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.
Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical ...interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis.
To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis.
A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020.
Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52).
The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks.
Among 100 randomized patients (mean age, 56 years; 45 45% women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points 95% CI, 6-14; P < .001) and 11 points in the placebo group (from 64 to 75 points 95% CI, 7-15; P < .001). The adjusted between-group difference over 26 weeks was -1 (95% CI, -6 to 3; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group.
Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis.
Netherlands Trial Register: NTR7261.
Background
Hindfoot malalignment is a recognized cause of foot and ankle disability. For preoperative planning and clinical follow-up, reliable radiographic assessment of hindfoot alignment is ...important. The long axial radiographic view and the hindfoot alignment view are commonly used for this purpose. However, their comparative reliabilities are unknown. As hindfoot varus or valgus malalignment is most pronounced during mid-stance of gait, a unilateral weight-bearing stance, in comparison with a bilateral stance, could increase measurement reliability. The purpose of this study was to compare the intra- and interobserver reliability of hindfoot alignment measurements of both radiographic views in bilateral and unilateral stance.
Materials and methods
A hindfoot alignment view and a long axial view were acquired from 18 healthy volunteers in bilateral and unilateral weight-bearing stances. Hindfoot alignment was defined as the angular deviation between the tibial anatomical axis and the calcaneus longitudinal axis from the radiographs. Repeat measurements of hindfoot alignment were performed by nine orthopaedic examiners.
Results
Measurements from the hindfoot alignment view gave intra- and interclass correlation coefficients (CCs) of 0.72 and 0.58, respectively, for bilateral stance and 0.91 and 0.49, respectively, for unilateral stance. The long axial view showed, respectively, intra- and interclass CCs of 0.93 and 0.79 for bilateral stance and 0.91 and 0.58 for unilateral stance.
Conclusion
The long axial view is more reliable than the hindfoot alignment view or the angular measurement of hindfoot alignment. Although intra-observer reliability is good/excellent for both methods, only the long axial view leads to good interobserver reliability. A unilateral weight-bearing stance does not lead to greater reliability of measurement.
Background:
Chronic lateral ankle instability (CLAI) is associated with the presence or development of intra-articular pathologies such as chondral or osteochondral lesions, or (O)CLs. Currently, the ...incidence of (O)CLs in patients with CLAI is unknown.
Purpose:
To determine the incidence of (O)CLs in patients with CLAI.
Study Design:
Systematic review and meta-analysis; Level of evidence, 4.
Methods:
A literature search was conducted in the PubMed (MEDLINE), Embase (Ovid), and Cochrane databases for articles published from January 2000 until December 2020. Two authors independently screened the search results and conducted the quality assessment using the methodological index for non-randomized studies (MINORS) criteria. Clinical studies were included that reported findings on the presence of ankle (O)CLs based on pre- or intraoperative diagnostic measures in patients with CLAI (>6 months of symptoms). Patient and lesion characteristics were pooled using a simplified method. Lesion characteristics included localization and chondral and osteochondral involvement. The primary outcome was the incidence of (O)CLs in ankles with CLAI. A random-effects model with 95% CIs was used to analyze the primary outcome. The distribution of (O)CLs in the ankle joint was reported according to talar or tibial involvement, with medial and lateral divisions for talar involvement.
Results:
Twelve studies were included with 2145 patients and 2170 ankles with CLAI. The pooled incidence of (O)CLs in ankles with CLAI was 32.2% (95% CI, 22.7%-41.7%). Among all lesions, 43% were chondral and 57% were osteochondral. Among all (O)CLs, 85% were located on the talus and 17% on the distal tibia. Of the talar (O)CLs, 68% were located medially and 32% laterally.
Conclusion:
(O)CLs were found in up to 32% of ankles with CLAI. The most common location was the talus (85%). Furthermore, most lesions were located on the medial talar dome (68%). These findings will aid physicians in the early recognition and treatment of ankle (O)CLs in the context of CLAI.
Objective
The role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, ...research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques.
Materials and methods
Fifteen patients with a mean age of 44 years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4 years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio.
Results
The mean incisura depth (M = 4.7 mm, SD = 1.1 mm), incisura height (M = 36.1 mm, SD = 5.3 mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8 mm, SD = 1.1 mm; M = 31.9 mm, SD = 3.2 mm; M = 143.2°, SD = 8.3°) (
P <
0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (
P >
0.05).
Conclusion
Our three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.
Purpose
Technical innovation now offers the possibility of 2-mm diameter operative arthroscopy: an alternative to conventional arthroscopy that no longer uses inner rod-lenses. The purpose of this ...study was to assess whether all significant structures in the ankle could be visualized and surgically reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage.
Methods
A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh-frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed.
Results
All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage.
Conclusion
2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.
Purpose
The purpose of the present study was to evaluate the clinical and radiological outcomes of arthroscopic bone marrow stimulation (BMS) for the treatment of osteochondral lesions of the talus ...(OLTs) at long-term follow-up.
Methods
A literature search was conducted from the earliest record until March 2021 to identify studies published using the PubMed, EMBASE (Ovid), and Cochrane Library databases. Clinical studies reporting on arthroscopic BMS for OLTs at a minimum of 8-year follow-up were included. The review was performed according to the PRISMA guidelines. Two authors independently conducted the article selection and conducted the quality assessment using the Methodological index for Non-randomized Studies (MINORS). The primary outcome was defined as clinical outcomes consisting of pain scores and patient-reported outcome measures. Secondary outcomes concerned the return to sport rate, reoperation rate, complication rate, and the rate of progression of degenerative changes within the tibiotalar joint as a measure of ankle osteoarthritis. Associated 95% confidence intervals (95% CI) were calculated based on the primary and secondary outcome measures.
Results
Six studies with a total of 323 ankles (310 patients) were included at a mean pooled follow-up of 13.0 (9.5–13.9) years. The mean MINORS score of the included studies was 7.7 out of 16 points (range 6–9), indicating a low to moderate quality. The mean postoperative pooled American Orthopaedic Foot and Ankle Society (AOFAS) score was 83.8 (95% CI 83.6–84.1). 78% (95% CI 69.5–86.8) participated in sports (at any level) at final follow-up. Return to preinjury level of sports was not reported. Reoperations were performed in 6.9% (95% CI 4.1–9.7) of ankles and complications related to the BMS procedure were observed in 2% (95% CI 0.4–3.0) of ankles. Progression of degenerative changes was observed in 28% (95% CI 22.3–33.2) of ankles.
Conclusion
Long-term clinical outcomes following arthroscopic BMS can be considered satisfactory even though one in three patients show progression of degenerative changes from a radiological perspective. These findings indicate that OLTs treated with BMS may be at risk of progressing towards end-stage ankle osteoarthritis over time in light of the incremental cartilage damage cascade. The findings of this study can aid clinicians and patients with the shared decision-making process when considering the long-term outcomes of BMS.
Level of evidence
Level IV.
Background:
Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) ...injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis.
Purpose:
To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks.
Study Design:
Randomized controlled trial; Level of evidence, 1.
Methods:
In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks.
Results:
Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was −2 points (95% CI, −5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures.
Conclusion:
For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections.
Registration:
NTR7261 (Netherlands Trial Register).
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