Percutaneous management of posterior malleolar fractures

Abstract

Posterior malleolar fractures (PMF) are present in up to 44% of ankle fractures. Despite its frequency, there is controversy over the fixation criteria and optimal technique. Historically, fragment size (> 25%) was used as a surgical indication, but today, criteria such as syndesmotic instability, articular step-off, and fragment morphology are used. To synthesize evidence on the percutaneous fixation of PMFs, analyze their indications and risks, compare them with the open approach, and describe the surgical technique preferred by the authors. Percutaneous fixation offers advantages such as the preservation of soft tissues and shorter surgical time in the supine position. However, studies show a higher malreduction rate than open reduction and internal fixation (ORIF) (up to 73% vs. 17%), especially in comminuted or displaced fragments ≥ 5 mm. In single-fragment fractures with minimal displacement, the functional results are comparable. Recent literature suggests that posteroanterior (PA) fixation is biomechanically superior and presents better clinical outcomes and lower rates of osteoarthritis than the anteroposterior (AP) technique. Percutaneous fixation is a valid and effective alternative in selected cases of simple, noncomminuted, minimally displaced PMFs, as well as in patients with low functional demand or soft-tissue compromise. The PA technique stands out for its stability. Success depends on proper computed tomography planning and the surgeon’s willingness to convert to an open approach if anatomical reduction is not achieved through indirect maneuvers. Level of Evidence V; Expert opinion.