Surgical versus conservative management of ankle fractures in adults: A systematic review and meta-analysis.

AIMS: This study compared outcomes of surgical versus conservative management of ankle fractures in adults through a systematic review and meta-analysis. METHODS: We searched CINAHL, EMBASE, MEDLINE and CENTRAL databases (1946-June 2019) for randomised and quasi-randomised controlled trials comparing surgical versus conservative management of closed adult ankle fractures of any type. Estimates of effect were pooled using random effects meta-analysis. RESULTS: 1153 patients from 7 trials were included. Our primary outcome, ankle function score, was not statistically significantly different at 6-months (pooled mean difference (surgical minus conservative) = 1.0; 95% CI: -2.3 to 4.3; p = 0.55) or 12-months or more (pooled mean difference = 4.6; 95% CI: -1.0 to 10.2; p = 0.11) between surgical and conservative groups in three trials assessing displaced or unstable fractures, and two trials using non-validated questionnaires. One trial assessing AO-type-B1 fractures without talar shift had a statistically significant difference favouring conservative management, which was not clinically meaningful. Surgery had lower rates of early treatment failure and malunion/non-union, but higher rates of further surgery and infection. CONCLUSIONS: Surgical and conservative management of displaced or unstable ankle fractures produce similar short-term functional outcomes. The higher risk of early treatment failure and malunion/non-union in the conservative group versus higher rates of further surgery and infection in the surgical group should be considered. Trials are needed to assess longer-term results and inform management of select patient groups.

Endovascular therapy for acute severe pulmonary embolism.

Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000-180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25-65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.