SLR - May 2017 - Michael F. Kelly

Close Contact Casting vs. Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Control Trial

Reference: Willett K, Keene DJ, Mistry D, Nam J, Tutton E, Handley R, Morgan L, Roberts E, Briggs A, Lall R, Chesser TJ, Pallister I, Lamb SE; Ankle Injury Management (AIM) Trial Collaborators. Close Contact Casting vs. Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Control Trial. JAMA. 2016 Oct 11;316(14):1455–1463.

Reviewed By: Michael F. Kelly, DPM
Residency Program: Steward-St. Elizabeth’s Medical Center, Brighton, MA

Podiatric Relevance: The number of older adults sustaining ankle fractures is increasing, and they experience disproportionately poor outcomes. Ankle fractures cause loss of independence and quality of life, incurring substantial health costs. Treatment of unstable fractures is either surgical, using open reduction and internal fixation, or nonsurgical, using externally applied casts. Neither method yields an entirely satisfactory outcome in older adults. Traditional casting techniques are associated with poor fracture alignment and healing, as well as plaster sores. Surgery is often complicated by poor implant fixation, wound problems and infection. This study aims to determine if close contact casting (a molded below-knee cast with minimal padding) compared with internal fixation surgery results in an equivalent functional outcome for adults older than 60 years with an unstable ankle fracture.

Methods: This is a multicenter, equivalence randomized clinical trial with blinded outcome assessors performed at 24 UK major trauma centers and general hospitals that included 620 adults greater than 60 years of age with acute, overtly unstable ankle (malleolar) fracture(s) from July 2010 to November 2013. Exclusions were serious limb or concomitant disease or substantial cognitive impairment. The primary outcome was the Olerud-Molander Ankle Score (OMAS) at six months. Secondary outcomes were quality of life, pain, ankle motion, mobility, complications, health resource use and patient satisfaction.

Results: There was no significant difference in the primary outcome measure, OMAS scores, between close contact casting and surgery at six months after randomization. There were no significant differences in the secondary outcome measures: quality of life, pain, mobility and patient satisfaction at either six weeks or six months. There were small differences in ankle motion at six weeks but no differences at six months. Infection and wound breakdown were more common with surgery, and radiographic malunion was more common in the casting group.

Conclusions: Among older adults with an unstable ankle fracture, the use of close contact casting compared with surgery resulted in similar functional and satisfaction outcomes at six months. Close contact casting may be an appropriate treatment for such patients. There were higher rates of radiologic malunion with close contact casting, indicating that maintaining position was more difficult. The overall equivalence in clinical outcome, however, challenges the importance of restoring exact joint congruence in older adults and suggests that function and pain are not as closely related to malunion as many clinicians believe. Further research must be performed to yield outcomes over a longer time period, particularly assessing for the development of posttraumatic arthritis and its resulting change in functional outcomes. Additionally, further research is needed to distinguish if these results correlate to patients with IDDM and serious concomitant disease, of which were excluded in this study, and furthermore are not ideal candidates for surgical intervention. 

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