Non-surgical treatment of lateral malleolar fractures is safe - Long-term follow-up of a comprehensive treatment algorithm

Abstract

Introduction: A previous study conducted at Sahlgrenska University Hospital (SU) revealed a significant variation in the treatment of ankle fractures, which resulted in the creation of a treatment algorithm (TA). The aim of TA was to standardise treatment and reduce the number of unnecessary surgical procedures. A follow-up study concluded that the number of surgeries had significantly decreased since the introduction of the TA. However, the long-term effects of the TA and the reduced number of surgical procedures remained unclear. Aim: To analyse the long-term effects of a structured TA for ankle fractures regarding complications and reoperation rates. Method: The present study is a long-term follow-up of the same two cohorts of patients with lateral malleolar fractures of type AO/OTA44-B1 as studied in the previous studies on the TA for ankle fractures at SU. The current study compares a group of AO/OTA 44B1-fractures treated before the introduction of the TA, the pre-TA cohort (n=410), with a group treated after the introduction of the TA, the post-TA cohort (n=333). Both groups were followed for a minimum of four years, and the outcomes were reoperation or complication. Reoperation was defined as any surgical procedure that occurred 30 days or more after the initial injury. Results: The results demonstrate a statistically significant reduction in the reoperation rate for lateral malleolar ankle fractures from 7.1% to 2.4% (p = 0.006) following the introduction of a TA that reduced the number of primary surgical procedures. Hardware-related complaints were the leading cause of reoperation in both cohorts. Three major reoperations were observed in the Pre-TA cohort compared to none in the Post-TA cohort. The present study revealed no increase in the frequency of late surgeries due to non-union. Conclusion: Treating stable ankle fractures non-surgically does not lead to an increase in reoperations, complications or late surgeries due to non-union. In fact, a structured treatment algorithm that reduce the number of primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 also led to a significant reduction in reoperation rates and no increase in failure rates. This long-term follow-up demonstrates that a non-surgical approach to isolated lateral malleolar fractures is safe.