Are We Ready for Arthroscopic Surgery for Ankle Fractures Yet?
Arthroscopic reduction and internal fixation (ARIF) of ankle fractures is an emerging procedure. Until now, the complexity of the ankle joint has required an open procedure called open reduction and internal fixation, more commonly known as ORIF.
In this review article, orthopedic surgeons from the United States team up with surgeons from Italy to discuss six conditions for which arthroscopic reduction and internal fixation (ARIF) can be used. These include: 1) transchondral fracture, 2) talar fracture, 3) distal tibial fracture, 4) syndesmotic disruption, 5) malleolar fracture, and 6) chronic ankle pain after treatment.
For each problem, the authors discuss the diagnosis, management, and results. Management refers to both the surgical treatment as well as the postoperative care and rehabilitation.
Photographs taken during each arthroscopic procedure provide an "inside" look at how the procedure was done. Follow-up X-rays show the placement of screws, rods, and metal plates used to stabilize the fractures.
Here's a brief summary of the main concepts, including the advantages and disadvantages of the arthroscopic reduction and internal fixation (ARIF) compared with open reduction and internal fixation (ORIF).
Arthroscopic surgery is less invasive than an open incision that cuts through soft tissues that protect and stabilize the joint. Arthroscopic surgery is image-guided through a tiny TV camera on the end of the scope.
A picture is projected up on a screen for the surgeon to see. This technology makes it possible to reach places in the joint that would require extensive dissection (cutting and opening) to see otherwise.
With less tissue disruption, there is much less swelling and potentially faster healing. One other advantage of arthroscopic ankle surgery is the reduced risk of accidentally cutting a nerve or important blood vessel.
For all those positive factors associated with arthroscopic reduction and internal fixation (ARIF), there are a few disadvantages. The procedure takes longer than an open reduction and internal fixation (ORIF). The risk of complications from anesthesia and surgery itself go up with increased time on the operating table.
In terms of costs, the ARIF is more expensive in the short-term. But if it prevents the chronic pain that can develop after ORIF, ARIF could potentially lower overall costs in the long-run.
The most important factor is effectiveness of these two procedures when compared against each other. And that's where research has not yet been done. Without the assurance that ARIF is indeed superior to ORIF when treating ankle fractures, most ankle fractures will continue to be managed using the open method.
Regardless of the method chosen to perform the surgery, pre-operative diagnosis and evaluation are very important. The surgeon will use X-rays, CT scans, and/or MRIs to view the location and extent of the damage.
The surgeon will look to see if the joint cartilage is affected. MRIs are especially good at showing the presence of swelling around the bone called bony edema. CTs show the pattern of fracture. All of this information is helpful in deciding the best surgical approach to take. For example, large displaced (separated) fractures may require open surgery.
The information gathered from imaging studies also help the surgeon decide whether to enter the joint arthroscopically from the front (anterior approach) or the back (posterior approach). The authors provide details about the best foot and ankle position and portal (opening for the scope) entry to use for each approach.
Even with careful and thorough imaging studies, it is possible to miss an important finding. The lesion depth for visible injuries isn't always readily apparent with imaging studies. Damage to the surface of the joint or a displaced fracture may not show up on imaging. There may be secondary fractures that haven't shown up at all on imaging studies.
Impacted fractures (the broken ends are smooshed together) or comminuted fractures (broken into tiny pieces) require special planning and attention. The surgeon must be prepared for any and all possibilities once inside the joint.
Fortunately, arthroscopy allows the surgeon to see the joint surface clearly when reducing the fracture (bringing the broken surfaces back together). Arthroscopy also makes it possible to look for tiny fragments of bone, cartilage, or other debris that would create problems later if not recognized and removed.
There are a few more challenges to consider with ankle fractures. Children and teens who have not completed their growth have growth plates that will allow further bone growth. The surgeon must be careful to avoid injury to these growth plates.
Finally, the care each patient receives after surgery is just as important as the procedure itself. The surgeon advises the patient, Physical Therapist, and nursing staff what to do based on what he or she (the surgeon) saw and did during the procedure.
Sometimes the patient can put weight on the foot right after surgery but full weight-bearing isn't usually allowed for several weeks. It may be necessary to wear a cast for six to eight weeks (sometimes longer). If there is any concern about the stability of the ankle, the patient will be transitioned from a cast to a walking boot.
Joint motion exercises are started around six weeks post-op for those who didn't have a cast or when the cast is removed. The surgeon uses X-rays to see how well the bone is healing and advise the patient and therapist when to advance weight-bearing, joint range-of-motion, and exercises.
Hardware used to fix (hold) the fracture stable during healing is often removed eight to 10 weeks later. The goal is to remove the screws or other instrumentation before bone and scar tissue grow over and around it making removal more difficult. Timing is important because removing it too soon could leave the ankle unstable.
The authors conclude that arthroscopy is a valuable tool for identifying all problems present in complex ankle fractures and injuries. Consideration should be given for the use of arthroscopic reduction and internal fixation (ARIF).
This technique is less invasive and allows the surgeon to take care of problems that might not be seen otherwise. Arthroscopic surgery should not be used when there is a fracture and dislocation.
Studies are needed to compare the results of surgery between arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF) before the arthroscopic technique will be adopted by all surgeons.
Reference: Davide E. Bonasia, MD, et al. The Role of Arthroscopy in the Management of Fractures About the Ankle. In Journal of the American Academy of Orthopaedic Surgeons. April 2011. Vol. 226-235.