Rehabilitation for ankle fractures in adults

Effectiveness of behavior change in rehabilitation interventions to improve functional recovery after lower limb fracture: a systematic review

Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .

Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial

BACKGROUND

After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy.

METHODS

This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants.

FINDINGS

Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%.

INTERPRETATION

An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing).

FUNDING

National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test

BACKGROUND

Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes.

METHODS

A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group.

RESULTS

A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment.

CONCLUSIONS

Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome.

TRIAL REGISTRATION

BASEC-Nr. 2018 - 01124.

The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates.

METHODS

The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively.

RESULTS

A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05).

CONCLUSION

The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.

Splint versus no splint after ankle fracture fixation; Results from the multi-centre post-operative ankle splint trial (PAST)

BACKGROUND

There is considerable variation in the rehabilitation of ankle fractures. Ankle fractures treated surgically are often immobilized or splinted in the early post-operative period, despite the lack of robust evidence supporting this intervention. Thus, this randomized controlled trial aims to investigate the anecdote that splinting reduces pain and oedema.

METHODS

A prospective multi-centre randomized controlled trial was performed in three trauma centres. Eligible patients were over 18 years of age that have sustained an isolated unilateral ankle fracture requiring surgical intervention. Patients were randomized to two groups receiving either; a plaster of Paris posterior back-slab or compressive bandage dressing. The post-operative rehabilitation protocol was standardized across both groups. Baseline demographics and fracture characteristics and classifications were analysed. Primary outcomes included; oedema measured by the figure-of-eight-20 technique and pain at multiple time points. Secondary outcomes included; the American Orthopaedic Foot and Ankle Society (AOFAS) score, satisfaction, unplanned emergency room (ER) visits and complications.

RESULTS

A total of 104 comparable participants were included; 54 in the non-splint group and 50 in the splint group. There was no significance difference in ankle oedema, ankle oedema compared to contralateral ankle and pain scores between the two groups (P = 0.56, P = 0.25, P = 0.39 respectively). Patient satisfaction was higher in the early postoperative period in the non-splint group (P = 0.016). The AOFAS score was not significantly different across any time point (P = 0.534). In the splint group, there was a 46% rate of splint-related complaints and complications. Unplanned ER visits occurred in 46% of the splint group and 7.4% of the non-splint group (P < 0.001). There were 2 wound infections, 1 non-union and 1 deep vein thrombosis in the splint group. There was 1 wound infection and 1 deep vein thrombosis in the no-splint group (P = 0.481) CONCLUSION: The routine use of a splint does not add any perceivable benefit to the postoperative course of an ankle fracture fixation, particularly in the reduction of oedema and postoperative pain. Another key finding is that the absence of a splint does not appear to result in higher complication rates, instead leads to higher unplanned ER visits and lower early satisfaction rates.

Patient preferences for physical therapy programs after a lower extremity fracture: a discrete choice experiment

OBJECTIVE

To quantify patients' preferences for physical therapy programmes after a lower extremity fracture and determine patient factors associated with preference variation.

DESIGN

Discrete choice experiment.

SETTING

Level I trauma centre.

PARTICIPANTS

One hundred fifty-one adult (≥18 years old) patients with lower extremity fractures treated operatively.

INTERVENTION

Patients were given hypothetical scenarios and asked to select their preferred therapy course when comparing cost, mobility, long-term pain, session duration, and treatment setting.

MAIN OUTCOME MEASURES

A multinomial logit model was used to determine the relative importance and willingness to pay for each attribute.

RESULTS

Mobility was of greatest relative importance (45%, 95% CI: 40% to 49%), more than cost (23%, 95% CI: 19% to 27%), long-term pain (19%, 95% CI: 16% to 23%), therapy session duration (12%, 95% CI: 9% to 5%) or setting (1%, 95% CI: 0.2% to 2%). Patients were willing to pay US$142 more per session to return to their preinjury mobility level (95% CI: US$103 to US$182). Willingness to pay for improved mobility was higher for women, patients aged 70 years and older, those with bachelor's degrees or higher and those living in less-deprived areas. Patients were willing to pay US$72 (95% CI: US$50 to US$93) more per session to reduce pain from severe to mild. Patients were indifferent between formal and independent home therapy (willingness to pay: -US$12, 95% CI: -US$33 to US$9).

CONCLUSIONS

Patients with lower extremity fractures highly value recovering mobility and are willing to pay more for postoperative physical therapy programmes that facilitate returning to their pre-injury mobility level. These patient preferences might be useful when prescribing and designing new techniques for postoperative therapy.

Analysis of Dynamic Plantar Pressure and Influence of Clinical-Functional Measures on Their Performance in Subjects with Bimalleolar Ankle Fracture at 6 and 12 Months Post-Surgery

Recovery after ankle fracture surgery can be slow and even present functional deficits in the long term, so it is essential to monitor the rehabilitation process objectively and detect which parameters are recovered earlier or later. The aim of this study was (1) to evaluate dynamic plantar pressure and functional status in patients with bimalleolar ankle fracture 6 and 12 months after surgery, and (2) to study their degree of correlation with previously collected clinical variables. Twenty-two subjects with bimalleolar ankle fractures and eleven healthy subjects were included in the study. Data collection was performed at 6 and 12 months after surgery and included clinical measurements (ankle dorsiflexion range of motion and bimalleolar/calf circumference), functional scales (AOFAS and OMAS), and dynamic plantar pressure analysis. The main results found in plantar pressure were a lower mean/peak plantar pressure, as well as a lower contact time at 6 and 12 months with respect to the healthy leg and control group and only the control group, respectively (effect size 0.63 ≤ d ≤ 0.97). Furthermore, in the ankle fracture group there is a moderate negative correlation (-0.435 ≤ r ≤ 0.674) between plantar pressures (average and peak) with bimalleolar and calf circumference. The AOFAS and OMAS scale scores increased at 12 months to 84.4 and 80.0 points, respectively. Despite the evident improvement one year after surgery, data collected using the pressure platform and functional scales suggest that recovery is not yet complete.

Effectiveness of Postoperative Physiotherapy Compared to Postoperative Instructions by Treating Specialist Only in Patients With an Ankle Fracture: A Systematic Review

Background

In current literature, the benefit of postoperative physiotherapy versus postoperative instructions by treating specialist only remains unclear. The aim of this review is to systematically assess existing literature regarding the functional outcome of postoperative physiotherapy compared to postoperative instructions by treating specialist only in the rehabilitation of patients with an ankle fracture. The secondary aim is to determine if there is a difference in ankle range of motion, strength, pain, complications, quality of life, and patient's satisfaction between these 2 rehabilitation methods.

