2000, Egol, Dolan, & Koval. ‘Functional outcome of surgery for fractures
of the ankle. A prospective, randomised comparison of management in a cast or a functional brace’. J Bone Joint Surg [Br] 2000;82-B:246-9.
Group 1 =below-knee cast; Group 2 = functional brace. Both groups kept non-weight-bearing.
Assessment: Mazur Scale and ‘return to work’ at 6,12,26, & 52 weeks; at 52 weeks the SF-36 form was administered. (Mazur scale non-validated, originally designed to assess arthrodesis, and reported on 12 patients. Has some issues but widely used).
Surprisingingly, only at 6 weeks was there a significant difference in scores, but the ‘surgery-return to work’ interval was 106.5 days for the cast group and 53.3 days for the functional brace, significant at p=0.01. The functional brace group also had higher SF-36 scores, but only in 2 aspects was this significant.
2001, Day et al. ‘Operative Treatment of Ankle Fractures: A Minimum Ten-Year Follow-Up’. Foot & Ankle Intemational/Vol. 22, No. 2, February 2001, 102-106.
n= 25. Assessment: Phillips scoring system at 10-14 years follow-up. 12M/13F. All fractures anatomically reduced. The Phillips score includes subjective and ‘objective’ measurements and a radiological assessment.
64% had good/excellent functional outcomes, and 52% had good/excellent overall. 36% had developed moderate or severe post-traumatic arthritis (PTA).
The authors comments were particularly pertinent in the context of long term outcome. They suggested a more guarded approach when prognosticating for the long term during the consent process than has hitherto been common. They pointed out that they had demonstrated a higher percentage of poorer outcomes than has been previously described; and that other studies with shorter term follow-up have already established a trend of increasing radiological evidence of post-traumatic arthritis with
successively longer-term outcome reports.
2002, Obremskey et al. ‘Change Over Time of SF‐36 Functional Outcomes for Operatively Treated Unstable Ankle Fractures’. Journal of Orthopaedic Trauma: January 2002 – Volume 16 – Issue 1 – p 30-33.
n=20. Assessment: SF-36 at 4 months and average 20 months post-injury. Both scores compared with population norms.
The authors found:
Patients had significant improvement (p < 0.5) in all domains of the SF-36 questionnaire at the later follow-up, except for general health, which was unchanged. Patients still had significant differences in SF-36 scores compared with the U.S. population at the time of release from routine follow-up. The scores of all the domains of the SF-36 at the later follow-up were not significantly different from U.S. population norms except for the domain of physical functioning.
This study indicates that patients have significant improvement in functional outcome after release from orthopaedic follow-up but have a residual physical effect at twenty months after injury. These data are important to guide a patient’s expectations after this injury and are also important in considering medicolegal and workers’ compensation issues. Patients continue to have improvement in function after we have routinely released them from orthopaedic follow-up. Maximal medical improvement appears to be longer than four months from this injury.
2002, Lash et al. ‘Ankle Fractures: Functional and lifestyle outcomes at 2 years’. ANZ J. Surg. 2002; 72: 724–730.
n= 74 out of 141 patients were followed up at 2 years. Assessment: Olerud-Molander Score.
The authors commented:
All fracture types averaged Olerud-Molander ankle scores of 71.1. Weber A fractures averaged ankle function scores of 90, Weber B fractures 80, and Weber C fractures 78. Four patients (5%) achieved ‘poor’ results, 12 (16%) patients achieved a ‘fair’ result, 30 (41%) patients gained a ‘good’
result, 27 (36%) patients attained ‘excellent’ results. Lifestyle outcomes were reflected in the patient’s ankle function outcomes (P < 0.05).
Conclusion: Patients who sustain ankle fractures can be expected to be still experiencing functional difficulties two years post-treatment.
2006, Egol et al. ‘Predictors of Short-Term Functional Outcome Following Ankle Fracture Surgery’. J Bone Joint Surg Am. 2006;88:974-979. doi:10.2106/JBJS.E.00343.
n=198. Assessment: AOFAS ankle/hindfoot score & Short Musculoskeletal Function Assessment (SMFA). No patient had developed Post-Traumatic Arthritis by this stage, but one had had ankle arthrodesis as a consequence of infection.
88% had no or mild pain at 1 year. 90% had no limitations or limitations only in recreational activities.
The AOFAS score suggested that >90% had >90% functional recovery.
The authors commented:
One year after ankle fracture surgery, patients are generally doing well, with most experiencing little or mild pain and few restrictions in functional activities. They have a significant improvement in function compared with
six months after the surgery. Younger age, male sex, absence of diabetes, and a lower ASA class are predictive of functional recovery at one year following ankle fracture surgery…..
2007, Shah et al. ‘Five-year functional outcome analysis of ankle
fracture fixation’. Injury, Int. J. Care Injured (2007) 38, 1308—1312.
n=69, 43 females, 26 males.
Assessment: Olerud-Molander Ankle Score. (Self-reported subjective score, x/100; 25 for pain, 20 for stiffness & swelling, 55 for function). Also Short Form-12 (SF-12). There was good correlation between the scores.
75% had a good/excellent functional outcome at 5 years post-injury. Patients below the age of 40 have better functional outcomes than those over that age.
62% returned to their former sporting level; 38% had not.
50.7% reported some degree of pain.
44.9% reported ongoing swelling.
63% reported ongoing stiffness.
39% thought they still had not fully recovered; of these 27, 4 had a poor result, 11 had a fair result; and 13 had a good or excellent result. (Comment: This implies a ceiling effect in the scores, and/or very high expectations).
All had returned to work apart from those who had retired prior to injury. Gender/fracture type/timing of surgery had no impact on functional outcome.
2020, Blom et al on behalf of EF3X-trial Study Group. ‘Posterior Malleolar Fractures. Predictors of Outcome.’ Bone Joint J 2020:102-B(9):1229-1241
Posterior Malleolar Ankle Fractures (PMAF) of a rotational type can be classified into 3 types on CT:
Haraguchi Type 1: Large Posterolateral-oblique
Haraguchi Type 2: Two-part posteromedial and posterolateral
Haraguchi Type 3: avulsion
n=70. Assessment = Foot & Ankle Outcome Score (FAOS).
Hamaguchi Type 2 PMAFs have worse outcomes as assessed by 2 year FAOS than Type 1 & Type 3.
Type or morphology of fragments, not size, seems to be the most important factor determining outcome. Whether or not to fix PMAFs is likely to depend on a better understanding of the benefits of fixing (or not) the distinct morphological subtypes.