Table 2.
Management and results of SER ankle fractures
| Study | Classification and fracture type* | Interventions | Followup (years)† | Outcome assessment‡ | Results | Conclusion(s) |
|---|---|---|---|---|---|---|
| Yde and Kristensen [46] | L-H SER-II | 34 ORIF vs 35 nonoperative | 6 (3–10) | Radiographic: | No need for surgery for stable isolated fibula SER fractures | |
| Anatomic reduction (Cedell) | 28/34 ORIF vs 1/35 nonoperative (p = 0.73) | |||||
| Arthritis | 1/34 ORIF vs 4/35 nonoperative (p = 0.36) | |||||
| Clinical (Cedell) | Good result in 30/34 ORIF vs 34/35 nonoperative | |||||
| Yde and Kristensen [47] | L-H SER-IV | 60 ORIF vs 29 nonoperative | 5.6 (3–10) 6.8 (3–10) |
Radiographic | Operative management showed better results or SER-IV ankle fractures | |
| Anatomic reduction (Cedell) | 42/60 (70%) ORIF vs 0/29 nonoperative | |||||
| Arthritis | 12/60 (20%) ORIF vs 19/29 (66%) nonoperative (p < 0.001) | |||||
| Clinical (Cedell) | Good result in 50/60 (83%) ORIF vs 16/29 (55%) nonoperative | |||||
| Kristensen and Hansen [20] | L-H SER-II | 94 nonoperative | 21 (16–25) | Radiographic | Good results with nonoperative management of SER-II fractures | |
| Reduction (Cedell) | Nonanatomic 89/94 | |||||
| Arthritis | None | |||||
| Clinical | Symptom-free: 73/94 Negligible symptoms: 16/94 Moderate symptoms: 5/94 Reduced capacity to work or exercise: none | |||||
| Bauer et al. [2] | L-H SER-II and SER-IV | 49 nonoperative 38 nonoperative | 29 (25–34) | Subjective outcome (Cedell) | 47/49 (96%) good, 2/49 (4%) medium, 1/49 (2%) not good | Not all ankle fractures need anatomic reduction |
| Symptoms | 29/38 (76%) symptom-free | |||||
| Arthritis | 14/38 (37%) | |||||
| Ponzer et al. [34] | OTA/AO 44-B | 53 ORIF (variable techniques) | > 2 | 41 patients > 2 years’ followup, 36 available | SF-36 is a useful outcome measure; self-perceived limitations in everyday life is common after B-type ankle fractures | |
| SF-36, VAS (mental and physical) | ||||||
| OMA score | 84 (SD = 22.5), 64% of patients > 90 8/9 B1 (stable) fractures scored > 90 B3 (bimalleolar) worse than B2 | |||||
| Residual tenderness | 15/36 (42%) | |||||
| Reduced ROM | 24/36 (67%) | |||||
| Incomplete recovery | 23/36 (64%) | |||||
| Limitations in sports | 22/36 (61%) | |||||
| Limitations at work | 16/36 (44%) | |||||
| Correlations: | ||||||
| OMA vs SF-36 | Significant for subscores for physical functioning, physical and emotional role functioning, social functioning, pain | |||||
| OMA vs VAS (physical) | Significant | |||||
| OMA vs VAS (mental) | Nonsignificant | |||||
| SF-36 vs VAS (physical) | Significant, all SF-36 subscores | |||||
| SF-36 vs VAS (mental) | Significant except for the SF-36 subscores for pain and physical role functioning | |||||
| Bhandari et al. [3] | OTA/AO 44-B | 30 (25 bimalleolar) ORIF | 2 | SF-36 VAS pain scale | Role–physical and physical function domains of SF-36 lower than US norms (p < 0.01) Smoking and alcohol negatively affected general health outcomes Smoking was predictor of physical function summary score VAS pain scale correlated with bodily pain SF-36 subscores | Social factors may be important determinants of outcome in patients with fractures |
| Finnan et al. [13] | L-H SER-IV | 156 ORIF 26 responded | 5.2 (0.6–8.9) | SMFA questionnaire | No significant effect on 5 of 6 SMFA domains Negative impact on the mobility index scores | Suboptimal surgical reduction was associated with a negative effect on quality of life and ambulation |
| Arthritis | 6/26 (23%) | |||||
| Correlation of operative reduction with results | Anatomic reduction in 19/26: no arthritis, good functional result Suboptimal reduction: fair/poor results | |||||
| McKenna et al. [26] | OTA/AO 44-B | 25 ORIF with plate vs 25 ORIF with lag screws | 1.1 | Infections | Plate: 4/16, lag screws: 0/18 | Lag screw fixation was safe, allowing stable fracture fixation, without failures |
| AOFAS | Plate: 76, lag screws: 86 (p = 0.02) | |||||
| Questionnaire (16 from the plate group and 18 from the lag screws group responded) | ||||||
| Palpable hardware | 8/16 (50%) plate group vs 0/18 lag screws group | |||||
| Lateral ankle pain lasting > 3 months | More common (p = 0.004) in plate group | |||||
| Koval et al. [19] | OTA/AO 44-B | 19 nonoperative (intact deep deltoid on MRI) | 1.8 | AOFAS (15/19 available) | 14/15 had score 100, 1/15 had 85 | Nonoperative management might be an option for SER-IV ankle fractures with medial space widening if the deep deltoid ligament is intact |
| VAS pain (0–10) | 0.87 (range, 0-3) | |||||
| SF-36 | Comparable to general population | |||||
| Patients satisfied with outcome | 14/15 | |||||
| Patients satisfied with decision of conservative management | 15/15 | |||||
| Tejwani et al. [40] | OTA/AO 44-B2, 44-B3 (SER-IV) | 266 ORIF | 1 | 213 available (80%) | Bimalleolar fractures were more common in women and patients with higher ASA | At 1 year, most patients have little or mild pain; bimalleolar fractures had worse outcomes than medial ligamentous injuries |
| SMFA | Worse for B3 vs B2 fracture | |||||
| AOFAS | Pain scores were comparable | |||||
| Regression analysis, controlled for age, gender, and ASA class | Poorer outcome for patients with bimalleolar fractures | |||||
| Clements et al. [7] | OTA/AO SER-IV (unimalleolar) | 51 nonoperative | 2.2 | AOFAS | 84.2 (all ankles) | Medial tenderness and ecchymosis are not sufficient to meet operative criteria; MCS of ≤ 4 mm was associated with excellent functional outcomes |
| Correlation of MCS with AOFAS | ||||||
| MCS 4 mm | 90.2 | |||||
| MCS 5 mm | 89.4 | |||||
| MCS 6 mm | 72.0 | |||||
| MCS 7 mm | 63.2 | |||||
| 4 mm vs 6 or 7 mm | Significant difference | |||||
| 5 mm vs 6 or 7 mm | Significant difference |
* Classification and fracture type include Lauge-Hansen (L-H) [22] and Orthopaedic Trauma Association/American Orthopaedic Association (OTA/AO) [1, 24]; †values expressed as means, with ranges in parentheses; ‡outcome assessments include Cedell criteria [4], SF-36 (mental and physical) [31], visual analog scale (VAS) [34], Olerud Molander Ankle (OMA) score [32], Short Musculoskeletal Function Assessment (SMFA) questionnaire [38], and American Orthopaedic Foot Ankle Score (AOFAS) [18]; SER = supination-external rotation; ORIF = open reduction and internal fixation; SD = standard deviation; ROM = range of motion; ASA = American Society of Anesthesiology; MCS = medial clear space (space between talus and medial malleolus on stress radiographs).