SLR - June 2023 - Jacob Gross, DPM
Title: Outcomes After Unstable Fractures of the Ankle: What’s New? A Systematic ReviewReference: Monestier L, Riva G, Coda Zabetta L, Surace MF. OUTCOMES AFTER UNSTABLE FRACTURES OF THE ANKLE: WHAT'S NEW? A SYSTEMATIC REVIEW. Orthop Rev (Pavia). 2022 May 31;14(4):35688. doi: 10.52965/001c.35688. PMID: 35769653; PMCID: PMC9235440.
Level of Evidence: Level I Evidence
Reviewed by: Jacob Gross, DPM
Residency Program: West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
Podiatric Relevance: Unstable ankle fractures are quite common with an incidence of 175/100,000 population a year. These fractures have significant podiatric relevance as they can result in long-term complications affecting the foot and ankle. One of the primary responsibilities of the foot and ankle surgeon is to accurately diagnose and assess the severity of the injury as well as perform surgical intervention for the unstable ankle fracture.
Methods: The authors conducted a systematic review of the literature from various databases. They identified studies that reported on the outcomes of patients who underwent surgical or non-surgical treatment for unstable ankle fractures. A total of 33 articles were enrolled in the analysis which included 14 retrospective case studies, 13 retrospective case-controlled studies, and 6 prospective studies. 3 authors independently evaluated each study for quality. Functional scores, influencing co-factors, and issues regarding the posterior malleolus were obtained from the different studies were analyzed and compared.
Results: Conservative and surgical treatments have been compared by two studies with better outcomes being reported after fixation. Infections were common with superficial infections being reported in up to 15% of patients and deep infections reported in up to 13% of patients. Roberts et al analyzed correlations between the adequacy of reduction/fixation and the functional outcomes, identifying three key points: 1. complex ankle fractures were more likely to be malreduced. 2. fractures involving the PM had significantly worse outcomes, even after good reduction. 3. The worse the malreduction, the lower the functional score achieved by the patient. When addressing posterior malleolar fractures; indirect reduction and A-P screws restored anatomic joint congruity in only 27% of patients, while restoration occurred in 83% of cases treated by a direct posterior surgical approach. ORIF was traditionally indicated with fragment sizes greater than 25%-33% of the articular surface. However, several authors recently recommend fixation regardless of size, because the development of osteoarthritis has been demonstrated also in the presence of small-sized fragments
Conclusions In: conclusion, the study by Monestier et al. provides an up-to-date review of the literature on the management of unstable ankle fractures. The review showed that surgical management resulted in better outcomes than non-surgical management for unstable ankle fractures. Surgery was associated with better functional outcomes, lower reoperation rates, and lower posttraumatic arthritis rates. Additionally, the study found an increase in the use of arthroscopic techniques for ankle fracture management, which resulted in better outcomes and fewer complications. The authors then discussed the potential reasons for the observed benefits of surgery. They suggest that surgery allows for better anatomical reduction and stabilization of the fracture, which in turn leads to improved healing and functional outcomes. The authors discuss limitations noting that the studies included in the review were heterogeneous in terms of patient populations, fracture types, and treatment protocols. The authors also highlight the importance of patient reported outcome measures in assessing the success of treatment for unstable ankle fractures. Overall, the discussion section of Monestier et al.'s study provides a thorough analysis of the results and their implications for clinical practice.