SLR - March 2017 - Alan C. Stuto
Preoperative Radiography Versus Computed Tomography for Surgical Planning for Ankle Fractures
Reference: Leung KH, Fang CX, Lau TW, Leung FK. Preoperative Radiography Versus Computed Tomography for Surgical Planning for Ankle Fractures J Orthop Surg (Hong Kong). 2016 24(2): 158–162.
Scientific Literature Review
Reviewed By: Alan C. Stuto, DPM
Residency Program: University Hospital, Newark, NJ
Podiatric Relevance: Surgical treatment is indicated for unstable ankle fractures. The outcome is usually good when there are no loose bodies or comminution of the articular surface. Unsatisfactory outcomes may occur due to failure in recognizing/treating displaced fracture fragments, articular incongruity and syndesmotic rupture. This study reviewed preoperative radiography and computed tomography (CT) in 69 patients who underwent ankle fracture surgery to determine the value of CT in diagnosis and surgical planning.
Methods: Preoperative radiography and computed tomography of the ankle were reviewed in 46 women and 23 men. The age range was 18 to 90 years, and data was collected on patients who underwent ankle fracture surgery between January 2012 and December 2013. CT was deemed necessary when radiographs had the following features: comminuted medial malleolus fracture involving the tibial plafond, comminuted posterior malleolus fracture, presence of loose bodies and suspected Chaput or Volkmann fracture. Pilon fractures and skeletally immature patients were excluded from this study. Two orthopaedic surgeons independently reviewed the radiographs for any of the features that were listed to see if CT scan was indicated.
Results: Based on the radiographs of the 69 patients; 19 had posterior malleolus comminution (n=7), medial malleolus comminution (n=7), suspected Chaput fragment (n=1), combination of two lesions (n=3) and were deemed to require CT. The Spearman intraobserver and interobserver agreement was 0.75 and 0.85 (p<0.001). In 10 of the remaining 50 patients, the surgical plan was modified after review of the CT scan. The Spearman intraobserver and interobserver agreement was 0.76 and 0.88 (p<0.05).
Conclusions: Malreduced and malunited intraarticular ankle fractures can lead to accelerated arthritis. More accurate imaging tools, such as CT, are necessary to enable a more precise diagnosis and surgical planning. MRI is highly accurate for the diagnosis of soft-tissue injury, but it has a high operational cost and is not widely available. In sum, radiography alone may be inadequate for surgical planning of some ankle fractures.