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

Non-surgical treatment of lateral malleolar fractures is safe - Long-term follow-up of a comprehensive treatment algorithm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Non-surgical treatment of lateral malleolar fractures is safe - Long-term follow-up of a comprehensive treatment algorithm Erik Börjesson, Karolina Johannesson, Jan Ekelund, Emilia Möller Rydberg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4558150/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 13 You are reading this latest preprint version Abstract Introduction : A previous study conducted at Sahlgrenska University Hospital (SU) revealed a significant variation in the treatment of ankle fractures, which resulted in the creation of a treatment algorithm (TA). The aim of TA was 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 introduction of the TA. However, the long-term effects of the TA and the reduced number of surgical procedures remained unclear. Aim : To analyse the long-term effects of a structured TA for ankle fractures regarding 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 the introduction of the TA, the pre-TA cohort (n=410), with a group treated after the introduction of the TA, the post-TA cohort (n=333). Both groups were followed for a minimum of four years, and the outcomes were reoperation or complication. Reoperation was defined as any surgical procedure that occurred 30 days or more after the initial injury. Results : The results demonstrate a statistically significant reduction in the reoperation rate for lateral malleolar ankle fractures from 7.1% to 2.4% (p = 0.006) following the introduction of a TA that reduced the number of primary surgical procedures. Hardware-related complaints were the leading 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 late surgeries due to non-union. Conclusion : Treating stable ankle fractures non-surgically does not lead to an increase in reoperations, complications or late surgeries due to non-union. In fact, a structured treatment algorithm that reduce the number of primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 also led to a significant reduction 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. Ankle fracture Swedish fracture Register Epidemiology Fracture management Treatment algorithm Figures Figure 1 Figure 2 Background Ankle fractures are among the most common fractures in the adult population and are the third most common fracture registered in the Swedish Fracture Register (SFR) ( 1 , 2 ). Ankle fractures can be the result of various types of trauma, but the most prevalent cause of ankle fractures is a fall at the same level, typically due to slipping, tripping, or stumbling ( 3 ). An ankle fracture is defined as a fracture to one or more of the malleoli, sometimes accompanied by injuries to the adjacent ligaments. Transsyndesmotic lateral malleolar ankle fracture (AO/OTA44-B) is the most common type, accounting for approximately 60% of all ankle fractures ( 3 ). AO/OTA44-B fractures can be either stable or unstable, depending on whether there is a fracture or ligament injury to the medial structures of the ankle. Isolated lateral malleolar fractures are referred to as AO44-B1; if combined with a ligamentous injury to the medial structures, the fracture is referred to as AO44-B2.1 and is no longer considered isolated ( 4 ). An isolated trans-syndesmotic lateral malleolar fracture without signs of deltoid ligament injury can safely be treated without surgical intervention ( 5 – 8 ). To make well-informed decisions about treating ankle fractures, a thorough understanding of ankle biomechanics and anatomy is crucial for assessing ankle stability ( 9 , 10 ). The SFR is a national quality registry that collects information on all types of fractures treated by orthopaedic surgeons in Sweden. Registrations performed by the treating physician include information about the cause of the injury, type of fracture, treatment provided, and subsequent outcomes ( 2 ). The SFR classifies fractures using the AO/OTA 2007 classification system and considers both fracture and ligament injuries ( 11 ). The validity of the data in the register has been confirmed by multiple studies, which have shown that the SFR is both valid and accurate ( 12 – 14 ). In 2015, a study was conducted at Sahlgrenska University Hospital (SU), revealing significant variation in the treatment of ankle fractures. This study demonstrated that accurately distinguishing between a stable, isolated lateral malleolar fracture and an unstable lateral malleolar fracture accompanied by medial ligament injury can be a complex and demanding task in daily clinical practice. The study also