that we have you know some people say you're really doing it just you're scoping for dollars you know is that really what we're looking for just to get that extra bang for your buck but there are other people that say you know it may change the world you know we can we find out more information we can help our patients better and we can we can get them into a better position down the road but really what do we know you know it not that much there's not a whole lot of literature out there prior to about 2000 in the last 20 years though there's been a pretty significant uptick in and the amount of literature that's out there that points us to this direction you can make your own conclusions but certainly there's there's more out there so the role of arthroscopy for for acute injuries has not been really well defined certainly technology is improving the techniques have improved over the past two decades and there's a lot of school of thought there's a pretty large school of thought that the younger generations of surgeons more adapt to the man's of arthroscopy largely because of the video game culture that's that's been going on over the last 40 years so what is the role is it to lavage the joint well I'll get into that to assist in the reduction of the joint we can better see the medial malleolar fracture any intra articular fractures that occur into the tibial plafon we can determine the stability both of the deltoid and syndesmosis and it gives us the ability to diagnose and address any particular articular cartilage pathology that can occur so you see all kinds of stuff when you get in there and this allows us to get a better picture Sam Adams in the group at Duke has done a pretty pretty good job of evaluating what the environment is like in a in a in an ankle fracture and they put out two really good studies one of which was the Goldner award winner that really looked at the inflammatory cytokines that are in the joint and a lot of this is based off the knee literature which was done with plateau fractures back in the 1990s and really what they found was that intra articular lavage may reduce the potential for post-traumatic arthritis because the cytokines that live there and then the ultimate secondary subjection of the joint to those elevated markers can have detrimental detrimental effects to the intra articular environment which can cause damage at the cellular level to the cartilage and then a reduction in those inflammatory markers can help in the immediate outcome for the for the patients relative to their pain levels by reducing their pain level. It also allows us to assess the stability of the joint. Dr. Bhimani talked about looking at the syndesmosis in the coronal plane and and I'm not going to go off into the syndesmotic tangent but it certainly allows us to better visualize things and you can see here with my probe 60 newtons of force is not a ton and you can see here I'm easily able to assess the syndesmotic instability and particularly the posterior translation that occurs and obviously a three millimeter shaver shouldn't go between the tibia and the fibula so you have an injury there that you can see very clearly and allows us to better assess that. So there have been a lot of a lot of papers recently. These are all papers that have been done in the last four years in the foot and ankle literature that specifically looked at our ability to assess what's going on with what's going on with the ligamentous stability there once we fix these fractures. So it gives us an idea of how we should be evaluating them. For example as I talked about with the syndesmosis looking at it in the coronal plane there's a great paper done by Ken Hunt when he was at Stanford that basically the conclusion of his paper was if you see medial clear space widening and syndesmotic widening you've missed the boat. Instability occurred long before that and there's a level of instability that occurs in both external rotation and in posterior translation of the fibula long before you see the widening and so there there's instability there and we need to recognize that and certainly arthroscopy allows us to better assess that. So in in arthroscopy and ankle fractures the long-term outcome relates more to the joint surface than the bony injury and that makes sense right? We want to know what's going on with a cartilage and there's some there's some literature that's been building these are some of the early papers back in the 2000s that that looked at that variation and certainly as we see from Weber A fractures to Weber C that number increases. Dr. Farkel has a couple papers out there that specifically correlates to that up to 80% of the ones he looked at that were Weber C fractures had cartilage damage. So what about those osteochondral lesions and fractures? Well trauma certainly is the leading cause that's from Captain Obvious for sure. That's reported anywhere from 23 to 80 percent and that's a pretty high number. There's a clear known correlation between osteochondral lesions of the talus and ankle fractures. So is that osteochondral lesion the reason for the patient's struggles despite anatomic reduction in healing? And I would argue if you don't know that and you're not aware of what's going on in that intra-articular environment you don't have the full picture for the patient. In arthroscopy one of the groups, Dr. Draco's group, looked at 116 consecutive patients. 78% of their patients had chondral lesions. 43% were full thickness lesions of the talar dome. Dislocation being the number one factor and then the level of the fibula fracture being the number two factor. And there were statistically significant worse outcomes with osteochondral lesions. In a secondary look out of Korea they looked at 254 consecutive patients and not only did they determine that it was a valuable tool for ligamentous stability that we talked about earlier, 52% of their Weber B fractures, so half of those had full thickness osteochondral lesions, or excuse me, had had lesions of the talus. 92% had ligamentous instability with Weber C fractures and 25% of those had full thickness lesions. That's a large number. So their conclusion was direct visualization through arthroscopy allows for more accurate reduction and it allows us to address all the pathology. So are we changing the outcomes? That's the real question. That's what people want to know and that's the literature that is not out there. That's what needs to be studied. Some people argue does the environment, does the traumatic environment allow that osteochondral lesion to heal on its own or do they need some sort of stimulation or help? And how do we address it? Certainly microfracture is a way, but there's a there's a pool getting away from microfracture because of concern of cyst formation in that high-pressure environment of a fracture. And are we better off doing abrasion chondroplasty, cleaning up the edges of the cartilage and stimulating the subchondral bone without breaking through the plate? So articular cartilage lesions occur in about 50 to 80 percent. So the medial malleolar fracture certainly as it goes to figure are more likely to have a loose body than a deltoid injury and are more likely to cause long-term damage. That also is common sense. And Takao, who's really put out a lot of very good papers on this subject, his first one really that dove into it, he was one of the first to argue that arthroscopic assessment of the joint at a time may lead to better outcomes. So I'm going to give a case example. So this was a 26-year-old professional athlete. He had a twisting injury during an athletic event. This was a pretty well-known injury. He came in celebrating his game-winning Grand Slam hit home plate and had a Weber B ankle fracture or Weber CB ankle fracture. He was treated with open reduction internal fixation by a foot and ankle specialist, anatomic reduction rigid fixation. No, certainly no critiques on the fixation and the reduction. Unfortunately, he didn't do very well. Post-op course was difficult, had pain stiffness. Nine months later was still unable to return to play due to pain and you can see the x-rays and the CTs show a pretty large osteochondral lesion. Arthrofibrosis and osteochondral lesion, once we took him back to the, once we took him back to the operating room, he was full of fibrosis. He was treated with debridement chondroplasty. You can see he had a large chondral lesion in the joint with pretty significant damage to his ankle. It's nearly two centimeter lesion. He was treated with curatage, exposed exposed the tailor bone and cyst, grafting of the lesion, cartilage substitute, fragment was sent to Genzyme. Fortunately, we didn't didn't have to go there. Ultimately, he would return to play. He missed two full years of play. He played seven more seasons in Major League Baseball and just retired after 13 seasons. So the morbidity is not small and I would argue that allowing us to fully understand the pathology of the patient, knowing what's going on, certainly if they have a difficult course down the road, it allows us to better understand the full picture besides knowing the immediate micro environment of their stability, the cartilage lesions and and at the very least can help reduce their pain. So thank you.

arthroscopy

ankle fractures

patient outcomes

ligaments

osteochondral lesions