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Arthroscopy-Assisted Surgery for Acute Ankle Fractures: A Systematic Review
Systematic Review
Arthroscopy-Assisted Surgery for Acute Ankle Fractures: A Systematic Review Xing-Zuo Chen, M.D., Ying Chen, M.D., Cheng-Gang Liu, M.D., Huan Yang, M.D., Xiao-Dong Xu, M.D., and Peng Lin, M.D.
Purpose: To summarize the clinical findings of adult patients undergoing arthroscopy-assisted open reductioneinternal fixation for acute ankle fractures. Methods: A systematic electronic search of the PubMed databases was performed for all published literature on December 8, 2014. All English-language clinical studies on acute ankle fractures treated with arthroscopy-assisted open reductioneinternal fixation were eligible for inclusion. Basic information related to the surgical procedure was collected. Results: The search criteria initially identified 187 articles, and 10 studies were included in this systematic review. There were 2 prospective, randomized studies; 2 prognostic studies; and 6 case-series studies. There were a total of 861 patients included in this systematic review. Danis-Weber type B fractures (335 of 483 patients) and supinationeexternal rotation fractures (187 of 366 patients) were the most common types of all the ankle fractures. Concomitant injuries were common: 63.3% of patients had chondral lesions, 60.9% had deltoid ligament injuries, and 77.9% had tibiofibular syndesmosis injuries. Lavage and debridement of the ankle joint were performed by almost all the surgeons. Chondral lesions were treated with shaving, excision, or microfracture. The mean American Orthopaedic Foot & Ankle Society hindfoot score was 91.7. Only mild complications were reported. Conclusions: Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment. Level of Evidence: Level IV, systematic review of Level I, II, III, and IV studies.
A
nkle fractures are one of the most common adult fractures. Unstable ankle fractures are generally treated with surgical anatomic reduction and internal fixation. However, it has been reported that even with anatomically successful surgical reduction of ankle fractures, clinically favorable outcomes are not always achieved.1-7 Residual symptoms after acute ankle fractures can be caused by various intra-articular pathologies, such as ligamentous damage or cartilage defects.2,3,5,8 With traditional open reductioneinternal fixation (ORIF), intra-articular lesions cannot be checked or treated thoroughly and accurately, which may induce chronic pain after acute ankle fractures. Since Watanabe9 described the Selfoc arthroscope in 1972, ankle arthroscopy has become a standard procedure in the diagnosis and treatment of certain disorders of the From the Orthopaedic Trauma Department, China-Japan Friendship Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 4, 2015; accepted March 24, 2015. Address correspondence to Peng Lin, M.D., Orthopaedic Trauma Department, China-Japan Friendship Hospital, No. 2, Ying Hua East Street, Chao Yang District, Beijing 10029, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/15112/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.03.043
ankle. Arthroscopy-assisted open reductioneinternal fixation (AORIF) for the treatment of acute ankle fractures has also been reported. AORIF has several advantages in theory, including the following: An accurate and direct evaluation of the intra-articular injuries is provided without formal arthrotomy2,8,10-14; lavage and debridement of the ankle joint may help the postoperative range of motion recover more quickly1,15,16; and the quality of the intra-articular reduction is assessed.2,3,5,8,13,14 Although arthroscopy has been proved to be a powerful tool in managing many ankle diseases,17,18 given the lack of clinical proof, Glazebrook et al.17 classified AORIF for acute ankle fractures as having “insufficient or conflicting evidence not allowing a recommendation for or against intervention.” The purpose of this systematic review was to summarize the clinical findings of adult patients undergoing AORIF for acute ankle fractures. The hypothesis of this review was that concomitant injuries would be common in acute ankle fractures and AORIF would be an effective, safe method of treatment.
Methods A systematic electronic search of the PubMed databases was performed for all published literature on
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December 8, 2014. The following key phrases were used in the title or abstract fields: [(ankle) OR (distal tibia*) OR (distal fibula*)] AND fracture* AND arthroscop*. In addition, we searched major American and European orthopaedic journals for relevant articles. The inclusion criteria included the following: acute ankle fractures treated with AORIF, clinical research, and article written in English. The exclusion criteria included the following: acute ankle fractures treated without arthroscopy; studies focused on chronic cases with ankle pain; studies focused on juvenile cases; radiologic studies; case reports or case series with fewer than 5 patients; reviews, meta-analyses, letters to editors, and technical notes; and noneEnglish-language articles. All articles were generally independently reviewed by 2 reviewers (X-Z.C., H.Y.) according to the inclusion and exclusion criteria. The full text of all the relevant studies was obtained and reviewed. Reference lists of all full-text articles were hand-checked to identify additional potential articles for inclusion. Any disagreement between the 2 reviewers was settled by another senior reviewer (P.L.). The level of evidence was determined according to the Oxford Levels of Evidence produced by the Oxford Centre for Evidence-Based Medicine. We assessed the methodologic quality of the articles using the modified Coleman Methodology Score (CMS) assigned by the 2 reviewers. The following data were extracted from the eligible articles: basic information about the article; the number, sex, and mean age of the patients; the mean and minimum follow-up times; classification of fractures and the numbers of each type; concomitant soft-tissue injuries and treatment; clinical results; and complications.
Results Literature Search and Quality Assessment The search criteria initially identified 187 articles for potential inclusion. After a detailed assessment of all the references, subsequent screening, and quality assessment (Fig 1), a total of 10 studies were included in this systematic review. Specifically, there was 1 Level I study; 1 Level II prospective, randomized study; 2 Level II prognostic studies; and 6 Level IV case-series studies. The mean modified CMS value was 68 (range, 50 to 95). The features and modified CMS values of each study are shown in Table 1. Patient Characteristics A total of 861 patients were enrolled in the systematic review. The mean age was 42.0 years. The mean follow-up time ranged from 21 to 154.8 months. Three studies used the Danis-Weber classification system,1,20,21 and 6 studies used the Lauge-Hansen classification system.2,3,8,11,12,19 Danis-Weber type B fractures (335 of 483 patients) and supinationeexternal
Fig 1. Flowchart for study selection.