Methods

For this review, the PubMed/MEDLINE, PEDro, Embase, Cochrane, and CINAHL databases were searched for studies that compared postoperative rehabilitation groups.

Results

The electronic data search detected 20 579 articles. After exclusion, 5 studies with a total of 552 patients were included. Overall, no significant benefit in functional outcome of postoperative physiotherapy was seen compared to the instructions-only group. One study even found a significant benefit in favor of the instructions-only group. An exemption for beneficial effect of the use of physiotherapy could be made for younger patients, as 2 studies described younger age as a factor for better outcomes (functional outcome and ankle range of motion) in the postoperative physiotherapy group. Patients' satisfaction, described by one study, was found to be significantly higher in the physiotherapy group (P = .047). All other secondary aims showed no significant difference.

Conclusion

Because of the limited number of studies and the heterogeneity among studies, a valid conclusion about the general effect of physiotherapy cannot be formed. However, we identified limited evidence suggesting a possible benefit of physiotherapy in younger patients with an ankle fracture in functional outcome and ankle range of motion.

Use of cast immobilization versus removable brace in adults with an ankle fracture: two-year follow-up of a multicentre randomized controlled trial

The aim of this study was to compare the longer-term outcomes of operatively and nonoperatively managed patients treated with a removable brace (fixed-angle removable orthosis) or a plaster cast immobilization for an acute ankle fracture. This is a secondary analysis of a multicentre randomized controlled trial comparing adults with an acute ankle fracture, initially managed either by operative or nonoperative care. Patients were randomly allocated to receive either a cast immobilization or a fixed-angle removable orthosis (removable brace). Data were collected on baseline characteristics, ankle function, quality of life, and complications. The Olerud-Molander Ankle Score (OMAS) was the primary outcome which was used to measure the participant's ankle function. The primary endpoint was at 16 weeks, with longer-term follow-up at 24 weeks and two years. Overall, 436 patients (65%) completed the final two-year follow-up. The mean difference in OMAS at two years was -0.3 points favouring the plaster cast (95% confidence interval -3.9 to 3.4), indicating no statistically significant difference between the interventions. There was no evidence of differences in patient quality of life (measured using the EuroQol five-dimension five-level questionnaire) or Disability Rating Index. This study demonstrated that patients treated with a removable brace had similar outcomes to those treated with a plaster cast in the first two years after injury. A removable brace is an effective alternative to traditional immobilization in a plaster cast for patients with an ankle fracture.

Braces versus casts for post-operational immobilization of ankle fractures: A meta-analysis

Background and aims

Both casts and braces can be used for post-operational immobilization of ankle fractures. This meta-analysis aimed to assess the complications and functional effects of the two types of immobilization.

Material and methods

PubMed, Embase, Cochrane, and CNKI was searched for randomized controlled trials (published between Jan 1, 1950, and March 2022). Relative risk (RR) or standard mean difference (SMD) with a 95% confidence interval (CI) was used to present the outcomes. The pooled data were assessed by using the fixed-effects model or random-effects model.

Results

A total of 5 randomized controlled studies involving 930 subjects were included according to our inclusion criteria. On the ankle score at 6w,12w and 52w, there was no statistically significant difference between the two groups. In terms of 6w, the brace group showed better ankle dorsiflexion (MD = 6.78, 95% CI 0.56-13.00, p = 0.03) and plantar flexion (MD = 6.58, 95% CI 1.60-11.55, p = 0.01) than the cast group. The wound complications (RR = 3.49, 95% CI 1.32 to 9.24, p = 0.01) and total complications (RR = 3.54, 95% CI 1.92 to 6.50, p < 0.0001) in the brace group were three times more than that in the cast group. There was no statistically significant difference between the two groups in the non-wound complications. There was no statistically significant difference between the two groups in the time of going back to work, swelling of the ankle, and atrophy of the calf muscle.

Conclusion

The short-term and long-term functional outcomes after postoperative treatment of adult ankle fractures with braces are similar to those with casts. The usage of braces may cause three times more wound complications than that of casts.

Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: the AFTER pilot randomised controlled trial

OBJECTIVE

The aim of the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study, a multicentre external pilot parallel-group randomised controlled trial (RCT), was to assess feasibility of a definitive trial comparing rehabilitation approaches after ankle fracture.

SETTING

Five UK National Health Service hospitals.

PARTICIPANTS

Participants were aged 50 years and over with an ankle fracture requiring immobilisation for at least 4 weeks.

INTERVENTIONS

Participants were allocated 1:1 via a central web-based randomisation system to: (1) best practice advice (one session of physiotherapy, up to two optional additional advice sessions) or (2) progressive exercise (up to six sessions of physiotherapy).

PRIMARY OUTCOME MEASURES

Feasibility: (1) participation rate, (2) intervention adherence and (3) retention.

RESULTS

Sixty-one of 112 (54%) eligible participants participated, exceeding progression criteria for participation of 25%. Recruitment progression criteria was 1.5 participants per site per month and 1.4 was observed. At least one intervention session was delivered for 28/30 (93%) of best practice advice and 28/31 (90%) of progressive exercise participants, exceeding the 85% progression criteria. For those providing follow-up data, the proportion of participants reporting performance of home exercises in the best practice advice and the progressive exercise groups at 3 months was 20/23 (87%) and 21/25 (84%), respectively. Mean time from injury to starting physiotherapy was 74.1 days (95% CI 53.9 to 94.1 days) for the best practice advice and 72.7 days (95% CI 54.7 to 88.9) for the progressive exercise group. Follow-up rate (6-month Olerud and Molander Ankle Score) was 28/30 (93%) for the best practice advice group and 26/31 (84%) in the progressive exercise group with an overall follow-up rate of 89%.

CONCLUSIONS

This pilot RCT demonstrated that a definitive trial would be feasible. The main issues to address for a definitive trial are intervention modifications to enable earlier provision of rehabilitation and ensuring similar rates of follow-up in each group.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials

BACKGROUND

What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures.

METHODS

A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union.

RESULTS

The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates.

CONCLUSION

This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of level I evidence.

