group included 359 patients (180 men, 179 women; mean age, 45 ± 16.9 years). Considering combination of CO-RADS 3, 4 and 5 and combination of typical and indeterminate RSNA categories as positive predictors for COVID-19 diagnosis, the overall sensitivity was the same for both classification systems (72.7%). Applying both systems in moderate and severe/critically ill patients resulted in a significant increase in sensitivity (94.7% and 97.8%, respectively). The overall inter-reviewer agreement was excellent for CO-RADS (κ = 0.801), and good for RSNA classification (κ = 0.781). Conclusion CO-RADS and RSNA chest CT classification systems are comparable in diagnosis of COVID-19 pneumonia with similar sensitivity and reliability.

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Polydactyly of the thumb: a modification of the Wassel-Flatt classification

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420981541 ◽

2021 ◽

pp. 175319342098154

Author(s):

Jae Kwang Kim ◽

Bassmh Abdullah A Al-Dhafer ◽

Young Ho Shin ◽

Hyun Seok Joo

Keyword(s):

Classification System ◽

Kappa Coefficient ◽

Classification Systems ◽

Level Of Evidence ◽

Observer Reliability ◽

System A ◽

Surgical Methods ◽

Definition Of ◽

Triphalangeal Thumb ◽

Original Classification

Although the Wassel-Flatt classification system has been widely used for radial polydactyly, it has some limitations. We modified the classification system by introducing the hypoplastic types and refining the definition of triphalangeal thumb without changing the main structure of the original classification system. A total of 200 consecutive duplicated thumbs of 183 patients treated surgically from June 2016 to June 2018 were included. We evaluated intra-observer and inter-observer reliability using the kappa coefficient in the modified and original Wassel-Flatt classification systems (three examiners evaluated each case twice, with an interval of 4 weeks). We also evaluated the surgical methods according to the types of deformity in the modified and original Wassel-Flatt classification systems. The modified Wassel-Flatt classification system had good inter-observer reliability and provides useful information for determining the surgical plan according to the types of radial polydactyly. Level of evidence: IV

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Interobserver and Intraobserver Reliability of an MRI-Based Classification System for Injuries to the Ulnar Collateral Ligament

The American Journal of Sports Medicine ◽

10.1177/0363546518786970 ◽

2018 ◽

Vol 46 (11) ◽

pp. 2755-2760 ◽

Cited By ~ 8

Author(s):

Prem N. Ramkumar ◽

Salvatore J. Frangiamore ◽

Sergio M. Navarro ◽

T. Sean Lynch ◽

Michael C. Forney ◽

...

Keyword(s):

Classification System ◽

Clinical Decision Making ◽

Interobserver Reliability ◽

Ulnar Collateral Ligament ◽

Random Order ◽

Weighted Kappa ◽

Intraobserver Variability ◽

Collateral Ligament ◽

Level Of Evidence ◽

Perfect Agreement

Background: Despite improvements in understanding biomechanics and surgical options for ulnar collateral ligament (UCL) tears, there remains a need for a reliable classification of UCL tears that has the potential to guide clinical decision making. Purpose: To assess the intra- and interobserver reliability of the newly proposed magnetic resonance imaging (MRI)–based classification for UCL tears. Secondary objectives included assessing the effect of additional views, discrimination between distal and nondistal tears, and correlation of imaging reads with intraoperative findings of the UCL. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Nine fellowship-trained specialists from 7 institutions independently completed 4 surveys consisting of 60 elbow MRI scans with UCL tears using a newly proposed 6-stage classification system. The first and third surveys contained 60 coronal images, while the second and fourth contained the same images with coronal and axial views presented in a random order to assess intraobserver variability via the weighted kappa value and the effect of additional imaging views. Weighted kappa values were also calculated for each of the 4 surveys to acquire interobserver reliability. Reliability analysis was repeated through a 2-group classification analysis for distal and nondistal tears. Observer readings were compared with intraoperative UCL findings. Results: For the newly proposed 6-stage MRI-based classification, intra- and interobserver reliability demonstrated near perfect and substantial agreement, respectively. These values increased only when substratified into the 2-group distal and nondistal tear classification ( P < .05). The additional axial view did not statistically improve the agreement within and among readers. When compared with intraoperative findings from 30 elbows, observer readings were accurate for tear grade (partial and complete), proximal location, and distal location but not midsubstance tears. Conclusion: The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers.

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Evaluation of Syndesmosis Reduction on CT Scan

Foot & Ankle International ◽

10.1177/1071100719849850 ◽

2019 ◽

Vol 40 (9) ◽

pp. 1087-1093 ◽

Cited By ~ 3

Author(s):

Mohamed Elghazy Abdelaziz ◽

Noortje Hagemeijer ◽

Daniel Guss ◽

Ahmed El-Hawary ◽

Hani El-Mowafi ◽

...

Keyword(s):

Ct Scan ◽

Evaluation Method ◽

Interobserver Reliability ◽

Measurement Techniques ◽

Case Series ◽

Intraobserver Reliability ◽

Area Measurement ◽

Level Of Evidence ◽

Radiological Measurement ◽

Tibial Plafond

Background: Computed tomography (CT) imaging has traditionally been considered the gold standard for evaluation of syndesmostic reduction, but there is no uniformly accepted method to assess reduction. The aim of this study was to evaluate the intra- and interobserver reliability of published measurement techniques for evaluation of syndesmotic reduction on weightbearing CT scan (WBCT) in hopes of determining which method is best. Methods: Medical records were reviewed to identify patients who underwent operative stabilization of unilateral syndesmotic injuries. Exclusion criteria included patients younger than 18 years, ipsilateral fractures extending to the tibial plafond, any contralateral ankle fracture or syndesmotic injury, and body mass index greater than 40 kg/m2. Twenty eligible patients underwent WBCT evaluation of both ankles at an average of 3 years after syndesmotic fixation. The anatomic accuracy of syndesmotic reduction was evaluated by 2 observers using axial CT images at a level 1 cm proximal to the tibial plafond using 9 previously published radiological measurement techniques. Inter- and intraobserver reliability were assessed for each evaluation method. Results: The syndesmotic area calculation showed the highest interobserver reliability (0.96), the highest intraobserver reliability for observer 2 (0.97), and the second highest intraobserver reliability for observer 1 (0.92). Fibular rotation had the second highest interobserver reliability in our results (0.84), with intraobserver reliability of 0.91 and 0.8 for first and second observers, respectively. The intraobserver reliability of the side-by-side method was 0.49 and 0.24 for the first and second observers, respectively, and the interobserver reliability was 0.26. Conclusion: Qualitatively assessing syndesmotic reduction via side-by-side comparison with the uninjured ankle had the least intra- and interobserver reliability and should not be relied on to determine syndesmotic reduction quality. In contradistinction, syndesmotic area calculation demonstrated the highest reliability when evaluating syndesmotic reduction, followed by fibular rotation. Given that syndesmotic area measurement techniques are not readily available on standard image viewers, technologically updating image viewers to allow such calculation would make this approach more accessible in clinical practice. Level of Evidence: Level IV, case series.

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