Non-surgical treatment of lateral malleolar fractures is safe: long-term follow-up of a comprehensive treatment algorithm.

Introduction: A study at Sahlgrenska University Hospital (SU) found significant variation in the treatment of ankle fractures, leading to the development of a structured treatment algorithm (TA). The TA aimed to standardise treatment and reduce the number of unnecessary surgical procedures. A follow-up study concluded that the number of surgeries had significantly decreased since the TA was introduced. However, the long-term effects of the TA and the reduced number of surgical procedures remain unclear. The aim of the study was to analyse the long-term effects of a structured TA for ankle fractures, focusing on complications and reoperation rates.

Method: The present study is a long-term follow-up of the same two cohorts of patients with lateral malleolar fractures of type AO/OTA44-B1, as studied in the previous studies on the TA for ankle fractures at SU. The current study compares a group of AO/OTA 44B1 fractures treated before introducing the TA, the pre-TA cohort (n = 410), with a group treated after introducing the TA, the post-TA cohort (n = 333). Both cohorts were followed for at least four years, and the outcomes were reoperation or complication. Reoperation was defined as any surgical procedure performed ≥ 30 days after the injury.

Results: The results highlight a statistically significant reduction in the reoperation rate for lateral malleolar ankle fractures from 7.1 to 2.4% (p = 0.006) after introducing a TA that reduced the number of primary surgical procedures. Hardware-related issues were identified as the dominant cause of reoperation in both cohorts. Three major reoperations were observed in the pre-TA cohort compared to none in the post-TA cohort. The present study revealed no increase in the frequency of reoperations (late surgeries) due to non-union.

Conclusion: The non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union. A TA that reduces the need for primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 has resulted in a significant decrease in reoperation rates and no increase in failure rates. This long-term follow-up demonstrates that a non-surgical approach to isolated lateral malleolar fractures is safe.