Effect of transcutaneous electrical acupoint stimulation on bone metabolism in patients with immobilisation after foot and ankle fracture surgery: a randomised controlled trial study protocol

INTRODUCTION

Fracture is a disease with a high incidence worldwide. Foot and ankle fractures are common among fractures of the lower extremities. Foot and ankle fractures usually require surgical fixation and a period of fixed treatment, which can lead to decreased bone density. Although transcutaneous electrical acupoint stimulation (TEAS) is widely used for movement system diseases, there is minimal evidence to show the effectiveness of TEAS on patients after surgical fixation of ankle and foot fractures. This trial aims to evaluate whether TEAS can reduce bone loss in patients with immobilisation after ankle and foot fractures.

METHODS AND ANALYSIS

A randomised controlled trial will be conducted in which 60 patients will be randomly divided into two groups: (a) the control group will be treated according to the routine procedures of basic orthopaedics treatment; (b) in the treatment group, bilateral SP36, BL23 and ST36 will be performed on the basis of the control group, and the test will be performed for 30 min every other day for a total of 8 weeks. Bone turnover markers will be used as primary outcome. Secondary outcomes are composed of blood phosphorus, blood calcium and bone mineral density. Treatment safety will be monitored and recorded.

ETHICS AND DISSEMINATION

This trial is approved by the Ethics Committee of Beijing University of Chinese Medicine (2020BZYLL0611) and the Ethics Committee of Beijing Luhe Hospital (2020-LHKY-055-02), and inpatients who meet the following diagnostic and inclusion criteria are eligible to participate in this study.

TRIAL REGISTRATION NUMBER

ChiCTR 2000039944.

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures.

METHODS

We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3.

RESULTS

This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively.

CONCLUSION

Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

When is the optimum time for the initiation of early rehabilitative exercise on the postoperative functional recovery of peri-ankle fractures? A network meta-analysis

Objective

The purpose of this study was to explore the safe and most effective initiation time for the functional recovery of patients with peri-ankle fractures after surgery.

Method

We searched electronic databases, including the Cochrane Library, Embase, PubMed and the reference lists of relevant articles published from inception to October 30, 2021. Two researchers independently performed literature screening and data extraction and evaluated the quality of the included literature using the Newcastle–Ottawa Scale. Network meta-analysis, including consistency testing, publication bias, and graphical plotting, was performed using Stata (v16.0).

Results

A total of 25 articles involving 1756 patients were included in this study. The results of the meta-analysis showed that functional exercise within 2 days after surgery may result in lower VAS scores compared to other techniques (P < 0.05). Functional exercise within 12 months may lead to higher AOFAS scores than that of other techniques (P < 0.05). The total postoperative complication rate, including deep vein thrombosis, showed no statistically significant differences between any two interventions (P > 0.05). The results of the surface under the cumulative ranking (SUCRA) showed that functional exercise within two days postoperatively may have the lowest VAS scores (SUCRA = 82.8%), functional exercise within 1 week postoperatively may have the lowest deep vein thrombosis rate (SUCRA = 66.8%), functional exercise within 10 days postoperatively may have the fewest total postoperative complication rate (SUCRA = 73.3%) and functional exercise within 12 months postoperatively may contribute to the highest AOFAS scores (SUCRA = 85.5%).

Conclusion

The results of this study suggest that initiation of rehabilitation within two days after surgery may be the best time to reduce postoperative pain; rehabilitation interventions within 10 days after surgery may be the optimal time for reducing the total postoperative complication rate, including deep vein thrombosis; and continued functional exercise within 12 months after surgery may steadily and ideally improve the function of the ankle joint.

Systematic Review Registration: doi: 10.37766/inplasy2021.12.0030, identifier: INPLASY2021120030

The Fragility Fracture Postoperative Mobilisation multicentre audit : the reality of weightbearing practices following operations for lower limb fragility fractures

AIMS

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

METHODS

The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, "all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living".

RESULTS

A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients).

CONCLUSION

Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972-979.

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BACKGROUND

The incidence of ankle fractures is increasing and the clinical outcome is highly variable.

QUESTION

What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?

DATA SOURCES

Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.

STUDY SELECTION

Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.

RESULTS

Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.

CONCLUSION

There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020184830.

Quantifying balance deficit in people with ankle fracture six months after surgical intervention through the Y-Balance test

BACKGROUND

Ankle fractures are among the most common traumatic fractures and have a great socio-economic impact. Consequences of an ankle fracture requiring surgical treatment (e.g. pain, reduced ankle range of motion (ROM), muscle weakness, etc.) lead to balance deterioration, which has a profound impact on activities of daily living. However, to the best of the authors' knowledge, no reliable clinical tests are available to monitor balance in patients after ankle surgery.

OBJECTIVES

To quantify single-leg dynamic balance in patients with bimalleolar ankle fracture through the Y-Balance test (YBT). The second objective was to analyze the impact of ankle dorsiflexion ROM and hip strength on balance to optimize balance rehabilitation programs.

DESIGN

Cross-sectional study.

METHODS

22 participants, who had undergone surgery after bimalleolar ankle fractures, were assessed for ankle ROM, hip strength, and dynamic balance six-months after the surgical intervention. The within-session reliability of YBT was calculated through the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). Student's t-tests were used to assess leg differences. A multiple regression analysis was performed to evaluate the role of ankle dorsiflexion ROM and hip abductor and adductor strength in predicting balance performance.

RESULTS

YBT showed high-to-excellent within-session relative reliability (Healthy leg: 0.85 ≤ ICC≤0.96; Operated leg: 0.84 ≤ ICC≤0.96). SEM values were below 3.3 %. The operated leg showed significant lower YBT scores for anterior reach direction (-9.0 %; g=-0.70) and composite score (-4.5 %; g=-0.34). Multiple regression analysis showed that both, ankle dorsiflexion and hip abductor and adductor strength explained 66 % of the variance in the YBT anterior direction of the operated leg.

CONCLUSIONS

The YBT is a reliable tool that allows the quantification of single-leg dynamic balance impairments from 6-months after surgery in patients with bimalleolar ankle fracture. Between-leg YBT differences in the anterior direction can be used as reference scores (3.3 %) for balance restoration. Balance rehabilitation programs should focus on improving ankle functionality and reducing hip muscle weakness with specific hip strength exercises and balance exercises with similar demands to the reaching tasks of the YBT to promote a faster recovery.

