• Maarten Mertens, Julia Wouters, Johannes Kloos, Stefaan Nijs, and Harm Hoekstra.
• University Hospitals Leuven, Department of Trauma Surgery, Herestraat 49, B-3000 Leuven, Belgium.
• Injury. 2020 Apr 1; 51 (4): 1118-1124.

IntroductionThe necessity for reduction and fixation of posterior malleolus fractures remains under debate. Therefore, we assessed the functional outcome and quality after plate osteosynthesis of the posterior malleolus, identified the main drivers of outcome and aimed to determine which patient and fracture type are eligible for plate osteosynthesis of the posterior malleolus.Materials And MethodsA prospective patient cohort of 50 patients with an ankle fracture including the posterior malleolus underwent plate osteosynthesis via a posterior approach, and was compared to a retrospective patient cohort of 85 consecutive patients who did not. Twenty-five demographic, operative and postoperative characteristics were assessed. Outcome was recorded using questionnaires: AOFAS, EQ-5D, EQ-5D-VAS, EQ-5D-TTO, sensory nerve-associated complications, and flexion deficit of the hallux.ResultsDirect reduction and plate osteosynthesis of posterior malleolus fractures was inferior to non-operative treatment. Subanalysis of trimalleolar fractures revealed that the outcome of plate osteosynthesis was equal. Both fracture type and plate osteosynthesis were independent drivers of the outcome; Haraguchi type 3 posterior malleolus fractures were associated with the best functional outcome and quality of life scores. Comorbidity, age, postoperative complications and reintervention largely determined the outcome. Up to 30% of the patients reported (temporarily) flexion deficit of the hallux and 38% numbness at the lateral side of the foot.ConclusionsThere is no indication for routine plate osteosynthesis of all posterior malleolus fractures. Careful patient selection, less invasive surgery and modified postoperative rehabilitation seem mandatory to improve the outcome and prevent adverse effects.Copyright © 2020 Elsevier Ltd. All rights reserved.

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