Injury, Int. J.

Care Injured 41 (2010) 986–995

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Articular step-off and risk of post-traumatic osteoarthritis. Evidence today
P.V. Giannoudis a,*, C. Tzioupis a, A. Papathanassopoulos a, O. Obakponovwe a, C. Roberts b
a b

Academic Dept. of Trauma and Orthopaedics, School of Medicine, University of Leeds, UK Academic Dept. of Orthopaedic Surgery, School of Medicine, University of Louisville, Kentucky, USA

A R T I C L E I N F O

A B S T R A C T

Keywords: Articular step-off Post-traumatic arthritis Tibia Acetabulum Distal radius

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau. In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to be an adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone; these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs. ß 2010 Published by Elsevier Ltd.

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic science pathoanatomy . . . . . . . . . . . . . . . . . . . . . . . Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POINT 1 – quality of reduction-injury severity . . . POINT 2 – assessment method-validity of results. POINT 3 – incongruity and instability . . . . . . . . . . POINT 4 – age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POINT 5 – suitability of experimental models. . . . POINT 6 – differences among joints. . . . . . . . . . . . POINT 7 – comorbidities. . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 987 987 987 987 988 992 992 992 992 993 993 993 993 993

* Corresponding author at: Trauma & Orthopaedic Surgery, Academic Department of Trauma & Orthopaedics, Leeds General Infirmary, Clarendon wing, Level A, Great George Street, LS1 3EX, Leeds, UK; LIMM Section Musculoskeletal Disease, University of Leeds, UK. Tel.: +44 113 392 2750; fax: +44 113 392 3290. E-mail address: pgiannoudi@aol.com (P.V. Giannoudis). 0020–1383/$ – see front matter ß 2010 Published by Elsevier Ltd. doi:10.1016/j.injury.2010.08.003

