scholarly journals Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0026
Author(s):  
Shain Howard ◽  
Victor C. Hoang ◽  
Troy S. Watson ◽  
Candice L. Brady ◽  
Adam Eudy
Keyword(s):  
Fracture Fixation ◽  
Ankle Fracture ◽  
External Rotation ◽  
Ankle Arthroscopy ◽  
Ankle Fractures ◽  
Osteochondral Lesions ◽  
Fracture Type ◽  
Syndesmotic Injury ◽  
Patient Reported ◽  
Articular Pathology

Category: Ankle; Arthroscopy; Trauma Introduction/Purpose: Ankle fractures are among the most common operatively treated injuries by orthopedic surgeons. However, up to 20% of patients will have continued pain and poor patient reported outcomes despite good/excellent radiographic results. Ankle fractures typically occur with varying degrees of intra-articular and soft tissue injury which can include ligamentous injury, loose bodies, and chondral lesions. The aim of study is to document intra-articular findings with ankle arthroscopy prior to ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe adjunct to fracture fixation. Methods: IRB approval was obtained prior to chart review. This is a retrospective review of ankle fractures that were treated with arthroscopy and ORIF by a single surgeon. Between August 2016 and July 2018 Operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury. Results: Fifty-seven ankle fractures were identified that met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect. Conclusion: Arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns give a more detailed examination of associated pathology. Arthroscopy at the time of ankle fracture fixation is a safe adjunct and should be considered a potential compliment to routine ORIF of ankle fractures.

scholarly journals The Role of Arthroscopic Debridement after Ankle Fractures Treated with ORIF

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0001
Author(s):  
Paolo Ceccarini ◽  
Giuseppe Rinonapoli ◽  
Julien Teodori ◽  
Auro Caraffa
Keyword(s):  
Distal Tibia ◽  
Case Series ◽  
Activity Level ◽  
Ankle Arthroscopy ◽  
Ankle Fractures ◽  
Osteochondral Lesions ◽  
Operation Rate ◽  
Patient Reported

Category: Ankle, Ankle Arthritis, Arthroscopy Introduction/Purpose: The role of ankle arthroscopy in managing the consequences of ankle fractures is yet to be fully estab- lished. This study aims to assess this procedure in terms of the accuracy of preoperative diagnosis, re-operation rate and patient- reported outcomes. Methods: We compared two homogeneous groups of 16 patients (32 in total, average age 40.6 years) operated for a fracture of the distal tibia and/or fibula treated with ORIF. For all fractures the AO classification was used. The baseline was 6 months after surgery. Inclusion criteria were: patients aged between 19 and 50 a pre-trauma Tegner score >3, FAOS score <75 at the baseline, R.O.M. <20° vs contralateral; we included patients with well-aligned osteosynthesis and with radiographic union. Patients with open fractures, with osteochondral lesions and with previous were excluded. In the first group we planned an arthroscopy of the ankle from 6 to 12 months after trauma, in the second group, we continued with conservative rehabilitation treatment. All patients were then re-evaluated at 3,6 and 12 months with questionnaires (Tegner activity level, and FAOS). The mean follow-up was 18.2 months. For all data statistical analysis was performed. Results: The results of our case-series showed excellent patient satisfaction (12/14) with a FAOS Score and an improved R.O.M. statistically significant (p <.001) in patients treated with ankle arthroscopy. Eighty percent was able to return to previous activity. The average time until return to sport was 5.3 ± 2.4 months. Seventy percent of the athletes still had occasional pain with sport. Conclusion: The literature on arthroscopic treatment after fracture is still poor but results obtained, even with a limited number of cases, and with a short follow-up, are positive, especially in those patients where the functional demand is highest.

scholarly journals Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

2022 ◽  
Vol 10 (1) ◽  
pp. 232596712110668
Author(s):  
Nathaniel B. Hinckley ◽  
Jeffrey D. Hassebrock ◽  
Phillip J. Karsen ◽  
David G. Deckey ◽  
Andrea Fernandez ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
External Rotation ◽  
Ankle Fractures ◽  
Open Approach ◽  
Appropriate Care ◽  
Data Points ◽  
The Mean ◽  
Superior Portion ◽  
Articular Pathology ◽  
Supination External Rotation

