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Casting as Good as Surgery for Unstable Ankle Fractures in Older Adults

March 27, 2018

By Will Boggs MD

NEW YORK (Reuters Health) – In older adults with unstable ankle fracture, function of that ankle, quality-of-life, and pain are similar years after treatment with close contact casting or surgery, according to extended follow-up of a randomized clinical trial.

"Our findings indicate that close contact casting is an equal and appropriate alternative treatment to achieve the standard of care for older people with an unstable ankle fracture,” Dr. David J. Keene from University of Oxford, UK told Reuters Health by email. “These longer-term outcomes will help surgeons and individual patients to make informed decisions about the right treatment for them.”

Dr. Keene and colleagues in the Ankle Injury Management Trial earlier found equivalent ankle function outcomes at six months after these treatments, but there were higher rates of radiological ankle malunion and nonunion in the casting group.

In a March 27th online report in JAMA, they report on 450 original participants who were contacted 2.9 to 9.5 years after treatment (73% of those randomized). Participants were all at least 60 years old at the time of fracture.

Ankle function scores remained equivalent between the surgery and casting groups, and there were no significant differences in quality of life or pain, the researchers found.

About 10% of surgery participants and 8% of casting participants had operations after six months. In post hoc analysis, from randomization to last follow-up, mean total operating room procedures were 1.2 per participant in the surgery group and 1.3 per participant in the casting group, and mean total surgical procedures were 1.2 per participant in the surgery group and 0.3 per participant in the casting group.

Patients who had radiological malleolar malunion or medial malleolar nonunion at six months had significantly worse ankle function scores at last follow-up, compared with patients without such radiological findings.

"The findings indicate that treatment of ankle fractures in older adults should focus on obtaining and maintaining a reduction until union, by the most conservative means possible," the researchers conclude.

“The initial close contact casting was applied in the operating room under anesthesia,” Dr. Keene noted.


JAMA 2018.

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