The Modified Posteromedial Approach for posterior malleolar fractures: report of soft tissue complications after ten years of experience.

Abstract

To evaluate soft tissue complications and the incidence of neurovascular bundle (NVB) injury following the modified posteromedial approach (moPMA) for posterior malleolar (PM) fractures, and to describe its indications in clinical practice. Design: Retrospective, observational case-series study. Single center with a dedicated foot and ankle trauma unit. Consecutive adult patients who underwent open reduction and internal fixation (ORIF) of PM fractures (AO/OTA 44 or 43) using the moPMA between 2014 and 2024. Exclusion criteria were open or pathological fractures, prior surgery at other institutions, or incomplete clinical records. Primary outcomes were incidence of soft tissue complications and NVB injuries, graded according to the modified Clavien-Dindo classification for foot and ankle surgery. Secondary outcomes included fracture classification according to AO/OTA and Bartoníček-Rammelt, associated procedures and approaches, surgical staging, fixation type, follow up, and use of intraoperative imaging. The mean age was 47 years (range 18-83 years), there were 14 male and 40 female patients. The mean time from injury to surgery was 5.9 days. According to the Bartoníček-Rammelt classification, 51.9% were type C, 31.5% type B, and 14.8% type D. Most cases (77.8%) were AO/OTA 44B3. The moPMA was used in the first surgical stage in 77.8% of cases. A second approach was required in 90.7%, most commonly for fibular fixation through a lateral approach (70.4%). Associated procedures were performed in 92.6%, with fibular osteosynthesis being the most frequent (66.7%). Fixation was plate-based in 92.5%. The mean follow-up was 63.1 ± 31.4 months. Hardware removal of the posterior fixation was performed in 37.1%. Soft tissue complications occurred in 4 patients (7.4%), all classified as grade IA. No NVB injuries or tibialis posterior tendon contractures were reported. The modified posteromedial approach for fixation of posterior malleolar fractures demonstrated low complication rates and no neurovascular injuries, supporting its use in a wide range of posterior malleolar fractures. Level IV. Retrospective observational case-series study.