Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial

Comparative efficacy of cast immobilization versus removable braces in patients with ankle fractures: a systematic review and meta-analysis

BACKGROUND

An effective and appropriate method to support the ankle joint optimally is particularly important during the healing phase of ankle fractures. The purpose of this review was to assess the functional outcomes, ankle-related quality of life, and associated complications of cast immobilization versus removable braces for the treatment of adult ankle fractures.

METHODS

Studies comparing cast immobilization and removable braces after ankle fracture were included by systematic searches of PubMed/MEDLINE, Web of Science, Scopus, and EMBASE databases according to PRISMA (Preferred Reporting Items for Systematic Evaluation and Meta-Analysis Statements) guidelines. Primary outcome measures included early to mid-late Olerud Molander Ankle Score (OMAS). Secondary outcomes were ankle dorsiflexion and plantarflexion, swelling, pain, time to return to work, calf muscle atrophy, and complications. Subgroup analysis was performed. Risk of bias was assessed in both randomized controlled trials and cohort studies.

RESULTS

Eleven studies including 1485 patients met the eligibility criteria. The fracture types of the study included Weber A/B/C and Lauge-Hansen supination external rotation (SER), supination-adduction (SA), pronation-external rotation (PER) and pronation-abduction (PA). The results of the meta-analysis showed that removable braces had better early (mean difference (MD) -2.14; 95% confidence interval (CI) -4.26, 0.00) and mid-term functional outcomes (MD -5.81; 95% CI -10.35, -1.27) after ankle fracture compared with cast immobilization. In addition, removable braces caused significantly more wound breakdown (Odds ratio (OR) 0.39; 95% CI 0.17, 0.90) and wound infections (OR 0.32; 95% CI 0.17, 0.58) than cast immobilization.

CONCLUSION

Compared with cast immobilization, removable braces had better functional outcomes in the early and mid-term periods after ankle fractures and were less likely to result in deep vein thrombosis (DVT). Overall, the removable brace is a comfortable ankle fracture option that might improve functional outcomes.

Weight-Bearing Versus Non-Weight-Bearing After Ankle Fracture: A Systematic Review and Meta-Analysis of Patient-Reported Outcome

BACKGROUND

Ankle fractures commonly affect mobility and quality of life. Although unstable fractures typically require surgery, post-treatment protocols vary widely, including both surgical and conservative approaches. This systematic review and meta-analysis evaluated the effects of early weight-bearing after ankle fracture treatment on functional outcomes and quality of life.

METHODS

Following the PRISMA guidelines and the PICOS strategy, we performed a meta-analysis across multiple databases (PubMed, Embase, Scopus, and Cochrane Library). Analysis was conducted using Review Manager 5.4, calculating the mean and standard mean differences with 95% confidence intervals (CIs).

RESULTS

Eleven studies (n = 939) showed favorable outcomes with weight-bearing. Significant functional improvements were observed at 6 weeks (MD 7.88, 95% CI 3.14-12.61), 3 months (MD 5.79, 95% CI 4.41-7.17), and 12 months (MD 4.74, 95% CI 3.01-6.46). RAND scores favored the weight-bearing group at 6 weeks (SMD 0.48, 95% CI 0.26-0.70) and 12 months (SMD 0.31, 95% CI 0.07-0.55), with no significant differences at 3 months (SMD 0.18, 95% CI -0.10-0.46).

CONCLUSION

The outcomes obtained indicated statistically significant differences in favor of the early weight-bearing group regarding ankle function and quality of life.

Co-design of a novel rehabilitation intervention for patients after ankle fracture surgery: establishing healthcare professional consensus

