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Cartilage Lesions and the Development of Osteoarthritis After Internal Fixation of Ankle FracturesA Prospective Study
Sjoerd A. Stufkens, MD1; Markus Knupp, MD1; Monika Horisberger, MD2; Christoph Lampert, MD3; Beat Hintermann, MD1
1 Department of Orthopaedic Surgery, Kantonsspital Liestal, Rheinstrasse 26, 4410 Liestal, Switzerland. E-mail address for S.A. Stufkens: stufkens@gmail.com. E-mail address for M. Knupp: markus.knupp@ksli.ch. E-mail address for B. Hintermann: beat.hintermann@ksli.ch
2 Department of Orthopaedic Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland. E-mail address: mhorisberger@uhbs.ch
3 Department of Orthopaedic Surgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, 9007 St. Gallen, Switzerland. E-mail address: christoph.lampert@kssg.ch
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the AO Research Fund Grant S-08-34H (Davos, Switzerland) and a grant from the Suva insurance company (Lucerne, Switzerland). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by Charles L. Saltzman, MD, Troy M. Gorman, MD and Florian Nickisch, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at Kantonsspital, Liestal, and Kantonsspital, St. Gallen, Switzerland

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Feb 01;92(2):279-286. doi: 10.2106/JBJS.H.01635
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Abstract

Background: 

The role of the location and severity of the initial cartilage lesions associated with an ankle fracture in the development of posttraumatic osteoarthritis has not been established, to our knowledge.

Methods: 

We performed a long-term follow-up study of a consecutive, prospectively included cohort of 288 ankle fractures that were treated operatively between June 1993 and November 1997. Arthroscopy had been performed in all cases in order to classify the extent and location of cartilage damage. One hundred and nine patients (47%) were available for follow-up after a mean of 12.9 years. The main outcome parameters were the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score for clinical evaluation and a modified Kannus osteoarthritis score for radiographic assessment of the development of posttraumatic osteoarthritis.

Results: 

Cartilage damage anywhere in the ankle joint was associated with a suboptimal clinical outcome (odds ratio, 5.0 [95% confidence interval = 1.3 to 20.1]; p = 0.02) and with a suboptimal radiographic outcome (odds ratio = 3.4 [95% confidence interval = 1.0 to 11.2]; p = 0.04). An association was also found between the development of clinical signs of osteoarthritis and a deep lesion (>50% of the cartilage thickness) on the anterior aspect of the talus (odds ratio = 12.3 [95% confidence interval = 1.4 to 108.0]; p = 0.02) and a deep lesion on the lateral aspect of the talus (odds ratio = 5.4 [95% confidence interval = 1.2 to 23.5]; p = 0.02). A deep lesion on the medial malleolus was associated with the development of clinical signs of osteoarthritis (odds ratio = 5.2 [95% confidence interval = 1.9 to 14.6]; p < 0.01) and radiographic signs of osteoarthritis (odds ratio = 2.9 [95% confidence interval = 1.1 to 7.9]; p = 0.03) of osteoarthritis. There was no significant correlation between cartilage lesions on the fibula and the long-term outcome.

Conclusions: 

Our findings show that initial cartilage damage seen arthroscopically following an ankle fracture is an independent predictor of the development of posttraumatic osteoarthritis. Specifically, lesions on the anterior and lateral aspects of the talus and on the medial malleolus correlate with an unfavorable clinical outcome.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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