Prevalence and Associated Factors of Intra-Articular Lesions in Acute Ankle Fractures Evaluated by Arthroscopy and Clinical Outcomes with Minimum 24-Month Follow-Up
Acute ankle fractures are common orthopedic injuries that often require surgical intervention to restore stability and function. While open reduction and internal fixation (ORIF) is the standard treatment for unstable ankle fractures, residual symptoms such as chronic pain, swelling, and limited range of motion can persist even after successful anatomical reduction and healing. These complications may be attributed to untreated intra-articular lesions, which are frequently associated with acute ankle fractures. Arthroscopy-assisted open reduction and internal fixation (AORIF) has emerged as a valuable adjunct to traditional ORIF, allowing for the identification and treatment of concomitant intra-articular injuries. This study aimed to evaluate the prevalence of intra-articular lesions in acute ankle fractures using arthroscopy, analyze their relationship with fracture type and severity, and assess clinical outcomes with a minimum 24-month follow-up.
Background and Rationale
Ankle fractures are often accompanied by soft tissue injuries, including ligamentous damage, osteochondral lesions, and tibiofibular syndesmosis injuries. These intra-articular lesions can compromise clinical outcomes if left untreated. Previous studies have reported that only 79.3% of optimally reduced ankle fractures achieve good to excellent long-term outcomes, with residual symptoms persisting in a significant proportion of patients. The use of arthroscopy in conjunction with ORIF provides a minimally invasive approach to diagnose and treat these associated injuries, potentially improving postoperative results.
This study was conducted to address the gap in understanding the factors that contribute to intra-articular lesions in acute ankle fractures. Specifically, the research sought to determine the prevalence of these lesions, their association with fracture type and severity, and the effectiveness of AORIF in managing these injuries.
Methods
Study Design and Patient Selection
This retrospective cohort study included 36 patients with acute unstable ankle fractures treated with AORIF between April 2014 and December 2015. Patients were excluded if they had chronic ankle fractures, previous trauma or deformity of the involved limb, or Pilon fractures. The cohort consisted of 14 male and 22 female patients, with an average age of 47 years (range: 20–78 years). The mechanism of injury included ankle sprains in 31 patients and traffic accidents in five patients. The average time from injury to surgery was 4.8 days (range: 6 hours to 13 days).
Surgical Technique
All surgeries were performed under general or spinal anesthesia, with patients in a supine position. Standard anteromedial and anterolateral portals were used for arthroscopy. Intra-articular structures were carefully inspected, and concomitant injuries such as ligament tears, osteochondral lesions, and tibiofibular syndesmosis injuries were documented. Chondral lesions were classified using the Outerbridge system, and unstable chondral flaps were removed. Loose bodies and bony spurs were also addressed during the procedure.
Fractures were classified according to the Lauge-Hansen classification system, which categorizes ankle fractures based on the mechanism of injury. Severe fractures were defined as supination-external rotation (SER) type IV, pronation-external rotation (PER) type IV, and pronation-abduction type II. All other fractures were classified as mild.
Clinical Evaluation
Postoperative function was assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. Patient satisfaction was also evaluated at the final follow-up. Statistical comparisons between intra-articular lesions, fracture type, and severity were performed using Chi-squared analysis.
Results
Patient Demographics and Fracture Characteristics
The study included 36 patients, with 23 supination-type fractures and 13 pronation-type fractures. Among the supination-type fractures, three were SER type II, five were SER type III, and 15 were SER type IV. Among the pronation-type fractures, two were PER type II, three were PER type III, four were PER type IV, two were pronation-abduction type II, and two were Maisonneuve fractures. Overall, 21 fractures were classified as severe, and 15 were classified as mild.
Prevalence of Intra-Articular Lesions
Intra-articular lesions were identified in 92% of patients. The most common injuries included tibiofibular syndesmosis injuries (92%), chondral lesions (72%), and loose bodies (39%). Avulsion fractures of the anterior tibiofibular syndesmosis were more common in supination-type fractures (45%) compared to pronation-type fractures (15%). Chondral lesions were more frequently observed in severe fractures (86%) than in mild fractures (53%).
Clinical Outcomes
At a mean follow-up of 41.7 months (range: 33–51 months), the average AOFAS ankle-hindfoot score was 96.9 (range: 85–100). Overall, 97.2% of patients were satisfied with the procedure. One patient reported occasional ankle pain and swelling after prolonged activity, expressing disappointment with the surgery.
Discussion
High Prevalence of Intra-Articular Lesions
The study confirmed that acute ankle fractures are frequently associated with intra-articular lesions, with a prevalence of 92%. This finding underscores the importance of arthroscopic evaluation during surgical treatment to identify and address these injuries. Untreated intra-articular lesions can lead to persistent symptoms and compromised clinical outcomes, even after successful fracture fixation.
Association with Fracture Type and Severity
The study revealed distinct patterns of intra-articular lesions based on fracture type and severity. Avulsion fractures of the anterior tibiofibular syndesmosis were more common in supination-type fractures, while chondral lesions were more prevalent in severe fractures. These findings suggest that the mechanism and severity of injury play a significant role in the nature and extent of concomitant intra-articular damage.
Effectiveness of AORIF
AORIF demonstrated excellent clinical outcomes, with a mean AOFAS score of 96.9 and high patient satisfaction. The use of arthroscopy allowed for precise diagnosis and treatment of intra-articular lesions, contributing to improved postoperative function. The study supports the use of AORIF as a reliable approach for managing acute ankle fractures and their associated injuries.
Limitations
The study had several limitations. Arthroscopy primarily allowed for the evaluation of the anterior and middle portions of the ankle, leaving the posterior structures less accessible. Additionally, the small sample size may limit the generalizability of the findings. Further research with larger cohorts and longer follow-up periods is needed to validate these results.
Conclusion
Acute ankle fractures are associated with a high prevalence of intra-articular lesions, which can significantly impact clinical outcomes if left untreated. Avulsion fractures of the anterior tibiofibular syndesmosis are more common in supination-type fractures, while chondral lesions are related to the severity of the fracture. Arthroscopy-assisted open reduction and internal fixation (AORIF) provides an effective solution for diagnosing and treating these associated injuries, leading to excellent functional outcomes and high patient satisfaction. The findings of this study highlight the importance of arthroscopic evaluation in the management of acute ankle fractures to optimize postoperative results.
doi.org/10.1097/CM9.0000000000000342
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