63. joint congruence should also be perceived as the one pole of a dipole with the other being instability. J. and the severity of the injury.49. distal femur.45.48. Follow-up more than 3 years.73 The literature abounds with a wide-range of reduction criteria for fractures of the articular fractures of the knee.88. different joints respond differently to intraarticular injuries of similar magnitude and the incidence of post-traumatic osteoarthritis in various anatomical areas is dependent of several additional factors like the age of the patient.6. joint dislocations and intra-articular fractures.39. Basic science pathoanatomy On the basis of the type of tissue damage. depends on avoidance of a mechanical environment that is deleterious to articular cartilage. and (3) visible mechanical disruption of articular cartilage and bone.60.2. a critical literature review reveals that although there are many reports of case series where patients have done surprisingly well in the presence of substantial incongruity. The degree of incongruity and the size of the gaps between fracture fragments influence the extent and outcome of the repair and remodelling responses leading to clinically evident joint instability or malalignment or both. As a result.31. / Injury. soft tissue injuries. namely. Giannoudis et al. Int. and activate the inflammatory response. and irrelevant.16. considerable controversy surrounds the formulation of reduction guideline criteria. Depending on the degree of tissue damage.52. one of the major unresolved questions in trauma reconstructive surgery. small number of patients and variability of them as well as underscoring of concomitant ligamentous injuries and different methods of assessment.18.25 In the presence of articular surface incongruity and joint instability there is an abnormal loading of the cartilage and subchondral bone which exceeds the load-bearing capabilities of hyaline cartilage and leads to progressive cartilage degeneration.87 Furthermore.31 wrist 54.11. 3. that is.85. Care Injured 41 (2010) 986–995 987 Introduction The effects of injury to the articular cartilage sustained during articular fracture. or chondral defects. in most of these studies there is a heterogeneity of injuries. (2) visible mechanical disruption of articular cartilage only in the form of chondral fissures. and editorials were excluded.65 Therefore. The search was restricted to studies published in English.62. which begin forming a new matrix. Clear correlation of the Post-traumatic Arthritis (PA) with the residual step-off.36. others fare poorly in the presence of joint instability despite the congruously repaired intra-articular injuries.P. type-2 and -3 injuries have associated type-1 injuries. that is. Our inclusion criteria were: 1.15.65.75.74. Materials and methods We carried out an electronic search of the Medline database using the PubMed search engine from January 1970 up to January 2010 to retrieve all the relevant articles.99. Inclusion of more than 15 patients in clinical studies.16.107 . We have also excluded all publications that did not report the exact size of the step-off as well as publications which referred only to the residual post-traumatic gap.87.98.52. Case reports. 4.38.63 Commonly held beliefs inside the orthopaedic community are not consistently substantiated by evidence based data.33.72. 5.90.16.104 Successful orthopaedic treatment of intra-articular fractures.79.83. Furthermore.76. In each article.77 Platelets release vasoactive mediators. ‘‘joint’’ which were also used as keywords connected by boolean operators: OR/AND.18 Each type of tissue damage stimulates a different repair response and has a different prognosis.73. stimulating angiogenesis and migration of undifferentiated mesenchymal cells into the clot.41.50. Intra-articular fractures pertaining to four anatomical areas: distal radius. Full articles of the first category were retrieved.55.44.2–4. increase the risk of progressive joint degeneration that causes post-traumatic osteoarthritis (PA).34.25.V. and platelet-derived growth factors. acetabulum. flap tears.35.81.72.94. For these reasons.91 Indeed.20. tibial plateau.89. possibly relevant.71 based on the anatomical reduction of the cartilage and absolute stable fixation of the articular fragments.112 The clinical observation that the presence of residual incongruity at the time of fracture healing could lead to joint stiffness and long-term morbidity1. 2. provided that joint stability is maintained. Cadaveric. the repair response varies from restoration of matrix macromolecules to formation of fibrocartilaginous repair tissue. is the association between the accuracy of the reduction and the development of post-traumatic osteoarthritis. the degree to which a step-off of the joint must be reduced to ensure a satisfactory functional clinical result. which with their turn decrease the cartilage repair potential. reviews.96 However.102 Clinical experience and epidemiologic studies have showed that direct and indirect joint impact loading.18.95. Type-3 injuries cause haemorrhage and fibrin clot formation. we focused on the different methods of assessment that the authors used to determine the relationship between the functional result and the degree of the residual incongruity.69.103. English language.37.4.65. as well as the outcome of treatment interventions on joint preservation and function are yet poorly identified. 6.13. Results Our initial search yielded 77 potentially eligible publications out of which 36 were finally included in our study.51.12.100.11 Consequently.40.70. relevant.78.30.68. the repair and remodelling of intra-articular fractures differs from the events that follow injuries that cause only cell and matrix injury or disruption of the articular surface limited to articular cartilage. animal and clinical human studies.9.102 and acetabulum.1.19.27. The search was performed by use of The Medical Subject Headings (MeSH) using the terms ‘‘step-off’’.24. an intra-articular fracture. In clinical practice.42 The purpose of this study is to evaluate the current evidence with regards to articular step-offs and risk of osteoarthritis.32. intra-articular fractures include all three types of articular surface injury. In spite of several experimental data highlighting the joint degeneration following intra-articular injuries the pathomechanic predisposing factor of PA has yet to be identified. 29. articular surface injuries caused by mechanical forces can be classified into three types: (1) damage to the cells and matrices of articular cartilage and subchondral bone not related to detectable disruption of the joint surface.53. It appears that some lesions are well tolerated for many years without the development of advanced osteoarthritis. 22.108 has established the restoration of articular congruity as the key principle on the management of these injuries.35. Two reviewers evaluated each abstract according to the scientific content and allocated them to three broad categories.38.56–59.14. forming an ongoing vicious cycle.45. cytokines.

