Injury, Int. J.

Care Injured 41 (2010) 986995

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 xation. 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-specied 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. 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 Inrmary, 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). 00201383/$ see front matter 2010 Published by Elsevier Ltd. doi:10.1016/j.injury.2010.08.003

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Introduction The effects of injury to the articular cartilage sustained during articular fracture, as well as the outcome of treatment interventions on joint preservation and function are yet poorly identied.14,31,34,63 Commonly held beliefs inside the orthopaedic community are not consistently substantiated by evidence based data.65,99,112 The clinical observation that the presence of residual incongruity at the time of fracture healing could lead to joint stiffness and long-term morbidity1,2,4,20,33,108 has established the restoration of articular congruity as the key principle on the management of these injuries.35,39,40,52,68,74,83,87,94,95,98,103,104 Successful orthopaedic treatment of intra-articular fractures,71 based on the anatomical reduction of the cartilage and absolute stable xation of the articular fragments, depends on avoidance of a mechanical environment that is deleterious to articular cartilage.12,25 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.72,102 Clinical experience and epidemiologic studies have showed that direct and indirect joint impact loading, soft tissue injuries, joint dislocations and intra-articular fractures, increase the risk of progressive joint degeneration that causes post-traumatic osteoarthritis (PA).13,15,16,27,30,37,45,49,50,96 However, 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, provided that joint stability is maintained, others fare poorly in the presence of joint instability despite the congruously repaired intra-articular injuries.16,65 Therefore, joint congruence should also be perceived as the one pole of a dipole with the other being instability. Furthermore, 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, and the severity of the injury.25,36,81,91 Indeed, one of the major unresolved questions in trauma reconstructive surgery, is the association between the accuracy of the reduction and the development of post-traumatic osteoarthritis. It appears that some lesions are well tolerated for many years without the development of advanced osteoarthritis.11 Consequently, considerable controversy surrounds the formulation of reduction guideline criteria, that is, the degree to which a step-off of the joint must be reduced to ensure a satisfactory functional clinical result.73 The literature abounds with a wide-range of reduction criteria for fractures of the articular fractures of the knee,31 wrist 54,102 and acetabulum.38,65,87 Furthermore, in most of these studies there is a heterogeneity of injuries, small number of patients and variability of them as well as underscoring of concomitant ligamentous injuries and different methods of assessment. In spite of several experimental data highlighting the joint degeneration following intra-articular injuries the pathomechanic predisposing factor of PA has yet to be identied.42 The purpose of this study is to evaluate the current evidence with regards to articular step-offs and risk of osteoarthritis. Basic science pathoanatomy On the basis of the type of tissue damage, articular surface injuries caused by mechanical forces can be classied 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, (2) visible mechanical disruption of articular cartilage only in the form of chondral ssures, ap tears, or chondral defects, and (3) visible mechanical disruption of articular cartilage and bone, that is, an intra-articular fracture.11,18 Each type of tissue damage stimulates a different repair response and has a different prognosis. In clinical practice, type-2 and -3 injuries have associated type-1 injuries. Type-3 injuries cause haemorrhage and brin clot formation, and activate the inammatory response.18,77 Platelets release vasoactive mediators, cytokines, and platelet-derived growth factors, stimulating angiogenesis and migration of undifferentiated mesenchymal cells into the clot, which begin forming a new matrix. As a result, 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. For these reasons, intra-articular fractures include all three types of articular surface injury. Depending on the degree of tissue damage, the repair response varies from restoration of matrix macromolecules to formation of brocartilaginous repair tissue. The degree of incongruity and the size of the gaps between fracture fragments inuence the extent and outcome of the repair and remodelling responses leading to clinically evident joint instability or malalignment or both, which with their turn decrease the cartilage repair potential, forming an ongoing vicious cycle. 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. The search was restricted to studies published in English. The search was performed by use of The Medical Subject Headings (MeSH) using the terms step-off, joint which were also used as keywords connected by boolean operators: OR/AND. Two reviewers evaluated each abstract according to the scientic content and allocated them to three broad categories, namely, relevant, possibly relevant, and irrelevant. Full articles of the rst category were retrieved. Our inclusion criteria were: 1. English language. 2. Cadaveric, animal and clinical human studies. 3. Intra-articular fractures pertaining to four anatomical areas: distal radius, acetabulum, distal femur, tibial plateau. 4. Clear correlation of the Post-traumatic Arthritis (PA) with the residual step-off. 5. Inclusion of more than 15 patients in clinical studies. 6. Follow-up more than 3 years. Case reports, reviews, and editorials were excluded. 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. In each article, 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. Results Our initial search yielded 77 potentially eligible publications out of which 36 were nally included in our study.1,24,6,9,16,18,
22,24,32,35,38,41,44,53,45,5659,60,51,52,55,62,63,69,70,72,73,48,78,88,89,79,90,85,19, 29,75,76,100,107