rotation fractures (187 of 366 patients) were the most common types of all the ankle fractures in this systematic review. There were also 30 Danis-Weber type A and 118 Danis-Weber type C fractures. According to the Lauge-Hansen classification system, 61 patients had pronationeexternal rotation fractures; 21 patients, supinationeadduction rotation; and 91 patients, pronationeabduction rotation (Table 2). Concomitant Soft-Tissue Injuries Chondral lesions, which were found in 63.3% of the patients (495 of 782), were one of the most common soft-tissue injuries concomitant with acute ankle fracture. Lesions of the talus were present in 405 of 773 patients (52.4%). All types of treatments were performed, including shaving, excision, and microfracture. Deltoid ligament injuries (60.9%) and tibiofibular syndesmosis injuries (77.9%) were also commonly found. One study performed a second-look arthroscopy 1 year after the injury.19 The results showed that all of the chondral lesions were covered with cartilaginous tissue and no patients had instability of the tibiofibular articulation after hardware removal (Tables 3 and 4). Clinical Results and Complications Lavage and debridement of the ankle joint were performed by almost all the surgeons. Four studies evaluated the clinical results of AORIF,3,19-21 with mean follow-up times ranging from 21.0 to 154.8 months; 3 of these studies used the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score,19-21 with a mean score of 91.7. There were no severe complications related to arthroscopy. A total of 18 minor complications were reported by one study, including transient impaired function of the superficial peroneal nerve, irritation by scar, and synovial cyst (Table 5).1
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ACUTE ANKLE FRACTURES Table 1. Summary of Study Features and Quality Assessment Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15
Year 2001 2004 2004 2014
Type of Study Retrospective comparative study Case series Retrospective comparative study Case series
Level of Evidence II IV I IV
Leontaritis et al.2
2009
Prognostic study
II
Hintermann et al.1
2000
Case series
IV
Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
2002 2001 2008 2010
Case series Case series Case series Prognostic study
IV IV IV II
Journal Foot & Ankle International Arthroscopy The Journal of Trauma Archives of Orthopaedic and Trauma Surgery The Journal of Bone & Joint Surgery, American Edition The Journal of Bone & Joint Surgery, British Edition Arthroscopy Arthroscopy Foot & Ankle International The Journal of Bone & Joint Surgery, American Edition
CMS 67 70 95 53 50 65 72 64 70 69
CMS, Coleman Methodology Score.
Discussion
Chondral Lesions The prevalence of chondral lesions in acute ankle fracture, which have been proved to be an independent predictor of the development of post-traumatic osteoarthritis,21 varied from 20.0% to 88.9%, with a mean rate of 63.3%, based on this systematic review. It is easy to presume that a more unstable fracture would increase the risk of a chondral lesion. Hintermann et al.1
Through this systematic review, we have shown that AORIF is an effective, safe treatment for acute ankle fractures that usually occur concomitantly with multiple soft-tissue injuries. Although arthroscopy could offer a favorable clinical result and an accurate diagnosis of soft-tissue injury, there is not enough evidence to make it indispensable.
Table 2. Patient Characteristics in Studies Involved in Systematic Review Patients, n AORIF, 9 ORIF, 10 105
Sex (M/F), n 17/2
Mean Age, yr 29.0
Mean Follow-up, mo 21
Minimum Follow-up, mo 6
59/46
45.9
46
24
AORIF, 41 ORIF, 31 12
48/24
37.0
40
28
NA
54.4
NA
NA
84
NA
NA
NA
NA
Hintermann et al.1
288
148/140
45.6
NA
NA
Loren and Ferkel12
48
29/19
35.0
NA
NA
Takao et al.11
38
26/12
40.0
31
12
Aktas et al.20
86
48/38
41.4
33.9
21
109
61/48
37.4
154.8
135.6
Authors Thordarson et al.3 Ono et al.8
Takao et al.19 Swart and Vosseller15 Leontaritis et al.2
Stufkens et al.21
Fracture Classification, n SER, 16 PER, 3 SER, 58 PER, 17 SAD, 15 PAB, 15 SER, 22 PAB, 50 6 bimalleolar 6 trimalleolar SER, 52 PER, 31 SAD, 1 D-W type A, 14 D-W type B, 198 D-W type C, 76 SER, 24 PER, 10 SAD, 5 PAB, 4 SER, 16 PAB, 22 D-W type B, 63 D-W type C, 23 D-W type A, 16 D-W type B, 74 D-W type C, 19
AORIF, arthroscopy-assisted open reductioneinternal fixation; D-W, Danis-Weber classification; F, female; M, male; NA, not available; ORIF, open reductioneinternal fixation; PAB, pronationeabduction rotation; PER, pronationeexternal rotation; SAD, supinationeadduction rotation; SER, supinationeexternal rotation.
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Table 3. Chondral Lesions Concomitant With Acute Ankle Fracture Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15 Leontaritis et al.2 Hintermann et al.1 Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
Rate (Injured, n/Total, n) 88.9% (8/9) 20% (21/105) 73.2% (30/41) 41.6% (5/12) 73% (61/84) 79.2% (228/288) 63% (30/48) NA 27.9% (24/86) 81% (88/109)
Distal Tibia, n NA 5 NA 2 5 132 11 NA NA 38
Talus, n NA 6 30 4 51 200 19 NA 24 71
Medial Lateral Malleolus, n Malleolus, n NA NA 3 7 NA NA 1 0 10 (total number on malleolus) 119 130 0 0 NA NA NA NA 42 42
Treatment Debridement Debridement Microfracture Microfracture NA NA Debridement NA Microfracture NA
NA, not available.
reported that 228 of 288 patients (79.2%) had acute ankle fractures combined with chondral lesions. Moreover, they found that the frequency and severity of the lesions increased from Danis-Weber type B to type C fractures and that the lesions increased within each type of fracture from subgroups 1 to 3. In the study of Leontaritis et al.,2 chondral lesions were found in 61 of 84 patients (73%). The clinical findings also showed that the number of intra-articular chondral lesions associated with the more severe ankle fracture patterns was greater than the number associated with the less severe ankle fracture patterns. In contrast, Aktas et al.20 showed that there were more chondral lesions in isolated distal fibular fractures than in bimalleolar fractures or trimalleolar fractures. They suggested that if there is less bone damage, the energy of the trauma may be directly transmitted from the bone to the cartilage, which produces greater chondral damage. Although the exact mechanisms that cause chondral lesions are still unclear, some studies showed that unstable syndesmosis injuries, which are commonly observed in pronation-rotationetype injuries, are associated with a high risk of chondral lesions.12,16 Loren and Ferkel12 analyzed 48 patients with acute unstable ankle fractures who underwent AORIF. They found that talar articular lesions had a strong relation
with tibiofibular syndesmosis disruptions but not with deltoid ligament injuries. Similarly, Thomas et al.16 suggested that the more superior the lateral malleolar fractures were in relation to the syndesmosis, the higher the occurrence was of chondral damage to the talus. On the other hand, Ono et al.8 found that there was no correlation between fracture type and the sites of cartilaginous damage. As for the treatment of chondral lesions combined with acute ankle fractures, debridement3,8,12 or microfracture15,19,20 was performed in most studies. Takao et al.19 performed microfracture on grade III or IV chondral lesions of the talar dome. At a mean follow-up time of 40 months, compared with patients without chondral lesions, no significant differences in AOFAS scores were detected. Nevertheless, the effect of treating these chondral lesions at the time of ankle fracture fixation on the functional outcome is still unknown. There is only an assumption that the standard treatment of chondral lesions is actually effective in reducing symptoms.10 Except for 1 study that reported a high chondral lesion rate of up to 90%,16 the rate of chondral lesions in chronic cases was reported to be between 3% and 33%. It was far lower than the rate reported in acute cases.1-3,12,15,19,21 Utsugi et al.6 suggested that cartilage damage incurred at the time of the fracture may have healed itself later. Some other studies also
Table 4. Ligamentous Injuries Concomitant With Acute Ankle Fracture Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15 Leontaritis et al.2 Hintermann et al.1 Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
Patients, n 9 105 41 12 84 288 48 38 86 109
Deltoid Ligament, n 3 5 41 NA NA 243 19 11 NA NA
ATFL, anterior talofibular ligament; LB, loose body; NA, not available.