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

scholarly journals Functional and Radiographic Outcomes Following Repair of Osteochondral Lesions After Ankle Fracture with Arthrex BioCartilage and Bone Marrow Aspirate Concentrate compared to Microfracture

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0045
Author(s):  
Drew N. Stal ◽  
Stephanie K. Eble ◽  
Oliver B. Hansen ◽  
Bopha Chrea ◽  
Mark C. Drakos
Keyword(s):  
Bone Marrow ◽  
Outcome Measures ◽  
Fracture Fixation ◽  
Ankle Fracture ◽  
Bone Marrow Aspirate ◽  
Osteochondral Lesions ◽  
Bone Marrow Aspirate Concentrate ◽  
Significant Difference ◽  
Patient Reported

Category: Arthroscopy; Basic Sciences/Biologics; Trauma Introduction/Purpose: There has been an increasing role for arthroscopy in ankle fracture fixation, particularly in assessing osteochondral lesions (OCL). Initial cartilage damage has been found to be an independent risk factor for post-traumatic ankle arthritis. Rates of osteochondral injury with ankle fracture remain varied, but have been reported up to 62-80%. Treatment for osteochondral injuries classically included debridement alone or debridement with microfracture. Recently, new biologic augments have come to market, including BioCartilage (Arthrex): a mixture of cadaveric articular cartilage extracellular matrix. This has been used in conjunction with bone marrow aspirate concentrate (BMAC). To date, no study has evaluated the outcomes of utilizing BioCartilage in the treatment of osteochondral lesions, or in comparison to microfracture alone, in conjunction with ankle fracture fixation. Methods: We conducted a retrospective analysis of all adult patients (age > 18) undergoing operative ankle fracture or syndesmotic fixation with concomitant ankle arthroscopy utilizing our Foot and Ankle Registry. Institutional Review Board (IRB) approval was obtained prior to data collection. Patient demographic data, laterality, fracture pattern and OCL size were documented. Those with full-thickness lesions requiring treatment were divided into groups based on the use of Biocartilage + BMAC or microfracture alone. Exclusion criteria included pediatric patients, distal tibia intra-articular, and open fractures. Outcome scores for pre- and postoperative patient reported outcome measures (PROMIS) were recorded, with a minimum 6- month follow up. Magnetic resonance observation of cartilage repair tissue (MOCART) scoring was performed for those with postoperative MRIs to evaluate OCL healing. We also included a group that had ankle fracture fixation and arthroscopy but without any osteochondral lesion to serve as a control. Results: 28 patients were treated with Biocartilage/BMAC; 19 with preoperative and 17 with postoperative PROMIS. 41 patients had microfracture; 20 with preoperative and 18 with postoperative PROMIS. 75 patients were identified in the non-OCL group; 60 with preoperative and 45 with postoperative PROMIS. Average follow-up was 20.61 months. There were no significant differences in postoperative PROMIS scores between the two treatment groups in all sub-categories. When comparing each treatment group to the control, there was a statistically significant increase in pre to postoperative global physical health scores for the non-OCL group compared to Biocartilage/BMAC. Postoperative MRIs were obtained in 12/28 patients with Biocartilage/BMAC and 10 /41 with microfracture. There was no significant difference between either group in overall MOCART scores or individual scoring categories. Conclusion: The role for arthroscopy in ankle fracture fixation is evolving, as is the treatment of identifiable osteochondral lesions. We sought to compare a novel biologic technique of Biocartilage and BMAC with microfracture for OCL management. Our results demonstrated no significant difference between treatments for postoperative PROMIS and MOCART scores. Outcome measures did not differ significantly when compared to our control group. Unfortunately, complete PROMIS and MOCART data was lacking in each group, limiting the ability to draw definitive conclusions. However, we believe this is a positive first step in understanding the role in treating osteochondral lesions associated with ankle fractures.

scholarly journals Incidence of Chondral and Osteochondral Lesions in Ankle Fracture Patients Identified with Ankle Arthroscopy Following Rotational Ankle Fracture

