SLR - February 2020 - Edmund Yu

Risk of Ankle Fusion or Arthroplasty After Operatively and Nonoperatively Treated Ankle Fractures: A Matched Cohort Population Study

Reference: Axelrod D, Veljkovic  A, Zochowski  T, Marks P, Mahomed N, Wasserstein D. Risk of Ankle Fusion or Arthroplasty After Operatively and Nonoperatively Treated Ankle Fractures: A Matched Cohort Population Study. J Orthop Trauma. 2020 Jan; 34(1), e1-e5.

Scientific Literature Review

Reviewed By: Edmund Yu, DPM
Residency Program: Scripps Mercy Kaiser Hospital – San Diego, CA

Podiatric Relevance: Post traumatic ankle arthritis is a challenging consequence of ankle fractures especially with a rotational mechanism of injury. Even in surgically repaired ankle fractures with restoration of joint alignment, there is still increased risk of arthritic changes long term. There has been effective literature published on treatment strategies and debate between ankle arthrodesis or arthroplasty for symptomatic ankle arthritis. This study reviewed a total of 132,399 ankle fractures either operative or non-operative with a match control of non-fractured patients to determine the quantifiable risk of need an ankle arthrodesis or arthroplasty. Authors hypothesized the ankle fracture cohort were at higher risk for arthrodesis or arthroplasty in the future.

Methods: A prognostic level II study was performed for all patients included in the study whom were captured from large insurance and physician panel databases. Two groups for rotational ankle fractures – operative and non-operative – included a total of 44,133 and 88,266 patients. For each patient in the operative group, four individuals from general population were matched based on age, gender, income and place of residence. From this, their primary outcome was whether patients received ankle arthrodesis or arthroplasty based on procedural code reference and at least two years of follow up.

Results: The operative ankle fracture group were statistically more likely to have an arthroplasty/arthrodesis compared to non-operative ankle fracture group (p<0.001). Even more, the non-operative ankle fracture group was 4.5 times more likely to have subsequent arthroplasty/arthrodesis when match-controlled to the non-injured population (p<0.001). Overall, the data supported that rotational ankle fractures were 3.5 times more likely for an arthroplasty/arthrodesis. However, only a total of 540 patients (0.29 percent) required these procedures at the end of study’s follow up.

Conclusions: The study further validates the importance of restoring near anatomical alignment of the ankle joint to preserve motion and reducing risk of post-traumatic arthritis. The biomechanical effects of articular step off in the ankle joint is an important concept when treating ankle fractures – operatively and non-operatively – to best maximize long term outcomes. This discussion should be tailored to each patient, especially with a 3.5 times greater risk of future procedures. Overall, the study’s longitudinal long term follow up combined with a non-injured matched population for comparison strengthened the results. Future studies can continue to build off a continuous database on ankle fractures and likelihood of subsequent procedures.

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