SLR - May 2018 - Phillip M. Savage
Reference: Keene DJ, Lamb SE, Mistry D. Three-Year Follow-Up of a Trial of Close Contact Casting vs. Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults. JAMA. 2018; 319(12): 1274–1276.Scientific Literature Review
Reviewed By: Phillip M. Savage, DPM
Residency Program: Highlands-Presbyterian/St. Luke’s Medical Center, Denver, CO
Podiatric Relevance: Ankle fractures are commonly seen by podiatrists. They are either treated conservatively with immobilization or treated surgically. Much debate exists as to the factors that determine which route of treatment is best. This study examined an older population of patients with unstable ankle fractures who underwent either conservative treatment with close contact casting or surgical treatment. The authors examined functional outcomes comparing these two treatment methods.
Methods: This study was a longer-term follow-up for an original study published in in 2016. The original study randomized 620 adults over the age of 60 who sustained unstable ankle fractures to receive either closed reduction under anesthesia with close contact casting or surgical open reduction with internal fixation (ORIF). The close contact casting involved the use of a stockinette with padding over bony prominences and then a layer of plaster so that the cast was in total contact with the lower extremity before a superficial layer of synthetic casting material was applied. All surgeons were trained on how to apply the cast so that their techniques did not differ. The techniques and implants used in the ORIF group were based on individual surgeon preferences. The outcome measures used included the Olerud-Molander Ankle Score (OMAS), quality of life, pain scores and additional procedures performed. While the original study had a follow-up period of six months, this study continued to follow these outcome measures for three years.
Results: Four hundred fifty of the original 620 participants responded at a median follow-up of three years. The casting and surgery groups had equal ankle function with an OMAS in the casting group of 76.3 and an OMAS in the surgery group of 79.4. There were no significant differences between the two groups in regard to quality of life or pain scores. Eight percent of the casting group required an operation after six months while 10 percent of the surgery group required a reoperation after six months. These operations included hardware removal, arthrodesis, arthroplasty, and incision and drainage.
Conclusions: The authors concluded that in an older population with unstable ankle fractures, good functional outcomes can be obtained from either closed reduction with close contact casting or surgical ORIF. They found that equal functional outcomes were maintained at three years between the two groups. They state that their findings indicate that the treatment of ankle fractures in older patients should focus on obtaining and maintaining a reduction until union, by the most conservative means possible. I concluded that in an older population with ankle fractures, we should consider conservative treatment with closed reduction and total contact casting over traditional casting methods or other immobilization techniques, such as a CAM boot. The total contact casting appeared to maintain the reduction well with good outcomes at three years. In the case of more complex fractures with significant displacement, I would still consider surgical ORIF if closed reduction was difficult to obtain. In an older population, risks for complications following surgery are greater than in a younger population, which must also be taken into consideration when choosing a treatment method.