Validity and prognostic value of a novel intraoperative assessment tool for reduction in trimalleolar fractures: the SGSC checklist approach

Abstract Background Trimalleolar fractures present substantial surgical challenges, and the quality of fracture reduction significantly influences patient outcomes. Current intraoperative assessment methods, including fluoroscopy and arthroscopy, each possess inherent limitations when used independently. This study aimed to validate the effectiveness of a novel intraoperative evaluation tool, the SGSC (Step, Gap, Syndesmosis, Congruity) “traffic light” checklist, that integrates arthroscopic and fluoroscopic assessment, and to evaluate its predictive value for clinical prognosis. Methods This single-center retrospective cohort study enrolled 36 patients who underwent surgical treatment for trimalleolar fractures. Validation proceeded in two stages: first, we calculated inter-rater reliability (Kappa statistic) and concordance with postoperative CT as the reference standard to establish the reliability and validity of the SGSC checklist (accuracy validation); second, patients were stratified into “All-Green” and “Non-All-Green” groups based on intraoperative SGSC assessment, and we compared AOFAS scores and early radiographic degenerative changes at final follow-up (prognostic validation). Results For accuracy validation, inter-rater agreement between the two assessors demonstrated excellent reliability (Kappa = 0.827; 95% CI: 0.644-1.000). The overall concordance between SGSC checklist assessments and postoperative CT findings was 91.67%. Regarding prognostic value, the All-Green group ( n = 25) achieved a mean AOFAS score of 88.9 ± 3.0, significantly exceeding the 78.4 ± 4.4 observed in the Non-All-Green group ( n = 11) (t = 8.32, P < 0.001). Furthermore, early radiographic degenerative changes (Kellgren-Lawrence grade ≥ 2) developed in only 8% (2/25) of the All-Green group compared with 45.5% (5/11) in the Non-All-Green group ( P = 0.012). Conclusions The SGSC checklist represents a valid and reliable intraoperative assessment instrument. Achieving “All-Green” status effectively predicts superior short-term functional outcomes and a lower incidence of early degenerative changes. However, these preliminary findings are limited by small sample size and retrospective design. Prospective studies are needed to confirm clinical utility.