Initial cartilage lesions after ankle fracture may have role in post-traumatic OA

Patients with more severe talar, medial malleolar lesions had worse clinical, radiological results.

DENVER — Recent Swiss research links the severity of initial cartilage lesions following ankle fracture to the development of post-traumatic osteoarthritis at long-term follow-up in surgically-treated cases.

Sjoerd A. Stufkens, MD, and colleagues studied a consecutive series of 288 patients with ankle fracture who were treated with open reduction and internal fixation and were arthroscopically examined before surgery.

The overall long-term results of operative treatment of ankle fractures were good: a cross-sectional follow-up of 108 patients after a mean of 13.2 years revealed that 61.1% of patients had no clinical osteoarthritis (OA) as evidenced by an American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score of greater than 90. The study also showed that 57.4% had no signs of radiological OA as determined by a modified Kannus arthritis score of greater than 90.

However, almost all of the patients who had no residual complaints suffered only a fibular fracture at the level of the syndesmosis. The investigators discovered that initial cartilage lesions after ankle fracture occurred more often in patients with bimalleolar, trimalleolar and high-fibular fractures.

They also found that patients who had deeper initial lesions on either the talus or the medial malleolus had significantly worse clinical and radiological long-term results than those with less severe lesions.

“We conclude that the deep initial cartilage lesions occurred more frequently in the worse fractures, and that the lesions on the talus and the medial malleolus correlated with the long-term outcome,” Stufkens said during his presentation at the American Orthopaedic Foot and Ankle Society 24th Annual Summer Meeting.

Arthroscopic images of a patient in whom no initial cartilage damage was found. Images: Stufkens SA

Arthroscopic images show a patient with severe damage that can be seen on the talus.

Frequency

Stufkens and his colleagues studied patients who had surgery between 1993 and 1997, and excluded patients who had a suboptimal fracture reduction and those who developed systematic inflammatory disease.

The investigators found that patients with Lauge-Hansen SE-2 fractures had the best clinical and radiological outcomes at long-term follow-up. Nearly 90% of patients with these fractures had both clinical and radiographic scores greater than 90.

“The high fibular fractures, the Weber C-type fractures, had a significantly worse outcome at the long-term,” Stufkens said. He reported that 55.6% of patients with Lauge-Hansen PE-3 fractures had a clinical score greater than 90 and one-third had a radiological score greater than 90. Roughly 57% of patients with Lauge-Hansen PE-4 fractures had a clinical score greater than 90 and as few as 14.3% had a radiological score greater than 90.

“Interestingly, in the patients who had the severe fractures, there were significantly more and deeper cartilage lesions found,” Stufkens said. The investigators found initial cartilage lesions in all of the patients with Lauge-Hansen PE-4 fractures, 92.5% of those with Lauge-Hansen SE-4 fractures, 88.9% of patients with Lauge-Hansen PE-3 fractures and only in 60.7% of those with Lauge-Hansen SE-2 fractures, which were mostly superficial fissures.

Location

“We found that on the talus, the deeper lesions had significantly worse clinical long-term outcome and radiological outcome,” Stufkens said. For example, patients with lesions reaching the subchondral bone had worse mean AOFAS scores than those with lesions measuring more than half the depth of the talar cartilage. In addition, those with lesions reaching the subchondral bone showed worse mean Kannus radiological scores than patients with lesions that were less than half the depth of the chondral layer on the talus.

Likewise, patients with lesions reaching the subchondral bone had worse mean AOFAS scores than those with intact cartilage, and those with lesions to the subchondral bone showed worse mean radiologic scores than patients with intact cartilage.

AP and lateral X-ray views of a patient with no signs of osteoarthritis several years after ankle fracture.

AP and lateral X-ray views of a patient with severe post-traumatic osteoarthritis resulting from an ankle fracture.

For more information:

• Sjoerd A. Stufkens, MD, can be reached at department of orthopaedics & traumatology, Kantonsspital Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland; 41-061-925-3345; e-mail: sjoerd.stufkens@ksli.ch. He has no direct financial interest in any product or company mentioned in this article.

Reference:

• Stufkens S, Knupp M, Barg A, et al. Predicting the development of posttraumatic osteoarthritis after ankle fracture. Presented at the American Orthopaedic Foot and Ankle Society 24th Annual Summer Meeting. June 26-28, 2008. Denver.