Iffy Suggestions About Posterior Malleolar Fragments in Ankle ORIF — What Now?

Has the pendulum to operate swung too far?

The CORRelations post "Beware This Meta-analysis Favoring ORIF of Posterior Malleolar Fragments in Ankle ORIF" urges caution in blindly accepting the conclusions of the meta-analysis in question, which favored ORIF of posterior malleolar fragments during surgical treatment of bi- or trimalleolar ankle fractures rather than closed reduction using AP screws or no treatment. The CORRelations post explained how selection bias in the source studies used by the meta-analysis will tend to inflate the apparent benefits of the treatment in question and affect the study’s recommendations.

But I think the post points to another idea that is worth considering.

Posterior malleolar fractures were often ignored in the not-too-distant past, and recent attention to these injury patterns has certainly improved the quality of ankle fracture reduction. It may just be the pendulum to operate on them has swung too far. What we may need is a rational reconsideration of the indications to operate on this component of common ankle fractures.

Anecdotally, I’m seeing them come up more and more on the ABOS Part II Oral Examination. I commend surgeons for giving them due consideration, especially since it often involves adding time to the procedure to reposition the patient or to work through a surgical window with limited view. Some skeptics may say that this increase is driven by the increased value of the CPT code for ORIF of trimalleolar fractures relative to bimalleolar injuries, but in my experience, the added work is not worth the additional 2.54 RVUs. The reason surgeons fix these fractures is they believe it’s best for the patient.

Let’s find the sweet spot. The CORRelations coverage of the meta-analysis I mentioned earlier is a great step in the direction of delivering value-oriented care. The added cost of operating on posterior malleolar fractures, using expensive locking plates and arthroscopically assessing ankle fracture reductions, must produce a commensurate increase in quality — differences in outcomes that patients can perceive. Until we can demonstrate that this increase in time and expense really helps our patients, we should weigh these “advances” skeptically.