Midterm Follow-up of a Novel Algorithm for Nonoperative Weber B Ankle Fractures

Abstract

Background: Stable Weber B ankle fractures are routinely treated nonoperatively. Our group previously presented a novel algorithm that provides radiographic parameters guiding when Weber B ankle fractures can be treated nonoperatively.2 The purpose of this study is to evaluate the durability of those results with a minimum 5-year follow-up. Methods: All 51 patients who were included in the initial study were contacted by telephone and asked to return to clinic for repeat evaluation where American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander Ankle (OMA), and visual analog scale (VAS) scores were collected. Bilateral standing ankle radiographs were obtained and evaluated using the Kellgren-Lawrence grading scale for ankle arthritis. Results: Twenty-nine of 51 patients (56%) participated in this follow-up study with a mean follow-up of 6.8 (range 5.6-8) years. Average functional score results were as follows: AOFAS, 98.43; OMA score, 94.11; and VAS, 0.46. AOFAS scores improved by an average of 5 points between 1 year and 5 years ( P = .002); OMA and VAS scores were stable. All patients achieved union of their fracture on follow-up radiographs. Conclusion: Our findings demonstrate the durability of the previous study results conducted by Holmes et al,2 and support that appropriately selected patients can be treated nonoperatively using the study’s novel algorithm. This reinforces our theory that medial clear space widening on weightbearing radiographs up to 7 mm should be considered for nonoperative management. Level of Evidence: Level IV, case series.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively

“…However, the number of operatively treated patients would have been 63 (42%) of 151 if gravity stress test results had been used as the indication for a surgical procedure. These numbers correspond with previous observations 2-4,10-13 . Based on the observed similar efficacy of the new nonoperative treatment for SER4a fractures compared with the same, established treatment for SER2 fractures in this study, the necessity of a surgical procedure for SER4a fractures seems questionable.…”

“…Our results are broadly consistent with those in previous studies in that nonoperative treatment for Weber B fractures that are stable on weight-bearing (SER2 or SER4a) leads to satisfactory patient-reported and radiographic outcomes 2-4,10-13 . However, most studies have shown results for weight-bearing-stable fractures as a homogenous group and did not consider that weight-bearing-stable ankles may be entirely stable (SER2) or partially unstable (SER4a) as determined by stress tests.…”

“…However, our previous study assessed radiographic results only, and the study by Seidel et al 4 should be interpreted cautiously because of inconsistent treatment with different orthotic devices and immobilization. Our study avoided some of the methodological shortcomings of previous studies that were primarily retrospective 10,12,13 , lacking controls [10][11][12][13] , or biased by inconsistent followup protocols 4 , use of outcome measures lacking validity 10,11 , or did not report a power calculation 4,10,11 . The present study prospectively enrolled a large sample of patients with comparable baseline characteristics and standard care for SER2 fractures as a comparator and had a high follow-up rate at 2 years.…”

“…A solitary randomized controlled trial (RCT) found no outcome differences between operative and nonoperative treatment 9 . Cohorts have suggested that fractures deemed to be stable on weight-bearing radiographs (corresponding to SER2 and SER4a) can be managed nonoperatively with satisfactory results [2][3][4][10][11][12][13] . These studies were small and retrospective 4,[10][11][12][13] , and treatment protocols varied 4 ; thus, the treatment choice for SER4a fractures remains controversial.…”

Comparison of Outcomes at Midterm Follow-up of Operatively and Non-Operatively Treated Isolated Weber B Ankle Fractures

“…This nonoperative cohort underwent nonoperative treatment and ultimately had excellent clinical, radiographic, and patient-reported outcomes at initial and mid-term follow-up, with 100% union rates. 14,16 To date, there has been no operative group for comparison, which is necessary to further elucidate the optimal treatment for these ankle fractures.…”