Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2012 Aug 15;2012(8):CD008470.
doi: 10.1002/14651858.CD008470.pub2.

Surgical versus conservative interventions for treating ankle fractures in adults

Christian C M A Donken  1 , Hesham Al-Khateeb, Michael H J Verhofstad, Cornelis J H M van Laarhoven
Affiliations
Meta-Analysis

Surgical versus conservative interventions for treating ankle fractures in adults

Christian C M A Donken et al. Cochrane Database Syst Rev. .

Abstract

Background: The annual incidence of ankle fractures is 122 per 100,000 people. They usually affect young men and older women. The question of whether surgery or conservative treatment should be used for ankle fractures remains controversial.

Objectives: To assess the effects of surgical versus conservative interventions for treating ankle fractures in adults.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 1), MEDLINE, EMBASE, CINAHL and the WHO International Clinical Trials Registry Platform and Current Controlled Trials. Date of last search: 6 February 2012.

Selection criteria: Randomised and quasi-randomised controlled clinical studies comparing surgical and conservative treatments for ankle fractures in adults were included.

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment and data extraction. Authors of the included studies were contacted to obtain original data.

Main results: Three randomised controlled trials and one quasi-randomised controlled trial were included. These involved a total of 292 participants with ankle fractures. All studies were at high risk of bias from lack of blinding. Additionally, loss to follow-up or inappropriate exclusion of participants put two trials at high risk of attrition bias. The trials used different and incompatible outcome measures for assessing function and pain. Only limited meta-analysis was possible for early treatment failure, some adverse events and radiological signs of arthritis.One trial, following up 92 of 111 randomised participants, found no statistically significant differences between surgery and conservative treatment in patient-reported symptoms (self assessed ankle "troubles": 11/43 versus 14/49; risk ratio (RR) 0.90, 95% CI 0.46 to 1.76) or walking difficulties at seven years follow-up. One trial, reporting data for 31 of 43 randomised participants, found a statistically significantly better mean Olerud score in the surgically treated group but no difference between the two groups in pain scores after a mean follow-up of 27 months. A third trial, reporting data for 49 of 96 randomised participants at 3.5 years follow-up, reported no difference between the two groups in a non-validated clinical score.Early treatment failure, generally reflecting the failure of closed reduction (criteria not reported in two trials) probably or explicitly leading to surgery in patients allocated conservative treatment, was significantly higher in the conservative treatment group (2/116 versus 19/129; RR 0.18, 95% CI 0.06 to 0.54). Otherwise, there were no statistically significant differences between the two groups in any of the reported complications. Pooled results from two trials of participants with radiological signs of osteoarthritis at averages of 3.5 and 7.0 years follow-up showed no between-group differences (44/66 versus 50/75; RR 1.05, 95% CI 0.83 to 1.31).

Authors' conclusions: There is currently insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults. The identification of several ongoing randomised trials means that better evidence to inform this question is likely to be available in future.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 1 Complaints of symptoms (pain, restricted range of ankle motion, unsteadiness, swelling) and walking difficulties at 7 years.
1.2
1.2. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 2 Functional or combined scores.
1.3
1.3. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 3 Pain scores (VAS: assume maximum of 100: worst) at mean of 27 months.
1.4
1.4. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 4 Adverse events.
1.5
1.5. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 5 Functional impairment at 20 weeks.
1.6
1.6. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 6 Differences in range of motion (injured ankle ‐ other ankle).
1.7
1.7. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 7 Radiological results: non‐union and malunion.
1.8
1.8. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 8 Radiological signs of osteoarthritis.
1.9
1.9. Analysis
Comparison 1 Surgical versus conservative treatment, Outcome 9 Length of hospital stay (days).
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD008470

