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Foot Ankle Orthop
Foot Ankle Orthop
FAO
spfao
Foot & Ankle Orthopaedics
2473-0114
SAGE Publications Sage CA: Los Angeles, CA

10.1177/24730114241278725
10.1177_24730114241278725
Letter to the Editor
Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review
https://orcid.org/0000-0002-0386-7270
Talia Adrian J. BBiomed, MD, MS, FRACS, FAOrthA
2 9 2024
7 2024
9 3 24730114241278725© The Author(s) 2024
2024
American Orthopaedic Foot & Ankle Society, unless otherwise noted. Manuscript content on this site is licensed under Creative Commons Licenses.
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
cover-dateJuly-September 2024
typesetterts1
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pmcDear Editor:

Congratulations to the authors on their recent article discussing percutaneous fixation of the posterior malleolus (PM) in ankle fractures 5 ; the article provides a comprehensive and contemporary overview of the technique. However I believe the article misses two important points about fixation of the PM: (1) postoperative stiffness and (2) hardware removal.

Traditional teaching states that if the size of the fragment is 25% to 33% of the articular surface (or greater) on a lateral radiograph then fixation is recommended. With computed tomography, in recent years there has been a paradigm shift; authors are now recommending more aggressive fixation via open approaches, 4 and there is sound biomechanical evidence to support this. 1

The literature is replete with reports of successful radiographic outcomes with an open approach 3 but fails to address critical aspects of this aggressive strategy, postoperative stiffness caused by a large open approach to the posterior malleolus, and the difficulty in removing hardware should the need arise. As the literature in this space focuses on radiographic results and arises from retrospective series, 2 I fear much of the patient experience cannot be conveyed in these publications.

Our service has seen significant postoperative ankle stiffness in patients treated with an open approach to the PM compared with those who undergo indirect reduction and percutaneous fixation; thus, we have a strong preference for the percutaneous fixation techniques (either AP or PA depending on the case) described in this article and hence welcome its publication. For our department, it is enough of a problem to avoid the technique in all but the worst of fractures (in which patients are likely to be very stiff postoperatively anyway). In addition, there is scant literature on the difficulty and complications of removal of this hardware, and it is not published to my knowledge, but logic would dictate that an anteroposterior screw is much easier to remove, with a lesser complicated profile than a posteroanterior screw or a posterior malleolar plate.

It is not specifically mentioned in the article, but I would raise these issues to the readership’s attention and would like to ask the authors directly if they had uncovered any literature on the postoperative range of motion after PM fixation via open and percutaneous approaches. If not, do they see this as a big problem in their practice, as we do? I would also ask if the authors would provide commentary on their technique and experience for hardware removal in these cases and how it differs from open fixation of the posterior malleolus.

Sincerely,

Supplemental Material

sj-pdf-1-fao-10.1177_24730114241278725 – Supplemental material for Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review

Supplemental material, sj-pdf-1-fao-10.1177_24730114241278725 for Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review by Adrian J. Talia in Foot & Ankle Orthopaedics

Adrian J. Talia, BBiomed, MD, MS, FRACS, FAOrthA 
Department of Orthopaedic Surgery, Western Health, Footscray Hospital
Footscray, Victoria, Australia
Department of Foot & Ankle Surgery, Nuffield Orthopaedic Centre
Oxford University Hospitals NHS Trust
Oxford, United Kingdom
Email: ajtalia@gmail.com
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Funding: The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Adrian J. Talia, BBiomed, MD, MS, FRACS, FAOrthA, https://orcid.org/0000-0002-0386-7270
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References

1 Bennett C Behn A Daoud A , et al . Buttress plating versus anterior-to-posterior lag screws for fixation of the posterior malleolus: a biomechanical study. J Orthop Trauma. 2016;30 (12 ):664-669. doi:10.1097/BOT.0000000000000699 27755282
2 Chong LSL Khademi M Reddy KM Anderson GH . Ten year outcomes after non-fixation of the smaller posterior malleolar fragment: a retrospective cohort study. Foot. 2024;59 :102091. doi:10.1016/j.foot.2024.102091 38513374
3 Haws BE Karnyski S DiStefano DA Soin SP Flemister AS Ketz JP. Reduction of posterior malleolus fractures with open fixation compared to percutaneous treatment. Foot Ankle Orthop. 2023;8 (3 ):24730114231200485. doi:10.1177/24730114231200485 37786607
4 Mason LW Kaye A Widnall J Redfern J Molloy A. Posterior malleolar ankle fractures: an effort at improving outcomes. JBJS Open Access. 2019;4 (2 ):e0058. doi:10.2106/JBJS.OA.18.00058
5 Massri-Pugin J Morales S Serrano J Mery P Filippi J Villa A. Percutaneous fixation of posterior malleolar fractures: a contemporary review. Foot Ankle Orthop. 2024;9 (2 ):24730114241256371. doi:10.1177/24730114241256371 38840784