7.9.111 In total.22 Others.19. the severity of the injury to the articular cartilage.53. In a biomechanical study.62 Assessment methods were based mainly radiological imaging and clinical functional outcomes.26.69. In fractures of the acetabulum.75.47 21 fractures were treated non-operative (3%).100. Nevertheless. particularly lateral plateau injuries.6 Assessment methods were based mainly radiological imaging and clinical functional outcomes. The Tibial plateau has thicker articular cartilage than other joints which may have a protective effect against the development of POA. the extent of soft tissue injury and the expertise of the surgeon.69.19.90 One of these was biomechanical study62 and nine of them retrospective series.29. articular incongruities that are as large as the full thickness of the articular cartilage have remarkable ability to restore a nearly normal articular surface. 715 patients with 721 fractures of the tibial plateau were included.48. the results of operative treatment are dependent on several additional factors. In animal models the potential of the remodelling of various step-offs and their relation to the thickness of articular cartilage has been evaluated.7. the goal is to obtain anatomical restoration of the articular surface and stable internal fixation.88–90 827 patients with 827 fractures of the acetabulum were included.70.5.100.61.111 However.70.76.44.51.53.7 Additionally.75 However.22. Fracture patterns were classified according to the AO80.6. claimed that despite the radiographic evidence of osteoarthritis of the radiocarpal joint.88. high levels of function are achieved despite radio- graphic evidence of deterioration of the radiocarpal joint.6.61. Giannoudis et al.V. fall from a height (40%). is critical for a good clinical outcome.79. Steinman pins or plating. Schatzker97 classification or based on their topography. and Fernandez28 (10%) classification system.107 Two of these were biomechanical studies3. the authors advocate that the goal of treatment must be anatomical restoration of the articular surface of the distal aspect of the radius in order to minimise the risk of osteoarthrosis of the radiocarpal joint.22. 5 hip joints from three cadavers were used to determine the effect of intra-articular step-off on cartilage degeneration. The indications for surgical treatment vary from minimal displacement up to 10 mm step-off. Opinions differ as to degree of accuracy within which a given fractured articular surface needs to be restored. Several studies indicated that articular incongruity after tibial plateau fractures.5. Ten studies were analysed in the group of the acetabular fractures41.41.106 This could explain why joints with the same residual step-off following an intra-articular fracture vary greatly with respect to the risk of developing POA. 13 fresh cadaveric knees were used to determine the effect of residual intra-articular step-off on the occurrence of POA.56–60 The authors agree that step-offs greater than the average thickness of femoral articular cartilage cannot remodel successfully. The majority of the fractures (92%) were treated by closed or open reduction using K-wires.79.100 Catalano et al.44. Fractures were classified according to the Letournel-Judet system. However. Fracture were classified according to the Frykman32 (60%).25 Many studies attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome.51.9 The impact of articular step-off on the development of POA is shown on Table 1. A previous study . is well tolerated and that the quantity of articular congruity has little effect in determining management outcomes.61.78.69.8. it has long been a subject of controversy.22.43 Retention or not of the menisci during surgery.62. Discussion In the treatment of intra-articular fractures.62. all the authors have reported a positive correlation between the reduction of the superior articular surface and clinical – radiological outcome.89.79. the long-term negative clinical impact of these radiographic changes has not been clearly defined. valgus-varus angulation is poorly tolerated.19. Many studies have shown instability of the knee to be strongly associated with poor clinical outcomes.106 Factors other than articular congruence are also important for the final outcome.89 Complete or near anatomic reduction is essential for an excellent and longstanding recovery of the hip and this is extremely difficult to accomplish by non-operative treatment. The impact of articular step-off in relation to joint degeneration is shown in Table 3. Contrary to the tibial plateau fractures.78.62.107 Almost all the authors have shown that fractures being healed with an incongruous step-off >2 mm are associated with early osteoarthritis and in the majority of cases with a poor clinical result. Accident falls were the most frequent mechanism of injury (65% of the cases).51. The most common mechanisms of injury included motor vehicle accident (51%).70.3. Surprisingly. In the group of the distal radius fractures 10 studies were analysed. such as the involvement of the posterior wall.90 All of them agree that an anatomic reduction of the weight-bearing dome of the acetabulum should be achieved to minimise the incidence of post-traumatic arthritis.29.26.44.92. Two hundred and fifty-eight fractures (35%) were treated conservatively while the remaining 65% (463 fractures) were treated by closed or open reduction with internal fixation. In the group of the femoral condyles fractures five studies were eligible for further analysis. Assessment methods were based mainly on radiological imaging and clinical functional outcomes.78. The great majority of the patients were involved in traffic accidents (85%) while 11% of the patients sustained their injury after a fall.6 and eight of them retrospective series. the presence of articular steps at the time of the healing results in a higher prevalence of radiographic signs of arthritis.3.53. Most authors agree that the acceptable range of intra-articular step-off is in the range of 2–10 mm. only a few studies have examined the effect of articular reduction accuracy on distal femur fractures and none of them is clinical.56–60 All of them were animal studies and they used 159 rabbits to study the potential of the remodelling of various step-offs related to the thickness of articular cartilage (Table 4).2. and sport injuries (4%). Twenty human cadaver arms were used to determine the effect of intra-articular step-off on joint degeneration. patients assessed clinically demonstrated good or excellent functional outcome.92.55 Malalignment of the proximal tibia with the shaft may also contribute to poor outcomes after tibial plateau fractures. there is no agreement regarding the maximal acceptable step-off.92.44. The effect of stepoff on the development of POA is shown in Table 2.18.19 Plausible explanations for this could be that a longer follow-up may demonstrate deterioration in function and that radiographic measurements of step-offs may be imprecise because of nonstandardised radiographic techniques.76.75. On the other hand.26. claim that anatomic reduction <2 mm. Regarding the fractures of the distal radius.5.48. the accuracy of fracture reduction has been shown to be related directly to the clinical outcome regarding all acetabular fracture types.988 P. / Injury.8.55. Care Injured 41 (2010) 986–995 In the group of the tibial plateau fractures 11 studies met the inclusion criteria. Concerning the management of tibial plateau fractures.29. J. Regarding the biomechanical studies.5 A last attempt to explain the high tolerance for articular malalignment has been oriented towards the thickness of the cartilage.111 Two were biomechanical studies5.43.76.9 and nine of them retrospective. ‘‘Joint sensitivity’’ to step-offs is inversely correlated to cartilage thickness. AO80 (30%). Int.19.48.4.9.41.79 Finally. also plays a significant important role in the risk of developing osteoarthritis.107 Two hundred and sixty patients with 262 fractures of the distal radius were included.55.

