Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults

Willett, Keith; Keene, David; Mistry, Dipesh; Nam, Julian; Tutton, Elizabeth; Handley, Robert; Morgan, Lesley; Roberts, Emma; Briggs, Andrew; Lall, Ranjit; Chesser, T.J.S.; Pallister, Ian; Lamb, Sarah E

doi:10.1001/jama.2016.14719

Cited by 99 publications

(90 citation statements)

References 28 publications

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“…Patients in both study arms were kept on non- or limited weight-bearing status at the discretion of the treating physician. All patients in this study with insulin-dependent diabetes mellitus (IDDM) were excluded [21•]. Six-hundred twenty patients were included, and after 6 months, the Olerud-Molander ankle score (OMAS), post-fracture symptoms, quality of life, pain, ankle motion, patient satisfaction, and mobility were equivalent in both groups.…”

Section: Introductionmentioning

confidence: 99%

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

2017

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Purpose of ReviewTreatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.Recent FindingsTreatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.SummaryAn optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.

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Section: Introductionmentioning

confidence: 99%

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

2017

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“…One trial on unstable malleolar fractures (n = 592) [50] and one trial on humeral shaft fractures (n = 96) [42] demonstrated fewer SAEs in the surgical compared to the non-surgical group.…”

Section: Synthesis Of Resultsmentioning

confidence: 99%

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

et al. 2020

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Background: A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures. Methods: We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used. Results: Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.

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“…Infections and additional procedures were more common in the surgical group (10% vs. 1 and 6% vs. 1%, respectively), although 19% of patients initially treated with casts later had surgery. A higher rate of malunion and non-union of the medial malleolus was observed at long-term follow-up in the close-contact-cast group but this did not affect functional outcomes which remained equivalent at 3 years [7,8]. Close-contact-casting resulted in high initial and modest long-term cost savings and had a high probability of being cost-effective [9].…”

Section: Introductionmentioning

confidence: 88%

“…Participants in the surgical group spent longer in hospital and had more minor adverse events [5], however, delayed bone union was more common in the non-surgical group [6]. In older patients with unstable ankle fractures, a large RCT comparing internal fixation versus close-contact-casting reported equivalent ankle function at 6-months [7]. Infections and additional procedures were more common in the surgical group (10% vs. 1 and 6% vs. 1%, respectively), although 19% of patients initially treated with casts later had surgery.…”

Section: Introductionmentioning

confidence: 99%

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Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

Scott

Jones

Whitehouse

et al. 2020

BMC Health Serv Res

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Background: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contactcasting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. Methods: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. Results: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. Conclusions: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contactcasting, in line with recent evidence.

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Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults

Cited by 99 publications

References 28 publications

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

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