Direct or indirect reduction internal fixation for posterior ankle fractures: A systematic review and meta-analysis

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.