8y Model 109 fractures Fracture type Undisplaced 28% Central depression 23% Split # with depression 17% Bicondylar 19% LATERAL 79 MEDIAL 11 BICONDYL 19 LATERAL 136 MEDIAL 23 BICONDYL 33 AO classific TYPE 1 = 16 TYPE 2 = 1 TYPE 3 = 22 TYPE 4 = 25 LATERAL 183 MEDIAL 29 BICONDYL 48 Intervention type OPERAT 47% 21 ORIF 30 BONE GRAFT CONSER 53% NON CONSERV Closed or open reduction with internal fixation OPERAT 60 (ORIF) 38 CLOSED METHODS 22 Method of assessment Clinical Radiological Conclusion Acceptable functional result with depression <10 mm Rasmussen (1972)92 Blokker et al.Table 1 Tibial plateau. 989 .V.1y Cadaver Clinical Retrospec F/U = 16m 260 fractures DeCoster et al. (1994)44 Clinical Retrospec F/U = 7.6m 192 fractures Clinical Radiological No different clinical outcome between <5 mm and >5 mm articular incongruity Adequacy of reduction is the most important factor in predicting outcome of operative treatment. Questionnaires.3y Clinical Retrosp F/U = 38. Classific = classification. Giannoudis et al. F/U = follow-up. J. Percutan = percutaneous. Care Injured 41 (2010) 986–995 Lansinger et al. Int. (2001)5 Cadav 6 knee LATERAL MEDIAL BICONDYL LATERAL 52% MEDIAL 12% BICONDYL 35% Osteochondral fracture of the lateral tibial plateau Schatzker classification Type 1 = 7 Type 2 = 8 Type 3 = 1 Type 4 = 2 Type 5 = 2 Lateral split Lateral split-compression Lateral compression Medial condyle Laterally tilting bicondylar Medial tilting bicondylar Split fractures of the lateral tibial plateau CONSERV 143 OPERATIV 117 Closed reduction Percutan fixation ORIF + bone graft CONSERV Cast Brace CLOSED TECHNIQ 73 Clinical Clinical Questionnaires Radiological Clinical Radiological Satisfactory results with conservative treatment for <4 mm displacement Operative stabilisation of tibial plateau fractures should be based not on roentgenographic criteria but on the knee stability in full extension Satisfactory results despite residual incongruity of 5–10 mm No difference between <2 mm and >2 mm Knee loading fixture Indirect reduction and percutan. (1992) 53 7 knee 20 fractures Honkonen et al. (1986)55 Clinical Retrosp F/U = 7. (2002)111 Clinical Retrosp F/U = 8y 24 fractures AO CLASSIF TYPE 2 = 1 TYPE 4 = 1 TYPE 5 = 1 TYPE 6 = 21 Monolateral external fixator and limited internal fixation Clinical. which is apparent at more than 4 mm step-off No correlation between articular surface reduction and knee score Cadav = cadaveric.4y Clinical Retrosp F/U = 5. Author (year) Lucht and Pilgaard (1971)61 Study Clinical Retrosp F/U = 5. Retrosp = retrospective. (1988)22 28 fractures Duwelius and Connolly (1988)26 100 fractures Brown et al. A residual step >5 mm associated with unsatisfactory result Inferior results when step-off >10 mm treated conservatively 60 fractures Clinical Radiological P. (1988)9 Koval et al. screw fixation Clinical Radiological OPER 58% ORIF CONSERV 42% Clinical Radiological No difference between <3 mm and >3 mm External fixator Biomechanical testing fixture Weigel et al.3y for 204 F/U = 20y for 102 Clinical Retrosp F/U = 11. / Injury. (1984)7 Clinical Retrosp F/U = 7.6y 131 fractures Bai et al. Radiological Increased articular step-off heights progressively increased valgus angulation and maximum contact pressures.