Post-surgical rehabilitation advice after ankle fracture surgery, particularly regarding weight-bearing, varies significantly, leading to patient frustration and inconsistent recovery outcomes. This study aimed to establish a consensus for ankle fracture rehabilitation advice and identify content and implementation options for future interventions through consultation with healthcare professionals (HCPs). This study was part of the weight-bearing in ankle fractures (WAX) trial, a multicentre, randomised controlled trial. Using the behaviour change wheel (BCW) framework, three online workshops with HCPs were conducted between April 25, 2022, to May 4, 2022, to generate consensus on rehabilitation interventions. Participants completed pre-workshop tasks, and data were collected using an adapted nominal group technique (NGT). Workshop data were collated to create a survey with indicative statements about rehabilitation preferences. An online survey was subsequently disseminated to surgeons and physiotherapists between May 5, 2022, and July 13, 2022. Respondents were asked to indicate how strongly they agreed with various statements by ranking statements on a 5-point Likert scale from "strongly disagree" to "strongly agree"; 75% was used as a threshold for consensus agreement. Eight HCPs participated in the workshops, and 79 HCPs responded to the survey, representing 38 different NHS hospital trusts. Consensus was achieved on several key aspects: Patients could rest their foot on the floor while seated during non-weight-bearing periods and gradually increase weight-bearing based on comfort. It was agreed that orthotic boots are for comfort, and patients can discontinue use as early as two weeks post-operatively if weight-bearing is permitted. Guidelines for wound management, including when to get wounds wet and how to handle numbness, were also established. This study established a consensus for ankle fracture rehabilitation, emphasising patient autonomy and clear, standardised advice. The findings support the development of a tailored, patient-centred rehabilitation interventions, potentially delivered through digital platforms, to enhance recovery outcomes.

Femoral prosthesis alignment of augmented reality-assisted versus accelerometer-based navigation in total knee arthroplasty: A noninferiority analysis

INTRODUCTION

The purpose of this study was to examine the comparative precision of the augmented reality (AR)-assisted navigation system and the accelerometer-based navigation system in total knee arthroplasty (TKA).

MATERIALS AND METHODS

We performed noninferiority analysis in a retrospective cohort. The coronal alignment of femoral prosthesis was compared between 109 TKAs performed using the AR-assisted navigation system and 118 TKAs performed using the accelerometer-based navigation system. All femoral prostheses were planned to be positioned perpendicular to the mechanical axis of the femur. The primary outcome was the success rate of coronal alignment of the femoral prosthesis defined as alignment error relative to neutral alignment <3°. We calculated the noninferiority margin as 7%-points using the 95%-95 % method and also confirmed the validity of the noninferiority margin using the fixed margin method. Noninferiority would be shown if the lower boundary of the 95 % confidence interval (CI) for the between-group difference in percentage of the success rate was not less than 0.93 (i.e., 1.00 - 0.07).

RESULTS

Treatment success was achieved in 104 of 109 patients (95.4 %) in the AR-assisted navigation group and 110 of 118 (93.2 %) in the accelerometer-based navigation group. The risk ratio of success between the AR-assisted navigation group versus accelerometer-based navigation group was 1.02 (95 % CI, 0.96 to 1.09): the CIs did not include the noninferiority margin of 0.93.

CONCLUSION

The AR-assisted navigation system was noninferior to the accelerometer-based navigation system in terms of coronal alignment of the femoral prosthesis in TKA.

Rehabilitation for ankle fractures in adults

BACKGROUND

Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.

OBJECTIVES

To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.

MAIN RESULTS

We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise. All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data. Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants) Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence). Removable versus non-removable ankle support (25 studies, 2206 participants) Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence). Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants). Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants) Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.

AUTHORS' CONCLUSIONS

Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.

Unresolved issues with noninferiority pragmatic trials: Results of a literature survey

BACKGROUND

Issues with specification of margins, adherence, and analytic population can potentially bias results toward the alternative in randomized noninferiority pragmatic trials. To investigate this potential for bias, we conducted a targeted search of the medical literature to examine how noninferiority pragmatic trials address these issues.

METHODS

An Ovid MEDLINE database search was performed identifying publications in New England Journal of Medicine, Journal of the American Medical Association, Lancet, or British Medical Journal published between 2015 and 2021 that included the words "pragmatic" or "comparative effectiveness" and "noninferiority" or "non-inferiority." Our search identified 14 potential trials, 12 meeting our inclusion criteria (11 individually randomized, 1 cluster-randomized).

RESULTS

Eleven trials had results that met the criteria established for noninferiority. Noninferiority margins were prespecified for all trials; all but two trials provided justification of the margin. Most trials did some monitoring of treatment adherence. All trials conducted intent-to-treat or modified intent-to-treat analyses along with per-protocol analyses and these analyses reached similar conclusions. Only two trials included all randomized participants in the primary analysis, one used multiple imputation for missing data. The percentage excluded from primary analyses ranged from ∼2% to 30%. Reasons for exclusion included randomization in error, nonadherence, not receiving assigned treatment, death, withdrawal, lost to follow-up, and incomplete data.