Tibiofibular Syndesmosis, n NA 51 33 NA NA 266 22 33 NA NA
ATFL, n NA 3 NA NA NA 218 2 NA NA NA
LB, n 1 NA NA 1 13 NA 13 NA NA NA
ACUTE ANKLE FRACTURES Table 5. Clinical Evaluation of Arthroscopy-Assisted Open ReductioneInternal Fixation for Acute Ankle Fracture
Authors Thordarson et al.3 Takao et al.19 Aktas et al.20 Stufkens et al.21
Evaluation System MODEMS AOFAS AOFAS AOFAS
Mean Follow-up, mo 21 40 33.9 154.8
Mean Postoperative Score 91.1 95.6 88.9
AOFAS, American Orthopaedic Foot & Ankle Society hindfoot score; MODEMS, foot and ankle Musculoskeletal Outcomes Data Evaluation and Management Systems questionnaire.
reported that chondral lesions may heal spontaneously without any surgical interference.22,23 More clinical evidence is needed to determine whether microfractures are over-treated in fracture cases. Deltoid Ligament Injuries The deltoid ligament plays a key role in ankle biomechanics. The main function of the deltoid ligament is the firm fixation of the tibia above the talus and the restriction of the tendency of the talus to shift into a valgus position.24 A rupture of the deep deltoid ligament may result in ankle instability after distal fibular fracture.25 Evaluation of the integrity of the deltoid ligament can be tricky. Most physicians favored physical examinations, which have been proved to have a sensitivity of 57% and a specificity of 59% for medial tenderness as a measure of deep deltoid ligament incompetence.26 Widening of the medial clear space measured from a mortise view was also not a reliable indicator. With a medial clear space no less than 3 mm, 4 mm, and 5 mm, the false-positive rate was 88.5%, 53.6%, and 26.9%, respectively.27 Only stress radiographic views and arthroscopy have been advocated as the gold standard for an accurate diagnosis of the deep deltoid ligament incompetence.25 The appropriate treatment for deltoid ligament injuries concomitant with acute ankle fracture is still under debate. Most studies suggested that with adequate reduction in the fibula and normalization of the medial clear space, it was unnecessary to explore and reconstruct the deltoid ligament.24 However, whether the untreated deltoid ligament can be a source of persistent pain or pronation deformity is still unknown.28,29 Among all of the studies involved in this systematic review, none repaired the deltoid ligament and no chronic instability case was reported. Tibiofibular Syndesmosis Injuries Syndesmotic injuries commonly occur with acute ankle fractures. Latent syndesmotic insufficiency can be one of the main reasons that patients have less favorable prognoses and residual symptoms. A correct diagnosis of tibiofibular syndesmosis disruption is important in the treatment of ankle fractures.11
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Arthroscopy is the most sensitive tool for the diagnosis of syndesmosis injuries. Takao et al.11 performed AORIF in 38 patients with Denis-Weber type B distal fibular fractures. The results showed that tibiofibular syndesmosis disruptions were diagnosed in 42% of patients by anteroposterior radiography, 55% of patients by mortise radiography, and 87% of patients by ankle arthroscopy. Similarly, Lui et al.30 found that 66.0% of their patients had positive arthroscopic findings of syndesmosis diastasis but only 30.2% had positive intraoperative stress radiographs. In this systematic review, 77.8% of the ankle fracture patients had tibiofibular syndesmosis injuries, which was much higher than the rate of 23% that has been reported previously.31 This finding may have been observed because only AORIF cases were calculated in this systematic review. Syndesmotic malreduction occurred in 25.5% to 52% of patients,31 and arthroscopy may provide a solution. Lui et al.30 fixed 34 syndesmosis injuries combined with ankle fractures under arthroscopy. Second-look arthroscopy after the removal of the syndesmotic screws showed that 31 patients had regained stability of the syndesmosis. Lui et al. suggested that ankle arthroscopy could assist in anatomic reduction of the syndesmosis. However, the observation of a ruptured anterior syndesmotic ligament during arthroscopy does not mean that there is syndesmotic instability.32 Robinson and Sri-Ram33 suggested that routine arthroscopy for ankle fractures may lead to the overtreatment of syndesmotic injuries. Clinical examination and radiologic findings should never be forgotten before a syndesmotic screw is inserted. Chronic Pain After ORIF Approximately 20% of patients with an operatively treated malleolar fracture do not achieve good or excellent outcomes despite optimal reduction and fixation.4 It is clear that patients without ankle pain after ORIF have better functional outcomes than patients who have ankle pain.34 Several different reasons may lead to these unpleasant results, such as hardware irritation, softtissue injuries, and post-traumatic arthritis. Hardware irritation is an explicit cause of chronic pain, but not all patients had pain relief after hardware removal. Brown et al.34 reported that 39 of 126 patients who underwent ORIF for unstable ankle fractures had chronic pain after surgery and 22 of them had their hardware removed after bone healing. With a mean follow-up time of 27 months, half of the patients still had persistent pain after hardware removal. In the other half of the patients, the analog pain scores decreased from a mean of 6 to 3. Arthrofibrosis after ankle fracture may cause impingement that can lead to articular dysfunction,
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such as chronic ankle pain and loss of motion.6,16 Arthroscopic debridement of fibrous tissue could offer an effective method for improving articular function. Utsugi et al.6 reported that 27% of their patients had functional deterioration of the ankle joint after ORIF. Arthroscopy showed that arthrofibrosis was present in all of the functionally deteriorating cases. With a mean follow-up time of 43.7 months after arthroscopic examination, 89% of the patients with functional deterioration benefited from arthroscopic debridement of fibrous tissue. Thomas et al.16 reviewed 50 patients who underwent ankle arthroscopy because of residual complaints after an ankle fracture. Synovitis was present in 92% and arthrofibrosis was noted in 40% of the patients. Chondral lesions have been proved to be an independent predictor of the development of post-traumatic osteoarthritis.21 Utsugi et al.6 performed arthroscopy in 33 patients at the time of implant removal after ORIF of ankle fractures. Chondral damage was found in 33% of the patients. The mean AOFAS score was 96.4 in patients without chondral damage, 79.7 in patients with chondral damage comprising less than 50% of the thickness of the articular cartilage, and 71 in patients with chondral damage comprising 50% or more of the thickness. Stufkens et al.21 found that patients who had chondral lesions on the anterior and