990 Table 2 Acetabulum.5y 57 fractures 58 fractures LETOURNEL Classification Fractures displaced at least 5 mm and involving at least one entire column 60% transverse and associated transverse with post-wall fractures OPERAT All the 58 Kocher-Langenbeck most often Clinical Radiological Clinical Radiological Excellent results for step-offs <2 mm P. (1993)89 Clinical Clinical Retrosp F/U = 7y Clinical Retrosp F/U = 7y Clinical Retrosp F/U = 3.V. (2000)78 94 fractures Malkani et al.7y Model 64 fractures Fracture type LETOURNEL Classification Fractures displaced at least 5 mm and involving at least one entire column Intervention type OPERAT 43 Kocher-Langenbeck CONSERV Pin traction 7w 21 Method of assessment Clinical Radiological Conclusion Residual displacement of more than 3 mm lead to progressive post-traumatic osteoarthrosis and a poor functional result Heeg et al. . Author (year) Matta et al.8y 100 fractures 50 fractures Kocher-Langenbeck mostly Lag screw + buttress plates Kocher-Langenbeck in all patients Multiple intra-fragmentary screws and combination of screws and reconstruct plates Clinical Radiological CT Biomechanical Testing Fixture Clinical Radiological Clinical (D’Aubigne-Postel scoring system) Radiological Acetabular posterior wall fracture step-off >1 cm considered as risk factor for unsatisfactory clinical result Transverse fracture >1 mm of displacement lead to significant increase in peak pressure at the articular surface Best clinical outcome with displacement <1 mm Excellent or good clinical outcome when residual displacement <2 mm Cadav = cadaveric. (1987)41 Pantazopoulos and Mousafiris (1989)88 Clinical Clinical Retrosp F/U = 5. F/U = follow-up. Care Injured 41 (2010) 986–995 Satisfactory results when displacement of the articular surface <3 mm Kebaish et al. (1986)70 Study Clinical Retrosp F/U = 3. Retrosp = retrospective. / Injury. J. (2002)79 Petsatodis et al. Percutan = percutaneous. Giannoudis et al. (2007)90 Clinical Retrosp F/U = 5y Clinical Retrosp F/U = 5.5y Cadav 90 fractures 52 fractures Waller’s classification Type 2 = 16 Type 3 = 36 LETOURNEL Classification 21% simple # 79% associated # Posterior wall fracture of the acetabulum associated with hip instability Transverse acetabular fracture at the weight-bearing dome Posterior wall fracture of the acetabulum associated with hip instability LETOURNEL Classification OPERAT All the 52 Kocher-Langenbeck most often Kocher-Langenbeck 43% Ilioinguinal 33% Iliofemoral 23% Kocher-Langenbeck mostly Lag screw + buttress plates Clinical Radiological Clinical Radiological Anatomic restoration of the joint led to 86% excellent or good result Minimal degenerative changes seen when acetabular posterior wall fracture step-off is less than 3 mm Excellent clinical results when<1 mm displacement and poor when >3 mm Matta et al. Classific = classification. (1996)69 262 fractures Clinical Radiological Moed et al. (1991)48 Pantazopoulos et al. (2001)62 5 hips Moed et al. Int.