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In the group of the tibial plateau fractures 11 studies met the inclusion criteria.2,4,6,18,22,44,53,44,5,61,92,111 Two were biomechanical studies5,9 and nine of them retrospective.7,22,26,44,53,55,61,92,111 In total, 715 patients with 721 fractures of the tibial plateau were included. The most common mechanisms of injury included motor vehicle accident (51%), fall from a height (40%), and sport injuries (4%). Fracture patterns were classied according to the AO80, Schatzker97 classication or based on their topography. Two hundred and fty-eight fractures (35%) were treated conservatively while the remaining 65% (463 fractures) were treated by closed or open reduction with internal xation. Assessment methods were based mainly on radiological imaging and clinical functional outcomes. Regarding the biomechanical studies, 13 fresh cadaveric knees were used to determine the effect of residual intra-articular step-off on the occurrence of POA.5,9 The impact of articular step-off on the development of POA is shown on Table 1. Ten studies were analysed in the group of the acetabular fractures41,48,69,70,78,88,89,62,79,90 One of these was biomechanical study62 and nine of them retrospective series.41,48,69,70,78,79,8890 827 patients with 827 fractures of the acetabulum were included. The great majority of the patients were involved in trafc accidents (85%) while 11% of the patients sustained their injury after a fall. Fractures were classied according to the Letournel-Judet system,47 21 fractures were treated non-operative (3%). In a biomechanical study, 5 hip joints from three cadavers were used to determine the effect of intra-articular step-off on cartilage degeneration.62 Assessment methods were based mainly radiological imaging and clinical functional outcomes. The effect of stepoff on the development of POA is shown in Table 2. In the group of the distal radius fractures 10 studies were analysed.3,6,19,29,75,76,100,107 Two of these were biomechanical studies3,6 and eight of them retrospective series.8,19,29,51,75,76,100,107 Two hundred and sixty patients with 262 fractures of the distal radius were included. Accident falls were the most frequent mechanism of injury (65% of the cases). Fracture were classied according to the Frykman32 (60%), AO80 (30%), and Fernandez28 (10%) classication system. The majority of the fractures (92%) were treated by closed or open reduction using K-wires, Steinman pins or plating. Twenty human cadaver arms were used to determine the effect of intra-articular step-off on joint degeneration.3,6 Assessment methods were based mainly radiological imaging and clinical functional outcomes. The impact of articular step-off in relation to joint degeneration is shown in Table 3. In the group of the femoral condyles fractures ve studies were eligible for further analysis.5660 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). Discussion In the treatment of intra-articular fractures, the goal is to obtain anatomical restoration of the articular surface and stable internal xation.25 Many studies attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. Regarding the fractures of the distal radius, the presence of articular steps at the time of the healing results in a higher prevalence of radiographic signs of arthritis.29,51,76,107 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.8,19,51,75 However, the long-term negative clinical impact of these radiographic changes has not been clearly dened. Surprisingly, high levels of function are achieved despite radio-

