SLR - March 2019 - Natalya Salowich

When and How to Operate the Posterior Malleolus Fragment in Trimalleolar Fractures: A Systematic Literature Review

Reference: Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and How to Operate the Posterior Malleolus Fragment in Trimalleolar Fractures: A Systematic Literature Review. Arch Orthop Trauma Surg. 2018 May 12.

Scientific Literature Review

Reviewed By: Natalya Salowich, DPM 
Residency Program: Detroit Medical Center, Detroit, MI

Podiatric Relevance: In the case of a posterior malleolar fracture, the decision to operate is generally based on the size and displacement of the fracture fragment. It seems as though each surgeon has his or her own threshold for operation related to these two factors. Given that greater than 40 percent of ankle fractures include the posterior mallelous, it is important to identify guidelines for treatment of the fragment. A summary of the literature offers a standard for the treatment of the posterior fragment in trimalleolar fractures.

Methods: This therapeutic level II systematic review focused on publications between January 1995 and April 30, 2017. PubMed, Embase and Cochrane were searched using keywords to tailor results toward when and how to fix the posterior fragment in trimalleolar fractures in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.

Results: One hundred eighty studies were identified, and 17 were included—two prospective and 15 retrospective. Indications for fixation were discussed in six studies, and fixation approaches and techniques were compared in 11 studies. Inadequate anatomical reduction correlated with outcome while fragment size did not influence functional outcome or the development of osteoarthritis. The posterolateral approach resulted in better radiographical and functional outcomes than a percutaneous anterior-to-posterior screw fixation.

Conclusions: The general recommendations by the authors were as follows: a step-off correlates with the development of worse functional outcomes and posttraumatic arthritis. When the intraarticular surface is malaligned, then it is crucial to reduce and fixate the fragment to decrease the chances of poor function and posttraumatic arthritis. Appropriate fixation is best achieved through an open posterolateral approach rather than percutaneous anterior-to-posterior fixation. A larger sized fragment does not necessarily require fixation.

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