SLR - August 2018 - Catlea M. Gorman
Reference: Rachael J. Da Cunha, M.D., F.R.C.S.C., Sydney C. Karnovsky, B.A., William Schairer, M.D., and Mark C. Drakos, M.D. Ankle Arthroscopy for Diagnosis of Full-Thickness Talar Cartilage Lesions in the Setting of Acute Ankle Fractures. Arthroscopy. 2018 Jun;34(6):1950–1957.Scientific Literature Review
Reviewed By: Catlea M. Gorman, DPM
Residency Program: Regions Hospital/HealthPartners Institute, St. Paul, MN
Podiatric Relevance: Unstable ankle fractures typically undergo ORIF; however, despite achieving anatomic reduction, 14–50 percent of patients develop posttraumatic arthritis or continued pain. This could partly be due to the development of osteochondral lesions (OCLs) at the time of injury. Ankle trauma is the most common cause of OCLs. There is minimal literature demonstrating whether OCLs should be treated at the time of ORIF, especially since these lesions may not always be symptomatic. Currently, ankle arthroscopy in the setting of ankle ORIF is not the standard of care. There is a wide range of reported association between ankle trauma and OCLs ranging from 23–79 percent. This study was conducted to determine the prevalence of OCLs with the use of arthroscopy in the setting of acute ankle ORIF and to evaluate how this affects clinical outcomes.
Methods: This was a level IV retrospective study. All cases were performed by a single orthopaedic surgeon. Consecutive cases of acute ankle ORIF with concomitant ankle arthroscopy were included from 2012–2016. Exclusion criteria included fractures greater than four weeks old, revision cases, nonunions and patients with previous ankle pathology. Charts were reviewed to determine the prevalence, grade and location of chondral lesions, as well as the Lauge-Hansen classification and fracture type by location. Clinical outcomes were assessed using the FAOS and QOL with a minimum of one year follow-up. One hundred sixteen patients met inclusion criteria. In all cases, ankle arthroscopy was performed prior to ORIF to identify any OCLs. The type of treatment for a cartilage lesion was decided intraoperatively based on grade and size. Smaller, partial thickness lesions underwent either debridement or chondroplasty. Larger, full-thickness lesions underwent microfracture with bone marrow aspirate concentrate with or without Biocartilage.
Results: Ninety of 116 (78 percent) patients who underwent acute ankle fracture ORIF with concomitant ankle arthroscopy were found to have a chondral lesion. Of these, 83 of 90 (92 percent) had talar dome involvement and 39 of 90 (43 percent) had a full-thickness talar dome lesion. The most common location of OCL was anteromedial (37/83, 46 percent). A chondral lesion was present in 100 percent (20/20) of patients with a history of ankle dislocation requiring closed reduction at the time of injury. Patients with complete syndesmotic disruption were more likely to have a chondral lesion than those without (96 percent vs. 73 percent). The presence of deltoid ligament injury and the fracture type were not significant factors. There was average follow-up of 20.8 months. All patients had significant improvement in FAOS with an average preoperative score of 30.0 and a postoperative score of 83.5. Patients with a chondral lesion had significantly worse total FAOS than patients without. Patients with a full-thickness lesion were also found to have decreased postoperative QOL scores compared to those without.
Conclusions: This study demonstrates that concomitant arthroscopy at the time of ankle ORIF allows for acute diagnoses of chondral and osteochondral injuries. These were shown to be associated with worse clinical outcomes postoperatively despite anatomic reduction and lack of complications. Direct visualization with ankle arthroscopy is currently the most reliable way to assess for OCLs, and this study advocates for routine use of arthroscopy during acute ankle ORIF.