Introduction
Methods
Study design
Search strategy and selection of studies
Assessment of methodological quality
Data extraction
Outcome measures
Data analysis
Results
Search
Baseline characteristics
First author | Year | Country | Study design | Number of patients | Fracture classification | Mean age in years (range) | % of patients male |
---|---|---|---|---|---|---|---|
Abdelaal [30] | 2021 | United Kingdom | Retrospective cohort study | 123 | Weber | 52 (18–92) | 43 |
Kortekangasc [32] | 2019 | Finland | Multicentre RCTa | 247 | Weber | 45 (16–85) | 51 |
Stuart [33] | 1989 | United Kingdom | Prospective cohort study | 37 | Lauge-Hansen | N/Ab | N/Ab |
van den Berg [23] | 2018 | Netherlands | RCTa | 44 | Weber | 43 (18–74) | 55 |
Port [31] | 1996 | England | Prospective cohort study | 65 | Lauge-Hansen | 48 (18–87) | 29 |
Study | Patients treated with removable orthosis; n (%) | Type of removable orthosis | Patients treated with cast; n (%) | Duration of nonoperative management in weeks |
---|---|---|---|---|
Abdelaal [30] | 61 (49.6) | Long walking boot | 62 (50.4) | 6 weeks |
Kortekangas [32] | 80 (32.3) | Dynacast-orthoglass | 3 weeks: 83 (33.6)a 6 weeks: 84 (34) | Orthosis 3 weeks Cast 3 or 6 weeksa |
Stuart [33] | 19 (51.4) | Air stirrup | 18 (48.6) | 4 weeks |
van den Berg [23] | 23 (52.3) | Bauerfeind malleoloc | 21 (47.7) | 6 weeks |
Port [31] | 30 (46.2) | Elastic support bandage | 35 (53.8) | 4 weeks |
Study | Stability test | Criteria of stability | Timing of testing (in days) | Weight-bearingb |
---|---|---|---|---|
Abdelaal [30] | Weight-bearing radiograph | MCSa < SCSd | Secondary visit (7–14) | Yes, after stability test |
Kortekangas [32] | External rotation stress test under fluoroscopy | MCSa < 5 mm under external rotation stress | Primary visit | Yes, immediate |
Stuart [33] | Anterior posterior Radiograph | No medial side tenderness, unclear radiographic criteria | Primary visit | Yes, after 48 h |
van den Berg [23] | Mortise and lateral Radiograph | MCSa < 4 mm and (MCSa < SCSd + 1 mm) Dislocation < 2 mm on Mortise + lateral x-rays | Primary visit | No, non-weight-bearing splint |
Mortise and lateral Radiograph | MCSa < 4 mm and (MCSa < SCSd + 1 mm) Dislocation < 2 mm on Mortise view + lateral x-rays | Secondary visit (7) | Yes, after stability test | |
Port [31] | Radiograph | No medial side tenderness, unclear radiographic criteria | N/Ac | Yes, immediate |
Assessment of methodological quality
A stated aim of the study | Inclusion of consecutive patients | Prospective collection of data | Endpoint appropriate to the study aim | Unbiased evaluation of endpoint | Follow-up period appropriate to the major endpoint | Loss to follow-up < 5% | Prospective sample size calculation | Gold standard for control group | Contemporary groups | Baseline equivalence | Statistical analysis for study design | Total score | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Abdelaal [30] | 1 | 2 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 2 | 1 | 1 | 10 |
Kortekangas [32] | 2 | 1 | 2 | 2 | 1 | 2 | 0 | 2 | 2 | 2 | 2 | 2 | 20 |
Stuart [33] | 1 | 1 | 2 | 1 | 1 | 1 | 0 | 0 | 0 | 2 | 0 | 0 | 9 |
van den Berg [23] | 2 | 1 | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 2 | 2 | 2 | 21 |
Port [31] | 1 | 1 | 2 | 1 | 1 | 2 | 0 | 0 | 1 | 2 | 1 | 0 | 12 |
Safety
Study | Removable orthosis | Cast | ||||
---|---|---|---|---|---|---|
Type of complications; n (%) | PROMs (timing in weeks) | Mean score (range or SD) | Type of complications; n (%) | PROMs (timing in weeks) | Mean score (n, range or SD) | |
Abdelaal [30] | 0 (0) | OMASb (≥ 26) | 92.2 (75–100) | DVTc, 1 (2) Delayed union, 1 (2) Displacement 3 (5) | OMASb (≥ 26) | 90 (45, 78–100) |
Kortekangas [32] | Nerve compression 2 (1) | OMASb (6) OMASb (12) OMASb (52) | 55 (± 20)a 70 (± 21)a 89.8 (± 18.3)a | DVTc, 3 (4) Non-union, 2 (2) Nerve compression, 1 (1) | OMASb (6) OMASb (12) OMASb (52)e | 54 (± 18)a 73 (± 19)a 91.7 (± 12.9)a |
DVTc, 5 (6) Cast pain, 2 (2) Nerve compression, 1 (1) | OMASb (52)f | 87.6 (± 18.4)a | ||||
Stuart [33] | Superficial ulcer 1 (4) | N/Ad | N/Ad | DVTc, 2 (11) Breakage of cast 1 (5) | N/Ad | N/Ad |
van den Berg [23] | 0 (0) | OMASb (6) OMASb (12) OMASb (26) AAOS (6) | 61.3 (± 22.3)a 78.1 (± 22.5)a 90.4 (± 17.1)a 95 (N/A)d | 0 (0) | OMASb (6) OMASb (12) OMASb (26) AAOSg (6) | 51.8 (± 22.3) 64.3 (± 24.9) 79.6 (± 23.1) 91.6 (N/A)d |
Port [31] | 0 (0) | OMASb (26) | 93 (± 1.2)a | Delayed union 1 (3) | OMASb (26) | 89 (± 3.8)a |
Functional outcome
Discussion
Comparison with other studies
Factors that influence recovery
Strengths and limitations
Clinical implications and future perspectives
Conclusion
What is already known on this topic?
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Traditionally, stable type B ankle fractures were managed with a cast, providing maximum bone support during healing.
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Cast immobilization can result in joint stiffness, muscle wasting and DVT; removable orthoses might help with these problems by allowing earlier mobilization and permissive weight-bearing.
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Stable type B fractures can adequately be treated with NOM.
What this study adds?
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Removable orthosis result in fewer complications than a cast after a stable type B ankle fracture.
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No statistically significant differences regarding short-term functional outcome were found between a removable orthosis and a cast in patients with a stable type B ankle fracture.
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A removable orthosis is non-inferior compared to a cast as NOM regarding functional outcomes at 6 weeks and at 26 weeks or after in patients with a stable type B ankle fracture.