Clinical-Functional Evaluation and Test-Retest Reliability of the G-WALK Sensor in Subjects with Bimalleolar Ankle Fractures 6 Months after Surgery

Ankle fractures can cause significant functional impairment in the short and long term. In recent years, gait analysis using inertial sensors has gained special relevance as a reliable measurement system. This study aimed to evaluate the differences in spatiotemporal gait parameters and clinical−functional measurements in patients with bimalleolar ankle fracture and healthy subjects, to study the correlation between the different variables, and to analyze the test−retest reliability of a single inertial sensor in our study population. Twenty-two subjects with bimalleolar ankle fracture six months after surgery and eleven healthy subjects were included in the study. Spatiotemporal parameters were analyzed with the G-WALK sensor. Functional scales and clinical measures were collected beforehand. In the ankle fracture group, the main differences were obtained in bilateral parameters (effect size: 0.61 ≤ d ≤ 0.80). Between-group differences were found in cadence, speed, stride length, and stride time (effect size: 1.61 ≤ d ≤ 1.82). Correlation was moderate (0.436 < r < 0.554) between spatiotemporal parameters and clinical−functional measures, explaining up to 46% of gait performance. Test−retest reliability scores were high to excellent (0.84 ≤ ICC ≤ 0.98), with the worst results in the gait phases. Our study population presents evident clinical−functional impairments 6 months after surgery. The G-WALK can be considered a reliable tool for clinical use in this population.

Recovery and Return to Activity 1 Year After Ankle Fracture Managed With Open Reduction and Internal Fixation: A Prospective Longitudinal Cohort Study

Background:

Ankle fractures are common and frequently managed with open reduction and internal fixation (ORIF). Although these fractures can occur at any age, they are most common in younger individuals with high-energy trauma or older adults with lower-energy trauma. Our investigation focused on those aged 65 years or younger. Our primary objective was to describe recovery over the first postfracture year in (1) functional dorsiflexion using the weightbearing lunge test (WBLT), (2) patient-reported functional outcomes using the Olerud Molander Ankle Score (OMAS), (3) return to prefracture activity levels, and (4) return to work. Secondarily, we examined patient and clinical factors (including the WBLT and OMAS) associated with return to prefracture activities, including sports.

Methods:

Using a prospective inception cohort of 142 patients between 18 and 65 years old who underwent ORIF after ankle fracture and attended follow-up visits, we collected information from participants and their medical charts. We assessed functional dorsiflexion (using side-to-side difference in WBLT), patient-reported functional outcome (OMAS), and self-reported return to prefracture activity levels and work at 6 weeks, 6 months and 1 year postoperatively.

Results:

The WBLT, OMAS, and return to prefracture activity and work improved significantly over time ( P < .001). However, at 1 year postoperation, the mean side-to-side difference in the WBLT was 3.22±2.68 cm, 69 (72%) reported ankle stiffness, and only 49 (52%) had returned to prefracture activity levels. Of those who were working, 97% had returned to work by 1 year postoperation. Only the OMAS ( P < .001) and side-to-side difference in WBLT ( P = .011) were significantly associated with return to prefracture activity levels.

Conclusion:

Although participants improved significantly over the first postoperative year in all outcomes, many reported limitations in functional dorsiflexion and return to prefracture activities. Those with higher OMAS scores and smaller side-to-side difference in WBLT were more likely to return to prefracture activity levels by 1 year postoperatively. Level of Evidence: Level II, prognostic study.

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis

PURPOSE

Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing.

METHOD

This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis.

RESULTS

Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion.

CONCLUSION

The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

Sociodemographic and health system factors associated with variations in hospitalization costs for fractures in adults aged 45 years and over: a cross-sectional study of provincial health accounts in Jiangsu Province, China

This study reports hospitalization costs of fracture in Chinese patients aged over 45 years and evaluates their related factors in different fracture groups.

PURPOSE

To report hospitalization costs of treating fractures in Chinese patients aged over 45 years and to investigate the sociodemographic and health system factors related to variation in the costs.

METHODS

Study participants were selected from the 2016 Health Accounts Database in Jiangsu in which patients' hospitalization costs were kept at various levels in hospitals. A multi-stage stratified sampling method was used to select study participants. Electronic medical records of patients aged 45 years and over with fractures were included. The International Classification of Diseases, Tenth Revision (ICD-10) was used to identify patients who were hospitalized due to fractures. A generalized linear model was used to estimate the extent to which a range of health system and sociodemographic factors were associated with the variation on hospitalization costs. Costs data were presented and analyzed using 2016 U.S. dollars.

RESULTS

A total of 39,300 patients were included in the study. Vertebra, tibia/fibula, and hip were the most frequent fracture sites. The mean (median) of hospitalization cost of included fractures ranged from USD 3142 (USD 2420) for hand and wrist fractures to USD 10,355 (USD 9673) for hip fractures. Longer length of hospital stay, higher hospital level, and being covered by a health insurance were associated with higher hospitalization costs for all fracture types.

CONCLUSION

Our study reports hospital costs of the fracture using a large health accounts database in China and investigates the associated factors of hospital costs. Our results may inform cost-of-illness studies and economic evaluations of fracture preventions.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

EMG Activity With Use of a Hands-Free Single Crutch vs a Knee Scooter

BACKGROUND

Foot and ankle injuries frequently require a period of nonweightbearing, resulting in muscle atrophy. Our previous study compared a hands-free single crutch (HFSC) to standard axillary crutches and found increased muscle recruitment and intensity while using the HFSC. Knee scooters are another commonly prescribed nonweightbearing device. The purpose of this study is to examine the electromyographic (EMG) differences between an HFSC and knee scooter, in conjunction with device preference and perceived exertion.

METHODS

A randomized crossover study was performed using 30 noninjured young adults. Wireless surface EMG electrodes were placed on the belly of the rectus femoris (RF), vastus lateralis (VL), lateral gastrocnemius (LG), and gluteus maximus (GM). Participants then ambulated along a 20-m walking area while 15 seconds of the gait cycle was recorded across 3 conditions: walking with a knee scooter, an HFSC, and with no assistive device. Mean muscle activity and peak EMG activity were recorded for each ambulatory modality. Immediately following testing, patient exertion and device preference was recorded.

RESULTS

The RF, LG, and GM showed increased peak EMG activity percentage, and the LG showed increased mean muscle activity while using the HFSC compared with the knee scooter. When comparing the knee scooter and HFSC to walking, both showed increased muscle activity in the RF, VL, and LG but no difference in the GM. There was no statistical difference in participant preference, whereas the HFSC had a statistically significant higher perceived exertion than the knee scooter (P < .001).