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0049
Author(s):  
Emilie Williamson ◽  
Kevin Rosas ◽  
John Dankert ◽  
James P. Toale ◽  
Eoghan T. Hurley ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Ankle Arthroscopy ◽  
Chondral Lesion ◽  
Lateral Malleolus ◽  
Ankle Fractures ◽  
Medial Malleolus ◽  
Fracture Type ◽  
Malleolar Fracture ◽  
Chondral Lesions ◽  
Chondral Injury

Category: Ankle; Trauma Introduction/Purpose: It is controversial whether routine arthroscopy is beneficial at the time of ankle fracture fixation. This may be, in part, due to sparse information regarding the incidence of chondral injury in the setting of ankle fractures.The purpose of this study is to systematically review the incidence of chondral injures in patients with ankle fractures and to further characterize intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following an ankle fracture. Methods: The literature search was performed based on the PRISMA guidelines. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures were included. The incidence of intraarticular chondral lesions was recorded, as well as location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. All statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL, USA). Multiple comparisons were used to compare incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < 0.05 was considered statistically significant. Results: Fifteen studies with 1,355 ankle fractures were included. Of those ankles, 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Overall, 648 ankles had chondral lesions on the talus (47.8%), 207 ankles had lesions on the tibial plafond (15.3%), 165 has lesions of the lateral malleolus (12.2%), and 133 had lesions of the medial malleolus (9.8%). Weber C group had significantly higher incidence than Weber A group (p=0.015). Trimalleolar and isolated lateral malleolar fracture groups had significantly higher incidence of chondral injury than bimalleolar and isolated medial malleolar fracture groups (p<0.001). A significant difference was found in occurrence rate of chondral injury among Lauge-Hansen classification, with supination-adduction having the lowest incidence (p=0.001). Conclusion: Our study found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy, with more than half of all patients having a chondral lesion. Talar lesions were most common. This study may help direct greater attention to the Talus as a source of chondral injury particularly in higher grade fracture patterns.

scholarly journals Syndesmosis Injuries in Ankle Fractures: Correlation of Fracture Type and Syndesmotic Instability

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0021
Author(s):  
Christina Freibott ◽  
Seth C. Shoap ◽  
Sebastian F. Baumbach ◽  
Kathrin Rellensmann ◽  
Rami Alrabaa ◽  
...  
Keyword(s):  
Internal Fixation ◽  
Ankle Fracture ◽  
Ankle Fractures ◽  
Fracture Type ◽  
Syndesmotic Injury ◽  
Type B ◽  
Chi Square ◽  
Ao Classification ◽  
Fibula Fracture ◽  
Chi Square Analysis

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are among the most common injuries treated by orthopedic surgeons. Syndesmotic disruption in ankle fractures can be identified preoperatively, however the decision to fix the syndesmosis is made after this intraoperative assessment. The AO classification groups ankle or malleolar fractures into A (infrasyndesmotic fibula fracture), B (transsyndesmotic fibula fracture), and C (suprasyndesmotic fibula fracture) with succeeding digits that further classify each fracture group in more detail. This study aimed to retrospectively review databases of ankle fractures across two major academic centers to determine the rate of syndesmotic injury and to assess the association between ankle fracture type (utilizing the AO classification) and presence of syndesmotic injury. Methods: Patients 18 years or older who were treated surgically for an ankle fracture at two major academic institutions between 2010 and 2016 were selected for review. Exclusion criteria were open fractures, pilon fractures, tibial shaft fractures, or patients who underwent open reduction and internal fixation of an ankle fracture involving the posterior malleolus. The preoperative injury films of each ankle fracture was reviewed and classified according to the AO classification. The postoperative films were then reviewed for each case to classify the fractures into stable or unstable syndesmosis based on whether syndesmotic fixation was performed. Stability of the syndesmosis was tested intraoperatively after internal fixation of the fracture fragments using the Cotton test and external rotation stress views. Fixation of the syndesmosis was performed with either a syndesmotic screw or suture button fixation per surgeon preference. Chi-square analysis was used to assess the association between fracture types and syndesmotic injury. Results: 733 patients met inclusion criteria. Average patient age was 54.22 with 52.8% being female. 273 patients had sustained a syndesmotic injury (Figure 1). Association between fracture type (AO classification) and syndesmotic injury was assessed with chi- square analysis showing significant association (X28=193.842, p<0.001). Type B fractures in this study were further classified with AO classification (9 subcategories) to assess for an association with syndesmotic injury within a subcategory of these fractures (Figure 1). Chi-square analysis of type B fracture subgroups revealed significant association between fracture subgroup and syndesmotic disruption (X28=76.379, p<0.001). There was a statistically significant association between single digit AO classification and syndesmotic injury (X28=193.842, p<0.001) as well as the two-digit AO classification for type B fractures and syndesmotic injury (X28=76.379, p<0.001). Conclusion: This study aimed to identify ankle fracture patterns that are prone to syndesmotic injury. Identifying fractures preoperatively that are likely to have syndesmotic injury is beneficial to surgeon and patient as it aids in operative planning, intraoperative equipment needs, managing patient expectations, and counselling patients preoperatively about changes in rehabilitation protocols with injuries that involve the syndesmosis. Most of the type C fractures (88.50%) had syndesmotic injury, 7.14% of type A fractures involved the syndesmosis, and type B fractures had variable syndesmotic involvement (31.15%). Chi- square analysis revealed that significant association exists between type B2 and syndesmotic injury (X28=76.379, p<0.001).

