Elderly patients with unstable ankle fractures could avoid surgery | University of Oxford

Elderly patients with unstable ankle fractures could avoid surgery

11 October 2016

Elderly patients with unstable ankle fractures could avoid surgery, according to research by a UK team led by Oxford University.

The study, published in the Journal of the American Medical Association, compared surgery to pin a broken ankle with a new plaster cast technique known as ‘close contact casting’.

Researcher Professor Keith Willett, of the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford, and the Kadoorie Centre for Critical Care Research and Education at Oxford University Hospitals NHS Foundation Trust, said: ‘Older adults – those over 60 – are suffering an increasing number of ankle fractures from leading more active lifestyles and the rising prevalence of osteoporosis. However, we know that older patients have disproportionately poor outcomes, and their quality of life can suffer as they lose mobility.’

Until now, two techniques have been used to treat unstable fractures. People either received open surgery to set and then fix the bones using plates and screws, or they received a traditional plaster cast.

Professor Willett said: ‘Each technique has drawbacks. Traditional plaster casts are associated with misaligned bones, poor healing and plaster sores. Surgery, especially in older people, is often complicated by poor implant fixation, wound healing problems and infection. However, a Cochrane review – considered a gold standard assessment of evidence for or against a medical technique or treatment – could not recommend preferring either treatment, as studies comparing them were of low quality.’

A new casting technique appeared to offer some advantages over both existing treatments, and a team of researchers set out to discover whether it could reduce the need for surgery while avoiding the drawbacks of traditional casts.

Close contact casting uses less padding than a traditional cast and sets the bones by being a close anatomical fit. The cast is applied by a surgeon under anaesthetic.

The study involved 620 patients at 24 UK hospitals, all of whom would usually have had surgery and who were randomly allocated to either surgery or to receive a close contact cast.

Each patient was assessed six weeks and then six months after treatment. After six months, there was no significant difference between the groups for pain, ankle motion or mobility. Patients were also given three questionnaires: the Olerud-Molander Ankle Score (specifically designed to assess progress in recovery from ankle injury) and the EQ-5D and SF-12 quality of life surveys. The average scores from these three questionnaires were also the same.

Surgery led to more adverse events, with 116 reported, compared with 71 for the close contact cast group. Close contact casting used less time in the operating theatre (around 54 minutes less per patient), though it required more outpatient consultations and use of hospital transport. The time spent in hospital and to get back on their feet was also similar.

Professor Willett said: ‘Overall, this study indicates that close contact casting may be an appropriate treatment for older adults, reducing the level of resources needed for treatment and avoiding some of the common complications of surgery.’

The trial was funded by the National Institute for Health Research (NIHR).

For further information, please contact Stuart Gillespie in the University of Oxford press office at stuart.gillespie@admin.ox.ac.uk or on +44 (0)1865 283877.

Notes to editors:

The paper ‘Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial’ will be published in the Journal of the American Medical Association, (DOI: 10.1001/jama.2016.14719).

The University of Oxford’s Medical Sciences Division is one of the largest biomedical research centres in Europe, with over 2,500 people involved in research and more than 2,800 students. The University is rated the best in the world for medicine, and it is home to the UK’s top-ranked medical school. From the genetic and molecular basis of disease to the latest advances in neuroscience, Oxford is at the forefront of medical research. It has one of the largest clinical trial portfolios in the UK and great expertise in taking discoveries from the lab into the clinic. Partnerships with the local NHS Trusts enable patients to benefit from close links between medical research and healthcare delivery. A great strength of Oxford medicine is its long-standing network of clinical research units in Asia and Africa, enabling world-leading research on the most pressing global health challenges such as malaria, TB, HIV/AIDS and flu. Oxford is also renowned for its large-scale studies which examine the role of factors such as smoking, alcohol and diet on cancer, heart disease and other conditions.

1. The National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme funds research about the effectiveness, costs, and broader impact of health technologies for those who use, manage and provide care in the NHS. It is the largest NIHR programme and publishes the results of its research in the Health Technology Assessment journal, with over 700 issues published to date. The journal’s 2014 Impact Factor (5.027) ranked it two out of 85 publications in the Health Care Sciences and Services category. All issues are available for download, free of charge, from the website. The HTA Programme is funded by the NIHR, with contributions from the CSO in Scotland, NISCHR in Wales, and the HSC R&D Division, Public Health Agency in Northern Ireland. www.nets.nihr.ac.uk/programmes/hta 

2. The National Institute for Health Research (NIHR) is funded by the Department of Health to improve the health and wealth of the nation through research. Since its establishment in April 2006, the NIHR has transformed research in the NHS. It has increased the volume of applied health research for the benefit of patients and the public, driven faster translation of basic science discoveries into tangible benefits for patients and the economy, and developed and supported the people who conduct and contribute to applied health research. The NIHR plays a key role in the Government’s strategy for economic growth, attracting investment by the life-sciences industries through its world-class infrastructure for health research. Together, the NIHR people, programmes, centres of excellence and systems represent the most integrated health research system in the world. For further information, visit the NIHR website (www.nihr.ac.uk).