SLR - October 2012 - Dong M. Kim
References: Sanders, D.W., Tieszer, C., Corbett, B. Operative Versus Nonoperative Treatment of Unstable Lateral Malleolar Fractures: A Randomized Multicenter Trial. J Orthop Trauma. 2012 Mar; 26(2): 129-34.
Scientific Literature Review
Reviewed by: Dong M. Kim, DPM
Residency Program: Inova Fairfax Hospital
Podiatric Relevance:
Ankle fractures are common fractures seen by foot and ankle surgeons. Depending on the extent of injury and instability caused by these fractures, surgical intervention is recommended. However, in certain patient populations and in simpler fractures, the need for surgical intervention is unclear. This study compared functional outcomes after operative versus nonoperative treatment of isolated unstable lateral malleolar fractures.
Methods:
The study design was a randomized multicenter clinical trial consisting of eighty-one patients with closed isolated lateral malleolar fractures from six level 1 trauma centers in North America. Only patients with “Weber B” fractures with a positive external rotation stress test were included. Patients were then randomized into an operative open reduction and internal fixation group or a nonoperative brace or cast immobilization group. Patients then completed functional outcome assessments as well as secondary assessments at enrollment, then six, 12, 24, and 52 weeks after treatment.
Results:
Utilizing the SF-36 score as well as the total OMA ankle score, the authors found no statistical significant difference at any time frame between the operative and nonoperative groups. With regard to radiographic results, there was one patient in the operative group with radiographic misalignment whereas eight patients in the nonoperative group had misalignment. Zero patients in the operative group had delayed or nonunion and eight patients in the nonoperative group had delayed or nonunion. Infection occurred in six patients in the operative group. Hardware removal was required in five patients in the operative group.
Conclusion:
Utilizing the functional scoring scales, there was no clear functional benefit to operative intervention. There were radiographic differences such as greater incidence of misalignment in the nonoperative group that may or may not have long term effects on function. The authors concluded that older and less active individuals can likely be safely treated with immobilization; however, younger patients may still warrant operative intervention.