scholarly journals A Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0018
Author(s):  
Jasen Gilley ◽  
Raheem Bell ◽  
Mateus Lima ◽  
Joshua E. Barrett ◽  
Bennett Butler ◽  
...  
Keyword(s):  
Physical Function ◽  
Ankle Fracture ◽  
Statistical Significance ◽  
Functional Mobility ◽  
Ankle Fractures ◽  
Pain Interference ◽  
X Rays ◽  
Syndesmotic Injury ◽  
Significant Difference ◽  
Patient Reported

Category: Ankle Introduction/Purpose: Ankle fractures are a common cause of functional mobility that have seen a dramatic rise incidence over the past decade1. The purpose of this study was to compare the outcomes and prognosis of various fracture sub-types by utilizing two validated patient reported outcome measures: the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (CATs) for patients at a major tertiary facility and level I trauma center. Methods: 12-month post-operative PROMIS Physical Function and Pain Interference CATs were collected for 125 ankle fracture patients presenting between 2014 and 2017. Patients were initially stratified by ankle fracture sub-type after examining pre- operative X-rays and further refined by the presence or absence of concomitant deltoid injury or posterior malleolar fracture. Patients defined as members of vulnerable populations and patients presenting more than 2 weeks from time of injury/with prior acute ipsilateral fracture were excluded. The distribution of PROMIS physical function and pain interference T-scores were assessed via a Shapiro-Wilk test and a one-way ANOVA was used for further evaluation. If significant differences were found between groups, pair-wise comparisons were tested via Dwass, Steel, Critchlow-Fligner multiple comparison analysis. Results: Fracture types and corresponding n-value in this study: (44) isolated lateral malleolar, (12) isolated medial malleolar, (12) bimalleolar, (44) trimalleolar, (6) isolated syndesmotic injury, and (8) isolated posterior malleolar fractures. Mean values for the PROMIS physical function and pain interference domains for each fracture sub-type were calculated and compared to reference population mean T-scores of 50 (SD = 10): isolated lateral malleolar (PF:50/PI:51), isolated medial malleolar (PF:52/PI:49), bimalleolar (PF:48/PI:50), trimalleoar (PF:47/PI:51), isolated posterior malleolar (PF:53/PI:44), and isolated syndesmotic injury (PF:60/PI:46). The Shapiro-Wilk test indicated a non-normal distribution for the post-operative PROMIS physical function T-scores across all fracture patients (p-value = 0.0421). Pair-wise comparisons were done to compare relative prognosis between fracture sub-types but failed to yield statistically significant differences in physical function or pain domains. Conclusion: Surgical intervention is effective in returning patients to normal levels of physical function and pain interference across all sub-types according to post-op T-scores. Although our analysis indicated a significant difference when comparing across all fracture sub-types, none of the pairwise sub-type comparisons showed statistical significance. Analyses of fracture sub-types determined trimalleolar injuries report the poorest outcomes for both PROMIS domains while the isolated syndesmotic and posterior malleolar groups reported the best outcomes. Further investigation with a larger sample size for each group is needed to delineate whether a significant difference exists for PROMIS physical function and pain interference scores.

