Elderly ankle fracture management: putting the evidence into practice

F. Liaw, H. O'Connor, N. McLaughlin, D. Townshend

Introduction: Following publication of the Ankle Injury Management (AIM) trial in 2016 which compared the management of ankle fractures with open reduction and internal fixation (ORIF) versus closed contact casting (CCC), we looked at how the results of this study have been adopted into practice in a trauma unit in the United Kingdom.

Methods: Institutional approval granted to identify eligible patients from a trauma database. 143 patients over 60 years with an unstable ankle fracture between 2017 and 2019 (1 year following publication of the AIM trial) were included. Open fractures, and patients with insulin-dependent diabetes or peripheral vessel disease were excluded (as per AIM criteria). Radiographs were reviewed for malunion and non-union. Clinical notes were reviewed for adverse events. Minimum follow up was 24 months.

Results: Of the 143 patients, 42 patients (29.4%) received a moulded cast with a return to theatre rate of 21.4%, malunion rate of 30.1%, and infection or wound problem rate of 4.8%. When the exact phrase "close contact cast" was specified in 21 patients (14.7%), there was a 19.0% return to theatre rate, 28.6% malunion rate, and a 4.8% infection or wound problem rate. 101 patients (70.6%) had ORIF with a return to theatre rate of 10.9%, malunion rate of 5.0%, and infection or wound problem rate of 13.9%.

Discussion: Our results show a high rate of complication with cast management of unstable ankle fractures in this older population. This was improved where CCC was specified, but remains higher even than those published in the AIM trial. Whilst there is certainly a role for CCC in carefully selected patients, we would advise caution in the widespread adoption of a close contact casting technique.