Treatment Strategy for Posterior Malleolar Fractures: Different Operative Strategies Are Needed for Each Morphological Type.

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Abstract

Conflict of interest statement: The authors declare no conflicts of interest. 11. Arch Orthop Trauma Surg. 2018 Sep;138(9):1213-1222. doi: 10.1007/s00402-018-2949-2. Epub 2018 May 12. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Verhage SM(1)(2), Hoogendoorn JM(3), Krijnen P(4), Schipper IB(4). Author information: (1)Department of Surgery, HMC Westeinde, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512 VA, The Hague, The Netherlands. s.verhage@haaglandenmc.nl. (2)Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands. s.verhage@haaglandenmc.nl. (3)Department of Surgery, HMC Westeinde, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512 VA, The Hague, The Netherlands. (4)Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands. OBJECTIVES: Whether or not and how to fixate the posterior malleolus fracture seems to depend on the fracture fragment size and its amount of dislocation, but clear guidelines for daily practice are lacking. In this review, we summarize the literature on preferred treatment of the posterior fragment in trimalleolar fractures. METHODS: A systematic review of publications between January 1995 and April 30 2017 on this topic in the PubMed, Embase, and Cochrane databases was performed according to the PRISMA statement. RESULTS: Seventeen (2 prospective and 15 retrospective) of the 180 identified studies were included. Six studies report on indications for fixation of posterior malleolus fracture fragments. Eleven studies compare different fixation approaches and techniques for the posterior fragment. Meta-analysis was not possible due to varying fixation criteria and outcomes. There was no clear association between posterior fragment size and functional outcome or development of osteoarthritis. The non-anatomical reduction of the fragment was of more influence on outcome. Radiological and functional outcome was better after open reduction and internal fixation via the posterolateral approach than after percutaneous anterior-to-posterior screw fixation. CONCLUSION: The posterior fragment size is not a clear indication for its fixation. A step-off, however, seems an important indicator for developing posttraumatic osteoarthritis and worse functional outcome. Posterior fragments involving the intra-articular surface need to be reduced and fixated to prevent postoperative persisting step-off. Furthermore, fixation of the posterior malleolus via an open posterolateral approach seems superior to percutaneous anterior-to-posterior fixation. However, these results need to be confirmed in a prospective comparative trial. LEVEL OF EVIDENCE: Therapeutic level II. DOI: 10.1007/s00402-018-2949-2