January 2020

A Role for Arthroscopy in Managing Ankle Trauma?

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Consider the benefit of arthroscopy for addressing intraarticular pathology at the time initial surgical repair of high-grade ankle fracture is performed.

By Kevin Burke, DPM and Jonathan Hook, DPM

Ankle fractures are a common orthopedic injury. Although surgical repair often yields good results, many cases are nonetheless associated with poor clinical outcome after repair.1,2,3  Most commonly, poor outcomes are posttraumatic arthritis, hardware irritation, infection, and wound complications.

Progression to posttraumatic arthritis has been reported in 14% to 50% of patients at long-term follow-up after open reduction internal fixation (ORIF) of acute ankle fracture.4 Even with anatomic alignment, poor functional outcomes continue to be reported after ORIF, possibly owing to osteochondral lesions (OCL) that occurred at the time of injury but that might not have been apparent on preoperative imaging.5 Nevertheless, ORIF remains the standard of treatment for unstable and displaced ankle fractures.

Recent literature6 has suggested that OCL are a source of pain and decreased functional outcome after ankle injury and, consequently, that lesions require subsequent treatment. Surgically, options include curettage, microfracture, grafting, and use of other biologic materials. These procedures require additional operating room time and anesthesia, and involve an additional recovery period when undertaken (as they often are) after initial ankle fracture repair.

In the face of evidence regarding the burden of treatment of OCL, arthroscopy of the ankle joint, concurrent with ankle fracture repair, has been gaining popularity—to detect OCL and treat them at the time of initial repair of ankle fracture. However, this procedure, for this indication, has yet to become a standard of practice—likely due to the paucity of high-level evidence in the literature to support its concurrent use at the time of acute repair.

Prevalence of Intraarticular Lesions with Acute Ankle Fracture

The incidence of intraarticular lesions in acute ankle fracture, including chondral and osteochondral defects, has been reported to be as high as 63% to 79%.1,2 In 2018, Da Cunha and colleagues4 reported on 116 patients who underwent acute ankle ORIF and concurrent arthroscopy. They found that 78% had a chondral lesion and 43% had a full-thickness OCL; furthermore, they found that patients who had an ankle dislocation or syndesmosis disruption were much more likely to develop a lesion.

The same year, Lambers and co-workers found a higher incidence of OCL with syndesmotic injury when evaluating postoperative computed tomographic scans after standard malleolar ORIF.7 Recent literature7,8,9 has been trending toward a correlation between poor clinical outcome and chondral or osteochondral lesions after fracture repair.

The diagnosis and timeline for treatment therefore comes into question: Should intra-articular pathology be addressed at the time of initial fracture repair via arthroscopy? Or is it better addressed as a subsequent procedure if postoperative discomfort ensues?

The incidence of intraarticular lesions in acute ankle fracture, including chondral and osteochondral defects, has been reported to be as high as 63% to 79%.

Advantages of Arthroscopy

The ability to diagnose intraarticular pathology is limited: Plain radiography can miss as many as 50% of OCL. Often, more advanced studies, such as magnetic resonance imaging, are necessary to make the diagnosis, but these tests are expensive and time-consuming for the patient. Yasui and colleagues10 reported that, in their study, magnetic resonance imaging overestimated the size of OCL, compared to arthroscopic measurement, more than 50% of the time. They concluded that direct visualization, by arthroscopy, is diagnostically superior. Arthroscopy has the advantages of direct visualization of any lesions present and better visualization of articular alignment during concurrent fracture reduction and offers immediate assessment and treatment of any cartilage or ligamentous damage.

Chiang and co-workers5 studied 105 patients with a supination-external rotation ankle fracture who were treated with either standard ORIF or arthroscopic-assisted minimally invasive ORIF. They reported a significantly lower complication rate (7.7%) and reoperation rate (1.5%) in the arthroscopic-assisted group than in the standard ORIF group (27.5% and 12.5%, respectively). Furthermore, arthroscopy was found to decrease soft-tissue disruption, preserve vascularity, allow removal of any loose bodies, and provide direct visualization of syndesmotic and deltoid ligaments.3 Also, more syndesmotic injuries were identified in the arthroscopic group.

It can be extrapolated, therefore, that, when intraarticular pathology is discovered and treated with arthroscopy at the time of initial repair, the utility of this procedure includes lower cost, less time in the operating room and under anesthesia, and better functional outcomes.