CONCLUSION

Specification of margins, adherence, and analytic population require careful consideration to prevent bias toward the alternative in noninferiority pragmatic trials. Although separate guidance has been developed for noninferiority and pragmatic trials, it is not compatible with conducting a noninferiority pragmatic trial. Hence, these trials should probably not be done in their current format without developing new guidelines.

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes

OBJECTIVES

The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks.

METHODS

DESIGN

Prospective case-control study.

SETTING

Academic medical center; Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort).

OUTCOME MEASURES AND COMPARISONS

The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts.

RESULTS

One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05).

CONCLUSIONS

EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prospective randomized controlled trial: early weight bearing after conservative treatment of Weber B ankle fractures (pancake trial)

PURPOSE

Different studies have shown that weightbearing is safe in stable transsyndesmotic, isolated lateral simple ankle fractures. Despite this evidence, AO guidelines still recommend immobilization with above-the-knee cast for 4-6 weeks for these fractures. The objective of this study was to compare the outcomes of mobilization and weightbearing to those of immobilization and non-weightbearing in patients with stable transsyndesmotic, lateral isolated simple ankle fractures.

METHODS

Fifty patients were randomly assigned to permissive weightbearing in a walking boot or non-weightbearing immobilization using a below-the-knee cast. Primary outcome was ankle functionality as scored by the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were radiological displacement of fracture, range of motion (ROM), calf circumference, and RAND 36-item health survey. Patients were in follow-up for 24 months.

RESULTS

Ankle functionality after six and twelve weeks was significantly higher for the intervention group, with respectively 30 points (p = 0.001) and 10 points (p = 0.015) of difference. ROM improved significantly in the intervention group after six weeks. All fractures showed radiological progression of fracture healing. RAND 36-item showed differences in both physical (60.3 vs. 46.3, p = 0.017) and mental (78.5 vs. 58.2, p = 0.034) components in favor of the intervention group. In 16% of patients who initially showed stable fractures on radiographic imaging, joint dislocation was identified on weightbearing radiographs prior to randomization, leading to exclusion.

CONCLUSION

Weightbearing and mobilization using a walking boot may be a safe treatment for patients with stable Weber B fractures.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis

PURPOSE

There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures.

METHODS

A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score.

RESULTS

Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25).

CONCLUSION

Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively: A 2-Year Outcome Study

BACKGROUND

Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures.

METHODS

We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events.

RESULTS

The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome.

CONCLUSIONS

In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making.

LEVEL OF EVIDENCE

Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Functional orthosis versus cast immobilization for weightbearing stable Weber B ankle fractures with concomitant unstable gravity stress tests

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.

Methods

A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014).

Discussion

Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences.

Assessment of articular cartilage of ankle joint in stable and unstable unilateral weber type-B/SER-type ankle fractures shortly after trauma using T2 relaxation time

Background

Early detection of post-traumatic cartilage damage in the ankle joint in magnetic resonance images can be difficult due to disturbances to structures usually appearing over time.

Purpose

To study the articular cartilage of unilateral Weber type-B/SER-type ankle fractures shortly post-trauma using T2 relaxation time.

Material and Methods

Fifty one fractured ankles were gathered from consecutively screened patients, compiled initially for RCT studies, and treated at Oulu University Hospital and classified as stable (n = 28) and unstable fractures (n = 23) based on external-rotation stress test: medial clear space of ≥5 mm was interpreted as unstable. A control group of healthy young individuals (n = 19) was also gathered. All ankles were imaged on average 9 (range: 1 to 25) days after injury on a 3.0T MRI unit for T2 relaxation time assessment, and the cartilage was divided into sub-regions for comparison.

Results

Control group displayed significantly higher T2 values in tibial cartilage compared to stable (six out of nine regions, p-values = .003-.043) and unstable (six out of nine regions, p-values = .001-.037) ankle fractures. No differences were detected in talar cartilage. Also, no differences were observed between stable and unstable fractures in tibial or talar cartilage.

Conclusions

Lower T2 relaxation times of tibial cartilage in fractured ankles suggest intact extra cellular matrix (ECM) of the cartilage. Severity of the ankle fracture, measured by ankle stability, does not seem to increase ECM degradation immediately after trauma.

Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis

Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation"

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes^® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss^®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

[Injuries of the foot and ankle in winter sports]

Winter sports injuries of the foot and ankle are a relevant entity due to the high enthusiasm for alpine skiing and snowboarding. The condition of the footwear and rigidity of the binding have a significant influence on the pathobiomechanics of fracture development and have been shown to influence the frequency of knee and ankle injuries. Foot injuries are rare due to the sport-specific footwear with good padding and frequent hard shell casings.

The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture

INTRODUCTION

The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury.

MATERIALS AND METHODS

Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC).

RESULTS

This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4-20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1-15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months.

CONCLUSIONS

The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3-6-month follow-up and from 7.5 to 11.4 at 6-12-month follow-up, depending on moment and method.

Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study

BACKGROUND

Open reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications.

METHODS

Between April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery.

RESULTS

The mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72).

CONCLUSIONS

Although functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.

Ankle fractures in Finland: 118,929 operatively treated between 1987 and 2019

BACKGROUND AND PURPOSE

Ankle fractures are one of the most common fractures requiring operative treatment. They occur most commonly in postmenopausal women and younger men and recent studies suggest that the incidence of ankle fractures is increasing. In this registry study, we analyze inpatient data of operatively treated ankle fractures during a period of 33 years from our comprehensive nationwide register data.

PATIENTS AND METHODS

The data on operatively treated ankle fracture patients between January 1, 1987 and December 31, 2019 was collected from the Finnish National Hospital Discharge Register and analyzed.

RESULTS

118,929 ankle fractures were treated operatively. These included lateral malleolar fractures (33%), bior trimalleolar fractures (51%), medial malleolar fractures (7%), and other fractures (9%). Mean age was 53 (SD 17) years for women and 43 (16) for men. The average annual incidence rate was 69 per 100,000 person-years. Over the past 3 decades incidence has leveled off for women and has started to decline for men. However, the incidence is increasing in the elderly women group (over 70 years of age). In the over 50 age group, comorbidities have increased over the years, being more common in men than in women. The incidence of ankle fractures was higher during the winter months (November-March).

INTERPRETATION

The number of operatively treated ankle fractures has leveled off during the last 33 years. However, nowadays we operate on more difficult fractures in elderly patients with comorbidities.

Pragmatic trials of pain therapies: a systematic review of methods

ABSTRACT

Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials that assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively, and correlation analyses between prespecified trial features and PRECIS-2 (PRagmatic-Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological, or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited patients with chronic pain, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis, and interpretation of data. These improvements will facilitate translatability to other real-world settings-the purpose of pragmatic trials.

Surgery versus non-operative treatment for ER-stress unstable Weber-B unimalleolar fractures: a study protocol for a prospective randomized non-inferiority (Super-Fin) trial

Roughly two-thirds of ankle fractures are unimalleolar injuries, the Weber B-type fibula fracture being by far the most common type. Depending on the trauma and the accompanying soft-tissue injury, these fractures are either stable or unstable. Current clinical practice guidelines recommend surgical treatment for unstable Weber B-type fibula fractures. An ongoing randomized, parallel group, non-inferiority trial comparing surgery and non-operative treatment for unstable Weber B-type ankle fractures with allocation ratio 1:1. The rationale for non-inferiority design is as follows: By being able to prove non-inferiority of non-operative treatment, we would be able to avoid complications related to surgery. However, the primary concern related to non-operative treatment is increased risks of ankle mortise incongruency, leading to secondary surgery, early post-traumatic osteoarthritis and poor function. After providing informed consent, 126 patients aged 16 years or older with an unimalleolar Weber B-type unstable fibula fracture were randomly assigned to surgery (open reduction and internal fixation) or non-operative treatment (6-week cast immobilization). We have completed the patient enrolment and are currently in the final stages of the 2-year follow-up. The primary, non-inferiority outcome is the Olerud-Molander Ankle Score (OMAS) at 2 years (primary time point). The predefined non-inferiority margin is set at 8 OMAS points. Secondary outcomes include the Foot and Ankle Score, a 100 mm Visual Analogue Scale for function and pain, the RAND-36-Item Health Survey for health-related quality-of-life, the range-of-motion of the injured ankle, malunion (ankle joint incongruity) and fracture union. Treatment-related complications and harms; symptomatic non-unions, loss of congruity of the ankle joint, reoperations and wound infections will also be recorded. We hypothesize that non-operative treatment yields non-inferior functional outcome to surgery, the current standard treatment, with no increased risk of harms.

