Identifying Intra-Articular Pathology with Arthroscopy Prior to Open Ankle Fracture Fixation

SLR - December 2021 - Steven A. Tocci

Reference: Howard S, Hoang V, Sagers K, Brady C, Eudy A, Watson TS. Identifying Intra-Articular Pathology with Arthroscopy Prior to Open Ankle Fracture Fixation. Arthrosc Sports Med Rehabil. 2021 Feb 4;3(1):e177-e181

Level of Evidence: Level 4

Scientific Literature Review

Reviewed By: Steven A. Tocci, DPM
Residency Program: Ascension SE Wisconsin - Milwaukee, WI

Podiatric Relevance: Ankle fractures are a common traumatic injury encountered by podiatric surgeons. Due to the traumatic nature of these injuries, intra-articular pathologies are a frequent finding. This article assesses the prevalence and type of pathology found during operative fixation of ankle fractures.

Methods: This is a retrospective review of 57 ankle fractures treated operatively by a single surgeon between 2016 and 2018. Operative reports, office notes and images were reviewed to identify intra-articular pathology and fracture type. Analysis was then performed with regard to fracture type, presence and location of osteochondral lesions, loose-bodies, syndesmotic injury and deltoid injury.

Results: Supination-external rotation (SER) injuries accounted for 75.4 percent of fractures. Overall, intra-articular pathology was seen in 84.2 percent of fractures treated. The most common pathology being syndesmotic injury at 59.6 percent, followed by 52.6 percent with loose-body and 38.6 percent having an OCD of the talus or tibial plafond. No deltoid injuries were observed in the supination-adduction (SAD) or pronation-abduction (PAB) groups. However, deltoid injuries were seen in 80 percent of pronation-external rotation (PER) and 30 percent of SER patterns. Intra-articular findings were observed in 100 percent of PER injuries, 86 percent in SER fractures, and 66.7 percent of both SAD and PAB groups. There were no arthroscopy-related complications in the study.

Conclusions: Although surgeons can have a good idea of concomitant pathology based on ankle fracture pattern, there is still a push to improve outcomes following operative reduction of these injuries. Arthroscopic evaluation is another tool that can be used to help diagnose cartilaginous defects and subtle instability in the ankle joint. This is warranted and supported by the increasing amount of literature proving the high prevalence of intra-articular injuries and ligamentous instability associated with ankle fractures. Furthermore, arthroscopic evaluation also allows the opportunity to evacuate the fracture hematoma, lavage the joint and possibly lead to less stiffness and improved time to activity postoperatively with a low rate of complication. Lastly, it also gives the surgeon the ability to manage postoperative expectations and prognosis based on intra-articular findings.