Posterior-Based Approaches to Open Reduction Internal Fixation of Bimalleolar and Trimalleolar Fractures: A Systematic Review and Meta-analysis

Although there is growing evidence supporting posterior-based surgical approaches to open reduction internal fixation (ORIF) of malleolar fractures, the lateral approach still remains the standard of care for this injury. The purpose of this review was to integrate the results of several studies investigating outcomes following posterior-based approaches to the ORIF of malleolar fractures. The literature search was undertaken using PubMed, the Cochrane Library, and Embase. Crude event rates for fracture healing and postoperative complications were calculated. When possible, meta-analyses were conducted to estimate the relative risk of these outcomes between patients treated by posterior-based approaches versus other approaches to ORIF of malleolar fractures. Twenty-two studies were eligible, and 4 studies were included in the meta-analyses. The healing rate was 100% in all patients, regardless of the surgical approach. Overall, 1.26% of patients developed an infection, 0.63% required reoperation, 1.13% experienced aseptic loosening, 5.53% experienced pain after treatment, and 2.52% experienced symptomatic hardware. No malunion or heterotopic ossification was reported in any study. Among patients treated with a posterior-based approach, the most frequently reported complication was infection (2.50%), with lower rates of reoperation and postoperative pain. Patients with trimalleolar fractures experienced slightly poorer outcomes. Patients treated by posterior-based approaches had a significantly increased risk of infection (p = .010) relative to those treated by the lateral approach; patients treated by the lateral approach had a significantly increased risk of pain after surgery (p = .004) and symptomatic hardware (p = .007). This study brought together evidence that posterior-based surgical approaches and non-posterior-based approaches to ORIF are effective in healing malleolar fractures, with significant differences in specific postoperative complications that need to be further explored.