Functional bracing is a safe and cost effective treatment for isolated Weber B fracture

BACKGROUND

Despite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution's experience in managing these injuries and compare it to the national guidelines.

PATIENTS AND METHODS

This is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed.

RESULTS

One hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications.

CONCLUSION

Isolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.

Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study

BACKGROUND

In Weber B/SER2-4 ankle fractures, assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union, vs the uninjured side, for stable SER2 and partially unstable SER4a fracture types.

METHODS

We conducted a prospective case-control study designed as an equivalence trial to evaluate if weightbearing radiographs predict whether stable/SER2 and partially unstable/SER4a Weber B ankle fractures reach union with preserved normal tibiotalar congruence and without a concomitant increase of treatment failure. A total of 149 patients with a Weber B fracture stable on weightbearing radiographs were recruited into the trial. All participants were treated with a functional orthosis and weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 mm. We also evaluated the reliability of obtaining measurements from weightbearing radiographs.

RESULTS

No differences in medial clear space between the injured and uninjured ankles were observed after fracture union for the SER2 group (mean difference 0.1 mm, 95% confidence interval [CI] -0.3, 0.0; P = .056), or the SER4a group (mean difference 0.0 mm (95% CI -0.1, 0.1; P = .797). No between-group differences were observed (mean difference 0.0 mm, 95% CI -0.2, 0.2; P = .842). These findings were consistent with equivalence. CIs for the intraclass correlation coefficients indicated excellent reliability.

CONCLUSION

Assessment of stability of Weber B SER2/4a ankle fractures, with weightbearing radiographs, also predicts preservation of normal ankle congruence in those deemed stable, with no difference between SER2 and SER4a fracture types. Further, excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated.

LEVEL OF EVIDENCE

Level III, case-control.

Use of cast immobilisation versus removable brace in adults with an ankle fracture: multicentre randomised controlled trial

OBJECTIVES

To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture.

DESIGN

Multicentre randomised controlled trial.

SETTING

20 trauma units in the UK National Health Service.

PARTICIPANTS

669 adults aged 18 years and older with an acute ankle fracture suitable for cast immobilisation: 334 were randomised to a plaster cast and 335 to a removable brace.

INTERVENTIONS

A below the knee cast was applied and ankle range of movement exercises started on cast removal. The removable brace was fitted, and ankle range of movement exercises were started immediately.

MAIN OUTCOME MEASURES

Primary outcome was the Olerud Molander ankle score at 16 weeks, analysed by intention to treat. Secondary outcomes were Manchester-Oxford foot questionnaire, disability rating index, quality of life, and complications at 6, 10, and 16 weeks.

RESULTS

The mean age of participants was 46 years (SD 17 years) and 381 (57%) were women. 502 (75%) participants completed the study. No statistically significant difference was found in the Olerud Molander ankle score between the cast and removable brace groups at 16 weeks (favours brace: 1.8, 95% confidence interval -2.0 to 5.6). No clinically significant differences were found in the Olerud Molander ankle scores at other time points, in the secondary unadjusted, imputed, or per protocol analyses.

CONCLUSIONS

Traditional plaster casting was not found to be superior to functional bracing in adults with an ankle fracture. No statistically difference was found in the Olerud Molander ankle score between the trial arms at 16 weeks.

TRIAL REGISTRATION

ISRCTN registry ISRCTN15537280.

[Comparison of the effectiveness of the posterior malleolus fixed or not on treatment of different Haraguchi's classification of posterior malleolus fractures]

Objective

To investigate the effectiveness of fixation the posterior malleolus or not to treat different Haraguchi's classification of posterior malleolus fractures.

