Isolated lateral malleolus fractures; operative versus nonoperative treatment

Abstract

Background Many surgeons would advocate surgical management for isolated stable Weber type B ankle fractures to avoid hazards of nonoperative management. Concerns about surgical risks urge other surgeons to consider nonoperative alternatives. Hence, it has become apparent that this type of fracture requires precise assessment of the overall ankle stability to achieve good outcomes using either operative or nonoperative treatment. Aim This study aimed to compare surgical and nonsurgical management of non or minimally-displaced stable Weber B ankle fractures regarding functional and radiological outcomes. Patients and methods This prospective randomized controlled trial was conducted between June 2021 and December 2022, involving 58 patients with stable isolated Weber B fractures with intact syndesmosis, in which stability was determined by Weight-bearing (WB) stress radiographs. Patients were randomized to group A [operative treatment with open reduction and internal fixation (ORIF)] or group B (nonoperative treatment with cast), including 29 patients in each group. Primary outcome analysis included American Orthopedic Foot and Ankle Society (AOFAS) score at 1-year follow-up for functional outcome. Secondary outcome analysis included an EQ-5D-5L questionnaire at 1 year for health status/functional outcome, in addition to a 3-weekly radiographic assessment till fracture union and at 6 months for radiological outcome. Results There were no significant differences identified between surgical and nonsurgical management of Weber B fractures concerning functional outcome; the mean American Orthopedic Foot and Ankle Society score at the end of the follow-up was (97.93 ± 4.123) for the operative group and (97.24 ± 4.549) for the conservative group (P-value= 0.548). Concerning quality of life (QoL), this study identified no differences between surgical and nonsurgical management. Radiological union was significantly earlier with the operative group, however, at 6 months, both groups showed fully radiologically united fibula on plain radiographs. Conclusion Nonoperative management is comparable with operative management for such type of fracture. Consequently, when deciding the optimal intervention for patients with such injuries it is important to consider individual surgeon’s experience and other outcomes such as effects and cost. A conversation regarding treatment options should be held with the patient.