showed considerable variation within the same department regarding weight-bearing restrictions, treatment choice, and follow-up ( 15 ). To address this issue, a treatment algorithm (TA) was created to standardise the treatment of ankle fractures and reduce unnecessary surgical interventions. Before the introduction of the TA at SU, as in most other hospitals, no such TA had been in place for ankle fractures, which made the treatment decision primarily up to the surgeon's preference. The introduction of the TA aimed to make the treatment decision more structured with clear indications on the choice of treatment and postoperative restrictions. A follow-up study conducted by Rydberg et al. in 2022 found that the TA significantly reduced the number of surgical treatments in patients with stable ankle fractures ( 16 ). Despite these promising results, the long-term effects of reducing surgical treatment for lateral malleolar fractures remain unknown. Therefore, the primary objective of the current study is to evaluate the long-term effects and safety of this treatment algorithm in terms of reoperations, complications and delayed surgeries due to non-union. Methods The present study is a long-term follow-up of the same two patient cohorts as investigated in the study by Rydberg et al. from 2022. Both cohorts consist of patients with lateral malleolar fractures registered as AO/OTA44-B1 in the SFR at the SU. The first cohort, referred to as the Pre-TA cohort, consists of patients treated between 1 April 2012 and 31 March 2014 (n = 410), before the introduction of the TA. The second cohort consists of patients who were treated after the introduction of the TA between 1 September 2017 and 31 August 2019 (n = 333). The follow-up time for both groups continued until 13 September 2023, when the follow-up time for all patients had reached at least four years (Fig. 1 ). The outcome of the present study was reoperation. Reoperation was defined as an unplanned surgical procedure occurring 30 days or more after the injury. Planned surgical procedures, such as removal of a syndesmotic screw, have not been considered as reoperations. Information regarding reoperations was extracted from the digital operating planning systems used at the SU. Medical records were further analysed to understand the reason behind each reoperation. The statistical software used was IBM SPSS Statistics version 29. The pre-TA and post-Ta cohorts were compared with respect to time to reoperation using Cox-regression with factors for cohort, sex and age group. Continuous variables are presented with mean and standard deviation, whereas categorical data are presented with frequency and percentages. P-values below 0.05 were considered statistically significant. Results There were 410 patients in the pre-TA cohort and 333 in the post-TA cohort. Both cohorts contained more women (56.0%) than men (44.0%). The mean age at the time of injury was 52.1 years in the pre-TA cohort and 52.6 years in the post-TA cohort. In total, women had a higher mean age at the time of injury, with a mean injury age of 54.5 years for women and 49.7 years for men (Table 1 ). Table 1 Demographic data of patients with ankle fractures before (pre-TA) and after (post-TA) the introduction of a structured TA*. Total n = 743 Pre-TA n = 410 Post-TA n = 333 Sex Male, n (%) 327 (44.0) 189 (46.1) 138 (41.4) Female, n (%) 416 (56.0) 221 (53.9) 195 (58.6) Mean injury age Total years (SD) 52.3 (19.2) 52.1 (19.2) 52.6 (19.4) Male years (SD) 49.7 (19.8) 48.2 (19.5) 51.6 (20.1) Female years (SD) 54.5 (18.5) 55.5 (18.3) 53.3 (18.8) Age groups 16–39 years, n (%) 203 (27.3) 113 (27.6) 90 (27.0) 40–59 years, n (%) 259 (34.9) 141 (34.4) 118 (35.4) 30–99 years, n (%) 281 (37.8) 156 (38.0) 125 (37.5) In the pre-TA cohort, 161 (39.3%) of patients had positive clinical findings indicating medial ligament injury, while 167 (40.8%) did not. In the post-TA cohort, 95 (28.5%) patients had clinical findings suggestive of medial ligament injury, and 193 (58.0%) patients did not have any such findings. Reoperations 131 (31.9%) patients were surgically treated within the pre-TA cohort. Of these, 27 (20.6%) had a later reoperation. Two patients (0.8%) who were initially non-surgically treated had to undergo a surgical procedure at a later stage (defined herein as a reoperation) due to non-union. Hence, 29 patients (7.1%) out of 410 in the pre-TA cohort required a procedure defined as reoperation (Table 2 ). In the post-TA cohort, 34 (11.3%) patients underwent initial surgical treatment, and five (14.7%) of those patients later needed reoperation. Additionally, three patients (1.0%) treated non-surgically had late surgery due to non-union. Hence, in total, eight patients (2.4%) out