Methods

The clinical data of 86 trimalleolar fracture patients who were admitted between January 2015 and September 2019 and met the selection criteria were retrospectively reviewed. There were 29 males and 57 females; the age ranged from 26 to 82 years with a mean age of 55.2 years. According to Haraguchi's classification, 38 patients were in type Ⅰ group, 30 patients in type Ⅱ group, and 18 patients in type Ⅲ group. There was no significant difference in the general data such as gender, age, and fracture location among the 3 groups ( P>0.05). The fixation of the posterior malleolus was performed in 23, 21, and 5 patients in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The operation time, fracture healing time, full weight-bearing time, postoperative joint flatness, and joint degeneration degree of the patients in each group were recorded and compared. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to evaluate ankle function, including pain, quality of daily life, joint range of motion, and joint stability. The AOFAS scores were compared between fixation and non-fixation groups in each group.

Results

The procedure was successfully completed by all patients in each group, and there was no significant difference in operation time ( F=3.677, P=0.159). All patients were followed up 12-36 months with a mean time of 16.8 months. At last follow-up, 6 patients were found to have suboptimal ankle planarity, including 2 patients (5.3%) in the type Ⅰ group and 4 patients (13.3%) in the type Ⅱ group, with no significant difference between groups ( χ ²=6.566, P=0.161). The ankle joints of all the patients in each group showed mild degeneration; the fractures all healed well and no delayed union or nonunion occurred. There was no significant difference in the fracture healing time and full weight-bearing time between groups ( P>0.05). No complications such as incision infection, fracture displacement, or plate screw loosening and fracture occurred during follow-up. At last follow-up, the total scores and pain scores of the AOFAS scores in the type Ⅱ group were significantly lower than those in the type Ⅰand Ⅲ groups ( P<0.05), there was no significant difference between groups in the scores for the quality of daily life, joint range of motion, and joint stability between groups ( P>0.05). There was no significant difference in any of the scores between the unfixed and fixed groups, except for the pain and quality of daily life scores, which were significantly lower ( P<0.05) in the unfixed group of type Ⅱ group than the fixed group.

Conclusion

Haraguchi type Ⅱ posterior malleolus fractures have a worse prognosis than types Ⅰ and Ⅲ fractures, especially in terms of postoperative pain, which can be significantly improved by fixing the posterior malleolus; the presence or absence of posterior malleolus fixation in types Ⅰ and Ⅲ has less influence on prognosis.

Effectiveness of a Brief Group Intervention Program for Young Adults with Gaming-Related Problems

Excessive digital gaming can have unfavorable effects on gamers’ well-being and everyday functioning. The aims of this study were to investigate the effects of a novel group intervention “Limitless Gaming Bootcamp” on (i) gaming disorder (GD) tendencies, (ii) the amount of time spent on leisure activities, and (iii) subjective well-being among Finnish young adults, and to determine the persistence of the intervention’s influence over time. A one-group pre- and post-test design with no control group was used. Thirty-seven participants were enrolled in the study. The inclusion criteria were being between the ages of 18 and 29; self-reported excessive gaming; a willingness to get support in monitoring one’s gaming behaviour; and a fluency in Finnish. Participants completed a 10-session group intervention designed to enhance conscious gaming behavior and well-being. Baseline, post-test, and six month follow-up measurements were conducted to gather data. Variables measured included background variables, gaming disorder tendencies (Problematic Online Gaming Questionnaire, POGQ), self-reported time spent on various leisure activities, and subjective well-being (Short Form of the Clinical Outcomes in Routine Evaluation Outcome Measure, CORE-SF/A). The time spent on gaming decreased from pre- to post-intervention measurement and further to the six month follow-up, and participants exhibited less severe GD symptoms during the post-intervention phase and six months after the intervention. Gradual improvements in subjective well-being were also observed. The group intervention was found to be particularly effective at reducing the severity of GD symptoms.

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up

OBJECTIVES

To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification.

DESIGN

Retrospective.

SETTING

Main Trauma Center, University Hospital.

PATIENTS AND INTERVENTIONS

One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records.

MAIN OUTCOME MEASURES

Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification.

RESULTS

Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up.

CONCLUSIONS

The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An evaluation of the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture

OBJECTIVES

The aim of this study is to evaluate the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture.

METHODS

Patients completed outcome measure questionnaires at baseline, six, 10- and 16-weeks postinjury as part of an ongoing clinical trial on ankle fracture rehabilitation. The internal consistency, convergent validity, structural validity and interpretability of the Olerud Molander Ankle Score was assessed. This was achieved through using the respective analysis methods of Cronbach's alpha, correlation coefficients, principal component analysis, evaluation of floor and ceiling scores and estimation of the minimally important change using anchor-based methods.

