Direct or indirect internal fixation for posterior ankle fractures remains a controversial topic. While direct plate or screw internal fixation is believed to provide better reduction, it may also cause more severe soft tissue damage, while indirect screw internal fixation is thought to result in less damage but may carry the risk of poor reduction. We conducted this meta-analysis to investigate the clinical efficacy and safety of direct versus indirect reduction internal fixation for posterior ankle fractures. The Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) guidelines were used to search the China Knowledge Network database (CNKI), PubMed, Web of Science, Embase, and other databases from the year of establishment- February 2025, and relevant journals were manually searched to collect the relevant literature, and articles that met the requirements were screened and analyzed. Meta-analysis was conducted using RevMan 5.4 software, and a systematic evaluation was carried out when the data from the included studies could not be synthesized. A total of 17 articles involving 1538 study subjects were included, and the results showed that there were no statistical differences in postoperative AOFAS scores, complications, and Dorsiflexion restriction between ankle fractures after direct plate or screw reduction and fixation and those after indirect screw reduction and fixation; however, the Radiological evaluation>2 mm and Osteoarthritis (P < 0.05) were statistically different. Direct reduction and fixation of posterior ankle fractures has better imaging performance and reduces the incidence of postoperative arthritic events.

Guidelines for treatment of medium-sized posterior fragments in trimalleolar fractures are scarce and show varying advice. Recent trials comparing fixation and no fixation of posterior fragments, show no difference in outcomes one year postoperatively. This study compares functional outcome and development of osteoarthritis in patients with fixation of a posterior malleolar fracture to patients without fixation of the posterior malleolus fracture.

This retrospective cohort study included patients operated for type B ankle fractures with medium-sized (5-25% of joint surface) posterior malleolar fragments in a Dutch level-1 trauma center between 2014 and 2018. ORIF of posterior fragments (FIX) was compared to no fixation (NO-FIX). Choice of treatment was based on the surgeon's preference. Functional outcome was assessed using the AOFAS-score, OMAS-score and VAS-pain. Development of osteoarthritis was assessed on radiographs. A linear regression analysis was performed to identify risk factors for worse functional outcome and osteoarthritis.

27 patients were included in the FIX group and 58 patients in the NO-FIX group. After a median follow-up of 74 months (range 50-108), no difference was observed for functional outcome and pain (median AOFAS 90 vs. 95, OMAS 85 vs. 88, VAS-pain 1 vs. 1; all p > 0.05). Osteoarthritis rates were comparable (grade ≥ 2: 22% in FIX vs. 21% in NO-FIX, p = 0.87). Median fragment size was 15.7% versus 13.6% of the tibial articular surface after FIX and NO-FIX respectively. Median postoperative step-off on radiograph was 0.0 mm after FIX and 0.8 mm after NO-FIX (p = 0.20). Complication rates, including infection, secondary operation and hardware removal, were comparable. Postoperative step-off > 1 mm increased the risk of osteoarthritis (odds ratio 3.9, 95% CI 1.2-12.7).

The value of fixation of medium-sized posterior fragments in type B ankle fractures seems limited after mid-term follow-up, although functional impairment caused by osteoarthritis might develop in the long-term. Because postoperative step-off > 1 mm increases the risk of osteoarthritis, restoration of the tibial plafond seems essential.