lateral aspects of the talus and on the medial malleolus during ankle fracture had both an AOFAS score and modified Kannus score (radiographic evaluation of osteoarthritis) no higher than 90 points with 12.9 years of follow-up time. Arthroscopy has been proved to be a powerful tool in managing chronic ankle diseases.17,18 Dawe et al.5 performed ankle arthroscopy in 66 patients who had sequelae after ankle fractures. The most common findings during arthroscopy were anterior impingement in 30 patients, followed by degenerative changes in 20 patients and osteochondral lesions in 12 patients. Three-quarters of patients (75%) reported benefitting from surgery, 78% were satisfied, and 86% would recommend the procedure to a friend. However, patients with residual complaints after an ankle fracture may benefit more from arthroscopic surgery with an accurate diagnosis preoperatively. Van Dijk et al.35 treated 34 patients who had residual complaints after ankle fracture with arthroscopy: 18 patients had anterior impingement (impingement group) and 16 patients had more diffuse pain without an accurate diagnosis (diagnostic group). After 2 years, 76% of the results were good or excellent in the impingement group compared with 43% in the diagnostic group. Kim et al.36 treated 53 patients with chronic pain after healed ankle fractures with or without arthroscopic intervention after hardware removal. With a minimum follow-up time of 12 months, the AOFAS scores
improved from 75 to 85 with arthroscopic intervention and from 74 to 76 without arthroscopic intervention. However, for patients with diffuse pain and swelling without a definite preoperative diagnosis, the median AOFAS score improved from 76 to 82 with arthroscopic intervention and from 75 to 78 without arthroscopic intervention. Kim et al. suggested that arthroscopy should be used with hardware removal for patients who had chronic pain after the ankle fracture healed. However, if there was generalized pain without a definitive diagnosis, arthroscopic treatment with hardware removal might not be a good option. AORIF Versus ORIF AORIF has several advantages in theory: An accurate and direct evaluation of intra-articular injuries may be provided without formal arthrotomy2,8,10-14; lavage and debridement of the ankle joint may improve the postoperative range of motion more quickly1,15,16; and an assessment of the quality of the intra-articular reduction may be performed.2,3,5,8,13,14 However, only 2 published studies compared the clinical results of AORIF versus ORIF in the treatment of acute ankle fractures.3,19 In a prospective, randomized study designed by Takao et al.,19 72 patients with DanisWeber type B distal fibular fractures were randomly treated with AORIF (41 patients) or ORIF (31 patients). After a mean follow-up time of 40 months and 41 months, respectively, the mean AOFAS score was 91.0 in the AORIF group compared with 87.6 in the ORIF group. There were significant differences between these 2 groups. Takao et al. suggested that the precise diagnosis and treatment of combined intra-articular disorders were important for gaining satisfactory clinical results in the treatment of distal fibular fractures. On the other hand, Thordarson et al.3 performed a prospective, randomized comparative study of the surgical treatment of malleolar fractures with or without ankle arthroscopy, among a total of 19 patients. They reported no significant difference between the groups. Given the lack of clinical evidence, Glazebrook et al.17 classified AORIF for acute ankle fracture as having “insufficient or conflicting evidence not allowing a recommendation for or against intervention.” It is clear that more prospective, randomized studies that contain a large number of patients and long-term follow-up time are necessary to show the usefulness of arthroscopic intervention. Risks and Pitfalls of AORIF The overall complication rate of ankle arthroscopy reported by Zengerink and van Dijk37 was 10.3%, and 1 case of pulmonary embolism was also mentioned. AORIF has some different characteristics compared with normal ankle arthroscopy, in which severe trauma already exists. In brief, the risks and pitfalls associated
ACUTE ANKLE FRACTURES
with the use of AORIF include compartment syndrome, neurologic injury, and increased operating time.10 Nonetheless, only 18 minor complications were reported in relation to AORIF. Compartment syndrome is one of the most catastrophic complications of all arthroscopy-related surgical procedures. It has been suggested that the extravasation fluid that leaks into the calf in the presence of fractures and capsular lesions may lead to compartment syndrome. However, only 1 case of compartment syndrome has ever been reported after AORIF, in the handling of an Maisonneuve fracture.38 Ekman and Poehling39 suggested that the risk of true compartment syndrome was low, even with significant fluid extravasation. Even still, the possibility of compartment syndrome during AORIF should always be remembered. A recently published systematic review of arthroscopy-assisted surgery for tibial plateau fractures provided some suggestions about how to prevent compartment syndrome, such as using gravity flow, monitoring the pulses, minimizing the tourniquet time, and performing surgery after soft-tissue stabilization.40
6.
7.
8.
9. 10.
11.
12.
13.
Limitations There are several limitations to this systematic review. First, most of the studies included in this systematic review were Level IV. Some selection bias may be present. Furthermore, only 4 studies evaluated the clinical outcomes of AORIF.3,19-21 The sample size is relatively small. Finally, 1 study clearly contained more patients than the others,1 which may also lead to some selection bias.
14.
15.
16.
Conclusions Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment.
17.
18. 19.
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24. Stufkens SAS, van den Bekerom MPJ, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: A review. Strat Traum Limb Recon 2012;7:73-85. 25. van den Bekerom MPJ, Mutsaerts ELAR, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: A systematic review of the literature. Arch Orthop Trauma Surg 2009;129:227-235. 26. DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 2007;21:244-247. 27. Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: A comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 2004;43:20-29. 28. Luckino FA III, Hardy MA. Use of a flexible implant and bioabsorbable anchor for deltoid rupture repair in bimalleolar equivalent Weber B ankle fractures. J Foot Ankle Surg 2015;54:513-516. 29. Bluman EM. Deltoid ligament injuries in ankle fractures: Should I leave it or fix it? Foot Ankle Int 2012;33:236-238. 30. Lui TH, Ip KY, Chow HT. Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy 2005;21: 1370-1374. 31. van Heest TJ, Lafferty PM. Injuries to the ankle syndesmosis. J Bone Joint Surg Am 2014;96:603-613.