of the 333 in the post-TA cohort underwent reoperation (Table 2 ). Table 2 Descriptive analysis of the number of reoperations with regard to the initial treatment method Total, n No reoperation, n (%) Reoperation, n (%) Non-surgical treatment Pre-TA 279 277 (99.3) 2 (0.7) Post-TA 299 296 (99.0) 3 (1.0) Total 578 573 (99.1) 5 (0.9) Surgical treatment Pre-TA 131 104 (79.4) 27 (20.6) Post-TA 34 29 (85.3) 5 (14.7) Total 165 133 (80.6) 32 (19.4) Total Pre-TA 410 381 (92.9) 29 (7.1) Post-TA 333 325 (97.6) 8 (2.4) Total 743 706 (95.0) 37 (5.0) To summarise, 29 (7.1%) patients in the pre-TA cohort and 8 (2.4%) of patients in the post-TA cohort underwent reoperation. There was a statistically significant difference in the number of reoperations between the pre-TA (20.6%) and post-TA (14.7%) cohorts (HR = 0.33; p = 0.006). Figure 2 shows a Kaplan-Meier plot of time to reoperation. Event is defined as reoperation (Table 3 , Fig. 2 ). Table 3 Estimated hazard ratio from cox regression for time to reoperation using group, sex, and age group as factors. Hazard Ratio 95.0% CI P-value Lower Upper Group Pre-TA REF 0.330 0.150 0.725 0.006 Sex male REF 1.397 0.714 2.732 0.329 Age group 16–39 REF Age group 40–59 0.916 0.457 1.838 0.805 Age group 60–99 0.183 0.060 0.555 0.003 Three major reoperations were performed, all of which were recorded in the Pre-TA cohort. In two of these patients, a review of radiographic images from the time of injury revealed a medial clear space of 14.5 mm and 9 mm, respectively, indicating incorrect fracture classification as AO/OTA-B1 in the SFR. The third patient underwent a major reoperation due to a severe infection at the operation site after the primary surgery. The patient was treated with antibiotics and hospitalised, and the plate and screws were removed. No major reoperations were observed in the post-TA cohort. Discussion The most important finding of this long-term follow-up study is that treating stable ankle fractures non-surgically is safe and does not lead to an increased risk of non-union, mal-union or increased reoperation rates. The current study builds upon the findings of a previous study by Rydberg et al. that demonstrated that implementing a standardised treatment algorithm for lateral malleolar ankle fractures led to a considerable decrease in surgical intervention ( 17 ). The present study can conclude that this approach is safe and reliable long term. With a minimum follow-up time of four years, the present study demonstrates that the rate of reoperations did not increase; in fact, it significantly decreased after the introduction of a TA. The present study also demonstrates no increase in the frequency of late surgeries due to non-union. The results of this study provide insight into the effectiveness and safety of implementing a standardised treatment algorithm for lateral malleolar fractures. Adhering to treatment guidelines can significantly reduce the number of surgeries required without increasing the risk of reoperations or the need for later surgical treatment. This highlights the importance of evidence-based treatment approaches to improve patient outcomes and optimise healthcare resource utilisation ( 18 ). In the present study, a reoperation was defined as an unplanned surgical treatment occurring 30 days or more after the injury, for both surgically and non-surgically treated patients. Planned procedures, such as removal of a syndesmotic screw, were not considered reoperations. Results demonstrate that the risk of reoperation for those who underwent surgery in each group respectively decreased from 20.6% pre-TA to 14.7% post-TA. As planned secondary procedures were not considered reoperation, the higher number of reoperations found in the pre-TA cohort can not be explained by a higher degree of patients receiving primary surgical treatment before introducing the TA. The majority of reoperations in both groups were minor reoperations. A minor reoperation was defined as a surgical procedure due to patient complaints, usually hardware-related pain. Even though minor reoperations are generally simple, routine procedures, they often require the patient to be under general anaesthesia and be conducted in an operating theatre. Reith et al. conducted a survey among patients with hardware-related pain. The most frequent indications for metal implant removal in the ankle were pain, personal preference, professional recommendation or impairment of function. After hardware removal, 52% of the patients experienced pain relief, and 52% experienced better function ( 19 ). All surgical procedures carry a risk of complications such as infections. Andersen et al. ( 20 ) concluded that there was a 5% risk of wound infections after