An Optimal Screw Fixation Strategy for Posterior Malleolar Fractures: A Systematic Review and Meta-Analysis Comparing Posteroanterior Versus Anteroposterior Screws

The most appropriate fixation trajectory for posterior malleolar fractures (PMFs) still remains a matter of debate. This meta-analysis aimed to evaluate and compare the outcomes of posteroanterior (PA) and anteroposterior (AP) screw fixation strategies. We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Both manual and electronic searches of multiple databases were conducted. Two independent reviewers screened the studies in accordance with the predefined PICOS criteria: Population (adult patients diagnosed with PMFs); Intervention (PA screw fixation); Comparison (AP screw fixation); Outcome (radiological parameters, screw malpositioning error, American Orthopaedic Foot and Ankle Society (AOFAS) scores, postoperative complications); and Study Design (evidence levels I-III). Statistical synthesis was carried out using Stata 15.1 software (StataCorp LLC, College Station, Texas, USA). A total of 14 articles were included, encompassing 1258 study participants. The findings revealed that there were no statistically significant differences in the postoperative complication rates between the posterior-anterior screw fixation technique and the anterior-posterior screw fixation technique for the management of posterior ankle fractures. Nevertheless, statistically significant differences were observed in the AOFAS scores, the incidence of screw malpositioning, and the radiographic parameters with displacement exceeding 2 mm (P < 0.05). However, the clinical relevance of the difference in AOFAS scores is uncertain. In comparison to the AP method, PA screw fixation yielded superior radiographic outcomes, higher implant accuracy, and better functional recovery as evaluated by the AOFAS scores. The choice of technique should be individualized based on fracture pattern and surgeon expertise.