SLR - January 2021 - Arwa Akram

Incidence of Concomitant Chondral/Osteochondral Lesions in Acute Ankle Fractures and Their Effect on Clinical Outcome: A Systematic Review and Meta-Analysis 

Reference: Darwich, A., Adam, J., Dally, F. et al. Incidence of Concomitant Chondral/Osteochondral Lesions in Acute Ankle Fractures and Their Effect on Clinical Outcome: A Systematic Review and Meta-Analysis . Arch Orthop Trauma Surg (2020). 

Scientific Literature Review

Level of Evidence: Level I 
Reviewed By: Arwa Akram, DPM
Residency Program: St. Vincent Hospital – Indianapolis, IN 

Podiatric Relevance: Ankle fractures are one of the most common lower extremity injuries. The main objectives of operative treatment consist of anatomical reduction, stable internal fixation, and restoration of the ankle stability. However, even after achieving these objectives, many patients continue to report pain, swelling, and decreased range of motion. One of the reasons for these complaints may be due to missed or delayed diagnosis of chondral lesions (CL) and/or osteochondral lesions (OCL) occurring during the initial trauma, leading to joint degeneration and chronic pain. The authors of this article performed a meta-analysis and hypothesized that the presence of CL and/or OCL negatively affect the postoperative outcomes after ORIF of ankle fractures. 

Methods: A systematic literature search revealed 111 publications on this topic. 92 publications were excluded. 19 studies (nine retrospective and 10 prospective) were systematically reviewed. Six studies were eligible to be included in the meta-analysis. Exclusion criteria involved: patients under 18 years, case reports, surgical techniques/ overviews of treatment options and experimental studies on animals/ cadavers, cartilage damage assessed postoperatively, and studies not recording cartilage damage or without clinical follow-up. All studies in the meta analysis evaluated clinical outcomes using FAOS or AOFAS.   

Results: The cumulative sample size was 400 patients (170 with and 230 without CL and/or OCL) for a mean follow-up 23.9 ± 11.56 months. The average age of patients was 44.3 ± 5.5 years. The mean incidence of CL and/or OCL in all studies was 58 ± 25 percent, with frequency ranging from 17 percent to 89 percent. The mean incidence using arthroscopy was 65 percent and 19 percent via MRI.  In five studies, cartilage damage was assessed intra-operatively via arthroscopy and treated via debridement, chondroplasty or microfracture. In one MRI-based study, the preoperatively detected cartilage lesions were not addressed intraoperatively. The clinical outcome showed slightly higher, however not statistically significant mean AOFAS values in patients without CL and/or OCL. Patients with cartilage lesions had a 3.5-fold higher chance of developing radiographic osteoarthritis (Kannus arthritis score < 90) and a 5-fold higher risk of having an unsatisfying long-term clinical outcome (AOFAS score < 90). Anterior and lateral talar lesions as well as medial malleolar lesions were found to significantly raise the possibility of developing posttraumatic osteoarthritis. 

Conclusions: Researchers found similar values of AOFAS/ FAOS scores regardless of the presence of CL and/ or OCL after ankle fractures. Most of the fractures with concomitant chondral lesions resulted from dislocated fractures with associated syndesmotic disruption. Reconstruction and healing of these anatomic structures should be considered as confounders affecting clinical outcome. Additionally, variability of the results can be attributed to the different diagnostic modalities; as MRI seems to overestimate the size/depth of the lesions. The incidence of CL and/or OCL after ankle fractures is high. However, there is a certain variability of the incidence of these lesions depending on the fracture type and diagnostic modality. More studies with higher sample size and homogeneous assessment methods are warranted to evaluate the clinical outcomes after ankle fractures with CL and/or OCL. 

Educational Opportunities