References

References to studies included in this review

Bauer 1985 {published data only}
    1. Bauer M, Bergstrom B, Hemborg A, Sandegard J. Closed versus open treatment of Weber type B ankle fracture [abstract]. Acta Orthopaedica Scandinavica 1986;57:607.
    1. Bauer M, Bergström B, Hemborg A, Sandegärd J. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clinical Orthopaedics and Related Research 1985;(199):17‐27. [PUBMED: 3930121] - PubMed
    1. Bauer M, Johnell O, Redlund‐Johnell I, Johnsson K. Ankle fractures. Foot and Ankle 1987;8:23‐5. - PubMed
Makwana 2001 {published data only}
    1. Makwana N, Bhowal B, Harper A. Displaced ankle fractures in the over 55 years of age. A prospective randomised study [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1999;81 Suppl 2:160. - PubMed
    1. Makwana NK, Bhowal B, Harper WM, Hui AW. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study. Journal of Bone and Joint Surgery ‐ British Volume 2001;83(1):525‐9. [PUBMED: 11380123] - PubMed
    1. Ramasamy PR, McDermott ID, Fowler AW, Makwana NK, Bhowal B, Harper WM. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age (letters). Journal of Bone and Joint Surgery ‐ British Volume 2001;83(7):1084‐6. - PubMed
Phillips 1985 {published data only}
    1. Harper MC, Phillips WA. A prospective, randomized study of the management of severe ankle fractures [letters]. Journal of Bone and Joint Surgery ‐ American Volume 1985;67:1303‐4. - PubMed
    1. Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, Laros GS. A prospective, randomized study of the management of severe ankle fractures. Journal of Bone and Joint Surgery ‐ American Volume 1985;67:67‐78. [PUBMED: 3881447] - PubMed
Rowley 1986 {published data only}
    1. Rowley DI, Norris SH, Duckworth T. A prospective trial comparing operative and manipulative treatment of ankle fractures. Journal of Bone and Joint Surgery ‐ British Volume 1986;68:610‐3. [PUBMED: 3090049] - PubMed

References to studies excluded from this review

Dietrich 2002 {published data only}
    1. Dietrich A, Lill H, Engel T, Schönfelder M, Josten C. Conservative functional treatment of ankle fractures. Archives of Orthopaedic Trauma Surgery 2002;122:165‐8. - PubMed
Doleżal 1995 {published data only}
    1. Doleżal SA. Assessment of therapeutic results of lateral ankle fractures [Ocena wyników leczenia złamań kostki bocznej]. Wiadomości Lekarskie 1995;48:5‐9. [CENTRAL: CN‐00151986] - PubMed
Hughes 1979 {published data only}
    1. Hughes JL, Weber H, Willenegger H, Kuner EH. Evaluation of ankle fractures: non‐operative and operative treatment. Clincal Orthopaedics and Related Research 1979;138:111‐9. [PUBMED: 445892] - PubMed
Richter 1994 {published data only}
    1. Richter J, Josten C, Schildhauer T, Muhr G. Conservative versus operative treatment for Weber B fractures [Funktionell‐konservative versus operative therapie der Weber‐B‐fraktur]. Langenbecks Arch Chir Suppl 1994;Suppl Kongressbericht:923‐6. [CENTRAL: CN‐00396173]
Salai 2000 {published data only}
    1. Salai M, Dudkieweicz I, Novikov I, Amit Y, Chechick A. The epidemic of ankle fractures in the elderly ‐ is surgical treatment warranted?. Archives of Orthopaedic Trauma Surgery 2000;120:511‐3. [PUBMED: 11011670] - PubMed
    1. Salai M, Dudkiewitz I, Novikov I, Amit Y, Chechick A. Ankle fractures in the elderly‐is surgical treatment warranted? [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1999;81 Suppl 2:160‐1.
Strömsöe 1995 {published data only}
    1. Strömsöe K, Höqevold HE, Skjeldal S, Alho A. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. Journal of Bone and Joint Surgery ‐ British Volume 1995;77‐B:920‐1. [PUBMED: 7593106] - PubMed
Velkovski 1995 {published data only}
    1. Velkovski G. The value of osteosynthesis in the treatment of bimalleolar fractures. Annales Chirurgiae et Gynaecologiae 1995;84:403‐16. [PUBMED: 8687088] - PubMed
Yde 1980a {published data only}
    1. Yde J, Kristensen D. Ankle fractures. Supination‐eversion stage II; primary and late results of operative and non‐operative treatment. Acta Orthopaedica Scandinavica 1980;51:695‐702. [PUBMED: 6778066] - PubMed
Yde 1980b {published data only}
    1. Yde J, Kristensen D. Ankle fractures. Supination‐eversion stage IV; primary and late results of operative and non‐operative treatment. Acta Orthopaedica Scandinavica 1980;51:981‐90. - PubMed

