Posterior malleolar fractures: Was the incidence of severe adverse 2 events unacceptably high, before increased use of direct posterior 3 fragment fixation?

Abstract Background: Fixation of posterior malleolar (PM) fragments remains a controversial topic in ankle fracture management. Our objective was to examine the incidence of severe adverse events (AEs) associated with surgical management of patients with ankle fractures involving the posterior malleolus before increased use of direct PM fragment fixation.Methods: This is a retrospective cohort study including patients from a level III trauma center in the Capital region of Denmark. Adult patients (age >18 years) with ankle fractures involving a PM fragment treated surgically with a minimum of 18 months follow-up were included. The main outcome measurements were adverse events (graded using the Orthopaedic Surgical Adverse Events Severity (OrthoSAVES) System) requiring revision in the first 12 months after surgery. Results: In 75 out of 421 included patients (17.8%), PM fragments were surgically fixed. During the first twelve months after surgery, 34 patients (8.1% (95% CI [5.9–11.1%])) experienced AEs requiring revision. 17 patients (4%) were revised due to deep infection, 10 patients (2.4%) due to malpositioned implants, and 3 patients (0.7%) due to postoperative loss of reduction. Additional causes of revision were impingement of intraarticular fragment, non-union, postoperative joint dislocation, and postoperative vascular insufficiency leading to transmetatarsal amputation. Conclusions: The incidence of AEs requiring revision within the first twelve months after surgery was 8.1%, and the overall risk of severe AEs seemed unacceptably high. If direct PM fragment fixation can decrease the risk of severe AEs, then a change of practice could be justified. Further prospective studies are needed to establish generalizability, safety and efficacy before direct PM fragment fixation can be recommended in clinical guidelines.