graphic evidence of deterioration of the radiocarpal joint.19,100 Catalano et al. claimed that despite the radiographic evidence of osteoarthritis of the radiocarpal joint, patients assessed clinically demonstrated good or excellent functional outcome.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. Nevertheless, 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. Concerning the management of tibial plateau fractures, it has long been a subject of controversy. Opinions differ as to degree of accuracy within which a given fractured articular surface needs to be restored. The indications for surgical treatment vary from minimal displacement up to 10 mm step-off. Most authors agree that the acceptable range of intra-articular step-off is in the range of 210 mm.7,9,22,26,43,53,55,61,92,111 However, there is no agreement regarding the maximal acceptable step-off. Several studies indicated that articular incongruity after tibial plateau fractures, particularly lateral plateau injuries, is well tolerated and that the quantity of articular congruity has little effect in determining management outcomes.9,22 Others, claim that anatomic reduction <2 mm, is critical for a good clinical outcome.106 Factors other than articular congruence are also important for the nal outcome. Many studies have shown instability of the knee to be strongly associated with poor clinical outcomes.26,44,55 Malalignment of the proximal tibia with the shaft may also contribute to poor outcomes after tibial plateau fractures.5,7 Additionally, valgus-varus angulation is poorly tolerated.43 Retention or not of the menisci during surgery, also plays a signicant important role in the risk of developing osteoarthritis.5 A last attempt to explain the high tolerance for articular malalignment has been oriented towards the thickness of the cartilage. Joint sensitivity to step-offs is inversely correlated to cartilage thickness.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. The Tibial plateau has thicker articular cartilage than other joints which may have a protective effect against the development of POA. Contrary to the tibial plateau fractures, the accuracy of fracture reduction has been shown to be related directly to the clinical outcome regarding all acetabular fracture types.41,78,79,89 Complete or near anatomic reduction is essential for an excellent and longstanding recovery of the hip and this is extremely difcult to accomplish by non-operative treatment. In fractures of the acetabulum, all the authors have reported a positive correlation between the reduction of the superior articular surface and clinical radiological outcome.48,62,69,70,90 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. However, the results of operative treatment are dependent on several additional factors, such as the involvement of the posterior wall, the severity of the injury to the articular cartilage, the extent of soft tissue injury and the expertise of the surgeon.62,79 Finally, only a few studies have examined the effect of articular reduction accuracy on distal femur fractures and none of them is clinical. In animal models the potential of the remodelling of various step-offs and their relation to the thickness of articular cartilage has been evaluated.5660 The authors agree that step-offs greater than the average thickness of femoral articular cartilage cannot remodel successfully. On the other hand, articular incongruities that are as large as the full thickness of the articular cartilage have remarkable ability to restore a nearly normal articular surface. A previous study

Table 1 Tibial plateau. Author (year) Lucht and Pilgaard (1971)61 Study Clinical Retrosp F/U = 5.8y 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 classic 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 xation 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. (1984)7

Clinical Retrosp F/U = 7.3y Clinical Retrosp F/U = 38.6m

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. A residual step >5 mm associated with unsatisfactory result Inferior results when step-off >10 mm treated conservatively

60 fractures

Clinical Radiological

P.V. Giannoudis et al. / Injury, Int. J. Care Injured 41 (2010) 986995

Lansinger et al. (1986)55

Clinical Retrosp F/U = 7.3y for 204 F/U = 20y for 102 Clinical Retrosp F/U = 11.4y Clinical Retrosp F/U = 5.1y Cadaver Clinical Retrospec F/U = 16m

260 fractures

DeCoster et al. (1988)22

28 fractures

Duwelius and Connolly (1988)26

100 fractures

Brown et al. (1988)9 Koval et al. (1992)

53

7 knee 20 fractures

Honkonen et al. (1994)44

Clinical Retrospec F/U = 7.6y

131 fractures

Bai et al. (2001)5

Cadav

6 knee

LATERAL MEDIAL BICONDYL LATERAL 52% MEDIAL 12% BICONDYL 35% Osteochondral fracture of the lateral tibial plateau Schatzker classication 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 xation 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 510 mm No difference between <2 mm and >2 mm

Knee loading xture Indirect reduction and percutan. screw xation Clinical Radiological

OPER 58% ORIF CONSERV 42%

Clinical Radiological

No difference between <3 mm and >3 mm

External xator

Biomechanical testing xture

Weigel et al. (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 xator and limited internal xation

Clinical, Questionnaires, Radiological

Increased articular step-off heights progressively increased valgus angulation and maximum contact pressures, which is apparent at more than 4 mm step-off No correlation between articular surface reduction and knee score

Cadav = cadaveric, Classic = classication, F/U = follow-up, Percutan = percutaneous, Retrosp = retrospective.

989

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Table 2 Acetabulum. Author (year) Matta et al. (1986)70 Study Clinical Retrosp F/U = 3.7y Model 64 fractures Fracture type LETOURNEL Classication 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. (1987)41 Pantazopoulos and Mousaris (1989)88

Clinical Clinical Retrosp F/U = 5.5y

57 fractures 58 fractures LETOURNEL Classication 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.V. Giannoudis et al. / Injury, Int. J. Care Injured 41 (2010) 986995 Satisfactory results when displacement of the articular surface <3 mm

Kebaish et al. (1991)48 Pantazopoulos et al. (1993)89

Clinical Clinical Retrosp F/U = 7y Clinical Retrosp F/U = 7y Clinical Retrosp F/U = 3.5y Cadav

90 fractures 52 fractures Wallers classication Type 2 = 16 Type 3 = 36 LETOURNEL Classication 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 Classication 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. (1996)69

262 fractures

Clinical Radiological

Moed et al. (2000)78

94 fractures

Malkani et al. (2001)62

5 hips

Moed et al. (2002)79

Petsatodis et al. (2007)90

Clinical Retrosp F/U = 5y Clinical Retrosp F/U = 5.8y

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 (DAubigne-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 signicant 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, Classic = classication, F/U = follow-up, Percutan = percutaneous, Retrosp = retrospective.

