Letter to the editor regarding "effect of buttress plate in herscovici type D vertical medial malleolar fractures and peripheral fractures: a retrospective comparative cohort study".

In this letter to the editor, we highlight several concerns that may affect the validity of the study results by Luo et al. entitled "Effect of Buttres plate in Herscovici type D vertical medial malleolar fractures and peripheral fractures: a retrospective comparative cohort study." First, we point out a methodological flaw in the selection of treatment groups, as insufficient standardization of criteria potentially led to selection bias. Second, we note that the angle of the screws in vertical fractures differed from the standard recommended in the literature, which may affect the effectiveness of fixation. Studies in the literature have increased the validity of their comparisons by using more reliable screw alignment techniques. They also recommend plate fixation instead of screws for vertical fractures, supporting the idea that plates provide more stable fixation in these cases. The inappropriate placement of screws in the Luo et al. study may therefore bias the results in favor of plate fixation and reduce the validity of the comparison between treatment modalities.