SLR - July 2020 - Megan A. Ishibashi
Reference: Smith KS, Drexelius K, Challa S, Moon DK, Metzl JA, Hunt KJ. Outcomes Following Ankle Fracture Fixation With or Without Ankle Arthroscopy. Foot Ankle Ortho. 2020 March, 5(1), 1-6.Scientific Literature Review
Reviewed By: Megan A. Ishibashi, DPM
Residency Program: Kaiser San Francisco Bay Area – Oakland, CA
Podiatric Relevance: Ankle open reduction and internal fixation (ORIF) for rotational injuries remains the gold standard for unstable fracture patterns with good to excellent results. However, for those patients with fair or poor outcomes a possible explanation may be attributed to the presence of intra-articular pathology. To date, there is no consensus on the role of arthroscopy in the management of acute ankle fractures. The purpose of the study is to evaluate the rate of intra-articular pathology and intervention for chondral damage and compare clinical and radiographic outcomes for ankle ORIF alone versus ankle ORIF with arthroscopy.
Methods: The authors retrospectively reviewed 213 patients who underwent ankle ORIF with or without arthroscopy for bimalleolar or trimalleolar fractures from 2014 through 2018. The study included 142 patients with traditional ORIF and 71 patients with ORIF and arthroscopy. Extracted data included demographic information, mechanism of injury, fracture pattern, tourniquet time, arthroscopic findings, any additional arthroscopic procedures performed, and final follow-up radiographs to evaluate for osteoarthritis and the presence of nonunion, malunion, or union of the fracture. Patient reported outcomes were obtained using the PROMIS Global Health Short Form and the two question PASS scale.
Results: During arthroscopy the total cartilage injury rate was 77 percent with a 28 percent rate of full thickness osteochondral lesions and 49 percent with small cartilage defects not requiring intervention. There was also noted to be a 33 percent rate of loose bodies requiring removal. In total, amongst patients who underwent arthroscopy, 48 percent of the patients had either a simple debridement, chondroplasty, or microfracture with or without allograft cartilage matrix. The difference in operative time between traditional ORIF and ORIF with arthroscopy was 79 minutes and 89 minutes, respectively. In looking specifically at Weber B fractures, patients with ORIF and arthroscopy had significantly higher PROMIS physical function scores. These patients also trended toward a higher overall satisfaction
Conclusions: In general, patients treated with ankle fracture ORIF typically have good to excellent outcomes; however, for patients with poor results there is no consensus on ways to predict these outcomes. This study is the largest study to date comparing ankle ORIF and ankle ORIF with arthroscopy. Patients treated with arthroscopy had improved patient-reported outcomes in Weber B fibula fractures and ankle fracture dislocations. This study also highlighted that amongst the arthroscopy cohort, there was a 77 percent rate of chondral or osteochondral injury and approximately 50 percent of this group underwent concomitant procedure to address the pathology. Overall, ankle arthroscopy is a safe, adjunctive procedure to ankle ORIF and may ultimately improve clinical outcomes without increasing complication rates or operative time.