Surgical fixation of posterior malleolus does not improve functional or radiological outcomes in tri-malleolar fracturesSurgical Fixation Shows No Advantage for Certain Ankle Fractures

BACKGROUND: This systematic review and meta-analysis addresses the ongoing debate regarding the optimal management of posterior malleolar fragments in tri-malleolar ankle fractures, particularly when fragment size involves less than 25-30% of the articular surface. Current treatment guidelines are inconsistent, with limited evidence supporting routine surgical fixation of smaller fragments. This study aimed to compare functional and radiological outcomes in patients with tri-malleolar fractures involving PMFs (≤30%) managed with surgical fixation versus non-fixation. METHODS: A comprehensive literature search was conducted according to PRISMA guidelines, including MEDLINE, Embase, Scopus, and CINAHL databases for studies published between April 2006 and April 2025. Studies directly comparing surgical fixation to non-fixation in this context were included and meta-analysis were performed when at least two or more studies reported identical outcome measures. Risk of bias was assessed using Cochrane tools for both randomised & non-randomised studies. RESULTS: Ten studies (two RCTs, eight cohort studies; 883 patients; mean age 47.1 years; mean follow-up of 41.09 ± 30.03 months in fixation group and 43.12 ± 28.47 months in the no-fixation group) were included. No significant difference was found in AOFAS scores (seven studies, n = 490; MD 3.76, 95% CI -3.56-11.08; P = 0.31; I² = 95%), OMAS (four studies, n = 529; MD 0.35, 95% CI -6.29-6.99; P = 0.92; I² = 71%), or incidence of OA ≥grade 2 (eight studies, n = 755; OR 0.84, 95% CI 0.32-2.22; P = 0.73; I² = 71%). GRADE certainty was low for functional outcomes and very low for OA. CONCLUSION: Although high study heterogeneity warrants cautious interpretation and highlights the need for further research, this study showed that surgical fixation of the posterior malleolus does not demonstrate superior functional or radiological outcomes compared to no-fixation.