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Those Advantages Notwithstanding…

Arthroscopy concurrent with ankle fracture repair is not, however, the standard of care among most surgeons. It has been reported that only 1% of surgeons are considering arthroscopy at the time of initial repair,1 (although this percentage is increasing). Why this low percentage? Consider these possibilities:

  • Arthroscopy has an associated learning curve; performing the procedure is a learned skill that not every surgeon is trained to perform adequately.
  • Simple fractures are less likely to be associated with an OCL. It has been suggested that, as the Lauge-Hansen grade of severity of fracture increases, so does the likelihood of a chondral or osteochondral lesion.4
  • Several studies4,5,12 have found an increased prevalence of OCL with ankle dislocation or syndesmotic injury.
  • Not all OCL are accessible through standard anterior or posterior portals. Depending on the size and location of the lesion, additional means, such as open arthrotomy, might be indicated.

Further research might be necessary to establish an algorithm for determining when arthroscopic management of ankle fracture is indicated.

Summing Up

Although the literature supports the contention that OCL cause poor outcomes and are highly prevalent in acute ankle fracture, ORIF and concurrent arthroscopy is not yet the standard of care. Evidence supports the expectation of good or excellent outcomes following traditional ORIF of ankle fractures; additional evidence indicates that ankle arthroscopy can be successful at identifying and treating intraarticular pathology.

However, there is insufficient high-level evidence regarding functional outcomes and complication rates on the use of arthroscopy with ankle fracture repair. No documentation supports a finding of improved outcomes with arthroscopy, compared with standard ORIF, for treatment of acute ankle fractures.

Although additional research is necessary, given the high prevalence of OCL with high-grade ankle fracture, it might be beneficial for the patient to undergo arthroscopy at the time of initial repair.

Kevin Burke, DPM, is a first-year resident at Mercy Hospital and Medical Center in Chicago, IL.

Jonathan Hook, DPM, is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. A Fellow of the American College of Foot and Ankle Surgeons, he is in private practice at Midland Orthopedic Associates and affiliated with the residency program at Mercy Hospital and Medical Center in Chicago, IL. 

REFERENCES
  1. Ackermann J, Fraser EJ, Murawski CD, Desai P, Vig K, Kennedy JG. Trends of concurrent ankle arthroscopy at the time of operative treatment of ankle fracture. Foot Ankle Spec. 2015;9(2):107-112.
  2. Sherman TI, Casscells N, Rabe J, McGuigan FX. Ankle arthroscopy for ankle fractures. Arthrosc Tech. 2015;4(1):e75-e79. [eCollection February 2019]
  3. Diefenbach C, Nguyen K, Kreulen C, Giza E. The role of ankle arthroscopy in ankle fractures. Tech Foot Ankle Surg. 2018;17(3):121-125.
  4. Da Cunha RJ, Karnovsky SC, Schairer W, Drakos MC. Ankle arthroscopy for diagnosis of full-thickness talar cartilage lesions in the setting of acute ankle fractures. Arthroscopy. 2018;34(6):1950-1957.
  5. Chiang CC, Tzeng YH, Jeff Lin CF, et al. Arthroscopic reduction and minimally invasive surgery in supination-external rotation ankle fractures: a comparative study with open reduction. Arthroscopy. 2019;35(9):2671-2683.
  6. Gianakos AL, Yasui Y, Hannon CP, Kennedy JG. Current management of talar osteochondral lesions. World J Orthop. 2017;8(1):12–20.
  7. Lambers KTA, Saarig A, Turner H, et al. Prevalence of osteochondral lesions in rotational type ankle fractures with syndesmotic injury. Foot Ankle Int. 2019;40(2):159-166.
  8. Dahmen J, Lambers KTA, Reilingh ML, van Bergen CJA, Stufkens SAS, Kerkhoffs GMMJ. No superior treatment for primary osteochondral defects of the talus. Knee Surg Sports Traumatol Arthrosc. 2018;26(7):2142–2157.
  9. Chen XZ, Chen Y, Zhu QZ, Wang LQ, Xu XD, Lin P. Prevalence and associated factors of intra-articular lesions in acute ankle fractures evaluated by arthroscopy and clinical outcomes with minimum 24 month follow-up. Chin Med J (Eng). 2019;132(15):1802-1806.
  10. Yasui Y, Hannon CP, Fraser EJ, et al. Lesion size measured on MRI does not accurately reflect arthroscopic measurement in talar osteochondral lesions. Orthop J Sports Med. 2019;7(2):2325967118825261.
  11. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. 2009;91(2):333-339.
  12. Regier M, Petersen JP, Hamurcu A, et al. High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: medium-term follow-up of 100 cases. Injury. 2015;47(3):757-761.

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