Posterolateral Versus Posteromedial Approach for Posterior Malleolus Fixation in Trimalleolar Fractures of the Ankle

Background Ankle fractures, particularly those involving the posterior malleolus, are prevalent injuries that can lead to significant functional impairment if not managed appropriately. The choice of surgical approach for posterior malleolus fixation - posteromedial (PM) or posterolateral (PL) - remains a debate among orthopedic surgeons. The PM approach is a traditional technique involving extensive soft tissue dissection, while the PL approach offers improved visualization and precision with potentially less soft tissue disruption. Materials and methods This prospective comparative study was conducted at the Department of Orthopedics, Dr. D. Y. Patil Hospital and Research Centre, Pune, between February 2022 and August 2024.A total of 42 patients with trimalleolar fractures involving the posterior malleolus were randomly assigned to either the PL or PM surgical groups, with 21 patients in each group. Surgical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scores, articular surface step-off, range of motion (ROM), and complications such as osteoarthritis, infection, neurovascular injury, nonunion, and deep vein thrombosis at six months, 12 months, and final follow-up. Results Patients in the PL group demonstrated superior clinical outcomes with higher mean AOFAS scores at six-month (87.52 ± 2.92) and 12-month (90.28 ± 1.72) follow-ups compared to the PM group (84.95 ± 3.25 at six months; 88.86 ± 2.41 at 12 months), with statistically significant differences favoring the PL approach. However, as per the final follow-up, the difference in AOFAS scores between the two groups was not statistically significant. The PL group also had more patients with excellent ROM and fewer complications, such as arthritis, than the PM group. Conclusion The PL approach for posterior malleolus fixation in trimalleolar fractures offers superior early functional outcomes and fewer complications than the PM approach. However, the long-term outcomes between the two approaches show no significant difference, indicating that both techniques can be effective depending on the specific fracture pattern and patient characteristics.