Abstract
Background
Posterior malleolus (PM) fractures compromise overall ankle stability, lending to poorer long-term prognosis without adequate fixation. There remains inconsistency in the preferred surgical approach to fixation of the posterior malleolus, however arthroscopic approaches can reduce trauma to the soft tissue envelope and may improve clinical and radiographic outcomes. This study reviews the technical considerations of arthroscopic-assisted reduction and fixation of PM fractures and the associated clinical outcomes.
Methods
A systematic review of Pubmed, EMBASE, and UNE Library Services databases included studies evaluating arthroscopic assisted treatment of ankle fractures with associated posterior malleolus fragment.
Results
Seven studies evaluating 101 patients who underwent fixation of ankle fractures with posterior malleolus involvement met inclusion criteria. Twenty-seven patients underwent open reduction internal fixation (ORIF) alone and 74 patients underwent various arthroscopic-assisted reductions of PM fractures. The studies reported no significant difference in VAS and AOFAS scores in ORIF vs arthroscopic approach, and favorable VAS, AOFAS, OMAS, and FADI scores in arthroscopically treated patients. Acceptable radiographic differences were reported in each case. Complication rates in arthroscopic groups were minimal (mean 12 %). Reported benefits of arthroscopic assistance include improved visualization, debridement, and manipulation of the posterior malleolar fragment.
Conclusion
Fixation of ankle fractures involving the posterior malleolus consistently report favorable clinical outcomes in patients treated with arthroscopy, with many patients achieving desirable AOFAS, OMAS, FADI, and VAS scores with a very low complication rate.
Level of Evidence
Level I, systematic review.
1
Introduction
Ankle fractures are common injuries , , of which approximately 44 % involve the posterior malleolus , . Posterior malleolar fractures specifically involve the posterior segment of the tibial plafond (Volkmann’s triangle) and are often the result of rotational injuries of the ankle . The posterior malleolus serves as an attachment point for the posterior-inferior tibiofibular ligament (PITFL) , , thus fractures within the posterior tibial plafond can compromise the integrity of the posterior talus and overall ankle stability. Previous studies have demonstrated that fractures involving the posterior malleolus that are not fixed primarily may be associated with poorer outcomes ,, and decreased ankle stability .
The decision to fix as well as the type of fixation of the posterior malleolus when managing unstable ankle fractures remains controversial in the literature ,, . There have been several studies that propose utilizing fragment size as a factor when determining whether the posterior fragment should be fixed , however consensus has yet to be established . Several studies have demonstrated restored ankle stability, particularly in cases where the posterior malleolus fragment involves the PITFL, with posterior malleolus reduction and fixation ,, . However, open approaches to access the posterior fragment may not be without complications. Disruption of the soft tissue envelope by open approaches to the fracture may be responsible for wound dehiscence, infection, and postoperative stiffness resulting in poorer functional outcomes , . Importantly, the ankle is particularly sensitive to soft tissue trauma resulting from a large posterior incision, which can lead to the development of arthrofibrosis . Therefore, there has been increased attention on minimally invasive alternatives to reduce these complications, while restoring the articular surface of the ankle joint.
Arthroscopic assisted fracture reduction is a minimally invasive surgical approach that can be utilized in the management of posterior malleolus fractures. Utilizing more minimally invasive procedures can result in reduced soft tissue trauma, shortened recovery times, decreased intraoperative blood loss, and lower infection rates . While the technique for arthroscopic assisted reduction in the management of ankle fractures has been described, there are few studies comparing ORIF to arthroscopic-assisted fixation of these fractures, particularly in the context of posterior malleolus fractures. This study attempts to summarize clinical outcomes associated with arthroscopic assisted fixation of the posterior malleolus to provide an alternative, minimally invasive strategy in the management of ankle fractures associated with a posterior malleolus fracture.
