SLR - August 2013 - Jessica A. Lickiss
Reference: Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, Kwon JY. Role of Preoperative Computed Tomography Scans in Operative Planning for Malleolar Ankle Fractures. Foot Ankle Int. 2013 May 34(5):697-704
Scientific Literature Review
Reviewed by: Jessica A. Lickiss, DPM
Residency Program: INOVA Fairfax Hospital, Falls Church, VA
Podiatric Relevance: The role of CT scans for preoperative planning in ankle fractures is sparse and debated within the literature. Many studies have shown the superiority of CT scans to plain film in regards to complex ankle fractures. These studies show as the complexity of injury increases, so does intra-articular involvement. However, there are few studies that provide parameters to utilize CT in patients presenting with ankle fractures or show evidence based justification for the increase in cost and radiation to the patient. The aim of this study was to subjectively determine the role of preoperative CT scans on operative planning in malleolar ankle fractures.
Methods: Researchers retrospectively reviewed 100 patients who sustained ankle fractures (AO type 44), with both preoperative radiographs and CT scans. A total of six physicians (three resident physicians and three senior attending physicians) reviewed radiographs of the patients and created a surgical plan including positioning, operative approach and fixation. The physicians then viewed CT scans and explained if and why they would change their surgical management. Characteristics identified by the physicians of the fracture pattern and the radiographs were then correlated with changes in operative strategy.
Results: After CT review, 24 percent of cases had a change in surgical plan. The most prominent predictors of change were an increase in malleolar fractures, preoperative dislocation, radiographs with plaster immobilization, and suprasyndesmotic injuries. There was no difference found between the surgical planning and changes made after reviewing CT scans between the resident physicians and senior physicians, indicating increased experience did not play a role. The most common changes involved fixation of medial malleolar (30 percent), posterior malleolar (24 percent), and anterolateral plafond fracture types (19 percent). An additional fracture line was found and warranted fixation in 14 percent of cases. Surgeons chose to change the position of the patient in 13 percent of these cases.
Conclusion: CT scans may be a valuable resource in preoperative planning for ankle fractures, particularly in trimalleolar ankle fractures and those with dislocation and injury to the syndesmosis. CT scans are particularly important with complex injury types with increased intra-articular involvement, not easily seen on plain film. The study serves as a guide for a potential prospective study about the parameters that would help guide physicians in ordering CT scans, as well as justification of the added cost and radiation. This study reveals there are fracture patterns not seen on plain film and there are changes in surgical management with the addition of CT imaging. These changes would potentially benefit the patient outcomes. While the study has limitations with its retrospective nature, it provides insight into the possible underutilization of CT scans for preoperative management of ankle fractures.