Post-traumatic; Arthrosis, Post-Traumatic Osteoarthritis of Ankle, Tibial Fractures
Conditions
Brief summary
High-energy tibial pilon fractures have historically been associated with poor outcomes largely due to the elevated risk of severe post-traumatic arthritis. Intraarticular fractures result in a pro-inflammatory hemarthrosis that may further exacerbate the chondral damage that was sustained due to the original injury. This project will study the effect of joint lavage on the concentration of inflammatory cytokines in the ankle following a high-energy tibial pilon fracture and the resultant effect on short-term patient outcomes.
Detailed description
High-energy pilon fractures are associated with an increased risk of post-traumatic arthritis and poor patient outcomes. The risk of arthritis is over 25% in many series and can be upwards of 50% in more highly comminuted fracture patterns. Intraarticular fractures result in an increase in the synovial concentrations of inflammatory cytokines and matrix metalloproteinases. Animal models have demonstrated the irreversible damage a persistent hemarthrosis may have on cartilage viability suggesting that prolonged exposure to blood in this highly pro-inflammatory milieu may further exacerbate the chondral damage from the initial injury. However, the impact of these local inflammatory processes on the risk of post-traumatic arthritis and patient outcomes remain unclear. The long-term goal of our research is to develop treatment modalities including surgical and pharmaceutical interventions to reduce the risk post-traumatic arthritis and dysfunction following intraarticular fractures. The objective of this study is to determine the effect of ankle joint lavage on the risk of post-traumatic arthritis and patient outcomes following high-energy pilon fractures. First, we will obtain synovial fluid samples from the ankle joint of patients undergoing temporary external fixation of a pilon fracture for cytokine analysis. Then, we will randomize patients to undergo standard treatment with or without ankle joint lavage at the time of external fixation. Patients will undergo repeat synovial fluid analysis at the time of definitive fixation to determine the effect of lavage on the concentration of pro-inflammatory cytokines. Last, patients will be followed for a period of six months after surgery to determine the impact on functional outcomes. The information generated in this study will substantially add to our understanding of the pathogenesis of post-traumatic arthritis in high-energy pilon fractures.
Interventions
PROCEDUREJoint Lavage
An arthrotomy will be made at the time of temporary external fixation and 1L normal saline will be used to irrigate the ankle joint.
Sponsors
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Brooke Army Medical Center
United States Naval Medical Center, San Diego
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Outcomes Assessor)
Masking description
Cytokine analysis and radiographic assessment will be performed by a blinded assessor.
Intervention model description
Parallel randomized controlled trial
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* Male or female age 18 years or older * Present with an axially unstable tibial pilon fracture requiring temporary external fixation followed by delayed definitive internal fixation * Able to give informed consent
Exclusion criteria
* Open fractures * Delayed presentation greater than 72 hours post-injury * Associated talar body fracture * Presentation after initial ex-fix placement * Unreconstructable or unsalvageable joint * Preexisting ankle arthritis * Previous ankle surgery * Contralateral ankle injury * Age less than 18 years * Pregnant women * Individuals who are incarcerated
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The effect of intraarticular lavage on the synovial concentration of inflammatory cytokines | 2 years | The concentration of multiple pro-inflammatory cytokines will be measured in both the injured and non-injured extremity at the time of initial temporary external fixation and definitive fixation. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Effect of intraarticular lavage on functional outcomes following high-energy pilon fractures | 6 months | American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores will be collected at 3 and 6 months post-operatively. The AOFAS Ankle-hindfoot score is on a scale of 0-100 with higher scores indicating better function. |
| Effect of intraarticular lavage on radiographic outcomes following high-energy pilon fractures | 6 months | We will evaluate radiographs obtained during the first 6 months to determine the presence and severity of post-traumatic arthritis. |
| Effect of intraarticular lavage on range of motion following high-energy pilon fractures | 6 months | Range of motion measurements will be obtained at 3 and 6 months post-operatively |
Countries
United States
Contacts
Primary ContactBenjamin M Wheatley, MD
Outcome results
None listed