2
Methods
A systematic review was conducted according to PRISMA guidelines. The following search terms were used in Pubmed, EMBASE, and UNE Library Services in October 2024: “arthroscopy OR arthroscopic fixation” PLUS “posterior malleolus fracture OR posterior pilon OR tibial plafond” or “trimalleolar fractures”. Inclusion criteria were: (1) comparative and non-comparative retrospective and prospective studies, case series, and technique papers; (2) published in a peer-reviewed journal; and (3) written in English. Studies of complex ankle fractures involving the posterior malleolus/posterior tibial plafond were included. Exclusion criteria were: review articles, video articles, studies that did not specify posterior malleolus fracture involvement, studies that involved concomitant open posterior approach. Three independent reviewers performed the literature search screening both title and abstract for all results. Potentially eligible studies received a full text review. References lists of the identified papers were reviewed for additional studies. The senior author was consulted if consensus could not be reached. The following information was recorded from the included studies: study design, patient number, inclusion criteria, fracture type, fixation technique, clinical outcome data, complications, radiographic data, and additional technical operative notes.
3
Results
Seven studies evaluating 101 patients who underwent fixation of ankle fractures with posterior malleolus involvement met inclusion criteria ( Fig. 1 , Table 1 ). Two retrospective case series , , one prospective case series , one retrospective cohort , one expert opinion , and two technique papers , were included. In total, 27 patients underwent open reduction internal fixation (ORIF) alone and 74 patients underwent various arthroscopic-assisted reductions of PM fractures without posterior open incision. Posterior malleolus fractures were classified as either Haraguchi Type 1, Type 2, or Type 3; bimalleolar, trimalleolar, complex ankle fractures involving the PM were reported using AO/OTA classification.
Prisma search strategy.
Table 1
Summary of literature review including fixation technique, functional and radiographic outcomes.
| Authors | Title | Scope Size | Fixation Technique | Notes | Fractures (N, Type) | Radiographic Findings | Functional Outcomes | Complications |
|---|---|---|---|---|---|---|---|---|
| Chou 2023 | Trimalleolar fractures treated by open reduction internal fixation compared with arthroscopically assisted reduction and minimally invasive surgery | 2.7-mm | Prone. MIPPO w/o tourniquet fixation of fibula . Small stab incisions and blunt dissection at the fracture line, avoiding SPN. Reduction clamp and 1.6-mm K-wires for temporary fixation. 1/3 tubular plate over LM and screws inserted through stab incisions. PM and PL portals for 2.7-mm 30 degree scope . Interval between FHL and transverse tibiofibular ligament to access posterior joint. Third portal above PL portal for PM manipulation . 3.0-mm threaded pin into PM for reduction, temporary fixation 1.6-mm K-wires, 2 or 3 4.0-mm partially threaded cannulated screws . AM and AL portals for MM fixation . | – | Trimalleolar ( N = 49 ); PM Type 1 and Type 2. ORIF : N = 27. AARMIS : N = 22. | All except for 1 ORIF achieved union of all 3 malleoli. Fibular length, TMMA, MCS, TFCS, TCA ns between ORIF and AARMIS. | ORIF : VAS 1.1, AOFAS 85.8. AARMIS : VAS 0.8, AOFAS 90.8. ROM only significant difference was greater inversion in AARMIS compared to ORIF. | ORIF : N = 6 (22 %); wound edge necrosis (N = 3), loss of reduction (N = 1), hardware irritation (N = 1), transient sural nerve paresthesia (N = 1), persistent pain/arthritis requiring ankle fusion (N = 1). AARMIS : N = 3 (13.6 %); wound edge necrosis (N = 1), transient sural nerve paresthesia (N = 2). |
| Diab 2018 | Arthroscopy assisted fixation of posterior malleolar fractures: case series for novel approach | 4.0-mm | Prone. PL and PM portals, 4.0-mm 30 degree scope ; initial reduction of cortical disruption to level articular surface, 1.2-mm guidewire for fragment manipulation; second guidewire followed by cannulated 2.7-mm drill bit and 4.0-mm cannulated screws (P-A) . | Helpful to localize PTFL, FHL tendon, dorsiflex and plantarflex to localize posterior subtalar joint. | N = 12 (all included PM) | All radiographs: good reduction of PM, even joint, mean TF clear space 4.2 mm. No cases of delayed or nonunion. | FAOS: 92.46 (88−98); Ankle-Hindfoot: 92.0 (86−96); Inverse VAS rest: 9.0; Inverse VAS active: 8.58; EQ−5D: 8.92; Overall satisfaction: 9.42. ROM ns difference between affected and contralateral limbs. | Transient sural nerve paresthesia: N = 1. Post-operative long PA screw: N = 1. |
