Posterior Malleolus - The Case for Leaving Most Alone

Description

In this presentation, Tim White discusses the treatment of posterior malleolar fractures at a symposium. He starts by acknowledging the limitations imposed by COVID-19, which has necessitated pre-recorded talks instead of live debates. The session follows a prior talk by Lyndon Mason on the advantages of fixing posterior malleolar fractures, which White has yet to review. He expresses his intention to argue why many of these fractures should be left untreated, highlighting that the significance of posterior malleolar fractures has surged since Haraguchi's classification paper in 2007. White critiques the growing enthusiasm for surgical intervention, warning against the potential pitfalls of adopting new surgical trends without sufficient supporting evidence. He recounts a concerning case wherein a young, active patient suffered severe complications and ultimately an amputation following unnecessary surgery for a minor posterior malleolar fracture.



Throughout his talk, White emphasizes the importance of adhering to the principle of "do no harm" in surgical practice. He discusses literature indicating high rates of complications (up to 30%) post-surgery for posterior malleolar fractures, which often doesn't translate into better outcomes compared to conservative treatment. He reviews classifications of malleolar fractures and stresses that fixation should primarily be reserved for those that cause instability in the ankle joint, as opposed to pursuing every fracture that presents on imaging.



For cases that warrant surgery, White outlines a technique for fixing posterior malleolar fractures using a supine position that avoids the need for prone positioning, allowing for a minimally invasive approach. He presents data from his own institution showcasing satisfactory outcomes in conservatively managed patients alongside those selectively treated. Ultimately, White advocates for a cautious approach to the surgical management of posterior malleolar fractures, emphasizing the need for further research and understanding before broadening the indications for surgical fixation.

DOI: 10.1302/3114-221299

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