SLR - December 2019 - Tyler K. Sorensen
Reference: Chiang CC, Tzeng YH, Jeff Lin CF, Wang CS, Lin CC, Chang MC. Arthroscopic Reduction and Minimally Invasive Surgery in Supination–External Rotation Ankle Fractures: A Comparative Study with Open Reduction. Arthroscopy. 2019 Sep;35(9):2671-2683.Scientific Literature Review
Reviewed By: Tyler K. Sorensen, DPM
Residency Program: Regions Hospital/HealthPartners Institute – Saint Paul, MN
Podiatric Relevance: Common conditions seen and treated by foot and ankle surgeons are supination external rotation (SER) ankle fractures. Internal fixation is typically warranted in these types of fracture patterns due to their unstable nature. Traditionally, these are fixated using an open technique, however this technique is not without risk with regards to wound healing and other post-operative complications. In recent years, advancements in the arthroscopic technique, and surgeon skill have allowed foot and ankle surgeons to utilize arthroscopic guided internal fixation of SER ankle fractures in an attempt to decrease post-operative complications and speed up patient recovery. This present study reviews a total of 105 patients with SER fractures treated by traditional open reduction with internal fixation (ORIF) or arthroscopic reduction and minimally invasive surgery (ARMIS) technique. Radiographic and functional outcomes are assessed, along with complications.
Methods: A level IV retrospective review of patients with SER fractures who underwent ORIF or ARMIS were compared. A total of 105 patients with SER fractures, 65 in the ARMIS group and 40 in the ORIF group were included. Radiographic and functional outcomes were recorded. The talocrural angle, fibular length, tibiomedial malleolar angle, medial clear space, and tibiofibular clear space were measured radiographically. Functional evaluations included visual analog score (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales and flexion/extension along with total arc of range of motion of bilateral ankles. Many secondary outcomes were recorded including hospital length of stay, complications and reoperations.
Results: There was no statistically significant differences between the traditional ORIF group and ARMIS group when comparing any of the post-operative radiographic angles measured. On day three postoperatively, the VAS pain score was significantly lower in the ARMIS group. No significant differences in AOFAS ankle-hindfoot scale scores or range of motion of the ankle joint at final follow-up were found between the two groups. A shorter hospital length of stay was observed in the ARMIS group compared to the ORIF group. The ARMIS group had significantly less blood loss, a longer operative time, longer fluoroscopic time and a higher dose of radiation. Fracture healing time was not statistically different. A total of five complications (7.7 percent) were observed in the ARMIS group with one reoperation (1.5 percent) for debridement with infection. There were 11 complications (27.5 percent) in the ORIF group which included five infections and three peroneal nerve paresthesias and five reoperations (12.5 percent). Both complication rates and reoperations were significantly lower in the ARMIS group compared to the ORIF group.
Conclusions: With less postoperative pain, a shorter postoperative stay and lower incidence of complications and reoperations, ARMIS achieved promising outcomes. However longer operative times and higher doses of radiation were found with the ARMIS technique. There were a number of limitations given the nature of the retrospective comparison study design, including, but not limited to, concerns for selection bias into surgical groups, follow up duration, and evaluation of time to union. Both ARMIS and ORIF show good results and future higher level studies are needed to evaluate outcomes associated with each procedure.