References to ongoing studies

Gray {published data only}
    1. Gray B. Influence of ankle skin perfusion on fracture treatment outcomes in the elderly: a randomised controlled trial comparing total contact cast with open reduction and internal fixation, the effect on cutaneous blood supply and relationship to skin complications. http://www.controlled‐trials.com/ISRCTN81174170 (accessed 6 February 2012).
Harris {published data only}
    1. Harris I, Mittal R. Combined randomised and observational study of type B ankle fracture treatment (CROSSBAT). http://clinicaltrials.gov/ct2/show/NCT01134094 (accessed 6 February 2012).
Pakarinen {published data only}
    1. Pakarinen H. Syndesmotic Injury and Fixation in Supination‐External (SE) Ankle Fractures. http://clinicaltrials.gov/ct2/show/NCT01234493 (accessed 6 February 2012).
Sanders {published data only}
    1. Sanders D. Operative versus non operative treatment for unstable ankle fractures. http://clinicaltrials.gov/ct2/show/NCT00336752 (accessed 6 February 2012).
Willett {published data only}
    1. Willett K. Comparison of close contact cast (CCC) technique to open surgical reduction and internal fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years. NIHR Health Technology Assessment Programme. HTA research projects: http://www.hta.ac.uk/1781 (accessed 2 February 2012).
    1. Willett K. Comparison of close contact cast (CCC) technique to open surgical reduction and internal fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years. http://www.controlled‐trials.com/ISRCTN04180738 (accessed 6 February 2012).

