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Older patients with unstable ankle fractures could avoid surgery with new plaster cast technique

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A new form of casting offers an alternative to surgery in older people who have unstable ankle fractures, researchers say.

In a study published in JAMA, the Journal of the American Medical Association, researchers at the University of Oxford’s Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) compared initial treatment with a plaster cast technique known as close contact casting (CCC) versus the usual open reduction and internal fixation (ORIF) surgery.

Close contact casting uses less padding than a traditional plaster cast and sets the bones by being a close anatomical fit, the Nursing Times explains. The cast is applied by a surgeon under anaesthetic.

The new study was a follow-up to a randomised clinical trial involving 620 participants, results of which were published in October 2016.

The original trial found that ankle function at six months was similar in those who had CCC and those who underwent surgery. People who had a cast were less likely to have infections or wound problems than those who had surgery.

However, one in five people in the casting group had to have surgery later because their fracture was not healing in the right position, NDORMS said. There was more abnormal healing of the fracture seen on radiographs in the casting group (15%, compared to 3% for surgery).

The follow-up study was conducted to determine if the equivalence found in the original study persisted after three years.

Dr David Keene, National Institute of Health Research (NIHR) Postdoctoral Research Fellow and NDORMS Research Fellow in Trauma Rehabilitation, who led the study, said: “After three years, we found that equivalence in function between close contact casting and immediate surgery was maintained.”

For patients whose fractures were not healing in the correct position at six months, ankle function at three years was poorer whether treated by casting or surgery.

“These longer-term outcomes will help surgeons and patients to make informed decisions about the right course of action for them,” Dr Keene added. “Our findings indicate that treatment of ankle fractures in older adults should focus on obtaining and maintaining a reduction until union, by the most conservative means possible.”