This study compared outcomes of surgical versus conservative management of ankle fractures in adults through a systematic review and meta-analysis.
MethodsWe searched CINAHL, EMBASE, MEDLINE and CENTRAL databases (1946 to 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.
Results1153 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.
ConclusionsSurgical 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.
Purpose There is limited evidence in literature regarding the patient-reported factors that inluence their return to sport (RTS) in revision anterior cruciate ligament reconstruction (ACLR). The medium-term results of a prospective consecutive cohort of patients undergoing single-and two-stage revision ACLR with bone patellar tendon bone graft (BPTB) and patient-reported factors that inluence their decision to return to sport are presented in this study. Methods Seventy-two patients were included in this prospective study. Single-or two-stage revision with BPTB graft was performed based on pre-operative planning. Iliac crest bone graft was used. Pre-operative and follow-up Lysholm and Tegner activity scores and RTS, level of sport and patient-reported factors afecting RTS were recorded. The mean follow-up was 9 years (SD 2.7 years). Results Single-stage revision ACLR was performed in 61 patients. In 11 patients (15%), revision ACLR was performed in two stages. There was a signiicant improvement in Lysholm score from mean 51.1 to 86.7 (p < 0.001). The incidence of re-rupture in this cohort was 0%. The median Tegner score was 6 (range 2-9). Twenty-ive patients (34.7%) did not return to any sport at inal follow-up. Twenty-nine (40.2%) patients returned to their pre-injury level of sport. Fear of reinjury (79%, p < 0.001) and persistent knee symptoms (35.8%, p = 0.03) were the most common factors limiting RTS in non-returners.
ConclusionPsychological and social factors may have an inluence on RTS in addition to physical factors. Level of evidence Level III Keywords Anterior cruciate ligament • Revision • Bone patellar tendon bone autograft • Psychological factors
Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training.
IntroductionAnkle fractures are common injuries in orthopaedic practice. Open reduction with internal fixation is the main line of management of displaced ankle fractures in fit patients. The study aims to analyse the complications, re-operation rate and cost difference between one-third tubular and locking plates which are the most frequently used constructs in lateral malleolus fractures.
Materials and methodsThe total number of presented ankle fractures from April to August during the years 2015, 2017 and 2019 to our Tertiary Hospital in the United Kingdom were screened. Data including operative fixation, plate used, complication rates, the need for revision surgery and metalwork removal were collected from the hospital's electronic Virtual Trauma Board. Patients who had less than one-year follow-up were excluded.
ResultsA total of 174 patients were included which represents more than half of presented ankle fractures (56%) with a decline in the mean age of operated patients from 56.4 in 2015 to 46.2 in 2019. The majority of fixation used tubular plates (n=122) versus (n=52) for locking plates. Locking plate fixation doubled from 10 in 2015 to 23 in 2019. However, they only contributed to 27% of the total operated ankle fractures. Despite the initial higher complications and removal rates of locking plates in 2015 (P<0.042 and P<0.038 respectively), there was no significant difference in overall complications, revision rates, and metalwork removal between locking plates and tubular plates (p=0.084, FEp= 0.158 and p=0.096 respectively). There was an estimated extra cost of £15938.60 for the use of locking plates during the study timeline.
ConclusionThere was no significant difference in overall complications, revision surgery and metalwork removal between tubular and locking plates in treating lateral malleolus fractures despite the significantly higher cost of locking constructs. Further studies are needed to illustrate the trend and cost-effective analysis of the tubular and locking plates in treating ankle fractures.
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