• Elena Vacas-Sánchez, Carlos Olaya-González, Ana Abarquero-Diezhandino, Enrique Sánchez-Morata, and Jesús Vilá-Rico.
• Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, Avda/Córdoba, s/n, 28041, Madrid, Spain. elena.vacas@gmail.com.
• Int Orthop. 2020 Jun 1; 44 (6): 1177-1185.

IntroductionThe posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages.MethodsThe fracture pattern of PM is classified according to Haraguchi or Bartoníček classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection.ResultsPosterolateral approach should be the election for Haraguchi I or III and Bartoníček 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartoníček 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartoníček 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach.ConclusionTo address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.

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