CONCLUSION

In this group of young, healthy noninjured volunteers, the HFSC demonstrated increased peak EMG activity in most muscle groups tested compared with the knee scooter.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture

Background

Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture.

Methods

Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery (‘early weight-bearing’ group) or to not weight-bear for a further four weeks (‘delayed weight -bearing’ group). All other treatment will be as per the guidance of the treating clinician.

Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation.

A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options.

Discussion

The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures.

Trial registration

ISRCTN12883981, Registered 02 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04560-7.

Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: A randomised clinical trial

OBJECTIVE

To compare the one-year postoperative outcomes of anti-gravity treadmill rehabilitation with those of standard rehabilitation in patients with ankle or tibial plateau fractures.

DESIGN

An open-label prospective randomised study.

SETTING

Three trauma centres.

SUBJECTS

Patients were randomised into the intervention (anti-gravity treadmill) or control (standard protocol) rehabilitation group.

MAIN MEASURES

The primary endpoint was changes in the Foot and Ankle Outcome Score for ankle fractures and Knee Injury and Osteoarthritis Outcome Score for tibial plateau fractures from baseline to 12 months after operation. Secondary endpoints were the subscores of these scores, muscle atrophy (leg circumference at 20 cm above and 10 cm below the knee joint) and the Dynamic Gait Index.

RESULTS

Initially, 73 patients (37 vs 36) underwent randomisation. After 12 months, 29 patients in the intervention group and 24 patients in the control group could be analysed. No significant difference was noted in the Foot and Ankle Outcome Score (80.8 ± 18.4 and 78.4 ± 21.1) and Knee Injury and Osteoarthritis Outcome Score (84.8 ± 15.2 and 81.7 ± 17.0). The change in the Dynamic Gait Index from 12 weeks to 12 months differed significantly between the groups (P = 0.04). Patients with tibial plateau fractures had a 3 cm wider thigh circumference in the intervention group than those in the control group (95% confidence interval: -0.2 to 6.3 cm, P = 0.08).

CONCLUSION

One year after surgery, patients who had undergone anti-gravity treadmill rehabilitation showed better gait than patients in the control group, and those with tibial plateau fractures had less muscle atrophy.

Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial

BACKGROUND

Acute ankle fractures can occur during sports activities, and unstable ankle fractures are commonly treated operatively. However, controversy exists about the optimal time to allow weightbearing.

HYPOTHESIS

Early weightbearing after the stable fixation of an ankle fracture is not inferior to nonweightbearing in terms of ankle function assessed at 12 months after injury.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 258 patients were assessed for eligibility. Of these patients, 194 were randomly allocated to either the early weightbearing group (95 patients who were allowed weightbearing at 2 weeks postoperatively) or the nonweightbearing group (99 patients who were not allowed weightbearing until 6 weeks postoperatively). The primary outcome measure was the mean difference in the Olerud-Molander ankle score (OMAS) between the groups, assessed at the 12-month follow-up examination. The secondary outcome measures were the time to return to preinjury activities and patients' subjective satisfaction. Complications such as hardware loosening or failure, fracture displacement, and nonunion were evaluated.

RESULTS

The mean difference in the OMAS for the early weightbearing group compared with the nonweightbearing group was 1.6 (95% CI, -1.9 to 5.0) in the intention-to-treat analysis. The lower limit of the 95% CI (-1.9) exceeded the noninferiority margin of -8, indicating that early weightbearing was not inferior to nonweightbearing. The difference in the proportion of patients who were satisfied or very satisfied with their treatment was not statistically significant (84.3% vs 76.2%; P = .19); however, the time taken to return to preinjury activities was shorter with early weightbearing than with nonweightbearing (9.1 ± 3.0 vs 11.0 ± 3.0 weeks; P < .001). No cases of nonunion were observed in either group.

CONCLUSION

Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. The patients' subjective satisfaction was similar between the groups, although the time taken to return to preinjury activities was shorter in the early weightbearing group.

REGISTRATION

NCT02029170 (ClinicalTrials.gov identifier).

Co-producing a multi-stakeholder Core Outcome Set for distal Tibia and Ankle fractures (COSTA): a study protocol

BACKGROUND

Ankle fracture is a common injury with a strong evidence base focused on effectiveness of treatments. However, there are no reporting guidelines on distal tibia and ankle fractures. This has led to heterogeneity in outcome reporting and consequently, restricted the contribution of evidence syntheses. Over the past decade, core outcome sets have been developed to address this issue and are available for several common fractures, including those of the hip, distal radius, and open tibial fractures. This protocol describes the process to co-produce-with patient partners and other key stakeholders-a multi-stakeholder derived Core Outcome Set for distal Tibia and Ankle fractures (COSTA). The scope of COSTA will be for clinical trials.

METHODS

The study will have five-stages which will include the following: (i) systematic reviews of existing qualitative studies and outcome reporting in randomised controlled trial studies to inform a developing list of potential outcome domains; (ii) qualitative interviews (including secondary data) and focus groups with patients and healthcare professionals to explore the impact of ankle fracture and the outcomes that really matter; (iii) generation of meaningful outcome statements with the study team, international advisory group and patient partners; (iv) a multi-round, international e-Delphi study to achieve consensus on the core domain set; and (v) an evidence-based consensus on a core measurement set will be achieved through a structured group consensus meeting, recommending best assessment approaches for each of the domains in the core domain set.

DISCUSSION

Development of COSTA will provide internationally endorsed outcome assessment guidance for clinical trials for distal tibia and ankle fractures. This will enhance comparative reviews of interventions, potentially reducing reporting bias and research waste.

Use of cast immobilisation versus removable brace in adults with an ankle fracture: multicentre randomised controlled trial

OBJECTIVES

To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture.

DESIGN

Multicentre randomised controlled trial.

SETTING

20 trauma units in the UK National Health Service.

PARTICIPANTS

669 adults aged 18 years and older with an acute ankle fracture suitable for cast immobilisation: 334 were randomised to a plaster cast and 335 to a removable brace.

INTERVENTIONS

A below the knee cast was applied and ankle range of movement exercises started on cast removal. The removable brace was fitted, and ankle range of movement exercises were started immediately.

MAIN OUTCOME MEASURES

Primary outcome was the Olerud Molander ankle score at 16 weeks, analysed by intention to treat. Secondary outcomes were Manchester-Oxford foot questionnaire, disability rating index, quality of life, and complications at 6, 10, and 16 weeks.

RESULTS

The mean age of participants was 46 years (SD 17 years) and 381 (57%) were women. 502 (75%) participants completed the study. No statistically significant difference was found in the Olerud Molander ankle score between the cast and removable brace groups at 16 weeks (favours brace: 1.8, 95% confidence interval -2.0 to 5.6). No clinically significant differences were found in the Olerud Molander ankle scores at other time points, in the secondary unadjusted, imputed, or per protocol analyses.

CONCLUSIONS

Traditional plaster casting was not found to be superior to functional bracing in adults with an ankle fracture. No statistically difference was found in the Olerud Molander ankle score between the trial arms at 16 weeks.

TRIAL REGISTRATION

ISRCTN registry ISRCTN15537280.

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

The Case for Retiring Flexibility as a Major Component of Physical Fitness

Flexibility refers to the intrinsic properties of body tissues that determine maximal joint range of motion without causing injury. For many years, flexibility has been classified by the American College of Sports Medicine as a major component of physical fitness. The notion flexibility is important for fitness has also led to the idea static stretching should be prescribed to improve flexibility. The current paper proposes flexibility be retired as a major component of physical fitness, and consequently, stretching be de-emphasized as a standard component of exercise prescriptions for most populations. First, I show flexibility has little predictive or concurrent validity with health and performance outcomes (e.g., mortality, falls, occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (i.e., body composition, cardiovascular endurance, muscle endurance, muscle strength). Second, I explain that if flexibility requires improvement, this does not necessitate a prescription of stretching in most populations. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching (e.g., resistance training). Retirement of flexibility as a major component of physical fitness will simplify fitness batteries; save time and resources dedicated to flexibility instruction, measurement, and evaluation; and prevent erroneous conclusions about fitness status when interpreting flexibility scores. De-emphasis of stretching in exercise prescriptions will ensure stretching does not negatively impact other exercise and does not take away from time that could be allocated to training activities that have more robust health and performance benefits.

An evaluation of the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture

OBJECTIVES

The aim of this study is to evaluate the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture.

METHODS

Patients completed outcome measure questionnaires at baseline, six, 10- and 16-weeks postinjury as part of an ongoing clinical trial on ankle fracture rehabilitation. The internal consistency, convergent validity, structural validity and interpretability of the Olerud Molander Ankle Score was assessed. This was achieved through using the respective analysis methods of Cronbach's alpha, correlation coefficients, principal component analysis, evaluation of floor and ceiling scores and estimation of the minimally important change using anchor-based methods.

RESULTS

The Olerud Molander Ankle Score showed adequate convergent validity against hypotheses set in relation to scores of comparator instruments. Principal component analysis demonstrated that the measure has two subscales: ankle function and ankle symptoms. The internal consistency of the measure and the ankle function subscale was sufficient, but inconclusive for the ankle symptoms subscale. There were no floor and ceiling effects present within the scores and the estimated minimally important change was 9.7 points.

CONCLUSION

The Olerud Molander Ankle Score demonstrates sufficient measurement properties and is likely to be primarily measuring the construct of patient reported function following ankle fracture. Further research should evaluate the relevance of other domains to individuals recovering from and ankle fracture, such as social participation and psychological wellbeing. The development of a core outcome set would be advantageous to standardise outcome measurement collection in this area.

Customized Three-Dimensional-Printed Orthopedic Close Contact Casts for the Treatment of Stable Ankle Fractures: Finite Element Analysis and a Pilot Study

Ankle fracture is one of the most common traumatic fractures among the elderly population. The majority of ankle fractures are stable types with the typically conservative strategy of close contact casting treatment. The continuous use of unventilated standard cast immobilization severely affects patient's satisfaction and compliance and markedly increases the rates of various complications. Three-dimensional (3D) printing for casts has advantages of lightweight, ventilated, proper-fit, and esthetic improvements. In this work, this novel 3D-printed cast has been applied to individuals with stable ankle fractures, and its effectiveness can be successfully validated with finite element analysis and a pilot study. A 30% reduction of the volume was chosen as the optimal result in topology optimization. Both 3D-printed casts and conventional casts showed significant ankle function improvement after immobilization for 6 weeks (p = 0.000). The 3D-printed casts were superior to the traditional casts in Olerud-Molander Ankle Scores (OMAS), with the mean difference of 8.3 ± 8.57 OMAS points (95% CI -10.8 to 27.5; p = 0.354) for 6 weeks, implying that the 3D-printed casts possibly maintain the equal clinical efficacy as the traditional casts. The statistically significant difference between groups from the 3D-printed cast and the traditional one observed in C-QUEST 2.0 was 11.3 ± 1.5 points (95% CI 8.0-14.6; p = 0.000), indicating that the 3D-printed cast possesses outperforming satisfaction and compliance and has great potential in practical applications. There were no severe complications in the 3D-printed casts, but more moderate complications were observed in the traditional casts.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Impact of anti-gravity treadmill rehabilitation therapy on the clinical outcomes after fixation of lower limb fractures: A randomized clinical trial

OBJECTIVE

To compare the effects of anti-gravity treadmill rehabilitation with those of standard rehabilitation on surgically treated ankle and tibial plateau fractures.

DESIGN

Open-label prospective randomized multicenter study.

SETTING

Three level 1 trauma centers.

SUBJECTS

Patients with tibial plateau or ankle fractures who underwent postoperative partial weight-bearing were randomized into the intervention (anti-gravity treadmill use) or control (standard rehabilitation protocol) groups.

MAIN MEASURES

The primary endpoint was the change in the Foot and Ankle Outcome Score for ankle fractures and total Knee injury and Osteoarthritis Outcome Score for tibial plateau fractures (0-100 points) from baseline (T1) to six weeks after operation (T4) in both groups. Leg circumference of both legs was measured to assess thigh muscle atrophy in the operated leg.

