Surgical versus conservative interventions for treating ankle fractures in adults
Department of General and Trauma Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands. . Cochrane database of systematic reviews (Online)
(Impact Factor: 6.03).
08/2012; 8(8):CD008470. DOI: 10.1002/14651858.CD008470.pub2
The annual incidence of ankle fractures is 122 per 100,000 people. They usually affect young men and older women. The question of whether surgery or conservative treatment should be used for ankle fractures remains controversial.
To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 1), MEDLINE, EMBASE, CINAHL and the WHO International Clinical Trials Registry Platform and Current Controlled Trials. Date of last search: 6 February 2012.
Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included.
Two review authors independently performed study selection, risk of bias assessment and data extraction. Authors of the included studies were contacted to obtain original data.
Three randomised controlled trials and one quasi-randomised controlled trial were included. These involved a total of 292 participants with ankle fractures. All studies were at high risk of bias from lack of blinding. Additionally, loss to follow-up or inappropriate exclusion of participants put two trials at high risk of attrition bias. The trials used different and incompatible outcome measures for assessing function and pain. Only limited meta-analysis was possible for early treatment failure, some adverse events and radiological signs of arthritis.One trial, following up 92 of 111 randomised participants, found no statistically significant differences between surgery and conservative treatment in patient-reported symptoms (self assessed ankle "troubles": 11/43 versus 14/49; risk ratio (RR) 0.90, 95% CI 0.46 to 1.76) or walking difficulties at seven years follow-up. One trial, reporting data for 31 of 43 randomised participants, found a statistically significantly better mean Olerud score in the surgically treated group but no difference between the two groups in pain scores after a mean follow-up of 27 months. A third trial, reporting data for 49 of 96 randomised participants at 3.5 years follow-up, reported no difference between the two groups in a non-validated clinical score.Early treatment failure, generally reflecting the failure of closed reduction (criteria not reported in two trials) probably or explicitly leading to surgery in patients allocated conservative treatment, was significantly higher in the conservative treatment group (2/116 versus 19/129; RR 0.18, 95% CI 0.06 to 0.54). Otherwise, there were no statistically significant differences between the two groups in any of the reported complications. Pooled results from two trials of participants with radiological signs of osteoarthritis at averages of 3.5 and 7.0 years follow-up showed no between-group differences (44/66 versus 50/75; RR 1.05, 95% CI 0.83 to 1.31).
There is currently insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults. The identification of several ongoing randomised trials means that better evidence to inform this question is likely to be available in future.
Available from: Andreas Xyrichis
- "Bachmann et al.'s (2003) systematic review explored the accuracy of OAR in ankle and mid-foot fractures and established that employing the OAR could reduce unnecessary radiography by 40%, but it did not consider how this would impact on ED LoS. Previous Cochrane reviews have looked at effective treatment for ankle fractures (Donken et al., 2012) and ligament injury treatment (Kerkhoffs et al., 2013) but have not considered the OAR as a diagnostic tool. Furthermore the National Institute for Health and Care Excellence (NICE) in England currently offers no specific guidelines for the use of the OAR. "
Available from: Jitendra Mangwani
- "The annual incidence of ankle fractures (AF) is approximately 122-184/100,000 person years (1:800).123 The two age groups most commonly affected are young active men with high-energy trauma, and older women with low energy trauma.1234 "
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ABSTRACT: Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.
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ABSTRACT: Zusammenfassung Spunggelenkfrakturen sind häufige Verletzungen in der Traumatologie und Sportmedizin. Die Therapiestratifizierung, ob konservativ
oder operativ, ist weiterhin Gegenstand intensiver Diskussionen. Lauge-Hansen-, AO/OTA- (Arbeitsgemeinschaft für Osteosynthesefragen/“Orthopaedic
Trauma Association“) sowie die Weber-Klassifikation gelten als für die Beschreibung und Charakterisierung des Frakturtyps
geeignet und sind im klinischen Alltag bewährt. Für die Therapiestratifizierung sind Frakturcharakteristika, aber auch Kovariablen
wie Komorbiditäten, Compliance, Mobilität u. a. bedeutend. Die Frakturstabilität ist eine Determinante für eine konservative
Behandlung. Sie kann dynamisch oder statisch radiologisch bestimmt werden. Bei Erfüllung der Stabilitätskriterien kann eine
konservative, funktionelle Therapie eingeleitet werden. Diese subsumiert eine Immobilisierung in Gips, Cast, Unterschenkelorthese
oder Luftkammerschiene mit adaptierten Belastungsformen von Entlastung bis hin zur schmerzorientierten Vollbelastung an Unterarmgehstützen.
Das funktionelle Outcome ist bei Integrität der Gelenkkongruenz meist als gut einzuschätzen. Komplikationen sind selten.
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