JAMA release gives even-handed account of casting vs surgery for ankle fracture in older adults
Rating
Modified cast instead of surgery results in similar functional outcomes for ankle fracture in older adults
Our Review Summary
This news release reports on the results of a randomized trial of older adults (average age 71) who had ankle fractures that were either treated with “close contact casting” or with surgery. While the outcomes after six months were similar in both groups the close contact casting was superior in terms of reduced infections and additional operating room procedures as well as being a lot safer. Yet many patients who received casting as an an initial treatment subsequently required repeat casting or surgery.
The release covers most of the bases and reported fairly on the essentials of the study, while not exaggerating either the benefits or risks of the surgical option. Readers might benefit from a definition of a ‘stable’ versus an ‘unstable’ ankle fracture and of “radiologic malunion.” The term sounds threatening but does not necessarily result in pain or functional impairment.
Why This Matters
Ankle fractures are extremely common, and perhaps more common in older people so if one type of lower-tech procedure (close casting) can be proven to be safer, equally effective and less costly than the current standard of care (surgery) this could be a major plus to the healthcare systems around the world. Even though some of the patients in the study (about 20%) who received the casting option first had to go on to have a surgical intervention or a recasting, this study reinforces the view that surgery should be the second resort in most cases. Proof that a simpler closed intervention works well and should be tried first for these fractures stands to change the treatment of this common fracture.
Criteria
Not Satisfactory
The release notes that casting instead of surgery as an initial treatment would result in “reduced intervention costs” but that’s not very helpful if you’re unsure of the base cost of surgery.
Estimates of a cost differential would have been helpful. Close contact casting would be much cheaper than open surgery for these fractures.
Satisfactory
The release includes a list of benefits of the modified casting method, with some quantification, mostly in terms of reduced complications. It says, “At 6 months, casting resulted in measures of ankle function equivalent to that with surgery. Infection and wound breakdown were more common with surgery (10 percent vs 1 percent), as were additional operating room procedures (6 percent vs 1 percent).”
Satisfactory
A release devotes a fair amount of space to harms from casting as compared with surgery:
“Radiologic malunion (abnormal healing of a fracture) was more common in the casting group (15 percent vs 3 percent for surgery). Casting required less operating room time compared with surgery. There were no significant differences in other secondary outcomes: quality of life, pain, ankle motion, mobility, and patient satisfaction.”
Satisfactory
This large randomized study with high rates of completion suggests a high quality of evidence, all noted in the news release.
The release would have been better if it had noted that the outcome was blinded, a very important marker of quality as it is likely to reduce the risk of bias.
Satisfactory
No signs of disease mongering. These fractures are actually quite common, especially in the elderly, so it would have been appropriate to discuss the high disease burden from these fractures.
Not Satisfactory
No funding sources and conflicts are mentioned in the news release. Instead, readers are referred to the published study for details on “financial disclosures, funding and support.” However, the study is only available to JAMA subscribers.
Satisfactory
The release aptly compares this new treatment with traditional surgery, which has largely been abandoned due to high rates of malunion resulting in functional deficits in displaced ankle fractures. The release also briefly mentions traditional “hard” casting.
Satisfactory
The release quotes an accompanying editorial stating that “close contact casting may be unfamiliar to some orthopedic surgeons.” Although that’s a vague statement, we can assume it’s not in widespread use.
In the U.S., most orthopedists are not trained in close contact casting nor do they feel comfortable using it. Most patients will not be offered this treatment as an option for their fracture care.
Satisfactory
This treatment is not novel, but the results of this study are new. It appears to be the first to compare these treatments and show the results in a well done randomized study.
Satisfactory
The release does not rely on sensational or exaggerated language.
Total Score: 8 of 10 Satisfactory
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