| Lee 2021 | Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures | Not reported | Posterolateral skin incision over LM for conversion to open if reduction unsuccessful; LM reduced first. Aiming drill guide placed laterally with ball tip through AL or AM portal; bone ejector through LM into PM fracture; ball tip positioned at depressed surface. K-wires for temporary fixation and reduced with PITFL ligamentotaxis after anatomic reduction of LM fracture. Percutaneous reduction and screw fixation technique . | Insertion angle of bone ejector as vertical as possible to ease reduction. | PM ( N = 11 ); Type 1 and Type 2 | TF clear space, TF overlap, Medial clear space = ns difference between affected and contralateral limbs. | OMAS: 87.7 (80−100); 100-mm VAS: 16.6 (0−53) | None reported. No cases of nonunion. |
| Martin 2020 | Posterior arthroscopic reduction and internal fixation for treatment of posterior malleolus fractures | 4.0-mm | PM and PL portals; 4.0-mm 30 degree scope; FHL used as medial safe border. Anatomic reduction of die-punch lesion if present. Accessory proximal PL portal for elevator, bone pusher, and antiglide screw insertion. 1.25-mm threaded guidewire through PL portal and not through the syndesmosis; second guidewire through PM portal; standard cannulated screws. | More distally placed portals allow for perpendicular insertion of screws into fracture. Sequence : die-punch, Volkmann, restore PITFL tension. Reduction is maintained through accessory portal and visualized through PM portal. Identify FHL tendon early to avoid medial neurovascular structures. Encourage early ROM and aggressive scar massage. | N = 29 (trimalleolar) | < 2 mm step off in all 29 cases. Remaining syndesmotic incongruity in 17 % of cases (AP >2 mm)* less than reported ORIF. | VAS: 1.1 (0−4); FADI: 88.1 (49−100); AOFAS: 85 (42−100); OMAS: 84 (40−100). | Conversion to open (N = 1). Return to OR for hardware (N = 1). No cases of fluid extravasation into surrounding tissues with 30 mmHg pump pressure. |
| Martin 2021 | Outcomes of posterior arthroscopic reduction and internal fixation (PARIF) for the posterior malleolar fragment in trimalleolar ankle fractures | 4.0-mm | Same protocol as Martin 2020; elevator used to reduce die-punch and PM fragments under direct arthroscopic visualization. Two 3.5-mm partially threaded cannulated screws , +/- third screw for large fragment. | Suture-button indication for PITFL disruption to improve syndesmotic congruity. | Same cases as Martin 2020 (2 year follow-up) | See Martin 2020 | 2 year follow-up: VAS: 1.1 (0−4); FADI: 85 (59−100); AOFAS: 84 (63−100); OMAS: 80 (40−100). | Persistent sural nerve paresthesia (N = 1). Cellulitis (N = 1). |
| Taki 2022 | Arthroscopic handlebar technique for the treatment of posterior malleolar fractures | Not reported | Supine. LM fixed first to faciliate PM reduction. Medial skin incision over the MM, open sheath of tibialis posterior tendon, allowing visualization of medial margin of PM fragment. 1.8–2.0-mm K-wire into lateral aspect of PMF and emerging out the medial side; this creates the handlebar with which PMF can be manipulated and reduced . AM/AL portals ; PMF then fixed via anterior incision using several screws. | No true posterior incision, however incisions are made over the MM and LM. | – | – | – | – |
| Willcox 2019 | Posterior malleolus arthroscopic reduction and internal fixation technique | Not reported | Anterior portals created first then visualization of joint space for reduction or removal of loose bodies; then posterior PL portal . Percutaneous K-wire + nerve hook to manipulate/reduce PM fragment. K-wire advanced followed by 2 PA screws across PM. Other malleoli addressed after PM. | Ensure adequate fracture site clearance for ease of reduction. Joint instability is an indication for reduction and fixation regardless of size. | – | – | – | – |
3.1
Functional outcomes
One study comparing standard ORIF to an arthroscopic-assisted approach reported favorable functional outcomes in all treatment groups at final follow-up . Chou et al. (2023) report comparable VAS (1.1 and 0.8) and AOFAS (85.8 and 90.8) scores following ORIF versus arthroscopically assisted reduction, respectively . Similarly, all non-comparative arthroscopic studies report acceptable functional outcomes at final follow-up: AOFAS mean 84 (range: 63–100) , VAS mean 1.1 (range: 0–4) , 100-mm VAS mean 16.6 (range: 0–53) , OMAS mean 83.85 (range:40–100) , , and FADI mean 85 (range: 59–100) .