syndesmotic screw removal. By reducing unnecessary surgical procedures for ankle fractures, both primary and planned secondary surgical procedures such as the removal of syndesmotic screws, the risk of complications can be minimised, leading to greater patient satisfaction and fewer complications. Avoiding unnecessary complications and reoperations can further save valuable healthcare resources. Three major reoperations were found in this study, all in the Pre-TA cohort. Upon evaluation of their radiological images, it was discovered that one patient had a medial clear space of 9 mm, and the second patient had a 14.5 mm medial clear space. For the medial clear space to increase this much, a medial ligament injury has to be present, indicating that these patients were, in fact, not type B1 fractures but misclassified. AO/OTA44-B1 should not have any significant medial ligament injuries, and the correct classification for these fractures should be AO/OTA44-B2.1 for which primary surgical treatment was recommended. It can be concluded that these ankle fractures were incorrectly classified at a group level in the AO/OTA classification in the SFR. A previous study by Juto et al. suggested that the SFR classification of ankle fractures is accurate but pointed out that classification at a group level can be challenging ( 12 ). The study by Juto et al. evaluated the accuracy of ankle fracture classifications in the SFR by applying strict AO/OTA classification guidelines on random samples. The results showed an accuracy of 88% for the AO/OTA type. However, the group level accuracy was slightly lower at 74%. Thus, it is more challenging to differentiate the different groups within type B injuries. This is in line with the findings of the present study where the two major reoperations found were probably due to misclassified fractures leading to the wrong treatment method. For the third major reoperation revealed in the current study the fracture was correctly classified in the SFR as an AO/OTA44-B1 fracture. The reason behind this reoperation was a deep infection after the primary surgery. The patient had to undergo hospitalisation with i.v. antibiotics, and it was decided to remove the plate and screws to help eliminate the infection. Serious infections are not uncommon after surgery. A study by Cammas et al. identified it as the second most common complication ( 21 ). A retrospective observational study at SU by Bergström et al. studied the incidence of surgical site infections (SSI) for surgically treated ankle fractures ( 22 ). The study included 480 patients who underwent primary surgery and revealed that 10.2% developed an SSI. In the study by Bergström et al., the patients who underwent a reoperation due to infection usually had one to four reoperations before the infection resolved. In addition, the infected patients had more medical follow-ups and a more extended hospital stay. Hence, surgery has substantial risks, and the best way to reduce these risks is to avoid unnecessary surgeries. In the present study, five patients required surgery at a later stage due to non-union. Two patients were found in the pre-TA cohort and three in the post-TA cohort. The mean age of injury for these patients was 45 years, which is younger than the overall mean age in the study. This finding is consistent with the literature, which suggests that non-union is more common among younger patients. According to Mills et al., the highest risk of non-union occurs in individuals aged 25–44 years ( 23 ). For the five non-unions in this study, the primary assessment at the A&E (Accident & Emergency Department) correctly suggested no indication for surgery, and the patients were treated with orthosis according to the TA. However, the fractures did not heal properly, and the patients sought care for pain and discomfort. A radiographic examination confirmed that the fractures had not healed properly and required surgical intervention. Finding an apparent reason for the failure of healing was impossible in all five patients. Non-union is a known orthopaedic problem. A study by Mills et al. suggested that 1% of all ankle fractures result in non-union ( 23 ). This is consistent with the findings in this study, where the total non-union risk was 0.9%, with 0.8% in the pre-TA cohort and 1.1% in the post-TA cohort. Hence, the risk of non-union is the same regardless of the TA, suggesting that there is no increased risk of non-union with fewer primary surgeries. The main strength of this study is the size of the cohorts studied, 743 patients with lateral malleolar ankle fractures, and the long follow-up period of at least four years for all patients. Another strength is that medical records were thoroughly