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Why Arthroscopy Is Essential In Treating Ankle Fractures

Arthroscopic evaluation of the ankle joint as part of an initial open reduction with internal fixation (ORIF) is not a new concept. Indeed, surgeons have discussed this in the literature for nearly three decades.1 Hamilton and colleagues even advocated for the use of arthroscopy as part of ankle ORIF in Podiatry Today more than a decade ago.2 

Until recently, however, surgeons had not widely adopted arthroscopy for joint evaluation or assisted fracture reduction. This is likely due to a lack of comfort with arthroscopy in practitioners of an earlier generation as well as a lack of evidence supporting the addition of a procedure to the surgical plan. Admittedly, there is still a lack of level one evidence to demonstrate superior outcomes for patients who had arthroscopy as part of their procedure in comparison to those who did not.  This arthroscopic image shows an anterior distal tibial avulsion fracture found on arthroscopic evaluation of the ankle joint as part of an open reduction with internal fixation of an ankle fracture.

Fortunately, we are seeing an increased comfort with arthroscopy among foot and ankle surgeons due to: a greater emphasis on arthroscopy in podiatric residency and fellowship programs; increased utilization of arthroscopy in trauma and reconstructive surgery as a whole; greater availability of resources such as courses (i.e. the American College of Foot and Ankle Surgeons (ACFAS) arthroscopy course and others) for beginner and advanced users of arthroscopy; and more literature supporting the use of arthroscopy in trauma cases.3,4 Additionally, the advent of disposable arthroscopic tools and cameras with high resolution have reduced setup time and decreased overall costs. These advantages will hopefully contribute to the trend of adding arthroscopy to our fracture cases.

I personally will seldom do an ankle ORIF without arthroscopy anymore for several reasons. 

One is due to the continually surprising nature of just how much This photo shows the fragment after excision from within the joint measuring greater than one cm. pathology I find when I do the arthroscopic evaluation of the joint. I find issues like osteochondral lesions, ligamentous injuries and intra-articular fracture fragments in even the most benign appearing ankle fractures with minimal displacement noted on the pre-reduction radiographs. These injuries would otherwise go untreated at the time of initial operative intervention if not for the arthroscopic evaluation of the joint. 

Additionally, I find that the use of arthroscopy allows for more accurate reduction of both syndesmotic and medial malleolar injuries, and allows for confirmation of a lack of soft tissue impingement within the fracture. This is also true for other injuries and can help with a more accurate calcaneus fracture reduction as well.

The routine use of arthroscopic techniques allows for better management of difficult fractures in high-risk patient populations (i.e. patients with diabetes mellitus and peripheral arterial A) This pre-reduction arthroscopic view demonstrates a posterior calcaneal facet fracture. B) This post-reduction arthroscopic image shows a posterior calcaneal facet fracture. C) This is a radiographic lateral view of the final reduction and fixation of the calcaneal fracture in image B. D) Here one can see a Broden's view of the final reduction and fixation confirming anatomic reduction of the fracture. disease). Surgeons may combine principles of minimally invasive surgery with highly rigid constructs via minimally invasive plate osteosynthesis through arthroscopic debridement of the fracture as well as assistance with and confirmation of the fracture reduction. 

In my experience, arthroscopy is routinely beneficial in treating fractures and I definitely recommend the routine addition of arthroscopy for your ankle fracture cases as well.

Dr. Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material. 

References

1. Ferkel RD, Orwin JF. Ankle arthroscopy: a new tool for treating acute and chronic ankle fractures. Arthroscopy. 1993;9(4):352-353. 

2. Hamilton GA, Sautter TL. A closer look at arthroscopy for ankle fractures and post-fracture defects. Podiatry Today. 2009;22(9):26-32. 

3. Liu C, You JX, Yang J, et al. Arthroscopy-assisted reduction in the management of isolated medial malleolar fracture. Arthroscopy. 2020;36(6):1714-1721,

4. Gonzalez TA, Macaulay AA, Ehrlichman LK, Drummond R, Mittal V, DiGiovanni CW. Arthroscopically assisted versus standard open reduction and internal fixation techniques for the acute ankle fracture. Foot Ankle Int. 2016;37(5):554-562. 

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