Posterior Malleolus Fractures of the Tibia: Open Reduction and Buttress Plating versus Percutaneous Fixation with an Anteroposterior Screw.

OBJECTIVE: The posterior malleolar fragment (PMF) in ankle fractures can be fixed with closed reduction and percutaneous fixation with an anteroposterior screw (Closed Reduction Internal Fixation - CRIF), or with open reduction using a posterior approach and buttress plating (Open Reduction Internal Fixation - ORIF). The objective of this study was to compare these two techniques with respect to postoperative complications and patient-reported outcome measures (PROMs).

MATERIALS AND METHODS: In this retrospective study, data were analysed from 106 consecutive ankle fracture cases involving the PMF that were operated between 2021 and 2022 in a single institution. The PMF was managed either via CRIF (n = 43) or via ORIF (n = 63). A comprehensive analysis was conducted, encompassing patient-, fracture-specific characteristics, and treatment modalities.A minimum follow-up period of three months was deemed necessary in order to ascertain the complication rate, which was available for a total of 65 patients. The documented complications included superficial wound healing impairment without surgical revision, deep wound healing impairment necessitating surgical revision, iatrogenic nerve injury, delayed bone union, and revision surgery.In the second part of the study, patients were contacted for a follow-up assessment using the Foot and Ankle Outcome Score (FAOS), the Foot and Ankle Ability Measure (FAAM) and a numerical rating scale for pain (NRS). Thirty-nine patients participated.

RESULTS: Analyses revealed significant disparities in the distribution of Bartoníček fracture types between the ORIF and CRIF groups: type II was more prevalent, and types III and IV less common, in the CRIF group (n = 43) than in the ORIF group (n = 63; p = 0.03). The PMFs in the ORIF group were found to be significantly larger (p = 0.006), and the mean surgical time was significantly prolonged in comparison to the CRIF group (p < 0.0001). The placement of a positioning screw was observed to be significantly more prevalent in the CRIF group than in the ORIF group (18 cases [42%] vs. 10 cases [16%], p = 0.003).Following a median follow-up period of eight months (range 3-37 months), the complication rate was found to be higher in the ORIF group (37%) than in the CRIF group (18%), although this difference was not statistically significant (p = 0.116).After a median follow-up period of 21 (14-36) months, the CRIF group patients showed significantly better results in the FAOS subscales activities of daily living and quality of life compared to the patients in the ORIF group (p = 0.049 and p = 0.045, respectively). Furthermore, the self-assessed ankle function compared to the status prior to the fracture, in the sports category of the FAAM, was better in the CRIF than in the ORIF group (p = 0.029).No significant differences were identified in FAOS total score or NRS between the two groups (p = 0.107 and p = 0.236, respectively).

CONCLUSION: ORIF of the PMF reduces the likelihood of additional syndesmotic stabilisation in comparison with CRIF; however, it is associated with increased surgical time while maintaining similar complication rates.