32. van den Bekerom MPJ. Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2011;18:51-56. 33. Robinson AHN, Sri-Ram K. Arthroscopic assessment of the syndesmosis following ankle fracture. Injury 2005;36: 675-678. 34. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 2001;15:271-274. 35. van Dijk CN, Verhagen RAW, Tol JL. Arthroscopy for problems after ankle fracture. J Bone Joint Surg Br 1997;79: 280-284. 36. Kim HN, Park YJ, Kim GL, Park YW. Arthroscopy combined with hardware removal for chronic pain after ankle fracture. Knee Surg Sports Traumatol Arthrosc 2013;21: 1427-1433. 37. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20: 1420-1431. 38. Imade S, Takao M, Miyamoto W, Nishi H, Uchio Y. Leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. Arthroscopy 2009;25:215-218. 39. Ekman E, Poehling G. An experimental assessment of the risk of compartment syndrome during knee arthroscopy. Arthroscopy 1996;12:193-199. 40. Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P. Arthroscopy-assisted surgery for tibial plateau fractures. Arthroscopy 2015;31:143-153.
Arthroscopy-Assisted Surgery for Acute Ankle Fractures: A Systematic Review Xing-Zuo Chen, M.D., Ying Chen, M.D., Cheng-Gang Liu, M.D., Huan Yang, M.D., Xiao-Dong Xu, M.D., and Peng Lin, M.D.
Purpose: To summarize the clinical findings of adult patients undergoing arthroscopy-assisted open reductioneinternal fixation for acute ankle fractures. Methods: A systematic electronic search of the PubMed databases was performed for all published literature on December 8, 2014. All English-language clinical studies on acute ankle fractures treated with arthroscopy-assisted open reductioneinternal fixation were eligible for inclusion. Basic information related to the surgical procedure was collected. Results: The search criteria initially identified 187 articles, and 10 studies were included in this systematic review. There were 2 prospective, randomized studies; 2 prognostic studies; and 6 case-series studies. There were a total of 861 patients included in this systematic review. Danis-Weber type B fractures (335 of 483 patients) and supinationeexternal rotation fractures (187 of 366 patients) were the most common types of all the ankle fractures. Concomitant injuries were common: 63.3% of patients had chondral lesions, 60.9% had deltoid ligament injuries, and 77.9% had tibiofibular syndesmosis injuries. Lavage and debridement of the ankle joint were performed by almost all the surgeons. Chondral lesions were treated with shaving, excision, or microfracture. The mean American Orthopaedic Foot & Ankle Society hindfoot score was 91.7. Only mild complications were reported. Conclusions: Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment. Level of Evidence: Level IV, systematic review of Level I, II, III, and IV studies.
A
nkle fractures are one of the most common adult fractures. Unstable ankle fractures are generally treated with surgical anatomic reduction and internal fixation. However, it has been reported that even with anatomically successful surgical reduction of ankle fractures, clinically favorable outcomes are not always achieved.1-7 Residual symptoms after acute ankle fractures can be caused by various intra-articular pathologies, such as ligamentous damage or cartilage defects.2,3,5,8 With traditional open reductioneinternal fixation (ORIF), intra-articular lesions cannot be checked or treated thoroughly and accurately, which may induce chronic pain after acute ankle fractures. Since Watanabe9 described the Selfoc arthroscope in 1972, ankle arthroscopy has become a standard procedure in the diagnosis and treatment of certain disorders of the From the Orthopaedic Trauma Department, China-Japan Friendship Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 4, 2015; accepted March 24, 2015. Address correspondence to Peng Lin, M.D., Orthopaedic Trauma Department, China-Japan Friendship Hospital, No. 2, Ying Hua East Street, Chao Yang District, Beijing 10029, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/15112/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.03.043
ankle. Arthroscopy-assisted open reductioneinternal fixation (AORIF) for the treatment of acute ankle fractures has also been reported. AORIF has several advantages in theory, including the following: An accurate and direct evaluation of the intra-articular injuries is provided without formal arthrotomy2,8,10-14; lavage and debridement of the ankle joint may help the postoperative range of motion recover more quickly1,15,16; and the quality of the intra-articular reduction is assessed.2,3,5,8,13,14 Although arthroscopy has been proved to be a powerful tool in managing many ankle diseases,17,18 given the lack of clinical proof, Glazebrook et al.17 classified AORIF for acute ankle fractures as having “insufficient or conflicting evidence not allowing a recommendation for or against intervention.” The purpose of this systematic review was to summarize the clinical findings of adult patients undergoing AORIF for acute ankle fractures. The hypothesis of this review was that concomitant injuries would be common in acute ankle fractures and AORIF would be an effective, safe method of treatment.
Methods A systematic electronic search of the PubMed databases was performed for all published literature on
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
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No
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December 8, 2014. The following key phrases were used in the title or abstract fields: [(ankle) OR (distal tibia*) OR (distal fibula*)] AND fracture* AND arthroscop*. In addition, we searched major American and European orthopaedic journals for relevant articles. The inclusion criteria included the following: acute ankle fractures treated with AORIF, clinical research, and article written in English. The exclusion criteria included the following: acute ankle fractures treated without arthroscopy; studies focused on chronic cases with ankle pain; studies focused on juvenile cases; radiologic studies; case reports or case series with fewer than 5 patients; reviews, meta-analyses, letters to editors, and technical notes; and noneEnglish-language articles. All articles were generally independently reviewed by 2 reviewers (X-Z.C., H.Y.) according to the inclusion and exclusion criteria. The full text of all the relevant studies was obtained and reviewed. Reference lists of all full-text articles were hand-checked to identify additional potential articles for inclusion. Any disagreement between the 2 reviewers was settled by another senior reviewer (P.L.). The level of evidence was determined according to the Oxford Levels of Evidence produced by the Oxford Centre for Evidence-Based Medicine. We assessed the methodologic quality of the articles using the modified Coleman Methodology Score (CMS) assigned by the 2 reviewers. The following data were extracted from the eligible articles: basic information about the article; the number, sex, and mean age of the patients; the mean and minimum follow-up times; classification of fractures and the numbers of each type; concomitant soft-tissue injuries and treatment; clinical results; and complications.
Results Literature Search and Quality Assessment The search criteria initially identified 187 articles for potential inclusion. After a detailed assessment of all the references, subsequent screening, and quality assessment (Fig 1), a total of 10 studies were included in this systematic review. Specifically, there was 1 Level I study; 1 Level II prospective, randomized study; 2 Level II prognostic studies; and 6 Level IV case-series studies. The mean modified CMS value was 68 (range, 50 to 95). The features and modified CMS values of each study are shown in Table 1. Patient Characteristics A total of 861 patients were enrolled in the systematic review. The mean age was 42.0 years. The mean follow-up time ranged from 21 to 154.8 months. Three studies used the Danis-Weber classification system,1,20,21 and 6 studies used the Lauge-Hansen classification system.2,3,8,11,12,19 Danis-Weber type B fractures (335 of 483 patients) and supinationeexternal
Fig 1. Flowchart for study selection.