FIX 2pat ORIF 3pat K-wires 12 Internal fixation plate 4 PERCUT REDUCT 21 ORIF 19 Method of assessment Clinical Radiological Conclusion Best outcome when reduction of the articular surface within 2 mm of anatomic alignment P. F/U = follow-up.6y Clinical Cadav 32 fractures Steffen et al. Care Injured 41 (2010) 986–995 Bradway et al. Retrosp = retrospective. Int. Classific = classification. (2000)75 Clinical Retrosp F/U = 19m 26 fractures Frykman Classificat Type 7 = 10 Type 8 = 11 Intra-articular fractures of the distal radius ORIF Arthroscopical reduction and percutan fixation with K-wires Cadav = cadaveric. Author (year) Knirk and Jupiter (1986)51 Study Clinical Retrosp F/U = 6. Giannoudis et al. (1996)6 52 fractures 8 arms Displaced fractures of the lunate fossa in the distal radius Barton’s # Anderson et al. (1992)76 Clinical Retrosp F/U = 4y Clinical Retrosp F/U = 11. (1997)19 Clinical Retrosp F/U = 7. J. 991 . (1989)8 Fernandez et al. (1991)29 Clinical Retrosp F/U = 4. Percutan = percutaneous. (1994)100 32 fractures AO classification Type C2 or C3 all fractures Classification FERNANDEZ 9 simple articular # (GROUP B) 31 complex (GROUP C) Frykman Classificat Type 7 = 5 Type 8 = 27 AO classific B fracture 9% C fracture 91% Clinical Radiological Clinical Radiological Best outcome when reduction of the articular surface within 2 mm of anatomic alignment No radiographic evidence of post-traumatic degenerative changes in fractures that healed with step-off up to 1 mm K-wires 8 K-wires + exfix 12 T-plate 10 Plate & exfix 2 AO external fixator Clinical Radiological Evidence of post-traumatic arthritis when intra-articular step-off exceeded 2 mm Clinical Radiological Clinical Radiological Biomechanical Testing Fixture Biomechanical Testing Fixture Clinical Radiological CT scan Clinical Radiological Evidence of post-traumatic arthritis when intra-articular step-off exceeded 2 mm Worse functional and radiographic outcome when step-offs >2 mm No increase in mean radiocarpal stress until step-offs of 3 mm Mean contact stress significantly greater at step-offs >3 mm Prevalence of osteoarthrosis when articular incongruity >2 mm but not correlated with the clinical outcome Acceptance of step-offs <1 mm Trumble et al.8y Clinical Retrosp F/U = 4y 16 fractures 40 fractures Missakian et al.V. / Injury. Exfix = external fixator.1y 21 fractures Mehta et al. (1994)107 Baratz et al.7y Model 43 fractures Fracture type Frykman Classificat Type 3 = 7% Type 4 = 12% Type 7 = 9% Type 8 = 72% Intervention type CONSER 21pat STEINMANN PINS 17 pat EXT. (1996)3 Cadav 12 arms Catalano et al.Table 3 Distal radius.

