## 4 Discussion
However, the comparison between the two groups based on the persistence of joint step-off yielded a borderline \(p\)-value (\(p\)-value = 0.07), not falling below the 5% significance level. However, the comparison between the two groups based on the persistence of joint step-off yielded no differences. Nevertheless, those with a joint step-off achieved a lower AOFAS score than those without. This result needs confirmation from studies with a larger sample size, but it appears to validate that the posterior ORIF technique, enabling direct visualization and mastery of the posterior malleolus fragment, substantially enhances the surgical chances of achieving anatomical joint reduction, restoring the fibular notch, and providing stable anatomical syndesmosis fixation. In our case series, post-operative joint incongruence (step-off \(\geq\) 2 mm and <3 mm) at the third malleolus occurred in 50% of patients treated with screws, while in those treated with a plate, it was 20%. This difference aligns with the recent literature [50], indicating that posterolateral plate synthesis compared to the anteroposterior percutaneous screw technique increases the probability of achieving anatomical reduction and is associated with better clinical outcomes [53; 54]. However, the association between joint step-off and better clinical outcomes in terms of AOFAS and ROM needs clarification. The posterolateral approach has shown superiority over anteroposterior percutaneous screws in several studies, but in the 2023 systematic review by [PERSON] et al. [43], this was confirmed only for better radiographic restoration of correct anatomy. Superiority was not confirmed regarding AOFAS scores, osteoarthritis development, infections, and sural nerve damage. Despite these limitations, our study suggests a fundamental contribution to improving outcomes, partly highlighted in our case series, due to the restoration of the fibular notch achieved through anatomical reduction of the posterior fragment and subsequent stabilization of the posterior-inferior tibiofibrular ligament [55; 56]. From our study and the recent scientific literature data, we believe that in treating trimalleolar fractures, the three fundamental objectives are the following:  
1. Anatomical reconstruction of the tibial plafond. 2. Anatomic restitution of the fibular notch. 3. Anatomical stabilization of the syndesmosis. These aspects need to be achieved for the surgeon to improve the outcomes of patients with trimalleolar fractures, forming the basis for selecting the correct treatment [57]. Study Limitations and Future Perspectives  
Critically analyzing our study reveals limitations, including a small sample size (54 patients) and uneven distribution of patients treated with two different techniques. This limited statistical power prevents the definition of subsets with greater comparability, such as age. Moreover, the distribution of ages in the two groups was not homogeneous. Other limitations of our study are a lack of post-operative CT analysis, lack of data about surgical times and complications, and surgeries performed by different surgeons in two different hospitals. In our study, two entirely different techniques were compared, and the results are understandably linked to this aspect. An intriguing aspect would have been the inclusion of third malleolus osteosynthesis with percutaneous postero-anterior screws and open reduction and internal fixation (ORIF) via postero-medial approach. Unfortunately, the percutaneous posteroanterior screw osteosynthesis is not performed in the two hospitals, and the available data for ORIF via the posteromedial approach in our possession were too limited, potentially further compromising the obtained results. The conduct of scientific studies that encompass larger case series involving all possible types of third malleolus osteosynthesis can provide a more in-depth understanding of which technique is optimal for each patient.