Effectiveness of ankle arthroscopic debridement in acute, subacute, ankle-bimalleolar, and trimalleolar ankle fractures

SLR - June 2022 - Orlando J. Martinez, DPM

Reference: Ceccarini P, Rinonapoli G, Antinolfi P, Caraffa A. Effectiveness of ankle arthroscopic debridement in acute, subacute ankle-bimalleolar, and trimalleolar fractures. Int Orthop. 2021 Mar;45(3): 721-729. Doi: 10.1007/s00264-020-04882-6. Epub 2021 Jan 8. PMID:33416908.

Level of Evidence: Level III- Retrospective Study

Scientific Literature Review

Reviewed By: Orlando J. Martinez, DPM
Residency Program: John Peter Smith Hospital – Fort Worth, TX

Podiatric Relevance: Bimalleolar and trimalleolar ankle fractures are intra-articular injuries with the well accepted standard of care being congruent articular reduction and stable osteosynthesis as soon as possible. The authors wanted to evaluate the usefulness of ankle arthroscopy with debridement at the time of primary ORIF vs after six months in patients with residual symptoms. The topic of acute ankle arthroscopy stems from the fact that a healthy percentage of patients have unsuccessful clinical recoveries with decreased functional capacity with time, largely thought to be due to undiagnosed intraarticular cartilage lesions not fully evaluated at the time of primary fracture stabilization. The general hypothesis of this study was that acute ankle arthroscopy and treatment of intra-articular pathology that may cause complications later will yield better clinical results and quicker return to activity than those patients receiving debridement at six months after injury or not at all. 

Methods: Retrospective single center study from January 1, 2013 to December 31, 2017. After inclusion & exclusion criteria, a total of 144 patients were selected and divided into two groups: A & B. The first group consisted of 38 patients treated with acute ankle arthroscopy at time of ORIF. The second group consisted of 106 patients who were only treated with ORIF (B1). Of these 106 patients, 24 possessed residual symptoms and underwent arthroscopic debridement after 6 months but no longer than 8 months, known as group B2. Follow up visits concentrated on functional FAOS score as well as ankle range of motion according to AAOS measurements. 

Results: Median global FAOS scores for each group were as follows for A, B1, & B2: 86.4, 81.6, and 84.5 with the mean final follow up for these scores at 38.8 months. Range of motion for each group were at final follow up were as follows for A, B1, & B2 with dorsiflexion preceding plantarflexion: -5.7 & -6 , -6.8 & -7 , and -7.7 & -7.6. These reductions in range of motion were compared to a “healthy ankle”. Of note it is important to report that there was no statistical improvement in pain, return to sport or recreation, and quality of life at final follow up in all three groups. Significant improvements in “other symptoms” and activities of daily living were noted in both arthroscopic groups compared to ORIF only. 

Conclusions: No obvious improved clinical outcome or quicker return to activity was noted with acute ankle arthroscopy compared to ankle debridement performed at six months after injury. There is much support in the literature that the additional cost and length of time added to the surgical procedure far outweigh any potential benefit to be obtained acutely. There is still limited research and no formal RCT’s are available to offer definitive benefit in acute setting. However, arthroscopy can provide a beneficial adjunct and in the appropriate setting can offer improvement in residual pain and reduced ankle range of motion in the long term after stable osteosynthesis and excellent anatomical reduction via open reduction internal fixation is performed.