Abstract
Background & Objectives: While the treatment of lateral and medial malleolar fractures is well established, several controversies exist in the management of posterior malleolar fractures. The involvement of the posterior malleolus in fractures of the ankle adversely affects the functional outcome and may be associated with the development of post-traumatic osteoarthritis. Although anatomical reduction is one of the predictors of successful outcomes, the most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws via an anterior approach. The purpose of this study was to compare radiographic and functional outcomes of posterior malleolar fractures treated with direct reduction via a posterolateral approach versus indirect reduction via an anterior approach.
Materials and Methods: We retrospectively analyzed 33 patients with posterior malleolar fractures who underwent open reduction and internal fixation using either posterolateral or anterior approaches between April 2007 and June 2018. Fixation of the posterior malleolus was made with buttress plate and/or posterior-to-anterior screws in 16 patients using the posterolateral approach, and anterior-to-posterior screws in 17 patients using the anterior approach. Demographic data, type of fracture, internal fixation method, surgeon experience, surgical time, blood loss, tourniquet time, postoperative complication, and Burwell criteria (including radiographic, subjective, and objective criteria) were used as the main outcome measurements, and results were evaluated at the 6-month follow-up visit.
Results: Demographic data were similar between groups, but the waiting duration from injury to surgery in the posterolateral group was significantly longer than in the anterior group (11 ± 4.2days vs 7 ± 4.3days, odd ratio: 0.7, p=0.025). Despite this increase in the waiting period, the posterolateral group demonstrated a significantly superior reduction compared to the anterior group (87.5% vs 52.9%, p=0.036) and indicated trends toward improvement in the subjective outcome (87.5% vs 58.8%, p=0.071) and objective outcome (87.5% vs 58.8%, p=0.071). As a postoperative complication, one patient showed signs of sural nerve disorder in the posterolateral group but with no evidence of wound dehiscence. In contrast, one patient in the anterior group did present with surgical site infection.
Conclusions: We concluded that the direct reduction technique via a posterolateral approach enables a better quality of reduction and better functional outcome in the management of the posterior malleolar fracture compared with the indirect technique via an anterior approach. Especially in cases of depressed fracture or late timing of surgery, the posterolateral approach should be adopted as an optimal treatment.
