SLR - December 2018 - Michelle A. Hurless

Surgery for Type B Ankle Fracture Treatment: A Combined Randomized and Observational Study (CROSSBAT)

Reference: Mittal R, Harris IA, Adie S, et al. Surgery for Type B Ankle Fracture Treatment: A Combined Randomized and Observational Study (CROSSBAT). BMJ Open 2017;7:e013298. doi:10.1136/bmjopen-2016-013298

Scientific Literature Review

Reviewed By: Michelle A. Hurless, DPM
Residency Program: Hunt Regional Medical Center, Greenville, TX

Podiatric Relevance: Surgical versus conservative treatment of ankle fractures is often a topic of debate in podiatric medicine, which is especially true in the cases of isolated fibular fractures. Isolated Weber type B ankle fractures (AO-type 44-B1) are the most common type of ankle fractures; therefore, close attention should be paid to the care and management of these. When addressing this issue with a patient, we must be able to provide evidence as to why we are choosing conservative versus surgical treatment. The goal of this study was to evaluate whether there was a significant difference in the outcome of surgical versus conservative management of AO-type 44-B1 ankle fractures.  

Methods: This study was a combined randomized controlled trial and observational study. One hundred sixty patients were randomized, and 276 made up the observational cohort. Included in the study were patients ages 18 to 65 who sustained an AO-type 44-B1 ankle fracture without significant talar shift, who were within 10 days of the initial injury. Surgical treatment along with postop course and nonsurgical treatment were standardized. Outcomes were assessed using patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the Physical Component Score (PCS) of SF-12v2 General Health Survey at 12 months.

Results: The results from this study demonstrated that surgical treatment was not superior to nonsurgical treatment. In regard to the FAOQ, there was a statistically significant difference, which favored the outcome of the nonsurgical group; however, this was not clinically meaningful as the minimum and maximum values were 5.8–55.6 for the surgical group and 32.6–55.6 for the nonsurgical group. In regard to PCS, there was no statistical significance in the scores between the two groups. The surgical group, however, had a higher proportion of adverse events.   

The authors conclude that there is no difference in the short-term outcome in surgical versus nonsurgical treatment of AO-type 44-B1 ankle fractures. Although this study has a large sample population and is partially randomized, there were some missing pieces of information, which would make it more helpful. The amount of fibular displacement or angulation is not recorded, which is a key part of examining whether an ankle fracture should be treated surgically or conservatively. This could potentially make a difference in the long-term results with regards to stability, risk of posttraumatic arthritis and functionality. Overall, this study demonstrates a parity in the outcomes of surgical versus nonsurgical treatments of AO-type 44-B1 ankle fractures and should be taken into consideration in the future treatment of these ankle fractures. However, further studies are needed with longer follow-up, as well as documentation of fibular position after initial injury to make this study more applicable in everyday practice. 

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