SAN DIEGO — Treatment of overtly unstable malleolar fractures with close contact casting showed outcomes equivalent to those of open reduction and internal fixation among elderly patients and were associated with a cost reduction in results of a multicenter study presented at the Orthopaedic Trauma Association Annual Meeting, here.
“Preferentially selecting a strategy of closed contact casting provided equivalent functional outcomes to open reduction internal fixation in all measures at 6 months with less resources used,” Prof. Keith Willett, FRCS, of the University of Oxford, in Oxford, United Kingdom, said. “A proportion of patients with close contact casting will convert to surgery. It can be avoided in four out of five patients.”
CCC vs ORIF
Willett and colleagues randomly assigned 620 patients older than 60 years with unstable malleolar fractures to undergo either close contact casting (CCC) or open reduction and internal fixation (ORIF). The primary outcome measure the investigators used was the Olerud and Molander ankle score at 6 months after treatment.
Willett noted in his presentation 9% of patients in the ORIF group underwent a second open surgery procedure for complications and 19% of patients in the CCC group were converted to open surgery.
Results showed CCC had equivalent functional outcomes to ORIF, which was also shown in the intention-to-treat analysis.
“At 6 weeks, you see a substantial reduction in patient function,” Willett said. “There is an improvement by 6 months, but at 6 months there is still a 25-point reduction and that is common in the elderly population, so quite a substantial disability.”
However, the investigators found no differences in secondary outcomes of mental and physical scores, quality of life, ankle range of motion, pain, mobility and patient satisfaction.
“The nonunion rate was higher in the close contact cast group, but that did not affect the mean treatment outcome. Neither did it affect the mobility Timed-Up-and-Go test,” Willett said. “Neither did it affect any difference between any of the other secondary outcome measures between the two groups,” he said
There were some significant complications seen, Willett said. They were “six-times more common in the open reduction internal fixation group in this patient population [with] 40% having comorbidities.”
As for the health economic evaluation the investigators performed, CCC cost about $2,000 less per patient than ORIF, Willett said.
He noted that investigators recommended patients in the CCC group not weight-bear for the first few weeks, but the patients chose when to weight-bear.
“Both groups of patients in fact started walking at the same time in recovery, so it made no difference,” Willett said.
He noted nearly all patients in the CCC group underwent at least one cast change, which was related to the importance of keeping the cast in close contact with the skin.
“It is important this cast remains in intimate contact with the skin. Any looseness requires a cast change and those were all done in the outpatient clinic,” Willett said. – by Casey Tingle
- Willett K, et al. Paper #31. Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 7-10, 2015; San Diego.
- For more information:
- Keith Willett, FRCS, can be reached at Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DLF, United Kingdom; email: firstname.lastname@example.org.
Disclosure: Willett reports he receives royalties from Zimmer Biomet unrelated to this subject area.