Table 3 Distal radius. Author (year) Knirk and Jupiter (1986)51 Study Clinical Retrosp F/U = 6.7y Model 43 fractures Fracture type Frykman Classicat Type 3 = 7% Type 4 = 12% Type 7 = 9% Type 8 = 72% Intervention type CONSER 21pat STEINMANN PINS 17 pat EXT. FIX 2pat ORIF 3pat K-wires 12 Internal xation 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

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Bradway et al. (1989)8

Fernandez et al. (1991)29

Clinical Retrosp F/U = 4.8y Clinical Retrosp F/U = 4y

16 fractures

40 fractures

Missakian et al. (1992)76

Clinical Retrosp F/U = 4y Clinical Retrosp F/U = 11.6y Clinical Cadav

32 fractures

Steffen et al. (1994)100

32 fractures

AO classication Type C2 or C3 all fractures Classication FERNANDEZ 9 simple articular # (GROUP B) 31 complex (GROUP C) Frykman Classicat Type 7 = 5 Type 8 = 27 AO classic 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 + exx 12 T-plate 10 Plate & exx 2 AO external xator

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 signicantly 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. (1994)107 Baratz et al. (1996)6

52 fractures 8 arms Displaced fractures of the lunate fossa in the distal radius Bartons #

Anderson et al. (1996)3

Cadav

12 arms

Catalano et al. (1997)19

Clinical Retrosp F/U = 7.1y

21 fractures

Mehta et al. (2000)75

Clinical Retrosp F/U = 19m

26 fractures

Frykman Classicat Type 7 = 10 Type 8 = 11 Intra-articular fractures of the distal radius

ORIF

Arthroscopical reduction and percutan xation with K-wires

Cadav = cadaveric, Classic = classication, F/U = follow-up, Percutan = percutaneous, Retrosp = retrospective, Exx = external xator.

991

992 Table 4 Femoral condyles. Author (year) Lefkoe et al. (1993)56 Study Cadav Model 34 rabbits

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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). Osteoarthrotic changes for 5 mm step-offs Articular step-offs of 0.5 mm, equal to the cartilage height, do not lead to rapid cartilage degeneration Even a minor step-off (0.5 mm) may induce rapid degeneration of cartilage when the stability of the knee is compromised

Llinas et al. (1993)58

Cadav

54 rabbits

Lefkoe et al. (1995)57

Cadav

26 rabbits

Coronal step-off 0.51.0 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. (1998)59

Cadav

21 rabbits

Coronal step-off of 0.5 mm created on the load-bearing surface of medial condyle Coronal step-off of 0.5 mm created on the load-bearing surface of medial condyle

Fixation with a 2 mm cortical screw

Lovasz et al. (2001)60

Cadav

24 rabbits

Fixation with a 2 mm cortical screw

Immunohistologic Macroscopic

Cadav = cadaveric.

conrms these ndings 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.57 Analysing the results obtained from the above studies, it is clear that it is difcult to evaluate the effect of the size of the step-off on the development of osteoarthritis. 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, even though the anatomical and radiological ndings are imperfect. The mechanisms involved in the onset and progression of joint degeneration after articular fracture are complex. Before concluding step-off as the only parameter in the development of posttraumatic osteoarthritis, we recommend that one should also take into consideration the following variables which play a crucial role in such a development. POINT 1 quality of reduction-injury severity To evaluate the quality of articular reduction fairly, its effects must be distinguished from those of the severity of the injury. The degree of articular displacement and comminution is linked to the quality of surgical reduction; fractures with more displacement and comminution tend to have less satisfactory reductions than simpler fractures do.25 Also, fractures with more comminution lead to less satisfactory clinical outcomes, regardless of articular reduction. 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. POINT 2 assessment method-validity of results To assess the effect of articular congruence on outcomes, variances in reduction must be measured accurately and reliably. However, clinical studies that have evaluated techniques to assess the accuracy of articular reduction have shown that none is a reliable clinical research tool. Conversely to plain radiographs, CT may provide a method to improve the reliability of measurement of articular surface displacements.17,20 Therefore, correlating outcome with postoperative radiographic congruity is difcult.