5 mm created on the load-bearing surface of medial condyle Coronal step-off of 0.67. The mechanisms involved in the onset and progression of joint degeneration after articular fracture are complex.14 Understanding these factors can help the surgeon anticipate outcomes and counsel patients appropriately. In addition. and the presence of instability and incongruity may severely exacerbate chronic hazardous cartilage loading. Care Injured 41 (2010) 986–995 Fracture type 5 mm articular condylar defect created Intervention type Fixation of the construct with a 2 mm cortical lag screw and k-wire Fixation with a 2 mm cortical screw Fixation of the construct with crossed k-wires Method of assessment Radiological Histological Biochemical Histological Biomechanical Radiological Histological Uronic Acid content Immunohistologic Autoradiographic Conclusion Step-off much greater than the average thickness of femoral articular cartilage cannot remodel successfully Step-offs exceeding the local thickness of articular cartilage (1 mm) do not heal Capacity for remodeling-repair of small step-offs (2 mm). changes that may be due to progressive cell senescence.67 These basic science studies have suggested that the risk of post-traumatic osteoarthritis increases with age.101 there has been a consistently observed association of instability with post-traumatic arthritis. even though the anatomical and radiological findings are imperfect. variances in reduction must be measured accurately and reliably. age appears to be one of the most substantial risk factors for the development of post-traumatic osteoarthritis.5 mm) may induce rapid degeneration of cartilage when the stability of the knee is compromised Llinas et al.0 mm created on the load-bearing surface of medial condyle Sagittal plane step-offs of 2 mm of the medial femoral condyle Lovasz et al.55.110 Indeed. J. Giannoudis et al. Patients who are .5 mm. CT may provide a method to improve the reliability of measurement of articular surface displacements. (1998)59 Cadav 21 rabbits Coronal step-off of 0. regardless of articular reduction.20 Therefore. Osteoarthrotic changes for 5 mm step-offs Articular step-offs of 0.V.64. clinical studies that have evaluated techniques to assess the accuracy of articular reduction have shown that none is a reliable clinical research tool. (1993)58 Cadav 54 rabbits Lefkoe et al. compared with one or the other alone.66. its effects must be distinguished from those of the severity of the injury. and biologic properties of the articular surface. fractures with more comminution lead to less satisfactory clinical outcomes.101. restoring normal anatomy does not necessarily decrease the risk of POA in all joints and in all individuals. However. Clinical studies have also supported the hypothesis that age is an important risk factor.992 Table 4 Femoral condyles.73 Equally or more important are differences among joints in the morphologic. POINT 3 – incongruity and instability The relation between articular fracture displacement and subsequent articular degeneration is complex. Studies relating congruity to outcome are furthermore complicated by the fact that the great majority of these studies do not control for the severity of the injury. it is clear that it is difficult to evaluate the effect of the size of the step-off on the development of osteoarthritis. Author (year) Lefkoe et al. then orthopaedic treatment ought to prioritise attaining suitable thresholds of joint stability.5 mm created on the load-bearing surface of medial condyle Fixation with a 2 mm cortical screw Lovasz et al. the stability of the joint. Before concluding step-off as the only parameter in the development of posttraumatic osteoarthritis. More importantly. fractures with more displacement and comminution tend to have less satisfactory reductions than simpler fractures do. POINT 1 – quality of reduction-injury severity To evaluate the quality of articular reduction fairly. The magnitude and type of articular fracture alone do not determine whether an injured joint will develop POA.57 Analysing the results obtained from the above studies. Int. confirms these findings showing that the sensitivity to step-offs was inversely correlated with cartilage thickness and in this way it can be explained why different joints with the same step-off following an intra-articular fracture vary greatly with respect to the risk of developing POA.25 Also. (1993)56 Study Cadav Model 34 rabbits P. / Injury.43.17. The degree of articular displacement and comminution is linked to the quality of surgical reduction. mechanical. Although clinical evidence linking incongruity to POA is inconclusive. However. the propensity for joint surface remodeling. and the age of the patient.66.43.21.5–1. if in fact instability per se is the more potent determinant of post-traumatic arthritis. both pathologic conditions often coexist after a severe intra-articular fracture. but their relative contribution to abnormal stress has not been well characterised.17. do not lead to rapid cartilage degeneration Even a minor step-off (0. (2001)60 Cadav 24 rabbits Fixation with a 2 mm cortical screw Immunohistologic Macroscopic Cadav = cadaveric. Conversely to plain radiographs. we recommend that one should also take into consideration the following variables which play a crucial role in such a development. POINT 2 – assessment method-validity of results To assess the effect of articular congruence on outcomes. Basic scientific investigations have shown that articular chondrocytes have profound age-related changes in the ability to respond to anabolic stimuli. correlating outcome with postoperative radiographic congruity is difficult. POINT 4 – age The risk of POA varies among joints and among individuals30 and investigators have been studying the reasons for the decreased capacity for healing of articular surface injuries with increasing age. (1995)57 Cadav 26 rabbits Coronal step-off 0. rather than its presently dominant strategy of attaining suitable thresholds of congruity.105.113 It is likely that instability and incongruity each can be important determinants of post-traumatic arthritis.23.24. equal to the cartilage height.93. Not all patients with an anatomic articular reduction have an optimal outcome and several long-term follow-up studies have revealed good functional results after non-operative treatment.

