Assessing the Reliability of the Lauge-Hansen Classification in Elderly Ankle Fractures
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Authors
Amini B.
Walters S.
Harland W.
Nielsen D.
Trompeter A.
Williamson M.
Counihan C.
Blackmore N.
Manoj N.
Rashid M.L.A.
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2026
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Introduction: Ankle fractures in elderly patients are increasingly common, often exhibiting complex or atypical fracture patterns that are not well described by traditional classification systems. We investigated the prevalence of atypical fracture appearances and evaluated the reliability of the Lauge-Hansen classification system in this setting. Method(s): A validation study was conducted using 194 radiographs from patients aged >=60 presenting with an ankle fracture over a 5-year period at our institution. Each anonymised radiograph was independently reviewed by 38 assessors, comprising of 15 Trauma & Orthopaedic (T&O) consultants, 18 registrars/residents, and 5 junior trainees in two rounds, with at least three months between reviews. Assessors classified each case according to the Lauge-Hansen system or designated it as 'unclassifiable'. Inter- and intra-rater reliability were analysed using Fleiss' and Cohen's kappa statistics respectively. Result(s): Overall inter-rater reliability was fair for both rounds (Fleiss kappa = 0.234 in Round 1; 0.280 in Round 2), with highest agreement among registrars, and lowest among junior trainees. Intra-rater reliability showed moderate agreement overall (mean Cohen kappa = 0.449), with lower reliability for less experienced assessors (kappa = 0.457 and 0.488 for consultants and registrars respectively, compared to kappa = 0.279 for junior trainees). An average of 4.9% cases were consistently deemed unclassifiable by >=50% of assessors, while an additional 23.7% showed inadequate agreement amongst assessors between a Lauge-Hansen pattern and unclassifiable grading. Common features of unclassifiable fractures included extensive metaphyseal communition, transverse fibula fractures and atypical medial malleolus involvement. Conclusion(s): The Lauge-Hansen classification demonstrates limited reliability in elderly patients, with a substantial proportion of fractures either unclassifiable or showing inconsistent agreement among assessors. This suggests that this classification system may have limited use in this population and an alternative approach may be required to account for atypical fracture patterns which may require different surgical strategies.Copyright © 2026, The Authors. All rights reserved.
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