Surgical versus conservative interventions for treating ankle fractures in adults.

BACKGROUND: The annual incidence of ankle fractures is 122 per 100,000 people. They usually affect young men and older women. The question of whether surgery or conservative treatment should be used for ankle fractures remains controversial. OBJECTIVES: To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 1), MEDLINE, EMBASE, CINAHL and the WHO International Clinical Trials Registry Platform and Current Controlled Trials. Date of last search: 6 February 2012. SELECTION CRITERIA: Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. Authors of the included studies were contacted to obtain original data. MAIN RESULTS: Three randomised controlled trials and one quasi-randomised controlled trial were included. These involved a total of 292 participants with ankle fractures. All studies were at high risk of bias from lack of blinding. Additionally, loss to follow-up or inappropriate exclusion of participants put two trials at high risk of attrition bias. The trials used different and incompatible outcome measures for assessing function and pain. Only limited meta-analysis was possible for early treatment failure, some adverse events and radiological signs of arthritis.One trial, following up 92 of 111 randomised participants, found no statistically significant differences between surgery and conservative treatment in patient-reported symptoms (self assessed ankle "troubles": 11/43 versus 14/49; risk ratio (RR) 0.90, 95% CI 0.46 to 1.76) or walking difficulties at seven years follow-up. One trial, reporting data for 31 of 43 randomised participants, found a statistically significantly better mean Olerud score in the surgically treated group but no difference between the two groups in pain scores after a mean follow-up of 27 months. A third trial, reporting data for 49 of 96 randomised participants at 3.5 years follow-up, reported no difference between the two groups in a non-validated clinical score.Early treatment failure, generally reflecting the failure of closed reduction (criteria not reported in two trials) probably or explicitly leading to surgery in patients allocated conservative treatment, was significantly higher in the conservative treatment group (2/116 versus 19/129; RR 0.18, 95% CI 0.06 to 0.54). Otherwise, there were no statistically significant differences between the two groups in any of the reported complications. Pooled results from two trials of participants with radiological signs of osteoarthritis at averages of 3.5 and 7.0 years follow-up showed no between-group differences (44/66 versus 50/75; RR 1.05, 95% CI 0.83 to 1.31). AUTHORS' CONCLUSIONS: There is currently insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults. The identification of several ongoing randomised trials means that better evidence to inform this question is likely to be available in future.

Misdiagnosis of OTA type B (Weber B) ankle fractures leading to nonunion.

Little is known about the specific etiology of nonunion of stable Orthopaedic Trauma Association (OTA) type B fractures. In the present retrospective cohort study, we investigated all patients with a nonunion in a level 1 trauma center during an 8.5-year period. Patient history, clinical findings, radiographic features, and therapeutic aspects were critically evaluated to be able to predict the nonunion. In the predefined period, 388 patients were treated for a stable OTA type B fracture. Eight patients (2.1%) developed a nonunion. Retrospectively, the radiographic features in 6 of the 8 patients and clinical findings in 1 of the 8 patients could predict the nonunion. We conclude that in almost every nonunion occurring after a "stable" OTA type B fracture in the present study were, in fact, originally unstable fractures.

Use of an acrylic mold for mortise view improvement in ankle fractures: a feasibility study.

We investigated an acrylic mold for use in obtaining ankle radiographs in 31 consecutive patients with ankle fracture. The radiologic examination consisted of routine lateral and mortise views, with the same views procured with the use of the acrylic mold to position the ankle. Radiographic evidence of ankle displacement was ascertained using both sets of radiographs, and 3 radiographic spaces (lateral talofibular, central talotibial, and medial talotibial) were considered identifiable on the mortise view. The routine radiographs identified 58 joint spaces (62.37%) and the use of the acrylic mold showed 74 (79.57%; p < .0001). On the basis of the medial clear space, surgical repair was indicated in 6 patients (19.36%) using the routine radiographs and in 8 (25.81%) using the radiographs procured with the acrylic mold (p = .317). On the basis of fibular dislocation alone, surgical repair was indicated in 12 patients (38.71%) using the routine radiographs and in 15 (48.39%) using the radiographs procured with the acrylic mold (p = .083). On the basis of medial clear space and fibular dislocation, surgery was indicated in 12 patients (38.71%) using the routine radiographs and in 16 (51.61%) using the radiographs procured with the acrylic mold (p = .046). The sensitivity and specificity of the radiographs obtained with the acrylic mold was 75% and 100%, respectively. We concluded that the use of the acrylic mold improved the radiographic diagnostic accuracy compared with routine radiographs for the treatment of ankle fractures.

