PerspectiveFrom OT Europe

ORIF, new casting method showed similar results for unstable ankle fractures

Fewer resources were used in close contact casting compared with open reduction internal fixation.

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.

Keith Willett

Keith Willett

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.

Functional results

“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

Complications observed

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

Disclosure: Willett reports he receives royalties from Zimmer Biomet unrelated to this subject area.

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.

Keith Willett

Keith Willett

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.

Functional results

“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

Complications observed

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

Disclosure: Willett reports he receives royalties from Zimmer Biomet unrelated to this subject area.

    Perspective

    This is a landmark study. It is a well-conducted multicenter randomized trial in the United Kingdom looking at the management of unstable ankle fractures, all comers, in the 60-year-old age group and older randomizing them to standard open reduction internal fixation vs. close contact casting (CCC), which is a new and simple technique performed under general anesthesia in the operating theatre with X-ray control. The technique can be seen on a YouTube video.

    At all time points the functional outcomes were the same with fewer complications in the CCC group. There were the same number of crossovers in each group. Follow-up was for 6 months, which has been researched as the time at which changes will be seen and are unlikely to progress. What is unanswered is whether the 16% of patients in the CCC group who healed with a radiological malunion will subsequently develop radiological arthritis and whether this will be symptomatic. A 2-year follow-up is in progress. What is also unanswered is whether this can be applied to the patients less than 60 years old. Persuading colleagues/surgeons to accept the clear results here in an excellently conducted and powered trial with a clear outcome is another unanswered challenge.

    • Nigel D. Rossiter, MB, BS, FRCS(Ed), FRCSEd(Tr&Orth)
    • Immediate past president, Orthopaedic Trauma Society Consultant Trauma & Orthopaedic Surgeon Hampshire Hospitals Basingstoke, United Kingdom

    Disclosures: Rossiter reports no relevant financial disclosures.