Arthroscopy Assisted Fixation of Posterior Malleolar Fractures

Case Series for Novel Approach

Hossam S. Diab, MD


Curr Orthop Pract. 2018;29(3):250-255. 

In This Article

Abstract and Introduction


Background: Posterior malleolar fractures are not uncommon ankle injuries. Despite their biomechanical significance for syndesmotic stability and stress distribution, there is no consensus about which fractures to treat surgically. The purpose of this study was to evaluate arthroscopic guided fixation of posterior malleolar fractures. This technique is hypothesized to provide visualized optimal reduction in a minimally invasive manner.

Methods: Twelve consecutive ankle injuries with posterior malleolar fracture were treated and enrolled in this prospective study. The standard procedure included posterior ankle arthroscopic guided reduction and cannulated screw fixation of the posterior malleolus. Patients were evaluated using the Foot and Ankle Outcome Score (FAOS) and Ankle-Hindfoot scale. A composite questionnaire, including the EQ-5D and visual analog scales (VAS) for pain and satisfaction was accomplished.

Results: Postoperatively, all radiographs showed good reduction of the posterior malleolus and an even joint, with a mean tibiofibular clear space of 4.2 mm. All patients had returned to their preinjury activity levels at their final follow-up. The mean FAOS score for patients included in the study was 92.46, and the mean Ankle-Hindfoot score was 92.0. Adequate range of motion was achieved in relation to the contralateral ankle, with insignificant comparative chi-square statistic at a P-value of 0.99, and overall satisfaction scale of 9.42.

Conclusions: Arthroscopic guided fixation of the posterior malleolar fracture is an effective treatment modality that achieves direct reduction of the fracture, faster rehabilitation, and has a lower risk of neurovascular complications.


Posterior malleolar fractures are not uncommon findings, with an occurrence rate of 7% to 44% among ankle fractures.[1,2] This type of fracture is commonly under-diagnosed due to insufficiency of the routine radiographic workup.[3] Plain radiographs can only show the extent and displacement of posterior fragment, while comminution and impaction are extremely underestimated. Consequently, some authors recommend preoperative CT evaluation for all patients with posterior malleolar fractures.[4] It is believed that posterior malleolar fractures are not sufficiently treated because there is a lack of consensus on which fractures to treat surgically. They are frequently neglected under the assumption of spontaneous reduction by ligamentotaxis after lateral malleolar fixation.[5,6]

Recent studies have shown the significance of posterior malleolar integrity for the stability of the tibiofibular syndesmosis and ankle joint.[5] The posterior malleolus and its attached posterior tibiofibular ligament are important pillars for proper syndesmotic stability and contact stress distribution.[7] Biomechanical analysis of fractured posterior fragments showed significant abnormality in stress distribution, with subsequent increased risk of joint arthrosis.[8,9]

Various surgical approaches have been described for fixation of the posterior malleolar fragment. Indirect reduction and fixation with either anteroposterior or posteroanterior screws have both been used.[10,11] A recent survey revealed surgeons' predilection for open reduction and internal fixation of the posterior fragment.[7] Open reduction allows visual reduction of the fracture, debridement of fracture hematoma and mini-fragments, if any, and removal of possibly entrapped soft tissue.[6,11,12]

The hypothesis of this study was that posterior ankle arthroscopy allows direct visualization of the posterior ankle, which facilitates debridement of the fracture hematoma and loose mini-fragments, allows for verification of reduction adequacy, and ameliorates anticipated complications associated with standard surgical approaches.