[Surgical Treatment of a Posterior Malleolus Fracture: Literature Review]

Fractures of the posterior margin of the distal end of the tibia, also referred to as posterior malleolus fractures, represent an important but often underestimated component of ankle injuries. They are rarely isolated but rather occur as part of more complex fractures classified as Weber type B and C, or they accompany high-energy pilon tibial fractures and spiral fractures of the tibial shaft. In recent decades, there has been a significant shift in the understanding of biomechanical importance of the posterior malleolus, which plays a key role in maintaining the stability of the distal tibiofibular syndesmosis and preserving the congruency of the ankle joint surface. Indications for surgical treatment as well as surgical approaches and fixation techniques have changed dramatically. This review article aims to summarize current knowledge of these fractures, with a focus on anatomy, diagnosis, classification, and particularly surgical treatment options, including the choice of approach and methods of fragment reduction. The literature search was conducted in the PubMed and Web of Science databases, focusing on publications released before the end of 2024. The search included the following keywords: "posterior malleolus fracture," "posterior tibial margin," "ankle fracture," "CT classification," "syndesmosis injury," and "surgical fixation." Original clinical studies, review articles, anatomical and biomechanical studies as well as case reports that provide clinically relevant information on the diagnosis and surgical management of these fractures were included in the review. The introduction of CT imaging has significantly contributed to a better understanding of the morphology of the posterior margin and led to the development of new classification systems (Haraguchi, Bartoníček and Rammelt, Mason), which serve as a guide in selecting the optimal surgical approach. Fixation of the posterior malleolus has a positive effect on ankle and syndesmotic stability even in small fragments. The choice of surgical approach is individualized - the posterolateral, posteromedial, transfibular, or modified lateral approach are used most commonly. Direct reduction and stabilization of the fragment allow for more accurate restoration of the joint surface and are associated with a lower risk of secondary displacement compared to indirect fixation. Surgical treatment of posterior tibial margin fractures should rely on a precise CT scan-based diagnosis and careful assessment of fracture morphology. Direct visualization, anatomical reduction, and fixation of the fragment provide better clinical and functional outcomes and should be preferred in displaced or complex fractures.