rotation fractures (187 of 366 patients) were the most common types of all the ankle fractures in this systematic review. There were also 30 Danis-Weber type A and 118 Danis-Weber type C fractures. According to the Lauge-Hansen classification system, 61 patients had pronationeexternal rotation fractures; 21 patients, supinationeadduction rotation; and 91 patients, pronationeabduction rotation (Table 2). Concomitant Soft-Tissue Injuries Chondral lesions, which were found in 63.3% of the patients (495 of 782), were one of the most common soft-tissue injuries concomitant with acute ankle fracture. Lesions of the talus were present in 405 of 773 patients (52.4%). All types of treatments were performed, including shaving, excision, and microfracture. Deltoid ligament injuries (60.9%) and tibiofibular syndesmosis injuries (77.9%) were also commonly found. One study performed a second-look arthroscopy 1 year after the injury.19 The results showed that all of the chondral lesions were covered with cartilaginous tissue and no patients had instability of the tibiofibular articulation after hardware removal (Tables 3 and 4). Clinical Results and Complications Lavage and debridement of the ankle joint were performed by almost all the surgeons. Four studies evaluated the clinical results of AORIF,3,19-21 with mean follow-up times ranging from 21.0 to 154.8 months; 3 of these studies used the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score,19-21 with a mean score of 91.7. There were no severe complications related to arthroscopy. A total of 18 minor complications were reported by one study, including transient impaired function of the superficial peroneal nerve, irritation by scar, and synovial cyst (Table 5).1
3
ACUTE ANKLE FRACTURES Table 1. Summary of Study Features and Quality Assessment Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15
Year 2001 2004 2004 2014
Type of Study Retrospective comparative study Case series Retrospective comparative study Case series
Level of Evidence II IV I IV
Leontaritis et al.2
2009
Prognostic study
II
Hintermann et al.1
2000
Case series
IV
Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
2002 2001 2008 2010
Case series Case series Case series Prognostic study
IV IV IV II
Journal Foot & Ankle International Arthroscopy The Journal of Trauma Archives of Orthopaedic and Trauma Surgery The Journal of Bone & Joint Surgery, American Edition The Journal of Bone & Joint Surgery, British Edition Arthroscopy Arthroscopy Foot & Ankle International The Journal of Bone & Joint Surgery, American Edition
CMS 67 70 95 53 50 65 72 64 70 69
CMS, Coleman Methodology Score.
Discussion
Chondral Lesions The prevalence of chondral lesions in acute ankle fracture, which have been proved to be an independent predictor of the development of post-traumatic osteoarthritis,21 varied from 20.0% to 88.9%, with a mean rate of 63.3%, based on this systematic review. It is easy to presume that a more unstable fracture would increase the risk of a chondral lesion. Hintermann et al.1
Through this systematic review, we have shown that AORIF is an effective, safe treatment for acute ankle fractures that usually occur concomitantly with multiple soft-tissue injuries. Although arthroscopy could offer a favorable clinical result and an accurate diagnosis of soft-tissue injury, there is not enough evidence to make it indispensable.
Table 2. Patient Characteristics in Studies Involved in Systematic Review Patients, n AORIF, 9 ORIF, 10 105
Sex (M/F), n 17/2
Mean Age, yr 29.0
Mean Follow-up, mo 21
Minimum Follow-up, mo 6
59/46
45.9
46
24
AORIF, 41 ORIF, 31 12
48/24
37.0
40
28
NA
54.4
NA
NA
84
NA
NA
NA
NA
Hintermann et al.1
288
148/140
45.6
NA
NA
Loren and Ferkel12
48
29/19
35.0
NA
NA
Takao et al.11
38
26/12
40.0
31
12
Aktas et al.20
86
48/38
41.4
33.9
21
109
61/48
37.4
154.8
135.6
Authors Thordarson et al.3 Ono et al.8
Takao et al.19 Swart and Vosseller15 Leontaritis et al.2
Stufkens et al.21
Fracture Classification, n SER, 16 PER, 3 SER, 58 PER, 17 SAD, 15 PAB, 15 SER, 22 PAB, 50 6 bimalleolar 6 trimalleolar SER, 52 PER, 31 SAD, 1 D-W type A, 14 D-W type B, 198 D-W type C, 76 SER, 24 PER, 10 SAD, 5 PAB, 4 SER, 16 PAB, 22 D-W type B, 63 D-W type C, 23 D-W type A, 16 D-W type B, 74 D-W type C, 19
AORIF, arthroscopy-assisted open reductioneinternal fixation; D-W, Danis-Weber classification; F, female; M, male; NA, not available; ORIF, open reductioneinternal fixation; PAB, pronationeabduction rotation; PER, pronationeexternal rotation; SAD, supinationeadduction rotation; SER, supinationeexternal rotation.
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Table 3. Chondral Lesions Concomitant With Acute Ankle Fracture Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15 Leontaritis et al.2 Hintermann et al.1 Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
Rate (Injured, n/Total, n) 88.9% (8/9) 20% (21/105) 73.2% (30/41) 41.6% (5/12) 73% (61/84) 79.2% (228/288) 63% (30/48) NA 27.9% (24/86) 81% (88/109)
Distal Tibia, n NA 5 NA 2 5 132 11 NA NA 38
Talus, n NA 6 30 4 51 200 19 NA 24 71
Medial Lateral Malleolus, n Malleolus, n NA NA 3 7 NA NA 1 0 10 (total number on malleolus) 119 130 0 0 NA NA NA NA 42 42
Treatment Debridement Debridement Microfracture Microfracture NA NA Debridement NA Microfracture NA
NA, not available.
