Unstable ankle fractures – a British multi-center study provides a neat alternative to surgery

Large multi-center RCTs are worth celebrating with fireworks. The image is CC by Colin Knowles.

The Brits have done it again: an amazing, multi-center study on ankle surgery. They looked at 620 unstable ankle fractures and compared close contact casting (CCC) with surgery. Like so many orthopaedic interventions it seems that both methods are equivalent regarding patient reported outcome although 15% had malunion vs 3% in in the surgical group. Likewise there was a higher non-union in the CCC group, 10% vs 3%. Furthermore about 1 in 5 in the CCC group required later surgery.

## Some thoughts

The major limitation is that the current follow-up time is only 6 months. The malunion an non-unions are certainly concerning and if there is no clear difference by 2 years, following them 5-10 years after surgery would be desirable. It is also important to remember that they only included patients over age of 60 and since the average age was 71 it may be wise to be restrictive with this approach in younger patients.

In summary I think this study offers an interesting alternative to surgery. The short follow-up time is the main issue, still in cases where I would prefer not to operate this may be a viable option. The authors are preparing the long-term follow-up, it will most likely be an interesting read.

D. J. Keene et al., The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years. 2016.

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