SLR - September 2023 - Rizvi
Title: Arthroscopically assisted versus open reduction internal fixation for ankle fractures: a systematic review and meta-analysisZhang, G., Chen, N., Ji, L. et al. Arthroscopically assisted versus open reduction internal fixation for ankle fractures: a systematic review and meta-analysis. J Orthop Surg Res 18, 118 (2023).
https://doi.org/10.1186/s13018-023-03597-9
Level of Evidence: I
Reviewed By: Syed Basar Rizvi
Residency Program: SSM DePaul Hospital
Podiatric Relevance: Persistent pain after open reduction internal fixation has been well documented, and can be linked to possible untreated intra articular disorders such as, ligament attenuation, or chondral lesions. Arthroscopic assisted reduction and internal fixation (ARIF) could assist in treatment of associated injuries related to ankle fractures. The purpose of this review was to understand whether ORIF vs ARIF led to better outcomes after 6 months.
Methods: Databases searched included PubMed, Embase, Cochrane Library. Only studies that were comparative studies and full text were included in the studies, while case reports, case series, and cadaveric or animal studies were excluded. Relevant patient information such as fracture type, study design, population, age, sex, outcome measures, and follow-up times were extracted. Software R was utilized for the statistical analysis with p value of
.05 deemed as statistically significant. Primary outcomes comparing ORIF vs ARIF were Olerud-Molander Ankle scores (OMA) and visual analog pain (VAS) score. Secondary outcomes were defined as: quality of reduction, surgery time, and arthritic changes.
Results: 1193 studies came back on initial search. After all inclusion and exclusion criteria were excluded, nine were included in the final meta analysis. Of the nine, two were RCT’s, six were retrospective cohort studies, and the final study was a prospective cohort study. A total of 273 patients were treated with ARIF, and 306 were treated with ORIF. In the RCT’s better outcomes were seen with ARIF with a MD of 6.6 with a p value of 0.04. However the MCID ranged from 10.5 to 15.0, therefore even through the difference was statistically significant it may not be clinically significant. Results were similar for VAS, with an MD of -.36 with an MCID of 1.16. ORIF was noted to have better internal fixation as well as shorter surgery time, but these results were not statistically significant. ARIF led to decreased arthritic changes but the findings were not significant.
Conclusion: The study concluded that ARIF was not superior to ORIF. Although there are differences between ARIF and ORIF, few appear to be statistically significant. The study also demonstrates that those values such as VAS, AOFAS and OMA showed outcomes favoring ARIF which were statistically significant, but are not significant clinically. Limitations of the article include minimal mention of surgical complication such as hardware removal, or infection, or compartment syndrome. There was also minimal mention on fixation technique efficacy between ARIF vs ORIF in regards to fracture pattern, which is a major limitation of this study. There is also limited analysis of surgeon skill when attempting arthroscopy, demonstrating a need for increased studies about this topic.