Pathogenesis and prevention of posttraumatic osteoarthritis after intra-articular fracture

Abstract

Posttraumatic osteoarthritis (PTOA) occurs after traumatic injury to the joint. It is most common following injuries that disrupt the articular surface or lead to joint instability. The reported risk of PTOA following significant joint trauma is as high as 75%; articular fractures can increase the risk more than 20-fold. Despite recent advances in surgical management, the incidence of PTOA following intra-articular fractures has remained relatively unchanged over the last few decades. Pathogenesis of PTOA after intra-articular fracture is likely multifactorial and may be associated with acute cartilage injury as well as chronic joint overload secondary to instability, incongruity, and malalignment. Additional studies are needed to better elucidate how these factors contribute to the development of PTOA and to develop advanced treatment algorithms that consist of both acute biologic interventions targeted to decrease inflammation and cellular death in response to injury and improved surgical methods to restore stability, congruity, and alignment.

Figure 1

Radiographs of the ankle demonstrating the progression of posttraumatic osteoarthritis over 2 years. A, AP radiograph of the ankle demonstrating a fracture-dislocation. B, Postoperative AP radiograph of the ankle following fracture fixation. C, Follow-up AP radiograph of the ankle demonstrating severe degenerative changes at 2 years postoperatively.

Figure 2

Schematic demonstrating the balance between articular congruity, stability, and alignment proposed for a normal joint (top) versus an injured acetabulum (bottom left) and an injured tibial plateau (bottom right). Chronic cartilage injury affects the balance of joint congruity, stability, and alignment. The contribution of these factors to the progression of posttraumatic osteoarthritis is likely related to the joint involved.

Figure 3

A, Preoperative AP radiograph of a knee demonstrating a lateral tibial plateau fracture. B, Postoperative AP radiograph of the knee obtained 6 months after fracture fixation, demonstrating mild lateral (and posterior, not shown) subluxation of the tibia. Posterior cruciate ligament reconstruction was subsequently performed. C, Postoperative AP radiograph of the knee following posterior cruciate ligament reconstruction (at 18 months postinjury), demonstrating no early degenerative changes.