Every once in a while, it is instructive to study a particular topic in detail rather than just finding the most recent review in the literature. This is a very challenging activity for most doctors in private practice (and even for those of us in academia). However, I’ve found it useful to spend extra time on those topics that appear unanswered, are controversial, or for those of which I just want to have an updated and fully fleshed-out comprehensive knowledge. An example of this is the question: should we do an arthroscopic ankle joint survey and repair lesions during open reduction internal fixation of ankle fractures?
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To answer this question for myself, I did a PubMed search of the topic and found 11 studies to review. To save myself time, after downloading the studies, I abbreviated my critical analysis of the studies with a focus on the methods and study conclusions. I’ve become reasonably quick at skimming through the main aspects of articles and picking out their methodological strengths and weakness. Practice really does make better!
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Let’s review what the research shows.First, I chose articles no earlier than the year 2000 in order to stay reasonably current but also to get a feel for the historical development of the topic.
The first two articles in our exploration are case series by Hintermann et al1 and Takao and colleagues2 with 326 patients between them. Both studies were essentially looking to find the incidence of intra-articular injuries in patients with malleolar ankle fractures treated operatively. Both studies found a high incidence of osteochondral and syndesmotic injuries, but neither of them examined patient outcomes. Hintermann found a 79.2% incidence of cartilage lesions1, and Takao found 87% incidence.2 This very high incidence of intra-articular and syndesmotic injuries is a common trend throughout the literature in all of the studies.
In 2001, Thordarson and colleagues performed the first of only two randomized controlled studies on this topic comparing patients with traditional ORIF versus those with arthroscopically assisted ORIF. Looking at the SF-36 postoperative functional scores after an average of 21 months follow-up, these researchers found no difference between the two groups.3 It’s important to be aware, though, that this study had a very small number of patients (19 of them), which is methodologically weak.
In 2004 Takao, et al performed the other prospective randomized study.6 They randomized 72 patients with Danis Weber B ankle fractures to either of two groups: ORIF + arthroscopy versus ORIF alone. Both groups were followed for an average of almost 3.5 years. They described intra-articular findings when found and compared outcomes between the two groups. If a lesion was found, it was drilled. As with the other studies, they found a high incidence of intra-articular lesions (30 cases with OCD of the talus (73.2%) and 33 cases with syndesmosis disruptions (80.5%). Postoperative AOFAS scores were 91.0 +/- 3.5 (range 85-100) in the ORIF+arthroscopy group and 87.6 +/- 5.5 (range 77-97) in the ORIF group (p 0.01). Note that this was a barely significant p-value, and I have to wonder: if the overall numbers were higher, would they have found a different result?
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Unfortunately, the next two studies, covering the 14 years subsequent to Takao’s study, were retrospective chart reviews that did not contribute much other than suggesting a correlation between higher Lauge-Hansen classified fractures and increased numbers of intra-articular injuries7 and no difference in functional or pain outcomes when looking at ORIF with arthroscopy versus without arthroscopy.8 Unfortunately, both of these studies were heavily flawed due to small numbers in one case7 and a very high loss of patients at follow-up8 in the other.
More recently Gonzalez, et al9 and Lee, et al10 performed a systematic review and meta-analysis, respectively, with Gonzalez concluding arthroscopy is useful to identify lesions but little evidence supporting improved outcomes, and Lee finding a medium effect size supporting arthroscopy with ankle fracture ORIF. Unfortunately, both of these studies were forced to use the weak prior data, leading to uncertain conclusions.
Our final study by Yasui and colleagues, published this January 2019 in the Journal of Foot and Ankle Surgery, may sum up the entire issue.11 They retrospectively reviewed a database including 32,307 patients who underwent ankle fracture ORIF, 248 of which also included intraoperative arthroscopy. They found no difference in reoperation rates and no evidence of improved outcomes with the use of ankle arthroscopy.
Based on these 11 studies covering 19 years, it is hard to make many definitive conclusions. However, the evidence appears to point to the following:
The incidence of intra-articular (chondral, osteochondral, and syndesmotic) injuries associated with ankle fractures is very high (around 65-75%).
It is unclear that these intra-articular injuries represent clinically significant entities.
It does not appear that arthroscopically assisted ankle fracture ORIF improves patient outcomes (though the evidence is most weak on this point).
The research evidence is flawed and requires more methodologically sound prospective randomized controlled studies to answer this question.
For me, I can’t see a strong argument for beginning to scope all of the ankle fractures I fix. Until better research lends stronger evidence to support arthroscopy, it seems appropriate to stay with the current paradigm of traditional ORIF. We’ll see what the future holds for our trauma patients.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic Findings in Acute Fractures of the Ankle. J Bone Joint Surg BR. 2000 Apr; 82(3):345-351.
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Takao M, Ochi M, Naito K, et al. Arthroscopic Diagnosis of Tibiofibular Syndesmosis Disruption. Arthroscopy. 2001 Oct;17(8):836-843.
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Thordarson DB, Bains R, Shephard LE. The Role of Ankle Arthroscopy on the Surgical Management of Ankle Fractures. Foot Ankle Int. 2001 Feb;22(2):123-125.
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Loren GJ and Ferkel RD. Arthroscopic Assessment of Occult Intra-articular Injury in Acute Ankle Fractures. Arthroscopy. 2002 Apr;18(4):412-421.
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Ono A, Nishikawa S, Nagao A, et al. Arthroscopically Assisted Treatment of Ankle Fractures: Arthroscopic Findings and Surgical Outcomes. Arthroscopy. 2004 Jul;20(6):627-631.
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Takao M, Uchio Y, Naito K, et al. Diagnosis and Treatment of Combined Intra-articular Disorders in Acute Distal Fibular Fractures. J Trauma. 2004 Dec;57(6):1303-1307.
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Leontaritis N, Hinojosa L, Panchbhaci VK. Arthroscopically Detected Intra-Articular Lesions Associated with Acute Ankle Fractures. J Bone Joint Surg Am. 2009 Feb;91(2):333-339.
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Fuchs D, Ho BS, LaBelle MW, Kelikian AS. Effect of Arthroscopic Evaluation of Acute Ankle Fractures on PROMIS Intermediate-Term Functional Outcomes. Foot Ankle Int. 2016 Jan;37(1):51-57.
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Gonzalez TA, Macaulay AA, Ehrlichman LK, et al. Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for Acute Ankle Fracture. Foot Ankle Int. 2016 May;37(5):554-562.
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Lee KM, Ahmed S, Park MS, et al. Effectiveness of Arthroscopically Assisted Surgery for Ankle Fractures: A Meta-analysis. Injury. 2017 Oct;48(10):2318-2322.
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Yasui Y, Shimozono Y, Hung CW, et al. Postoperative Reoperations and Complications in 32,307 Ankle Fractures With and Without Concurrent Ankle Arthroscopic Procedures in a 5-Year Period Based on a Large U.S. Healthcare Database. J Foot Ankle Surg. 2019 Jan;58(1):6-9.
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