Fractures of the ankle. When is arthroscopy indicated?

Poor outcome and residual symptoms after acute ankle fractures can be caused by occult intra-articular pathologies that are missed by the preoperative imaging diagnostics. The fracture type, presence of a posterior or medial malleolar fracture, syndesmotic instability and insufficient fracture reduction are further factors associated with a poor prognosis. Arthroscopy-assisted open reduction and internal fixation (AORIF) provides direct evaluation of intra-articular injuries, assessment of reduction without arthrotomy and minimal soft tissue trauma. Currently, the limited literature and lack of clinical proof do not enable a recommendation pro or contra AORIF, although intra-articular damage is reported in approximately 80% of malleolar fractures. Severe malleolar fractures in particular could benefit from arthroscopy-assisted treatment because intra-articular, fracture-associated injuries are even more frequent. The anatomic one stage reduction of posterior malleolar fractures (Volkmann's tubercle) has particular significance; however, an exact fluoroscopic assessment of this region is limited so that an arthroscopic evaluation of reduction is useful in fracture types involving the posterior malleolus (e. g. AO 44-B3). Compared with elective ankle arthroscopy, in AORIF soft tissue damage is already pre-existent. A strict fluid management is therefore necessary to prevent further soft tissue damage of the area of osteosynthesis due to fluid extravasation.