Functional reconstruction of a chronically ruptured extensor apparatus after patellectomy.

Rupture of the knee extensor mechanism after previous patellectomy is rare. A treatment protocol therefore is not available. This article presents a new and easy technique using a gracilis-semitendinosus tendon autograft for successful reconstruction of a ruptured knee extensor mechanism after previous patellectomy.

Twenty-one-year follow-up of supination-external rotation type II-IV (OTA type B) ankle fractures: a retrospective cohort study.

OBJECTIVE: To evaluate long-term results after protocoled treatment of supination-external rotation (SER) Type II-IV ankle injuries. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Two hundred seventy-six adult patients with an SER Type II-IV ankle fracture between January 1, 1985, and January 1, 1990. All patients were approached to participate in this study. INTERVENTION: Fractures with tibiotalar congruity were treated nonoperative and unstable fractures with joint incongruity were treated operatively. MEAN OUTCOME MEASUREMENTS: 1) a functional outcome questionnaire (Olerud score); 2) range of motion; 3) functional impairment (American Medical Association guidelines); and 4) radiologic anatomic result (medial clear space widening; osteoarthritis; Cedell score). RESULTS: After a median of 21 years in 54% (n = 148) of patients, follow-up was achieved. Seventy-six patients (51%) had a SER Type II injury, four patients (3%) a SER Type III injury, and 68 (46%) had sustained a SER Type IV. Excellent or good results were found in 92% (Olerud score), 97% (loaded dorsal range of motion), 92% (medial clear space widening), 97% (osteoarthritis), and 76% (Cedell score) of patients. Functional impairment expressed as percentage of whole person impairment varied between 0% and 16%. The various fracture types performed statistically equal on all outcome parameters. There was no difference between operative and nonoperative treatment. There was no correlation between the Olerud score and other parameters. CONCLUSIONS: The very long-term overall results of the stratified surgical treatment of SER Type II-IV ankle fractures is 'excellent' or 'good' in the majority of patients and therefore seems justified. Although additional soft tissue damage is unavoidable in case of operative treatment, it does not negatively affect outcome in the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Twenty-two-year follow-up of pronation external rotation type III-IV (OTA type C) ankle fractures: a retrospective cohort study.

OBJECTIVE: Long-term evaluation protocolled treatment of pronation external rotation (PER) type III-IV (OTA type C) ankle fractures. DESIGN: Level III retrospective cohort study. SETTING: Level I trauma center. PATIENTS: A consecutive series of 98 patients with PER III-IV ankle fractures between 1985 and 1990. INTERVENTION: Stable fractures with tibiotalar congruity were treated conservatively, whereas osteosynthesis was performed in unstable and displaced fractures to restore tibiotalar congruity. MAIN OUTCOME MEASUREMENTS: Outcome parameters were (1) functional outcome questionnaire (Olerud score), (2) physical evaluation (loaded dorsal range of motion), (3) functional impairment (AMA Guides, 5th ed.), and (4) radiographic evaluation (Cedell score, medial clear space widening, and osteoarthritis). RESULTS: After a median of 22 years, follow-up was achieved in 95% (n = 60) of living patients. Four patients had a true PER III injury, 5 patients had an unclear injury (between PER III and IV), and 51 patients (85%) sustained a PER IV injury. Excellent or good results were found in 90% of patients (Olerud score). Functional impairment, expressed as percentage of Whole Person Impairment, varied between 0% and 3%. Patients treated operatively and conservatively had statistically equivalent scores. CONCLUSIONS: The long-term result of surgical treatment of PER ankle fractures is "good" or "excellent" in the majority of patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.