Additional references

Bauer 1985a
    1. Bauer M, Bergström B, Hemborg A, Sandegärd J. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clinical Orthopaedics and Related Research 1985;(199):17‐27. [PUBMED: 3930121] - PubMed
Binkley 1999
    1. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Physical Therapy 1999;79(4):371‐83. [PUBMED: 10201543] - PubMed
Cedell 1967
    1. Cedell CA. Supination‐outward rotation injuries of the ankle. Acta Orthopaedica Scandinavica 1967;suppl 110:1‐117. [PUBMED: 4970319] - PubMed
Court‐Brown 1998
    1. Court‐Brown CM, McBirnie J, Wilson G. Adult ankle fractures ‐ an increasing problem?. Acta Orthopaedica Scandinavica 1998;69(1):43‐7. [PUBMED: 9524517] - PubMed
Danis 1949
    1. Danis R. Malleolar fractures [Les fractures malléolaires]. Théorie et pratique de l'ostéosynthèse, Liège: Desoer et Masson 1949;I:133‐65.
DeMets 1987
    1. DeMets DL. Methods of combining randomized clinical trials: strengths and limitations. Statistics in Medicine 1987;6(3):341‐50. [PUBMED: 3616287] - PubMed
DerSimonian 1986
    1. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Controlled Clinical Trials 1986;7(3):177‐88. [PUBMED: 3802833] - PubMed
Herscovici 2007
    1. Herscovici D Jr, Scaduto JM, Infante A. Conservative treatment of isolated fractures of the medial malleolus. Journal of Bone & Joint Surgery ‐ British Volume 2007;89(1):89‐93. [PUBMED: 17259423] - PubMed
Higgins 2008
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration 2008. Available from www.cochrane‐handbook.org.
Horisberger 2009
    1. Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteoarthritis after ankle‐related fractures. Journal of Orthpaedic Trauma 2009;23(1):60‐7. [PUBMED: 19104305] - PubMed
Koval 2002
    1. Koval, KJ. Orthopaedic Knowledge Update 7: Home Study Syllabus. 1st Edition. New York: American Academy of Orthopaedic Surgeons, 2002.
Koval 2005
    1. Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. Journal of Orthopaedic Trauma 2005;19(9):635‐9. [PUBMED: 16247309] - PubMed
Kristensen 1985
    1. Kristensen KD, Hansen T. Closed treatment of ankle fractures. Stage II supination‐eversion fractures followed for 20 years. Acta Orthopaedica Scandinavica 1985;56(2):107‐9. [PUBMED: 3925710 ] - PubMed
Lauge Hansen 1942
    1. Lauge Hansen N. Anklebrud I. Genetisk diagnose og reposition [Dissertation]. Munksgaard, Copenhagen, 1942.
Lefebvre 2009a
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 (updated September 2009). The Cochrane Collaboration, 2009. Available from www.cochrane‐handbook.org.
Lefebvre 2009b
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6.4.11: Search filters. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 (updated September 2009). The Cochrane Collaboration, 2009. Available from www.cochrane‐handbook.org.
Lin 2008
    1. Lin CWC, Moseley AM, Refshauge KM. Rehabilitation for ankle fractures in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. [DOI: 10.1002/14651858.CD005595.pub2] - DOI - PubMed
Magnusson 1944
    1. Magnusson R. On the late results in non‐operated cases of malleolar fractures: clinical‐roentgenological‐statistical study: fractures by external rotation. Acta Chirurgicaie Scandinavica 1944 [Suppl 84];90(1):1‐36.
Müller 1969
    1. Müller ME, Allgöwer M, Willenegger H. Manual der Osteosynthese, AO‐technik. Berlin/Heidelberg/NewYork: Spinger Verlag, 1969.
Müller 1979
    1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by the AO group. Second Edition. Berlin: Springer‐Verlag, 1979.
Müller 1990
    1. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of the long bones. Berlin/Heidelberg/New York: Springer Verlag, 1990.
Olerud 1984
    1. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Archives of Orthopaedic & Traumatic Surgery 1984;103(3):190‐4. [PUBMED: 6437370] - PubMed
Petrisor 2006
    1. Petrisor BA, Poolman R, Koval K, Tornetta P 3rd, Bhandari M, Evidence‐Based Orthopaedic Trauma Working Group. Management of displaced ankle fractures. Journal of Orthopaedic Trauma 2006;20(7):515‐8. [PUBMED: 16891946] - PubMed
Ramasamy 2001
    1. Ramasamy PR. Comment on: J Bone Joint Surg Br. 2001 May;83(4):525‐9. Journal of Bone and Joint Surgery ‐ British Volume 2001;83:1084‐6. [PUBMED: 11603529] - PubMed
Ramsey 1976
    1. Ramsey PL, Hamilton W. Changes in the tibiotalar area of contact caused by lateral shift. Journal of Bone and Joint Surgery ‐ American Volume 1976;58(3):356‐7. [PUBMED: 1262367 ] - PubMed
Rowley 1986a
    1. Rowley DI, Norris SH, Duckworth T. A prospective trial comparing operative and manipulative treatment of ankle fractures. Journal of Bone and Joint Surgery ‐ British Volume 1986;68:610‐3. [PUBMED: 3090049] - PubMed
Salai 2000a
    1. Salai M, Dudkieweicz I, Novikov I, Amit Y, Chechick A. The epidemic of ankle fractures in the elderly ‐ is surgical treatment warranted?. Archives of Orthopaedic Trauma Surgery 2000;120:511‐3. [PUBMED: 11011670] - PubMed
SooHoo 2009
    1. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. Journal of Bone & Joint Surgery ‐ American Volume 2009;91(5):1042‐9. [PUBMED: 19411451 ] - PubMed
Stanton‐Hicks 1995
    1. Stanton‐Hicks M, Janig W, Hassenbusch S, Haddox JD, Boas R, WIlson P. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995;63:127‐33. [PUBMED: 8577483] - PubMed
Walsh 2004
    1. Walsh EF, DiGiovanni C. Fibular nonunion after closed rotational ankle fracture. Foot & Ankle International 2004;25(7):488‐95. [PUBMED: 15319107] - PubMed
Weber 1972
    1. Weber BG. Die Verletzungen des oberen Sprunggelenkes. 2nd Edition. Bern: Huber, 1972.
Wei 1999
    1. Wei SY, Okereke E, Winiarsky R, Lotke PA. Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20‐year follow‐up. Foot & Ankle International 1999;20(7):404‐7. [PUBMED: 10437921 ] - PubMed

LinkOut - more resources