RESULTS

The Olerud Molander Ankle Score showed adequate convergent validity against hypotheses set in relation to scores of comparator instruments. Principal component analysis demonstrated that the measure has two subscales: ankle function and ankle symptoms. The internal consistency of the measure and the ankle function subscale was sufficient, but inconclusive for the ankle symptoms subscale. There were no floor and ceiling effects present within the scores and the estimated minimally important change was 9.7 points.

CONCLUSION

The Olerud Molander Ankle Score demonstrates sufficient measurement properties and is likely to be primarily measuring the construct of patient reported function following ankle fracture. Further research should evaluate the relevance of other domains to individuals recovering from and ankle fracture, such as social participation and psychological wellbeing. The development of a core outcome set would be advantageous to standardise outcome measurement collection in this area.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

Background

In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.

Methods

In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.

Results

Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.

Conclusions

The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.

Trial registration

Registered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

Customized Three-Dimensional-Printed Orthopedic Close Contact Casts for the Treatment of Stable Ankle Fractures: Finite Element Analysis and a Pilot Study

Ankle fracture is one of the most common traumatic fractures among the elderly population. The majority of ankle fractures are stable types with the typically conservative strategy of close contact casting treatment. The continuous use of unventilated standard cast immobilization severely affects patient's satisfaction and compliance and markedly increases the rates of various complications. Three-dimensional (3D) printing for casts has advantages of lightweight, ventilated, proper-fit, and esthetic improvements. In this work, this novel 3D-printed cast has been applied to individuals with stable ankle fractures, and its effectiveness can be successfully validated with finite element analysis and a pilot study. A 30% reduction of the volume was chosen as the optimal result in topology optimization. Both 3D-printed casts and conventional casts showed significant ankle function improvement after immobilization for 6 weeks (p = 0.000). The 3D-printed casts were superior to the traditional casts in Olerud-Molander Ankle Scores (OMAS), with the mean difference of 8.3 ± 8.57 OMAS points (95% CI -10.8 to 27.5; p = 0.354) for 6 weeks, implying that the 3D-printed casts possibly maintain the equal clinical efficacy as the traditional casts. The statistically significant difference between groups from the 3D-printed cast and the traditional one observed in C-QUEST 2.0 was 11.3 ± 1.5 points (95% CI 8.0-14.6; p = 0.000), indicating that the 3D-printed cast possesses outperforming satisfaction and compliance and has great potential in practical applications. There were no severe complications in the 3D-printed casts, but more moderate complications were observed in the traditional casts.

Retrospective chart review of perioperative pain management of patients having surgery for closed ankle fractures using peripheral nerve blocks at a level one trauma center

Chronic opioid use is unfortunately perceived among these postoperative patients, specifically within orthopedic surgery. Patients having orthopedic surgeries are at risk for becoming addicted to opioids, and one benefit of peripheral nerves blocks could be to provide an alternative mode of pain control. This study takes a retrospective look at the use of peripheral nerve blocks for pain control following surgery for isolated traumatic ankle injuries. We hypothesize that when peripheral nerve blocks are administered preoperatively to patients with closed ankle fractures, they will have overall better control of postoperative pain compared to patients who did not receive a peripheral nerve block.

OBJECTIVES

The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery.

METHODS

After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria.

RESULTS

Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 ± 2.91 vs 3.52 ± 3.09; P = 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P = 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 ± 1.05 vs 0.94 ± 1.21 hours; P = 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P = 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P = 0.047).

CONCLUSION

Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.

How useful are virtual fracture clinics?: a systematic review

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Methods

We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author.

Results

In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000).

Conclusions

This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients.

Cite this article: Bone Joint Open 2020;1-11:683–690.

Isolated Trans-syndesmotic Fibular Fracture in a Skateboarder

A 20-year-old male military technician reported to a direct-access physical therapy clinic 1 week after falling off a skateboard. His primary complaint was left lateral ankle pain. Following examination, the physical therapist ordered ankle radiographs, which revealed a minimally displaced oblique trans-syndesmotic fibular fracture. J Orthop Sports Phys Ther 2020;50(7):410. doi:10.2519/jospt.2020.9355.

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study

Background and purpose - Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods - The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results - 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29-32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12-14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation - Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.