Surgical versus conservative treatment for ankle fractures in adults

Each year, one in every 800 people break (fracture) their ankles. Such injuries typically happen to young men and older women. Ankle fractures can be treated surgically or conservatively (non-surgically). Surgery involves an operation to expose the fracture to reposition the broken parts of the bone and then fix them in place using wires, pins, screws and other devices. Treatment after surgery varies but may also include the use of a plaster cast. Conservative treatment involves repositioning of the fractured bone by manipulating it through the skin, followed by immobilisation of the ankle in a plaster cast for several weeks. This review aimed to find out whether surgery or conservative treatment gives a better long-term outcome for people with these injuries.

This review included four trials, involving a total of 292 participants. All four trials had flawed methods that could affect the reliability of their findings. No data could be pooled for long-term measures of function or pain. The largest trial found no evidence of differences between surgery and conservative treatment in patient-reported symptoms or walking difficulties at seven years follow-up. The second trial found better results for the surgical group for function but not pain at 27 months, while the third trial reported no difference between the two groups in clinical outcome at 3.5 years. In all four trials, there were some patients in the conservative treatment group who were treated surgically because the repositioning of the fractured bone was judged unsuccessful. Otherwise, there were no significant differences between the two groups in any of the reported complications nor in radiological signs of osteoarthritis.

Overall, there was not enough reliable evidence to draw conclusions about whether surgery or conservative treatment is more appropriate for treating broken ankles in adults.

Authors' conclusions: 

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.

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Background: 

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.

Objectives: 

To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults.

Search strategy: 

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.

Selection criteria: 

Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included.

Data collection and analysis: 

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.

Main results: 

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).

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