RESULTS

Thirty-seven patients constituted the intervention and 36 the control group, respectively; 14 patients dropped out during the follow-up period. Among the 59 remaining patients (mean age 42 [range, 19-65] years), no difference was noted in the Foot and Ankle Outcome Score (54.2 ± 16.1 vs. 56.0 ± 16.6) or Knee injury and Osteoarthritis Outcome Score (52.8 ± 18.3 vs 47.6 ± 17.7) between the intervention and control groups 6 weeks after operation. The change in the leg circumference from T1 to T4 was greater by 4.6 cm in the intervention group (95% confidence interval: 1.2-8.0, P = 0.005). No adverse event associated with anti-gravity treadmill rehabilitation was observed.

CONCLUSION

No significant difference was noted in patient-reported outcomes between the two groups. Significant differences in muscular atrophy of the thigh were observed six weeks after operation.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Functional Outcomes Following Operative and Nonoperative Management of Weber C Ankle Fractures: A Systematic Review

Weber C ankle fractures are unstable ankle fractures occurring above the syndesmosis. These fractures are often managed operatively, although a small population of patients are still selected for nonoperative management. This study primarily aimed to summarize the current evidence on functional outcomes for Weber C patients managed operatively and nonoperatively. Evidence on secondary outcomes such as complications and radiographic outcomes were also reviewed. This systematic search was conducted according to PRISMA guidelines. A literature search was conducted using the EMBASE, Medline, and Central databases. A total of 26 studies were included in the final analysis. All papers studied the management of Weber C fractures using open reduction and internal fixation (ORIF). Three main functional outcome scores were identified: American Orthopedic Foot and Ankle Society score, Olerud-Molander Ankle Score, and Foot and Ankle Outcome Score. Only 1 study compared operative and conservative management, which showed similar outcomes for either option (median Olerud-Molander Ankle Score 95 [range 20 to 95] vs 100 [70 to 100], respectively). Complications associated with operative management included infection, wound dehiscence, implant failure, and malunion or nonunion. The mean rate of syndesmosis malreduction was 18.2%. This study showed that operative management, regardless of the method of ORIF used, as well as nonoperative management resulted in good functional outcomes, indicating that patient selection for either method is important. However, there is limited evidence on the complications and radiographic outcomes associated with nonoperative management. We recommend further studies to compare all ORIF methods with conservative management and examine the complications associated with nonoperative management.

Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial

OBJECTIVE

To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures.

DESIGN

The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist.

SETTING

This study was done at a level 1 trauma centre.

SUBJECTS

One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study.

INTERVENTIONS

Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer.

MAIN MEASURES

Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered.

RESULTS

Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) (P = 0.021). At one-year follow-up, there was no difference between the groups (P = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group (P = 0.026).

CONCLUSION

The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.

Effect on Overall Health Status With Weightbearing at 2 Weeks vs 6 Weeks After Open Reduction and Internal Fixation of Ankle Fractures

BACKGROUND

Ongoing controversy exists on postoperative weightbearing status after open reduction and internal fixation of an ankle fracture. This prospective randomized controlled trial aimed to compare patient-based and physician-based outcomes after early weightbearing at 2 vs 6 weeks postoperatively.

METHODS

Fifty patients with unstable rotational-type ankle fractures were treated operatively with subsequent immobilization in a below-the-knee cast for 2 weeks and were then randomly allocated to 2 groups. The first group had early weightbearing at 2 weeks postoperation and the second group at 6 weeks postoperation. Follow-up included subjective and objective evaluations performed at 2, 6, 12, and 26 weeks postoperatively. The primary outcome was the patient-based general health status as measured with the EuroQol-5D (EQ-5D) scoring system. Secondary outcome was the Olerud and Molander ankle score. Power analysis revealed a study group of 50 patients was needed to show a clinically relevant effect size of 10 points in both EQ-5D visual analog scale (VAS) score and Olerud and Molander score.

RESULTS

Patients in the early weightbearing group had higher mean EQ-5D VAS scores at a 6-week follow-up (P = .014) of 77 ± 14 compared to 66 ± 15 for late mobilization. No difference was found at other follow-up points or between groups for physician-based outcome measures. At 26 weeks postoperatively, mean Olerud and Molander ankle scores were similar at 84 ± 16 and 81 ± 17 for mobilization at 2 and 6 weeks postoperation, respectively.

CONCLUSION

Early weightbearing after operative fixation of rotational-type ankle fractures had a clinically relevant and statistically significant benefit in patient-based general health status, as quantified with EQ-5D VAS scores, at 6 weeks postoperation. These results contribute to our understanding of early weightbearing and may encourage consideration of weightbearing at 2 weeks postoperatively in standard protocols.

LEVEL OF EVIDENCE

Therapeutic Level I, prospective randomized controlled trial.

Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma

Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.

Safety of Early Weight Bearing Following Fixation of Bimalleolar Ankle Fractures

Ankle fractures are common orthopedic injuries. Although operative indications and subsequent stabilization of these fractures have not significantly changed, postoperative protocols remain highly variable. Effects of early weight bearing (EWB) on fracture characteristics in operatively stabilized bimalleolar and bimalleolar equivalent ankle fractures remain poorly publicized. This study seeks to clarify postoperative fracture union rates, rates of hardware loosening or failure, and radiographic medial clear space changes when comparing EWB to late weight bearing (LWB) following open reduction and internal fixation (ORIF).

A total of 95 patients with either bimalleolar (66%) or bimalleolar equivalent (34%) fractures who underwent ORIF were retrospectively reviewed. Weight bearing was allowed at three weeks in the EWB group and when signs of radiographic union were noted in the LWB group. Postoperatively, patients were evaluated at regular intervals for fracture union, signs of implant failure, and evidence of medial clear space widening radiographically.

There were 38 patients (40%) in the EWB group and 57 patients (60%) comprising the LWB cohort. There were no significant demographic differences between groups. The EWB group on average began to weight bear at 3.1 + 1.4 weeks postoperatively, whereas the LWB group began at 7.2 + 2.1 weeks postoperatively (p<0.01). Union rate (p=0.51), time to union (p=0.23), and implant failure (p>0.1 at all time intervals) were not notably different between groups. No differences in medial clear space were detected at any postoperative interval between groups (p>0.1 at all time intervals). This study suggests that EWB at three weeks postoperatively does not increase markers of radiographic failure compared to six weeks of non-weight bearing (NWB), which has been regarded as the gold standard of treatment to allow for healing; this may represent an improvement to rehabilitation protocols after bimalleolar ankle ORIF of unstable ankle fractures.