reviewed for all reoperations found to understand the underlying causes. One limitation of this study is that it only includes reoperations performed at SU in patients who sought medical care on their own accord. Hence, the study does not include patients who might have undergone reoperations at other facilities within Sweden or abroad, and no information is present on the well-being of patients who did not seek medical care after the initial follow-up period. Moreover, this study does not consider complications that did not require surgical intervention. Conclusions This study demonstrates treating stable ankle fractures non-surgically does not lead to an increase in reoperations or late surgeries due to non-union. In fact, a structured treatment algorithm that reduce the number of primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 also led to a significant reduction 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. Abbreviations SU Sahlgrenska University Hospital TA Treatment algorithm AO Arbeitsgemeinschaft für Osteosynthesefragen OTA Orthopaedic Trauma Association SFR Swedish Fracture Register MRI Magnetic resonance imaging Declarations Ethics approval and consent to participate The current study was approved by the Swedish Ethical Review Authority (reference number 2023-03400-01- 441331). All patients were informed at registration in the Swedish Fracture Register that they had the right to withdraw. According to Swedish legislation, National Quality Registers do not require signed consent from the individual registered patient (24). All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding Open access funding was provided by the University of Gothenburg. Author contributions Acknowledgements We thank all our colleagues at the orthopaedic department at Sahlgrenska University Hospital for providing detailed data in the Swedish Fracture Register on busy working days. References Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691-7. Bergh C, Wennergren D, Moller M, Brisby H. Fracture incidence in adults in relation to age and gender: A study of 27,169 fractures in the Swedish Fracture Register in a well-defined catchment area. PLoS One. 2020;15(12):e0244291. 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Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 29 Aug, 2024 Reviewers agreed at journal 24 Jul, 2024 Reviews received at journal 21 Jul, 2024 Reviews received at journal 15 Jul, 2024 Reviewers agreed at journal 12 Jul, 2024 Reviewers agreed at journal 29 Jun, 2024 Reviews received at journal 27 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers invited by journal 25 Jun, 2024 Editor invited by journal 20 Jun, 2024 Editor assigned by journal 20 Jun, 2024 Submission checks completed at journal 20 Jun, 2024 First submitted to journal 10 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4558150","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":323830729,"identity":"0c768d56-b401-4685-b02f-293273bfb6dd","order_by":0,"name":"Erik Börjesson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABHElEQVRIie2QMUvEMBTHXwjUJaVrj4PmK7wiFIWiH8SlReh04HpjpZAuxVmnfga3joUMLuFchXMoFNTxiiCOptW7KXK6CeYHISG8X977B8Bi+ZOQAkgO09LEn5fJL5TsJwrQbfmI3D+WN5cFkia+oGXZb4bmPq3PpHzplo/Ay9yozK7SIiEqO76sVDS7Uev0dpVlR4l6AlStUUFFipYIieR64VBXrA/DikWYCgnomxOd7pT6uX91xUor3tuk8Lozd2FEDzZ1AZy7og04Y7QbFXgwx/d1F0xVhqRa6CziPEDmRJAoyVCZB/Oqg94fmhjD8k7/mDhhvKL98L6UAS/N8SfG18J8O2oLjq939n39F3x3yIFu9pZbLBbLf+IDjX1g//TaVgwAAAAASUVORK5CYII=","orcid":"","institution":"University of Gothenburg","correspondingAuthor":true,"prefix":"","firstName":"Erik","middleName":"","lastName":"Börjesson","suffix":""},{"id":323830730,"identity":"ab5a317b-1f06-4ef4-86e0-b025562c3f5c","order_by":1,"name":"Karolina Johannesson","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Karolina","middleName":"","lastName":"Johannesson","suffix":""},{"id":323830731,"identity":"d107bc9c-31ed-4cba-b0bd-5f5ae7c82877","order_by":2,"name":"Jan Ekelund","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Ekelund","suffix":""},{"id":323830732,"identity":"1259ada1-e948-43aa-86c8-19730d37af33","order_by":3,"name":"Emilia Möller Rydberg","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Emilia","middleName":"Möller","lastName":"Rydberg","suffix":""}],"badges":[],"createdAt":"2024-06-10 12:54:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4558150/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4558150/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-07924-x","type":"published","date":"2024-10-16T15:57:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60609564,"identity":"55c462d2-935d-47db-9164-8151cad841f6","added_by":"auto","created_at":"2024-07-18 