3.2
Radiographic assessment
Each study reported different radiographic parameters, however appropriate reduction of posterior malleolus and intra-articular fragments was consistently demonstrated in patients treated with arthroscopic-assisted techniques. In one comparative study of arthroscopic versus ORIF treatment of trimalleolar fractures, there was no significant difference in radiographic parameters between ORIF and arthroscopic groups, with all cases in the arthroscopic group (N = 22) achieving union of all three malleoli and one case (N = 1/27) of non-union in the ORIF group .
3.3
Complications
Of the ORIF-treated patients, the overall complication rate was 26 % (7/27 cases), including non-union (N = 1), wound edge necrosis (N = 3), loss of reduction (N = 1), transient sural nerve paresthesia (N = 1), and persistent pain/post-traumatic arthritis requiring ankle fusion (N = 1) . Across all arthroscopic studies, an overall 12 % complication rate (9/74 cases) included wound edge necrosis (N = 1) , transient sural nerve paresthesia (N = 4) ,, , hardware revision (N = 2) , , conversion to open (N = 1) , and cellulitis (N = 1) .
3.4
Technical Notes
Four studies report prone patient positioning ,,, with the use of standard posteromedial and posterolateral arthroscopic portals ( Figs. 2, 3 ), while two papers describe lateral decubitus patient positioning with standard anteromedial and anterolateral portals , . Martin et al. describe the use of an accessory posterolateral portal located above the standard posterolateral site, which is used to maintain the reduction , . Only one study placed the patient in a supine position with anteromedial and anterolateral portals, however this paper used a novel ‘handlebar’ technique in which a K-wire is used to manipulate the PM fragment . Similarly, Diab (2018) describes using a 1.2-mm guidewire for PM manipulation followed by fixation with 4.0-mm cannulated screws, however with patient positioned prone .
Anterior arthroscopic portals.
Posterior arthroscopic portals.
When present, preferential fixation of the lateral malleolus first in order to facilitate PM reduction is described in three studies ,, . PITFL ligamentotaxis for ease of PM reduction and use of a PITFL suture-button , for improved syndesmotic congruity are also described. Both K-wires (1.6-mm to 2.0-mm) and guidewires (1.2-mm to 1.25-mm) are reportedly used for fragment manipulation and temporary fixation, followed by either 3.5-mm or 4.0-mm partially threaded posterior-anterior cannulated screws for permanent fixation.
General pitfalls of an arthroscopic approach include dependence on surgeon experience and limitations with respect to fragment size and orientation ( Table 2 ). Although somewhat contested, arthroscopy may not substantially increase operative costs and is largely dependent on operative efficiency .
Table 2
Pearls and pitfalls of arthroscopic fixation of posterior malleolus fractures.
| Pearls | Pitfalls |
|---|---|
| Posterior approach maximizes strength of P-A screws | PM fracture > 5 cm likely requires open technique and plate fixation |
| Restoring PITFL tension eases PM reduction and improves syndesmotic congruity | Dependent on surgeon experience with arthroscopy |
| Targeting device can be used to approach and elevate depressed fragment | Increased operative costs |
| Reduction Sequence : (A) Die-punch lesion, Volkmann fragment, posteromedial fragment, or (B) fixation of LM first to restore fibular length and ease PM reduction | Sural nerve damage possible given portal locations |
| Joint instability is an indication for PM reduction and fixation |
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