Response to “Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review”

Dear Editor,

We thank Dr Talia for the letter to the Editor regarding our recent publication in Foot & Ankle Orthopaedics titled “Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review.” ¹

The main objective of our study was to summarize the literature on anatomic, biomechanical, and clinical aspects. Based on our search and experience, the ideal fracture for percutaneous fixation has a noncomminuted fragment that is minimally displaced and has no secondary, intercalated fracture fragments. Additionally, we suggest posterior-to-anterior (PA) instead of anterior-to-posterior (AP) percutaneous fixation for 2 reasons: (1) the risk of tendon and neurovascular injuries is low, and (2) PA screw fixation may provide better purchase or compression of the fragment. With smaller fracture fragments, the AP screw threads may not cross the fracture line, thus failing to grip the posterior malleolus fragment securely.

Dr Talia brings up two aspects of the fixation of posterior malleolar fractures: the postoperative stiffness and the need for hardware removal. After the Letter to the Editor of Dr Talia, we did a new search to evaluate if there are publications that compare the rate of hardware removal and the postoperative stiffness between the open approach and percutaneous technique for posterior malleolar fractures, without any results. That being said, the following comments will be based mainly on our clinical experience.

The stiffness after an ankle fracture surgery is a common problem. A prior study showed up to 72% of patients report stiffness at 1 year postsurgery. ² We agree with Dr Talia that an open approach can generate more stiffness than a percutaneous approach. However, postoperative ankle stiffness is not only determined by the open or percutaneous approach to the posterior malleolus but also by the degree of bone and ligament involvement, the presence of dislocation, the time between the injury and surgery, and the type of rehabilitation, among others.

Regarding the hardware removal, we agree that an AP cannulated screw could be easier to remove compared with PA percutaneous screw or a plate from a posterior approach.

Nevertheless, posterior implants are rarely symptomatic unless left in an incorrect position, irritating the posterior tibial tendon or penetrating the distal tibiofibular joint. In our institution, we have a very low rate of hardware removal in posterior malleolar fractures. Not so with the posterior fibula plates, which have a higher removal rate.

Finally, when a percutaneous AP or PA screw has to be removed, under radiographs, we visualize the location of the cannulated screw. After that, a mini-incision is performed at the level of the screw head and the soft tissues are separated with a mosquito forceps. Finally, a Kirschner wire is introduced in the cannulated screw, and the screw is removed with the screwdriver. When a posterior tibial plate must be removed, we use the same previous posterolateral or posteromedial approach.

Sincerely,

Supplemental Material

sj-pdf-1-fao-10.1177_24730114241278710 – Supplemental material for Response to “Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review”

Supplemental material, sj-pdf-1-fao-10.1177_24730114241278710 for Response to “Letter Regarding: Percutaneous Fixation of Posterior Malleolar Fractures: A Contemporary Review” by Jafet Massri-Pugin, Sergio Morales, Javier Serrano, Pablo Mery, Jorge Filippi and Andrés Villa in Foot & Ankle Orthopaedics

Jafet Massri-Pugin, MDFoot and Ankle Surgeon, Pontificia Universidad Católica de Chile, Santiago, Chile. Email: [e-mail] Sergio Morales, MD, MSc Javier Serrano, MD Pablo Mery, MD Jorge Filippi, MD, MBA Andrés Villa, MDDepartment of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile