High incidence of (osteo)chondral lesions in ankle fractures Martijn, Hugo A.; Lambers, Kaj T. A.; Dahmen, Jari ...
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA,
05/2021, Letnik:
29, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Purpose
To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to ...50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL).
Methods
A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis–Weber and/or Lauge–Hansen classification) was calculated and pooled. Two-sided
p
values of less than 0.05 were considered statistically significant.
Results
Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (
n
= 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge–Hansen categories (
p
= 0.049). Post hoc pairwise comparisons between Lauge–Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.).
Conclusion
OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery.
Level of evidence
IV.
Purpose
Although bone marrow stimulation (BMS) as a treatment for osteochondral lesions of the talus (OCLT) shows high rates of sport resumption at short-term follow-up, it is unclear whether the ...sports activity is still possible at longer follow-up. The purpose of this study was, therefore, to evaluate sports activity after arthroscopic BMS at long-term follow-up.
Methods
Sixty patients included in a previously published randomized-controlled trial were analyzed in the present study. All patients had undergone arthroscopic debridement and BMS for OCLT. Return to sports, level, and type were assessed in the first year post-operative and at final follow-up. Secondary outcome measures were assessed by standardized questionnaires with use of numeric rating scales for pain and satisfaction and the Foot and Ankle Outcome Score (FAOS).
Results
The mean follow-up was 6.4 years (SD ± 1.1 years). The mean level of activity measured with the AAS was 6.2 pre-injury and 3.4 post-injury. It increased to 5.2 at 1 year after surgery and was 5.8 at final follow-up. At final follow-up, 54 patients (90%) participated in 16 different sports. Thirty-three patients (53%) indicated they returned to play sport at their pre-injury level. Twenty patients (33%) were not able to obtain their pre-injury level of sport because of ankle problems and eight other patients (13%) because of other reasons. Mean NRS for pain during rest was 2.7 pre-operative, 1.1 at 1 year, and 1.0 at final follow-up. Mean NRS during activity changed from 7.9 to 3.7 to 4.4, respectively. The FAOS scores improved at 1 year follow-up, but all subscores significantly decreased at final follow-up.
Conclusion
At long-term follow-up (mean 6.4 years) after BMS for OCLT, 90% of patients still participate in sports activities, of whom 53% at pre-injury level. The AAS of the patients participating in sports remains similar pre-injury and post-operatively at final follow-up. A decrease over time in clinical outcomes was, however, seen when the follow-up scores at 1 year post-operatively were compared with the final follow-up.
Level of evidence
Level II.
BACKGROUND:Intramedullary (IM) nailing is the treatment of choice for most tibial shaft fractures. However, an iatrogenic pitfall may be rotational malalignment. The aims of this retrospective ...analysis were to determine (1) the prevalence of rotational malalignment using postoperative computed tomography (CT) as the reference standard; (2) the average baseline tibial torsion of uninjured limbs; and (3) based on that normal torsion, whether the contralateral, uninjured limb can be reliably used as the reference standard.
METHODS:The study included 154 patients (71% male and 29% female) with a median age of 37 years. All patients were treated for a unilateral tibial shaft fracture with an IM nail and underwent low-dose bilateral postoperative CT to assess rotational malalignment.
RESULTS:More than one-third of the patients (n = 55; 36%) had postoperative rotational malalignment of ≥10°. Right-sided tibial shaft fractures were significantly more likely to display external rotational malalignment whereas left-sided fractures were predisposed to internal rotational malalignment. The uninjured right tibiae were an average of 4° more externally rotated than the left (mean rotation and standard deviation, 41.1° ± 8.0° right versus 37.0° ± 8.2° left; p < 0.01). Applying this 4° correction to our cohort not only reduced the prevalence of rotational malalignment (n = 45; 29%), it also equalized the distribution of internal and external rotational malalignment between the left and right tibiae.
CONCLUSIONS:This study confirms a high prevalence of rotational malalignment following IM nailing of tibial shaft fractures (36%). There was a preexisting 4° left-right difference in tibial torsion, which sheds a different light on previous studies and current clinical practice and could have important implications for the diagnosis and management of tibial rotational malalignment.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Purpose
The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.
Methods
A literature search was performed ...to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle–Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.
Results
Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% CI 78–86%. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% CI 66–85%.
Conclusions
For primary talar osteochondral defects, none of the treatment options showed any superiority over others.
Level of evidence
IV.
Purpose
To describe the long-term clinical results of arthroscopic fragment fixation for chronic primary osteochondral lesions of the talus (OLT), using the Lift-Drill-Fill-Fix (LDFF) technique.
...Methods
Eighteen patients (20 ankles) underwent fixation for a primary OLT with an osteochondral fragment using arthroscopic LDFF and were evaluated at a minimum of 5-year follow-up. Pre- and postoperative clinical assessment was prospectively performed by measuring the Numeric Rating Scale (NRS) of pain at rest, during walking and when running. Additionally, the change in Foot and Ankle Outcome Score (FAOS) and the procedure survival (i.e., no reoperation for the OLT) at final follow-up was assessed.
Results
At a mean follow-up of 7 years, the median NRS during walking significantly improved from 7 (IQR 5–8) pre-operatively to 0 (IQR 0–1.5) at final follow-up (
p
= < 0.001). This result was sustained from 1-year follow-up to final follow-up. The NRS during running significantly improved from 8 (IQR 6−10) to 2 (IQR 0–4.5) (
p
< 0.001) and the NRS in rest from 2.5 (IQR 1–3) to 0 (IQR 0–0) (
p
= < 0.001). The median FAOS at final follow-up was 94 out of 100 for pain, 71 for other symptoms, 99 for activities of daily living, 80 for sport and 56 for quality of life. The FOAS remained significantly improved post-operatively on all subscales, except for the symptoms subscale. The procedure survival rate is 87% at final follow-up.
Conclusion
Arthroscopic LDFF for fixable chronic primary OLTs results in excellent pain reduction and improved patient-reported outcomes, with sustained results at long-term follow-up. These results indicate that surgeons may consider arthroscopic LDFF as treatment of choice for fragmentous OLT.
Level of evidence
Level IV, prospective case series.
Purpose
The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery.
Methods
A literature search was ...conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle–Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined.
Results
Twenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% CI 82–95% for the osteochondral autograft transfer procedure, 65% CI 46–81% for mosaicplasty and 55% CI 40–70% for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% CI 39–77%) and matrix-associated chondrocyte implantation (success rate of 73% CI 56–85%).
Conclusions
Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery.
Level of evidence
IV.
Background:
Ongoing controversy exists on postoperative weightbearing status after open reduction and internal fixation of an ankle fracture. This prospective randomized controlled trial aimed to ...compare patient-based and physician-based outcomes after early weightbearing at 2 vs 6 weeks postoperatively.
Methods:
Fifty patients with unstable rotational-type ankle fractures were treated operatively with subsequent immobilization in a below-the-knee cast for 2 weeks and were then randomly allocated to 2 groups. The first group had early weightbearing at 2 weeks postoperation and the second group at 6 weeks postoperation. Follow-up included subjective and objective evaluations performed at 2, 6, 12, and 26 weeks postoperatively. The primary outcome was the patient-based general health status as measured with the EuroQol-5D (EQ-5D) scoring system. Secondary outcome was the Olerud and Molander ankle score. Power analysis revealed a study group of 50 patients was needed to show a clinically relevant effect size of 10 points in both EQ-5D visual analog scale (VAS) score and Olerud and Molander score.
Results:
Patients in the early weightbearing group had higher mean EQ-5D VAS scores at a 6-week follow-up (P = .014) of 77 ± 14 compared to 66 ± 15 for late mobilization. No difference was found at other follow-up points or between groups for physician-based outcome measures. At 26 weeks postoperatively, mean Olerud and Molander ankle scores were similar at 84 ± 16 and 81 ± 17 for mobilization at 2 and 6 weeks postoperation, respectively.
Conclusion:
Early weightbearing after operative fixation of rotational-type ankle fractures had a clinically relevant and statistically significant benefit in patient-based general health status, as quantified with EQ-5D VAS scores, at 6 weeks postoperation. These results contribute to our understanding of early weightbearing and may encourage consideration of weightbearing at 2 weeks postoperatively in standard protocols.
Level of Evidence:
Therapeutic Level I, prospective randomized controlled trial.
Background:
Osteochondral defects (OCDs) of the talus are found subsequent to ankle sprains and ankle fractures. With many surgical treatment strategies available, there is no clear evidence on ...return-to-sport (RTS) times and rates.
Purpose:
To summarize RTS times and rates for talar OCDs treated by different surgical techniques.
Study Design:
Systematic review; Level of evidence, 4.
Methods:
The literature from January 1996 to November 2018 was screened, and identified studies were divided into 7 different surgical treatment groups. The RTS rate, with and without associated levels of activity, and the mean time to RTS were calculated per study. When methodologically possible, a simplified pooling method was used to combine studies within 1 treatment group. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system.
Results:
A total of 61 studies including 2347 talar OCDs were included. The methodological quality of the studies was poor. There were 10 retrospective case series (RCSs) that investigated bone marrow stimulation in 339 patients, with a pooled mean rate of RTS at any level of 88% (95% CI, 84%-91%); 2 RCSs investigating internal fixation in 47 patients found a pooled RTS rate of 97% (95% CI, 85%-99%), 5 RCSs in which autograft transplantation was performed in 194 patients found a pooled RTS rate of 90% (95% CI, 86%-94%), and 3 prospective case series on autologous chondrocyte implantation in 39 patients found a pooled RTS rate of 87% (95% CI, 73%-94%). The rate of return to preinjury level of sports was 79% (95% CI, 70%-85%) for 120 patients after bone marrow stimulation, 72% (95% CI, 60%-83%) for 67 patients after autograft transplantation, and 69% (95% CI, 54%-81%) for 39 patients after autologous chondrocyte implantation. The mean time to RTS ranged from 13 to 26 weeks, although no pooling was possible for this outcome measure.
Conclusion:
Different surgical treatment options for talar OCDs allow for adequate RTS times and rates. RTS rates decreased when considering patients’ return to preinjury levels versus return at any level.
Purpose
Arthroscopic bone marrow stimulation (BMS) has been considered the primary surgical treatment for osteochondral defects (OCDs) of the talus. However, fixation has been considered as a good ...alternative. Recently, a new arthroscopic fixation technique was described: the lift, drill, fill and fix procedure (LDFF). The purpose of this study was to evaluate the clinical and radiological results between arthroscopic LDFF and arthroscopic BMS in primary fixable talar OCDs at 1-year follow-up.
Methods
In a prospective comparative study, 14 patients were treated with arthroscopic BMS and 14 patients with arthroscopic LDFF. Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and the numeric rating scales (NRSs) of pain at rest and running. Additionally, the level of the subchondral plate (flush or depressed) was analysed on the 1 year postoperative computed tomography scans.
Results
No significant differences in the AOFAS and NRS pain at rest and running were found between both groups at 1-year follow-up. After LDFF the level of the subchondral bone plate was flush in 10 patients and after BMS in three patients (
p
= 0.02).
Conclusion
No clinical differences were found between arthroscopic LDFF and arthroscopic BMS in the treatment of talar OCDs at 1-year follow-up. However, the subchondral bone plate restores significantly superior after arthroscopic LDFF compared to arthroscopic BMS. It may therefore give less progression of ankle osteoarthritis in the future with a thus potential better long-term outcome.
Level of evidence
III.
Most total elbow arthroplasty (TEA) designs aim to replicate anatomy and provide stability in the treatment of the degenerative elbow joint. Given the promising results that have been reported ...following the use of TEA for the treatment of complex fractures, the indications for this procedure are growing. The objective of the present study was to review the most recent literature on the results of the most commonly performed TEAs.
A comprehensive literature search was conducted. All relevant studies were reviewed according to a set of predefined inclusion and exclusion criteria. After the initial assessment, 2 authors extracted data from the included articles. Groups were created on the basis of the design of TEA implant, the type of implant (linked or unlinked), and the indication for treatment. Outcome parameters were survival rate, pain, range of motion, complications, and specific elbow outcome scores.
Seventy-three articles involving a total of 9,379 TEAs were included. The level of evidence was primarily Level IV. Nineteen specific designs of TEA implants were described, including the Souter-Strathclyde (n = 2,387), Coonrad-Morrey (n = 1,586), Kudo (n = 560), and GSB III (n = 498). The most common indication for TEA was rheumatoid arthritis (70%). The weighted mean survival rate for the linked and unlinked prostheses was 85.5% at 7.8 years and 74% at 12.3 years, respectively. For the Coonrad-Morrey, Souter-Strathclyde, and GSB III, the weighted mean survival rate was 87.2% at 7.2 years, 70.6% at 14.2 years, and 81.7% at 9.5 years, respectively. The range of motion after TEA was good overall, with a mean flexion angle of 129° and a mean extension lag angle of 30°. The complication rates ranged from 11% to 38%, with clinical loosening being the most frequently reported complication (7%).
The results of TEA are respectable overall. It appears that there are small differences between designs. However, despite the fairly good functional results and elbow scores, the survival and complication rates are still not as favorable as those following arthroplasties in other joints.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
PDF