Hybrid Fixation for Danis-Weber Type C Fractures With Syndesmosis Injury

2020 ◽  
pp. 107110072096479
Author(s):  
Gi Beom Kim ◽  
Chul Hyun Park
Keyword(s):  
External Rotation ◽  
Case Series ◽  
Ankle Fractures ◽  
Syndesmotic Injury ◽  
Hybrid Fixation ◽  
Alternative Treatment Option ◽  
Syndesmosis Injury ◽  
Weber Type ◽  
Type C

Background: This study aimed to assess the clinical and radiological outcomes of hybrid fixation for Danis-Weber type C ankle fractures with a syndesmotic injury. Methods: From January 2016 to April 2018, we retrospectively reviewed consecutive patients who underwent hybrid fixation for Danis-Weber type C ankle fractures with syndesmotic injury with a minimum follow-up of 12 months. We excluded patients who achieved syndesmosis stability after fracture fixation. In all patients, we allowed partial weightbearing at 4 weeks postoperatively. We evaluated the visual analog scale for ankle pain, the Olerud-Molander ankle score, and the American Orthopaedic Foot & Ankle Society score. Malreduction of the syndesmosis was defined based on 2 previously reported methods. Fourteen patients (11 men and 3 women) were included in this study. There were 11 patients with pronation external rotation-type fractures and 3 patients with Maisonneuve fractures. The average age at operation was 37.2 years (range, 18-70 years). Results: Clinical scores were significantly improved at the last follow-up. Postoperative malreduction was observed only in 1 patient (7.1%). Conclusion: Hybrid fixation using a suture-button device combined with a syndesmotic screw in Danis-Weber type C fractures with syndesmosis injury showed a high accuracy of reduction, a low rate of diastasis, and favorable clinical outcomes. This combined method could be a good alternative treatment option for Danis-Weber type C ankle fractures with a syndesmosis injury. Level of Evidence: Level IV, case series.

Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures

2019 ◽  
Vol 41 (2) ◽  
pp. 206-210
Author(s):  
Jasen Gilley ◽  
Raheem Bell ◽  
Mateus Lima ◽  
Bennet Butler ◽  
Joshua E. Barrett ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Outcome Measurement ◽  
Patient Reported Outcome ◽  
Ankle Fractures ◽  
Measurement Information ◽  
Level Of Evidence ◽  
Mean Values ◽  
Population Mean ◽  
Patient Reported ◽  
Nonnormal Distribution

Background: Ankle fractures are a common cause of morbidity that have increased in incidence over the past decade. The purpose of this study was to compare the outcomes and prognosis of various fracture subtypes by using 2 validated patient-reported outcome measures: the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). Methods: Twelve-month postoperative PF and PI CATs were collected for 126 ankle fracture patients presenting between 2014 and 2017. Patients were stratified by ankle fracture subtype and refined by the presence/absence of concomitant deltoid injury or posterior malleolar fracture. Patients defined as members of vulnerable populations and patients presenting more than 2 weeks from time of injury or with prior acute ipsilateral fracture were excluded. The distribution of PF and PI T scores were assessed via a Shapiro-Wilk test and a 1-way analysis of variance. If significant differences were found between groups, pairwise comparisons were tested via Dwass, Steel, and Critchlow-Fligner multiple comparison analysis. Results: Mean values for the PROMIS PF and PI for each fracture subtype were calculated and compared to reference population mean (SD) T scores of 50 (10): isolated lateral malleolar (PF: 50/PI: 51), isolated medial malleolar (PF: 52/PI: 49), bimalleolar (PF: 48/PI: 50), trimalleoar (PF: 47/PI: 51), isolated posterior malleolar (PF: 53/PI: 44), and isolated syndesmotic injury (PF: 60/PI: 46). Shapiro-Wilk test indicated a nonnormal distribution for the postoperative PROMIS PF T scores across all fracture patients ( P = .0421). Conclusion: Operative fixation of an ankle fracture was able to return most patients to the population mean with regard to PROMIS function and pain regardless of fracture type. Level of Evidence: Level II, prospective comparative study.

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