reported that 228 of 288 patients (79.2%) had acute ankle fractures combined with chondral lesions. Moreover, they found that the frequency and severity of the lesions increased from Danis-Weber type B to type C fractures and that the lesions increased within each type of fracture from subgroups 1 to 3. In the study of Leontaritis et al.,2 chondral lesions were found in 61 of 84 patients (73%). The clinical findings also showed that the number of intra-articular chondral lesions associated with the more severe ankle fracture patterns was greater than the number associated with the less severe ankle fracture patterns. In contrast, Aktas et al.20 showed that there were more chondral lesions in isolated distal fibular fractures than in bimalleolar fractures or trimalleolar fractures. They suggested that if there is less bone damage, the energy of the trauma may be directly transmitted from the bone to the cartilage, which produces greater chondral damage. Although the exact mechanisms that cause chondral lesions are still unclear, some studies showed that unstable syndesmosis injuries, which are commonly observed in pronation-rotationetype injuries, are associated with a high risk of chondral lesions.12,16 Loren and Ferkel12 analyzed 48 patients with acute unstable ankle fractures who underwent AORIF. They found that talar articular lesions had a strong relation
with tibiofibular syndesmosis disruptions but not with deltoid ligament injuries. Similarly, Thomas et al.16 suggested that the more superior the lateral malleolar fractures were in relation to the syndesmosis, the higher the occurrence was of chondral damage to the talus. On the other hand, Ono et al.8 found that there was no correlation between fracture type and the sites of cartilaginous damage. As for the treatment of chondral lesions combined with acute ankle fractures, debridement3,8,12 or microfracture15,19,20 was performed in most studies. Takao et al.19 performed microfracture on grade III or IV chondral lesions of the talar dome. At a mean follow-up time of 40 months, compared with patients without chondral lesions, no significant differences in AOFAS scores were detected. Nevertheless, the effect of treating these chondral lesions at the time of ankle fracture fixation on the functional outcome is still unknown. There is only an assumption that the standard treatment of chondral lesions is actually effective in reducing symptoms.10 Except for 1 study that reported a high chondral lesion rate of up to 90%,16 the rate of chondral lesions in chronic cases was reported to be between 3% and 33%. It was far lower than the rate reported in acute cases.1-3,12,15,19,21 Utsugi et al.6 suggested that cartilage damage incurred at the time of the fracture may have healed itself later. Some other studies also
Table 4. Ligamentous Injuries Concomitant With Acute Ankle Fracture Authors Thordarson et al.3 Ono et al.8 Takao et al.19 Swart and Vosseller15 Leontaritis et al.2 Hintermann et al.1 Loren and Ferkel12 Takao et al.11 Aktas et al.20 Stufkens et al.21
Patients, n 9 105 41 12 84 288 48 38 86 109
Deltoid Ligament, n 3 5 41 NA NA 243 19 11 NA NA
ATFL, anterior talofibular ligament; LB, loose body; NA, not available.
Tibiofibular Syndesmosis, n NA 51 33 NA NA 266 22 33 NA NA
ATFL, n NA 3 NA NA NA 218 2 NA NA NA
LB, n 1 NA NA 1 13 NA 13 NA NA NA
ACUTE ANKLE FRACTURES Table 5. Clinical Evaluation of Arthroscopy-Assisted Open ReductioneInternal Fixation for Acute Ankle Fracture
Authors Thordarson et al.3 Takao et al.19 Aktas et al.20 Stufkens et al.21
Evaluation System MODEMS AOFAS AOFAS AOFAS
Mean Follow-up, mo 21 40 33.9 154.8
Mean Postoperative Score 91.1 95.6 88.9
AOFAS, American Orthopaedic Foot & Ankle Society hindfoot score; MODEMS, foot and ankle Musculoskeletal Outcomes Data Evaluation and Management Systems questionnaire.
reported that chondral lesions may heal spontaneously without any surgical interference.22,23 More clinical evidence is needed to determine whether microfractures are over-treated in fracture cases. Deltoid Ligament Injuries The deltoid ligament plays a key role in ankle biomechanics. The main function of the deltoid ligament is the firm fixation of the tibia above the talus and the restriction of the tendency of the talus to shift into a valgus position.24 A rupture of the deep deltoid ligament may result in ankle instability after distal fibular fracture.25 Evaluation of the integrity of the deltoid ligament can be tricky. Most physicians favored physical examinations, which have been proved to have a sensitivity of 57% and a specificity of 59% for medial tenderness as a measure of deep deltoid ligament incompetence.26 Widening of the medial clear space measured from a mortise view was also not a reliable indicator. With a medial clear space no less than 3 mm, 4 mm, and 5 mm, the false-positive rate was 88.5%, 53.6%, and 26.9%, respectively.27 Only stress radiographic views and arthroscopy have been advocated as the gold standard for an accurate diagnosis of the deep deltoid ligament incompetence.25 The appropriate treatment for deltoid ligament injuries concomitant with acute ankle fracture is still under debate. Most studies suggested that with adequate reduction in the fibula and normalization of the medial clear space, it was unnecessary to explore and reconstruct the deltoid ligament.24 However, whether the untreated deltoid ligament can be a source of persistent pain or pronation deformity is still unknown.28,29 Among all of the studies involved in this systematic review, none repaired the deltoid ligament and no chronic instability case was reported. Tibiofibular Syndesmosis Injuries Syndesmotic injuries commonly occur with acute ankle fractures. Latent syndesmotic insufficiency can be one of the main reasons that patients have less favorable prognoses and residual symptoms. A correct diagnosis of tibiofibular syndesmosis disruption is important in the treatment of ankle fractures.11
5
Arthroscopy is the most sensitive tool for the diagnosis of syndesmosis injuries. Takao et al.11 performed AORIF in 38 patients with Denis-Weber type B distal fibular fractures. The results showed that tibiofibular syndesmosis disruptions were diagnosed in 42% of patients by anteroposterior radiography, 55% of patients by mortise radiography, and 87% of patients by ankle arthroscopy. Similarly, Lui et al.30 found that 66.0% of their patients had positive arthroscopic findings of syndesmosis diastasis but only 30.2% had positive intraoperative stress radiographs. In this systematic review, 77.8% of the ankle fracture patients had tibiofibular syndesmosis injuries, which was much higher than the rate of 23% that has been reported previously.31 This finding may have been observed because only AORIF cases were calculated in this systematic review. Syndesmotic malreduction occurred in 25.5% to 52% of patients,31 and arthroscopy may provide a solution. Lui et al.30 fixed 34 syndesmosis injuries combined with ankle fractures under arthroscopy. Second-look arthroscopy after the removal of the syndesmotic screws showed that 31 patients had regained stability of the syndesmosis. Lui et al. suggested that ankle arthroscopy could assist in anatomic reduction of the syndesmosis. However, the observation of a ruptured anterior syndesmotic ligament during arthroscopy does not mean that there is syndesmotic instability.32 Robinson and Sri-Ram33 suggested that routine arthroscopy for ankle fractures may lead to the overtreatment of syndesmotic injuries. Clinical examination and radiologic findings should never be forgotten before a syndesmotic screw is inserted. Chronic Pain After ORIF Approximately 20% of patients with an operatively treated malleolar fracture do not achieve good or excellent outcomes despite optimal reduction and fixation.4 It is clear that patients without ankle pain after ORIF have better functional outcomes than patients who have ankle pain.34 Several different reasons may lead to these unpleasant results, such as hardware irritation, softtissue injuries, and post-traumatic arthritis. Hardware irritation is an explicit cause of chronic pain, but not all patients had pain relief after hardware removal. Brown et al.34 reported that 39 of 126 patients who underwent ORIF for unstable ankle fractures had chronic pain after surgery and 22 of them had their hardware removed after bone healing. With a mean follow-up time of 27 months, half of the patients still had persistent pain after hardware removal. In the other half of the patients, the analog pain scores decreased from a mean of 6 to 3. Arthrofibrosis after ankle fracture may cause impingement that can lead to articular dysfunction,
