SLR - December 2020 - Mai Pham

Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-Up Does Not Affect Outcomes: The Warrior Trial A Multicenter Randomized Controlled Trial

Reference: Van Gerven P, Krijnen P, Zuidema W, et al.Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes. The Journal of Bone and Joint Surgery. 2020;102(18):1588–1599. doi: 10.2106/JBJS.19.01381.

Level of evidence: Therapeutic Level 1

Scientific Literature Review

Reviewed By: Mai Pham, DPM
Residency Program: Montefiore Medical Center – Bronx, NY

Podiatric Relevance: Ankle fractures are common injuries treated by foot and ankle surgeons. Whether the patient is treated surgically or conservatively, routine radiographs have been utilized to evaluate for incongruity, bone healing, identifying complications, and patient education. Prior studies have shown that radiographs greater than three weeks after treatment has altered treatment regimen in only 1.2 percent of all patients. The goal of the study was to assess if omitting radiograph after the initial two weeks follow-up will affect functional and clinical outcomes in ankle fractures. 

Methods:  This study is a multicenter randomized controlled trial(RCT) with a noninferiority design which included 246 patients with an ankle fracture, 153 of these patients received operative treatment. The participants were randomly assigned to the routine care group(n=128) and reduced-imaging group(n=118) regardless of surgical or conservative management. The primary outcome was the Olerud-Molander Ankle Score (OMAS), which evaluates the patient-reported functional outcome. Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline(0) and at six, 12, 26, and 52 weeks of follow-up. The routine care group received routine radiographs at six weeks and 12 weeks, however was omitted for the reduced-imaging group. Data were analyzed with use of mixed models.

Results: The primary outcome using OMAS showed the reduced-imaging group was within the margin of noninferiority of the routine care group at all time points(ß, 20.9; 95 percent CI, 26.2 to 4.4). The secondary outcomes using AAOS showed comparable results at all time points as well. The EQ-5D-3L was similar at 52- weeks in both groups however the reduced-imaging group was higher at 6-weeks. HRQoL, pain, health perception, and self-perceived recovery was not significantly different between both groups. The reduced-imaging group received a median of four radiographs, whereas patients in the routine-care group received a median of five radiographs (p < 0.05). The rate of complications was (27.1 percent [32 of 118] in the reduced-imaging group compared with 22.7 percent [29 of 128] in the routine-care group, p = 0.42), which was not significantly different . The types of complications were also similar 

Conclusions: Although routine radiographs have been utilized as part of ankle fracture management, this study has shown that repeating radiographs did not have a significant difference in outcomes. This study’s findings can pave the way for new radiographic protocols following ankle fractures to reduce the number of unnecessary imaging. This article can help surgeons to apply this information towards clinical decision-making following ankle fractures necessitating routine follow-up radiographs.

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