AIM

Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial.

Willett K, Keene DJ, Mistry D, et al. JAMA 2016 · PMID 27727383 · doi:10.1001/jama.2016.14719

Question

In older adults with an unstable ankle fracture, is close contact casting non-inferior to open reduction and internal fixation for ankle function?

Design

Pragmatic multicentre equivalence RCT in UK NHS trauma units with blinded outcome assessment (Ankle Injury Management trial).

Patients

Adults older than 60 with an acute, unstable ankle fracture.

Intervention

Close contact casting applied in theatre by trained surgeons

Comparison

Open reduction and internal fixation

Primary outcome

Olerud-Molander Ankle Score (OMAS) at 6 months

Key result

Close contact casting gave ankle function equivalent to surgery on OMAS at 6 months. Casting had fewer infection and wound problems but more radiological malunion, and a minority of casting patients converted to surgery after early loss of reduction.

Limitations

Unblinded; casting required specific training and was delivered by surgeons trained in the technique; the clinical significance of malunion over the longer term is uncertain.

Impact on practice

Close contact casting is a valid alternative to fixation for unstable ankle fractures in older, often frail patients, particularly those with poor skin, diabetes or high anaesthetic risk.