Differences among joints in the morphologic. 3. Rosenberg LA. Hahnel JC. 2. Bourne RB. This effect may be independent of articular reduction. it is unclear how articular surface remodelling is influenced by the severity of the initial injury. 6-mm defects showed minimal degenerative changes at 11 months after injury. Articular cartilage and knee joint function: basic science and arthroscopy. J Orthop Trauma 2001.9:559–67. Articular cartilage: composition. joint shape and congruency. repair. or other diseases may significantly influence a patient’s overall repair capacity after fracture. these include joint stability.423:7–16.10: 331–7.6: 851–62. J Orthop Trauma 1996. J Rheumatol Suppl 1995. Contact stress distributions in malreduced intraarticular distal radius fractures. Park Ridge IL: American Academy of Orthopaedic Surgeons. 6. compared with normal knees. Morgan SJ. An analysis of the results of treatment in 60 patients. POINT 7 – comorbidities Additional systemic effects may have significant influences on the fate of a joint after trauma.109 Most experimental models of articular surface incongruity have measured relatively mild increases in articular surface contact stress. 83–96. Anand S. 11. p. Blokker CP. Martin J. Contact stress aberrations following imprecise reduction of simple tibial plateau fractures. 16. Pope DF. Sangeorzan BJ. Aminian A. Ipsilateral talar and calcaneal fractures: a retrospective review of complications and sequelae.10 In a similarly conceived canine defect repair model. et al. 9.182:193–9. 19–56. Baratz ME. Comorbidities such as obesity. Buckwalter JA.73 In a canine cadaveric model. a negative clinical impact of these radiographic changes has not been convincingly demonstrated. mechanical and biologic properties of the articular surface can also affect the results. Nepola JV.39:480–4.372:159–68. 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Bai B. age.10. 12. step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA. Variation in articular cartilage thickness is the reason why joints with the same step-off following an intraarticular fracture vary greatly with respect to the risk of developing POA. Care Injured 41 (2010) 986–995 993 more than 50 years old have a 2–4-fold greater risk for the development of osteoarthritis following an intra-articular fracture of the knee. Giannoudis PV. 18. Int. / Injury. with no appreciable increase in static contact stress compared with the contralateral normal knee. In static contact pressure studies of knees from human cadavers.46. Kummer FJ. Static tests also cannot measure potential pathologic loads associated with instability. Sala DA.71:839–47. seems to be an adverse prognostic sign. and cartilage biologic and mechanical properties. however.82. diabetes. cannot measure loading rates. Bradway JK. Buckwalter JA. 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Open patellar fractures: high energy injuries with a poor outcome? Injury 2008. Buckwalter JA. Lane NE. but clinical experience has suggested that there is considerable variability among joints and individuals.85. Effects of osteochondral defect size on cartilage contact stress. Clin Orthop Relat Res 2000. Anderson DD. Open reduction and internal fixation of displaced. Different joints and even different areas of the same joint have different tolerances for posttraumatic articular step-offs. Hunziker EB. 7.23. with substantially lower increases in mean pressures. Buckwalter JA. editor. Buckwalter JA. Sensitivity to step-offs is inversely correlated with cartilage thickness. Imbriglia JE. knee and ankle tolerate incongruity differently. Instr Course Lect 2000. Giannoudis et al. mechanical investigations at the knee have concentrated almost entirely on static articular surface contact stress changes associated with incongruity. but in the second 5 years after injury. et al. Bacon S. 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