Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review

Abstract

Background: Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date. Methods: A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications. Results: A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy. Conclusions: Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Arthroscopic management of pediatric ankle fractures: a systematic review

“…In our study, percutaneous fixation is commonly used during arthroscopic surgery as 85% of patients who only had arthroscopic surgery received percutaneous fixation for fracture stabilization. According to the literature, using arthroscopy as an adjunct to ORIF may be valuable to identify intra-articular pathology that may not be recognized during ORIF alone ( 10 , 27 ). This is an important point to underscore, as the rate of missed intra-articular pathology has been reported to be as high as 79% in ankle fractures ( 2 , 7 , 27 ).…”

“…A large amount of research has been performed to examine the impact and utility of ankle arthroscopy in adult ankle fractures. Arthroscopy can be applied as a diagnostic tool prior to open components of surgical fixation to assess for syndesmotic or other ligamentous disruption and osteochondral injury, or as an adjunct during open reduction and internal fixation (ORIF), to optimize visualization of articular congruity with compelling improvements in radiographic parameters and patient-reported outcomes ( 2 , 10 , 11 ). Despite the growing body of evidence supporting the use of arthroscopy for adult ankle fractures, there is limited evidence on the effectiveness of arthroscopic-assisted management of these injuries in the pediatric population.…”

Arthroscopically assisted internal fixation for treatment of acute ankle fracture: A systematic review and meta-analysis of comparative studies

“…This study only included four studies and summarized effect size based on different outcome measure tools. Williams et al [41] performed a systematic review on ARIF of foot and ankle fractures. The authors argued that despite limited evidence, arthroscopy is expected to become a valuable tool for internal fixation of foot and ankle fractures.…”

Endoscopic Screw Removal, Debridement of the Peroneal Tendons and Subtalar Joint and Lateral Calcaneal Ostectomy for Management of Chronic Heel Pain after Calcaneal Fracture

“…Adjunct arthroscopy to identify missed concomitant injuries and subtle articular malreduction has been proposed as a vehicle to enhance functional results for these patients. 7 Moreover, minimally invasive approaches tend to preserve blood supplies and, thus, may lead to faster healing times and less chance of wound complications compared to traditional extensile approaches. 2 , 4 , 7 , 8 …”

“… 7 Moreover, minimally invasive approaches tend to preserve blood supplies and, thus, may lead to faster healing times and less chance of wound complications compared to traditional extensile approaches. 2 , 4 , 7 , 8 …”