Orthopedic treatment and early weight-bearing for bimalleolar ankle fractures in elderly patients: Quality of life and complications

INTRODUCTION

Non-operative treatment of Weber's type B ankle fractures is essential in elderly patients. However, there is controversy in the post-reduction management of the fracture between the use of early weight-bearing or traditional treatment and non-weight-bearing for 6-8 weeks. There is limited evidence available regarding which rehabilitation regimen should be included. This study aimed to compare the quality of life and the number of complications between the two types of intervention (weight-bearing and non-weight-bearing).

METHODS

Prospective cohort study. The quality of life was analyzed through the SF-12 and the Barthel Index at 6 weeks, one year and two years. The mean age was 83 ± 3 years in the weight-bearing group and 82 ± 3 in the non-weight-bearing group. In addition, the associated complications and costs were analyzed.

RESULTS

A total of 70 patients were assigned in two groups: a control group of 37 patients (nonweight-bearing) and an experimental group of 33 patients (weight-bearing). A significant difference was observed in favor of early weight-bearing in SF-12 both, in the short and long terms (52.9 ± 5.3 vs 64.9 ± 4.6; p < 0.001 and 69.8 ± 4.1 vs 81.0 ± 3.6; p < 0.001). Significant differences were also observed in favor of early loading with respect to the Barthel Index (54.3 ± 4.9 vs 64.2 ± 3.9; p < 0.001 and 70.6 ± 4.2 vs 80.4 ± 3.0; p < 0.001). There were no significant differences in the complication rate between the two groups.

CONCLUSION

Early weight-bearing improves the quality of life and functionality in elderly patients with Weber type B fracture without increasing complications.

Pulsed short waves in the remineralization of alveolar bone structures of the jaw in patients with diabetes mellitus – a series of cases

This clinical study included three patients aged between 50 and 78 years who had chronic marginal periodontitis and type 2 diabetes mellitus, diseases that are frequently associated due to changes occurring in polymorphonuclear cells, as well as to alterations of microcirculation. No bone augmentation therapies were performed. Bone regeneration was strictly influenced by conventional periodontal therapy, supplemented with ten pulsed short wave sessions applied to the lower face shortly after closed periodontal curettage. The allocated time was ten minutes for the first two sessions, and 15 minutes for the following 8 sessions. Clinical and radiological evaluations were performed at the time of presentation, as well as after initiation of pulsed short wave therapy: in the first case, three weeks after initiation of therapy and three years after the end of complex oral rehabilitation; in the second case, eight weeks after the onset of pulsed short wave therapy and in the third case, five weeks after the onset of pulsed short wave therapy. The results were significant in all three cases, demonstrated radiologically by the same type of radiological examination at identical scales. Bone remineralization was obvious in the alveolar processes of the jaw. Although further studies in this direction are necessary, the results are both clinically and radiologically significant. Key words: pulsed short waves, alveolar bone resorption, periodontal disease, diabetes,

Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study

INTRODUCTION

Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up.

METHODS AND ANALYSIS

A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group.

ETHICS AND DISSEMINATION

Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2^nd July 2018.

TRIAL REGISTRATION NUMBER

ISRCTN16612336.

Comparison of Supervised Exercise and Home Exercise After Ankle Fracture

Ankle fractures are common fractures of the lower extremities that have an incidence rate of 101 fractures per 100.000 person-years. It is not clear which rehabilitation intervention should be performed after an ankle fracture. The aims of this study are to compare the effectiveness of a supervised exercise program with that of a home exercise program and to determine and compare the costs of these programs. A supervised exercise program and a home exercise program were performed for 8 weeks. The supervised exercise group consisted of 35 patients (mean age 39.23 years), and the home exercise group consisted of 73 patients (mean age 41.78 years). The average follow-up was 27.86 ± 9.88 months. Demographic information, injury details, type and classification of fracture, pain severity, and ankle range of motion were recorded. The clinical outcomes were determined by using the Pain Disability Index, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score, and the Short-Form 36 Health Survey. Surgical and rehabilitation satisfaction was evaluated with the use of a numeric scale. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scores were statistically significantly higher in the home exercise group (p = .036), and rehabilitation satisfaction of the supervised exercise group was statistically significantly better (p = .047). The total rehabilitation crude cost of a patient in the supervised exercise group is 1113.63 Turkish lira (310.25 U.S. dollars) versus 182.31 Turkish lira (50.79 U.S. dollars) in the home exercise group. Considering that the crude cost of the home exercise program is very low and clinical outcomes are satisfactory, we recommend that patients with surgically treated isolated ankle fractures be followed up with a postoperative home exercise program.

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations

OBJECTIVES

To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.

DESIGN

Web-based survey.

PARTICIPANTS

Orthopaedic Trauma Association (OTA) members.

METHODS

A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.

RESULTS

One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available.

CONCLUSIONS

Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.

Primary outcome measures used in interventional trials for ankle fractures: a systematic review

Background

Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture.

Methods

We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type.

Results

The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s.

Conclusion

This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.

Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study

Distal femur fractures are rare injuries with a bimodal distribution (high-energy injury in young males and low-energy fragility fractures in old females). Their management can be challenging: open reduction and internal fixation (ORIF) with distal femur locking plates is a commonly performed procedure especially in comminuted fractures with articular involvement. Anxiety regarding the stability of the fixation, especially in osteoporotic bone, leads to post-operative restrictive instructions with limitations regarding the weight-bearing status. Early weight bearing (EWB), however, was shown to enhance bone healing and was not correlated with an increased risk of fracture displacement or implant failure in previous published studies, which reported the results of proximal femur, tibia and ankle fractures surgical treatment. The current study analysed the results of a series of distal femur fractures (51 patients, mean age 64.3 ± 20.7) all treated with ORIF in a level-I major trauma centre, but differently rehabilitated. Group A was, in fact, instructed not to weight bear or to touch weight bear, while group B started to weight bear soon after surgery without specific restrictions. The objective was to compare the outcome and the complication rate in the two groups at 6 and 12 weeks after surgery. The results showed no statistically significant differences in the two groups and no post-operative complications in the EWB group. Six complications were observed in the non-weight-bearing group (four fractures displacement and two implants failure at 12-week follow-up). Distal femur fractures treated with locking plates can be rehabilitated with EWB to allow early return to function. There is no evidence that EWB increases the risk of fracture displacement or implant failure in distal femur fractures treated with distal locking plates. Instead, it is possible that post-operative non-weight-bearing status delays the fracture-healing process increasing the risk of failure of the fixation.