Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to 'A to P' screw fixation

Direct or indirect reduction internal fixation for posterior ankle fractures: A systematic review and meta-analysis

Direct or indirect internal fixation for posterior ankle fractures remains a controversial topic. While direct plate or screw internal fixation is believed to provide better reduction, it may also cause more severe soft tissue damage, while indirect screw internal fixation is thought to result in less damage but may carry the risk of poor reduction. We conducted this meta-analysis to investigate the clinical efficacy and safety of direct versus indirect reduction internal fixation for posterior ankle fractures. The Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) guidelines were used to search the China Knowledge Network database (CNKI), PubMed, Web of Science, Embase, and other databases from the year of establishment- February 2025, and relevant journals were manually searched to collect the relevant literature, and articles that met the requirements were screened and analyzed. Meta-analysis was conducted using RevMan 5.4 software, and a systematic evaluation was carried out when the data from the included studies could not be synthesized. A total of 17 articles involving 1538 study subjects were included, and the results showed that there were no statistical differences in postoperative AOFAS scores, complications, and Dorsiflexion restriction between ankle fractures after direct plate or screw reduction and fixation and those after indirect screw reduction and fixation; however, the Radiological evaluation>2 mm and Osteoarthritis (P < 0.05) were statistically different. Direct reduction and fixation of posterior ankle fractures has better imaging performance and reduces the incidence of postoperative arthritic events.

[Fractures of the upper ankle joint]

Fractures of the upper ankle joint are frequent injuries and part of routine clinical trauma surgery. In recent years, treatment strategies have changed in different ways due to advances in imaging diagnostics and a better understanding of the biomechanics. In addition, new implant systems are available. The goals of the reconstruction are anatomical reduction with restoration of the joint anatomy, reconstruction of the length, rotation and axial relationships as well as the restoration of stable joint guidance. In addition to the bony reconstruction, the focus is on restoring ligamentous instabilities. Keywords that are increasingly more in focus and controversial are: the posterior malleolar fragment, syndesmosis instability, the fourth malleolus and the importance of the deltoid ligament. For a good long-term result, anatomical reconstruction remains the basic requirement, regardless of the methods used.

Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: A retrospective cohort study

INTRODUCTION

Treatment of posterior malleolar (PM) ankle fractures remains controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation.

MATERIAL AND METHODS

A retrospective cohort study was performed on PM ankle fracture patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013. Inclusion criteria were ASA 1 and 2, independent mobility pre-trauma, no pre-existing ankle pathologies, with satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using visual analogue scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale for function, and patient satisfaction ratings. Osteoarthritis was assessed using modified Kellgren-Lawrence scale on follow-up weightbearing ankle radiographs.

RESULTS

Sixty-one participants were included. Mean follow-up was 10.26 years. Average PM size was 16.2 ± 7.39%. All participants were evaluated for clinical outcomes. Mean score of FAAM-ADL was 95.5 ± 7.13, FAAM-Sports 86.4 ± 15.5, patient satisfaction 86.2 ± 14.4% and pain score 1.13 ± 1.65. Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthritis in 36/52 (69%), mild osteoarthritis in 14/52 (27%) and moderate osteoarthritis in 2/52 (4%). Pain and functional scores were independent of PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off more than 1 mm and traumatic dislocation/subluxation were associated with worse radiographical osteoarthritis.

CONCLUSION

After controlling for confounders, the unfixated smaller posterior malleolus fragment at 10-year follow-up demonstrated largely satisfactory clinical outcomes with some radiographical progression of osteoarthritis.

LEVEL OF EVIDENCE

Level III - Retrospective cohort study.

Fixation of Posterior Malleolus in Trimalleolar Ankle Fractures: Anteroposterior Screw or Posterolateral Plate?

Background: The treatment of the third malleolus has evolved in recent years, and surgical treatment can be carried out with traditional percutaneous osteosynthesis using anteroposterior screws or ORIF with a posterolateral plate. Methods: Our study included 54 patients divided into two groups based on the intervention type (screw or plate). Instrumental assessments comprised pre- and post-operative X-rays and pre-operative CT scans to evaluate joint step-off. The mean follow-up duration was 1 year and 9 months. Results: Radiographic control revealed no loss of reduction or mobilization of the synthesis devices, and all patients achieved fracture healing. Articular step-off > 2 mm was observed in 21 patients (38.9%), including 4 in the plate group and 17 in the screw group, with a statistically significant likelihood of step-off presence in the latter. The mean AOFAS score was 90 points, negatively correlated with age, and lower in patients with joint step-off and a 15° reduction in ROM. Conclusions: The management of posterior malleolus fractures has changed with anatomical studies and an understanding of ankle stability through CT scans. ORIF with a posterior plate is advantageous for anatomical reduction of the tibial plafond but is disadvantageous in terms of surgical invasiveness and technical difficulty.