Physician Life Care Planners must understand the consequences of cartilage injuries and how it relates to future care.
No Just An Ankle Fracture
Ankle fractures and dislocations are often ‘associated’ injuries in major trauma caused by high speed motor vehicle accidents and are often not evaluated in the life care plans of the injured because the emphasis is placed on concomitant brain injuries, and major orthopaedic trauma. It is well recognized that the cost burden related to ankle pain over a lifetime is substantial and life care planners must understand the factors that may place an injured patient at substantial risk for traumatic arthritis and the future care associated with this diagnosis. Despite healed fractures with proper alignment following surgery only 80 percent have good to excellent long-term outcomes. Therefore, it is essential that life care planners understand issues of osteochondral lesions (cartilage) that occur with these fractures that are directly related to functional outcomes, as well as the necessary future care needs.
Dislocated and unstable ankle fractures are usually treated with internal fixation with a goal of achieving proper alignment to improve gait and lessen the risk of posttraumatic arthritis. Healing of these fractures with proper alignment doesn’t guarantee a satisfactory outcome for many because there are often cartilage lesions that occur in nearly 80 percent of patients with ankle fractures that may lead to progressive degeneration of the joint overtime. Studies have indicated that in patients with cartilage lesions only 33% have good functional outcomes.
Ankle fractures are classified by the Weber Classification System where Weber A fractures involve the lower fibula, Weber B are fibula fractures at the mid-ankle, and C are higher fractures above the ankle. Studies involving arthroscopic evaluation of the joint provided at the time of surgical repair of the ankle fracture indicate that there are cartilage lesions at various locations within the joint but most often at the talus regardless if the fracture was a Weber A, B, or C. This is significant since the talus bone is essential for connecting the lower leg to the foot, and allows for most of the weight transfer from the foot to the leg with walking. Cartilage lesions in this key location overtime can lead to osteoarthritis, pain, and disability. This study also showed that the frequency and severity of the cartilage lesions increased with B and C fractures which supports the widely help belief that the more severe the injury the higher the fracture is on the fibula.
Customary care of unstable ankle fractures may lead to undiagnosed cartilage lesions. Patients with acute ankle fractures usually present to emergency rooms where x-rays are ordered; orthopedic surgeons are consulted, and generally these patients proceed on to surgery. Rarely will a MRI of the ankle be ordered which are needed to identify cartilage and soft tissue injuries. Therefore, arthroscopic evaluation of the ankle at the time of surgical repair is useful to identify associated cartilage lesions in the joint some of which, if repaired at the time of surgery, would decrease the risk of posttraumatic arthritis in the future. Arthroscopic evaluation of the joint in this study was found to be safe without any significant complications.
Case Managers must understand that ankle pain following surgical repair of an ankle fracture that persist after three months may need referral to an orthopedic-foot specialist with all the current skills to deal with cartilage defects such as retrograde drilling, microfracture procedures, and tissue transplantation. Understanding that Weber C fractures are twice as likely of having cartilage lesions, and careful review to determine if arthroscopic evaluation was provided at the time of surgery, and review to ensure all other etiologies of pain have been ruled out may be necessary. More often than not a second opinion may be required merely as a second look from another provider with all the skills necessary for contemporary ankle management.
Physician Life Care Planners must understand the consequences of cartilage injuries and how it relates to future care. They must understand acute care issues and how it may relate to future care needs. Patients with post-traumatic arthritis of the ankle have prescription medication cost, laboratory testing, therapeutic injections, physician follow ups, diagnostic tests, physical therapy, and surgical treatments including both total ankle arthroplasty (replacement) and ankle arthrodesis (fusion).
http://orthoweb.co.uk/onewebmedia/Ankle%20meta%20analysis%20longterm%20outcome.pdf
http://www.bjj.boneandjoint.org.uk/content/82-B/3/345.full.pdf
http://www.researchgate.net/profile/Benton_Heyworth/publication/26325305_Current_concepts_in_the_diagnosis_and_treatment_of_osteochondral_lesions_of_the_ankle/links/00b495149b27028f6a000000.pdf
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