6
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such as chronic ankle pain and loss of motion.6,16 Arthroscopic debridement of fibrous tissue could offer an effective method for improving articular function. Utsugi et al.6 reported that 27% of their patients had functional deterioration of the ankle joint after ORIF. Arthroscopy showed that arthrofibrosis was present in all of the functionally deteriorating cases. With a mean follow-up time of 43.7 months after arthroscopic examination, 89% of the patients with functional deterioration benefited from arthroscopic debridement of fibrous tissue. Thomas et al.16 reviewed 50 patients who underwent ankle arthroscopy because of residual complaints after an ankle fracture. Synovitis was present in 92% and arthrofibrosis was noted in 40% of the patients. Chondral lesions have been proved to be an independent predictor of the development of post-traumatic osteoarthritis.21 Utsugi et al.6 performed arthroscopy in 33 patients at the time of implant removal after ORIF of ankle fractures. Chondral damage was found in 33% of the patients. The mean AOFAS score was 96.4 in patients without chondral damage, 79.7 in patients with chondral damage comprising less than 50% of the thickness of the articular cartilage, and 71 in patients with chondral damage comprising 50% or more of the thickness. Stufkens et al.21 found that patients who had chondral lesions on the anterior and lateral aspects of the talus and on the medial malleolus during ankle fracture had both an AOFAS score and modified Kannus score (radiographic evaluation of osteoarthritis) no higher than 90 points with 12.9 years of follow-up time. Arthroscopy has been proved to be a powerful tool in managing chronic ankle diseases.17,18 Dawe et al.5 performed ankle arthroscopy in 66 patients who had sequelae after ankle fractures. The most common findings during arthroscopy were anterior impingement in 30 patients, followed by degenerative changes in 20 patients and osteochondral lesions in 12 patients. Three-quarters of patients (75%) reported benefitting from surgery, 78% were satisfied, and 86% would recommend the procedure to a friend. However, patients with residual complaints after an ankle fracture may benefit more from arthroscopic surgery with an accurate diagnosis preoperatively. Van Dijk et al.35 treated 34 patients who had residual complaints after ankle fracture with arthroscopy: 18 patients had anterior impingement (impingement group) and 16 patients had more diffuse pain without an accurate diagnosis (diagnostic group). After 2 years, 76% of the results were good or excellent in the impingement group compared with 43% in the diagnostic group. Kim et al.36 treated 53 patients with chronic pain after healed ankle fractures with or without arthroscopic intervention after hardware removal. With a minimum follow-up time of 12 months, the AOFAS scores
improved from 75 to 85 with arthroscopic intervention and from 74 to 76 without arthroscopic intervention. However, for patients with diffuse pain and swelling without a definite preoperative diagnosis, the median AOFAS score improved from 76 to 82 with arthroscopic intervention and from 75 to 78 without arthroscopic intervention. Kim et al. suggested that arthroscopy should be used with hardware removal for patients who had chronic pain after the ankle fracture healed. However, if there was generalized pain without a definitive diagnosis, arthroscopic treatment with hardware removal might not be a good option. AORIF Versus ORIF AORIF has several advantages in theory: An accurate and direct evaluation of intra-articular injuries may be provided without formal arthrotomy2,8,10-14; lavage and debridement of the ankle joint may improve the postoperative range of motion more quickly1,15,16; and an assessment of the quality of the intra-articular reduction may be performed.2,3,5,8,13,14 However, only 2 published studies compared the clinical results of AORIF versus ORIF in the treatment of acute ankle fractures.3,19 In a prospective, randomized study designed by Takao et al.,19 72 patients with DanisWeber type B distal fibular fractures were randomly treated with AORIF (41 patients) or ORIF (31 patients). After a mean follow-up time of 40 months and 41 months, respectively, the mean AOFAS score was 91.0 in the AORIF group compared with 87.6 in the ORIF group. There were significant differences between these 2 groups. Takao et al. suggested that the precise diagnosis and treatment of combined intra-articular disorders were important for gaining satisfactory clinical results in the treatment of distal fibular fractures. On the other hand, Thordarson et al.3 performed a prospective, randomized comparative study of the surgical treatment of malleolar fractures with or without ankle arthroscopy, among a total of 19 patients. They reported no significant difference between the groups. Given the lack of clinical evidence, Glazebrook et al.17 classified AORIF for acute ankle fracture as having “insufficient or conflicting evidence not allowing a recommendation for or against intervention.” It is clear that more prospective, randomized studies that contain a large number of patients and long-term follow-up time are necessary to show the usefulness of arthroscopic intervention. Risks and Pitfalls of AORIF The overall complication rate of ankle arthroscopy reported by Zengerink and van Dijk37 was 10.3%, and 1 case of pulmonary embolism was also mentioned. AORIF has some different characteristics compared with normal ankle arthroscopy, in which severe trauma already exists. In brief, the risks and pitfalls associated
ACUTE ANKLE FRACTURES
with the use of AORIF include compartment syndrome, neurologic injury, and increased operating time.10 Nonetheless, only 18 minor complications were reported in relation to AORIF. Compartment syndrome is one of the most catastrophic complications of all arthroscopy-related surgical procedures. It has been suggested that the extravasation fluid that leaks into the calf in the presence of fractures and capsular lesions may lead to compartment syndrome. However, only 1 case of compartment syndrome has ever been reported after AORIF, in the handling of an Maisonneuve fracture.38 Ekman and Poehling39 suggested that the risk of true compartment syndrome was low, even with significant fluid extravasation. Even still, the possibility of compartment syndrome during AORIF should always be remembered. A recently published systematic review of arthroscopy-assisted surgery for tibial plateau fractures provided some suggestions about how to prevent compartment syndrome, such as using gravity flow, monitoring the pulses, minimizing the tourniquet time, and performing surgery after soft-tissue stabilization.40
6.
7.
8.
9. 10.
11.
12.
13.
Limitations There are several limitations to this systematic review. First, most of the studies included in this systematic review were Level IV. Some selection bias may be present. Furthermore, only 4 studies evaluated the clinical outcomes of AORIF.3,19-21 The sample size is relatively small. Finally, 1 study clearly contained more patients than the others,1 which may also lead to some selection bias.
14.
15.
16.
Conclusions Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment.
17.
18. 19.
References 1. Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 2000;82:345-351. 2. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am 2009;91:333-339. 3. Thordarson DB, Bains R, Shepherd LE. The role of ankle arthroscopy on the surgical management of ankle fractures. Foot Ankle Int 2001;22:123-125. 4. Stufkens SA, van den Bekerom MP, Kerkhoffs GM, Hintermann B, van Dijk CN. Long-term outcome after 1822 operatively treated ankle fractures: A systematic review of the literature. Injury 2011;42:119-127. 5. Dawe EJC, Jukes CP, Ganesan K, Wee A, Gougoulias N. Ankle arthroscopy to manage sequelae after ankle fractures. Knee Surg Sports Traumatol Arthrosc in press,
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