Willett, Keith, Keene, David J., Mistry, Dipesh, Nam, Julian, Tutton, Elizabeth, Handley, Robert, Morgan, Lesley, Roberts, Emma, Briggs, Andrew, Lall, Ranjit, Chesser, Timothy J. S., Pallister, Ian and Lamb, Sallie E. (2016) Close contact casting vs surgery for initial treatment of unstable ankle fractures in older adults. JAMA: The Journal of the American Medical Association, 316 (14). 1455. doi:10.1001/jama.2016.14719 ISSN 0098-7484.

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Abstract

Importance Ankle fractures cause substantial morbidity in older persons. Surgical fixation is the contemporary intervention but is associated with infection and other healing complications.

Objective To determine whether initial fracture treatment with close contact casting, a molded below-knee cast with minimal padding, offers outcome equivalent to that with immediate surgery, with fewer complications and less health resource use.

Design, Setting, and Participants This was a pragmatic, equivalence, randomized clinical trial with blinded outcome assessors. A pilot study commenced in May 2004, followed by multicenter recruitment from July 2010 to November 2013; follow-up was completed May 2014. Recruitment was from 24 UK major trauma centers and general hospitals. Participants were 620 adults older than 60 years with acute, overtly unstable ankle fracture. Exclusions were serious limb or concomitant disease or substantial cognitive impairment.

Interventions Participants were randomly assigned to surgery (n = 309) or casting (n = 311). Casts were applied in the operating room under general or spinal anesthesia by a trained surgeon.

Main Outcomes and Measures The primary 6-month, per-protocol outcome was the Olerud-Molander Ankle Score at 6 months (OMAS; range, 0-100; higher scores indicate better outcomes and fewer symptoms), equivalence prespecified as ±6 points. Secondary outcomes were quality of life, pain, ankle motion, mobility, complications, health resource use, and patient satisfaction.

Results Among 620 adults (mean age, 71 years; 460 [74%] women) who were randomized, 593 (96%) completed the study. Nearly all participants (579/620; 93%) received allocated treatment; 52 of 275 (19%) who initially received casting later converted to surgery, which was allowable in the casting treatment pathway to manage early loss of fracture reduction. At 6 months, casting resulted in ankle function equivalent to that with surgery (OMAS score, 66.0 [95% CI, 63.6-68.5] for surgery vs 64.5 [95% CI, 61.8-67.2] for casting; mean difference, –0.6 [95% CI, –3.9 to 2.6]; P for equivalence = .001). Infection and wound breakdown were more common with surgery (29/298 [10%] vs 4/275 [1%]; odds ratio [OR], 7.3 [95% CI, 2.6-20.2]), as were additional operating room procedures (18/298 [6%] for surgery and 3/275 [1%] for casting; OR, 5.8 [95% CI, 1.8-18.7]). Radiologic malunion was more common in the casting group (38/249 [15%] vs 8/274 [3%] for surgery; OR, 6.0 [95% CI, 2.8-12.9]). Casting required less operating room time compared with surgery (mean difference [minutes/participant], –54 [95% CI, –58 to –50]). There were no significant differences in other secondary outcomes: quality of life, pain, ankle motion, mobility, and patient satisfaction.

Conclusions and Relevance Among older adults with unstable ankle fracture, the use of close contact casting compared with surgery resulted in similar functional outcomes at 6 months. Close contact casting may be an appropriate treatment for such patients.

Item Type:	Journal Article
Subjects:	R Medicine > RD Surgery
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Ankle -- Fractures -- Treament, Fractures in old age, Older people -- Medical care
Journal or Publication Title:	JAMA: The Journal of the American Medical Association
Publisher:	American Medical Association
ISSN:	0098-7484
Official Date:	11 October 2016
Dates:	Date Event 11 October 2016 Published 7 October 2016 Available 12 September 2016 Accepted
Volume:	316
Number:	14
Article Number:	1455
DOI:	10.1001/jama.2016.14719
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Restricted or Subscription Access
Date of first compliant deposit:	9 December 2016
Date of first compliant Open Access:	9 December 2016
Funder:	National Institute for Health Research Health Technology Assessment (Great Britain) (NIHR HTA), AO Foundation
Grant number:	Project 07/37/61 (NIHR HTA), 03-W31 (AO Foundation)

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