## 4 Discussion  
In recent years, numerous studies have emphasized the critical importance of achieving an anatomical restoration of the articular surface in third malleolus fractures. Contrary to initial expectations, biomechanical studies on cadavers following posterior malleolus resection did not reveal a substantial increase in contact forces or joint instability. However, the prognosis for trimalleolar fractures, especially those involving the posterior malleolus, is associated with a less favorable prognosis, an elevated risk of post-traumatic osteoarthritis, and inferior functional outcomes compared to fractures excluding the posterior malleolus [38, 39]. The presence of joint step-off has emerged as a crucial indicator for predicting osteoarthritis development, although its impact on functional outcomes remains a subject of debate [40, 41, 42, 43]. The evolving consensus rejects reliance solely on dimensional criteria for the management of posterior malleolus fractures. Traditionally, surgical synthesis was indicated for fragments affecting over 25% of the articular surface. The recent literature, however, advocates synthesis for involvement as low as 5-10%, yielding superior clinical and radiographic results [40, 42, 44, 45]. The third malleolus has assumed a pivotal role in trimalleolar fracture management. Nevertheless, controversies persist in defining precise indications for the correct surgical approach due to the absence of a standardized method for evaluating functional outcomes across various treatments [46]. In the current literature, there is broad consensus that the actual size and tridimensional geometry of the posterior malleolus fracture can only be diagnosed through preoperative CT examination. Sagittal and axial scans combined with 3D reconstruction can provide information for accurate classification and appropriate preoperative planning [47]. The advent of CT imaging has facilitated the introduction of classification systems like [PERSON]'s [21]. These systems not only reveal factors unidentifiable with standard X-rays but also guide surgical treatment selection and suggest appropriate osteosarcoma types [48]. Historically, surgical synthesis of the third malleolus primarily involved percutaneous anteroposterior screws, a relatively straightforward and minimally invasive technique. However, challenges may arise in achieving proper anatomical reduction for small interposed fragments and synthesizing small, particularly displaced, fragments. The open posterolateral approach to the third malleolus allows anatomical reduction for posterior and laterally extended fragments, with the possibility of reaching the lateral malleolus [49, 50]. However, drawbacks include the need for a relatively extensive incision, longer operation times, and potential technical difficulties, including the risk of sural nerve damage. Skin healing difficulties for this approach are comparable to the direct lateral approach, while the infection rate ranges from 4-11% [44, 51]. Few comparative studies exist on different approaches for posterior malleolus fracture surgical synthesis. Existing studies present comparable clinical and radiological outcomes between posterolateral and posteromedial approaches [52]. Our retrospective comparative study suggests that clinical evaluation, based on the AOFAS scale, is worse for older patients, likely due to lower functional demand and, consequently, less adherence to post-operative rehabilitation programs. AOFAS scores were also lower for individuals with a joint step-off \(\geq\) 2 mm, although our experience does not provide strong evidence to support this hypothesis, possibly due to the limited sample size. Results were compared between the group with anatomical reduction and the group with a joint step-off \(\geq\) 2 mm. Statistical analysis confirmed better functional results in the group with anatomical reduction, regardless of the surgical technique performed.