POINT 3 incongruity and instability The relation between articular fracture displacement and subsequent articular degeneration is complex. The magnitude and type of articular fracture alone do not determine whether an injured joint will develop POA. In addition, restoring normal anatomy does not necessarily decrease the risk of POA in all joints and in all individuals.73 Equally or more important are differences among joints in the morphologic, mechanical, and biologic properties of the articular surface; the propensity for joint surface remodeling; the stability of the joint; and the age of the patient.14 Understanding these factors can help the surgeon anticipate outcomes and counsel patients appropriately. Although clinical evidence linking incongruity to POA is inconclusive,24,43,64,93,101 there has been a consistently observed association of instability with post-traumatic arthritis.21,23,55,105,113 It is likely that instability and incongruity each can be important determinants of post-traumatic arthritis, but their relative contribution to abnormal stress has not been well characterised. More importantly, both pathologic conditions often coexist after a severe intra-articular fracture, and the presence of instability and incongruity may severely exacerbate chronic hazardous cartilage loading, compared with one or the other alone. However, if in fact instability per se is the more potent determinant of post-traumatic arthritis, then orthopaedic treatment ought to prioritise attaining suitable thresholds of joint stability, rather than its presently dominant strategy of attaining suitable thresholds of congruity. 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.43,66,67,101,110 Indeed, age appears to be one of the most substantial risk factors for the development of post-traumatic osteoarthritis. Basic scientic investigations have shown that articular chondrocytes have profound age-related changes in the ability to respond to anabolic stimuli, changes that may be due to progressive cell senescence.17,66,67 These basic science studies have suggested that the risk of post-traumatic osteoarthritis increases with age. Clinical studies have also supported the hypothesis that age is an important risk factor. Patients who are

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more than 50 years old have a 24-fold greater risk for the development of osteoarthritis following an intra-articular fracture of the knee.43,110 POINT 5 suitability of experimental models As with the hip, mechanical investigations at the knee have concentrated almost entirely on static articular surface contact stress changes associated with incongruity. In static contact pressure studies of knees from human cadavers, articular surface step-offs as much as 5 mm on the tibial plateau resulted in 5075% increases in peak pressures, with substantially lower increases in mean pressures.73 In a canine cadaveric model, statically loaded cartilage defects as much as 7 mm in diameter in the medial femoral condyle showed mean contact stress increases of only 1030%, compared with normal knees.10 In a similarly conceived canine defect repair model, 6-mm defects showed minimal degenerative changes at 11 months after injury, with no appreciable increase in static contact stress compared with the contralateral normal knee.82 Instability induced in knees in canines by division of the ACL consistently produced POA, and dogs with ACL injuries modied their gait apparently to minimize instability.23,84,109 Most experimental models of articular surface incongruity have measured relatively mild increases in articular surface contact stress, even in the presence of large incongruities.9,10,46,82,85,86 However, the majority of these studies used static testing (loading across a joint in a xed position and no motion). Static testing cannot detect potential transiently elevated stresses, cannot measure loading rates, and cannot integrate potentially hazardous loads that accumulate as the joint courses through its ROM. Static tests also cannot measure potential pathologic loads associated with instability. Although these studies document that there is substantial potential for remodelling of intra articular step-offs and gaps in stable joints with isolated injuries, it is unclear how articular surface remodelling is inuenced by the severity of the initial injury, age, joint shape and congruency, cartilage thickness, and cartilage biologic and mechanical properties. Nor is it clear how rigid internal xation of intra articular step-offs and gaps affect remodeling of the articular surface. POINT 6 differences among joints Possible differences among joints and among individuals with regard to the risk of post-traumatic osteoarthritis have not been examined in experimental studies, but clinical experience has suggested that there is considerable variability among joints and individuals. Differences among joints in the morphologic, mechanical and biologic properties of the articular surface can also affect the results. Clinical studies show that the hip, knee and ankle tolerate incongruity differently. Differences in natural stability, congruity and cartilage thickness may be the explanation of this. Sensitivity to step-offs is inversely correlated with cartilage thickness. 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. POINT 7 comorbidities Additional systemic effects may have signicant inuences on the fate of a joint after trauma. Comorbidities such as obesity, diabetes, or other diseases may signicantly inuence a patients overall repair capacity after fracture.

Conclusions 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 have different tolerances for posttraumatic articular step-offs. 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. Animal experiments show that step-offs and gaps with a height or width comparable with that of the full thickness of the articular cartilage have considerable potential for repair and remodelling and suggest that isolated articular surface defects of this degree do not substantially increase the risk of joint degeneration in stable normally aligned joints. References
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