A systematic review investigating the effectiveness of surgical versus conservative management of unstable ankle fractures in adults

Nine percent of all fractures affect the ankle, with an annual incidence of 122/100,000 in Edinburgh, UK. While unstable 73 fractures are usually treated surgically, there has been no recent systematic review of the evidence supporting this deci- 74 sion. In this systematic review, relevant electronic databases (such as MEDLINE and CINHAL) were searched from incep- 75 tion to February 2017. Five randomized controlled trials that examined surgical versus conservative interventions in 76 951 adults with closed ankle fractures, with follow-up for at least 6 months, were selected for further synthesis of evi- 77 dence. The risk of selection bias in all selected trials was relatively low. However, most of the trials had a high risk of 78 performance and detection bias. Three of the 5 selected trials used the validated functional Olerud Molander Ankle 79 Score. One trial (n = 43), reported a statistically better score for the surgical group at 27-month follow-up, whereas a 80 second (n = 81) and a third (n = 620) trial found no significant difference at 12 and 6 months, respectively. No significant 81 differences between surgical and conservative treatments were reported in 2 trials (n = 111) and (n = 96) in nonvali- 82 dated functional outcome measures. Other outcomes were malunion (9/334 [2.6%] versus 48/301 [15.9%], p < .0001) 83 and nonunion (3/408 [0.7%] versus 28/383 [7.3%], p < .0001) and were considerably higher in the conservatively treated group. Early treatment failure was significantly lower with surgery (7/435 [1.6%] versus 70/419 [16.7%], p < .0001). The 84 risk of malunion, nonunion, and loss of reduction were greater in nonoperative care. However, the 2 treatment 85 approaches provided equivalent functional outcomes.