18:21:46","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86287,"visible":true,"origin":"","legend":"\u003cp\u003ePre-TA 1: April 2012 to 31 Mars 2014\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePost-TA: 1 September 2017 to 31 August 2019\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4558150/v1/b62b3a5aec5f1b70f2ae866a.jpg"},{"id":60609565,"identity":"bb0a10fa-8897-413e-90ab-f4ab58f7bad2","added_by":"auto","created_at":"2024-07-18 18:21:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41644,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier plot of time to reoperation\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4558150/v1/3cc3769c40ca05393f9224ef.jpg"},{"id":67148901,"identity":"3a1bb703-211d-4d8e-9184-e985a1d0fafb","added_by":"auto","created_at":"2024-10-21 16:09:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":540515,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4558150/v1/e3992f62-801c-4e38-9a64-fbaf3c31dbc7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Non-surgical treatment of lateral malleolar fractures is safe - Long-term follow-up of a comprehensive treatment algorithm","fulltext":[{"header":"Background","content":"\u003cp\u003eAnkle fractures are among the most common fractures in the adult population and are the third most common fracture registered in the Swedish Fracture Register (SFR) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Ankle fractures can be the result of various types of trauma, but the most prevalent cause of ankle fractures is a fall at the same level, typically due to slipping, tripping, or stumbling (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). An ankle fracture is defined as a fracture to one or more of the malleoli, sometimes accompanied by injuries to the adjacent ligaments. Transsyndesmotic lateral malleolar ankle fracture (AO/OTA44-B) is the most common type, accounting for approximately 60% of all ankle fractures (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). AO/OTA44-B fractures can be either stable or unstable, depending on whether there is a fracture or ligament injury to the medial structures of the ankle. Isolated lateral malleolar fractures are referred to as AO44-B1; if combined with a ligamentous injury to the medial structures, the fracture is referred to as AO44-B2.1 and is no longer considered isolated (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). An isolated trans-syndesmotic lateral malleolar fracture without signs of deltoid ligament injury can safely be treated without surgical intervention (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). To make well-informed decisions about treating ankle fractures, a thorough understanding of ankle biomechanics and anatomy is crucial for assessing ankle stability (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe SFR is a national quality registry that collects information on all types of fractures treated by orthopaedic surgeons in Sweden. Registrations performed by the treating physician include information about the cause of the injury, type of fracture, treatment provided, and subsequent outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The SFR classifies fractures using the AO/OTA 2007 classification system and considers both fracture and ligament injuries (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The validity of the data in the register has been confirmed by multiple studies, which have shown that the SFR is both valid and accurate (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In 2015, a study was conducted at Sahlgrenska University Hospital (SU), revealing significant variation in the treatment of ankle fractures. This study demonstrated that accurately distinguishing between a stable, isolated lateral malleolar fracture and an unstable lateral malleolar fracture accompanied by medial ligament injury can be a complex and demanding task in daily clinical practice. The study also showed considerable variation within the same department regarding weight-bearing restrictions, treatment choice, and follow-up (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To address this issue, a treatment algorithm (TA) was created to standardise the treatment of ankle fractures and reduce unnecessary surgical interventions. Before the introduction of the TA at SU, as in most other hospitals, no such TA had been in place for ankle fractures, which made the treatment decision primarily up to the surgeon's preference. The introduction of the TA aimed to make the treatment decision more structured with clear indications on the choice of treatment and postoperative restrictions. A follow-up study conducted by Rydberg et al. in 2022 found that the TA significantly reduced the number of surgical treatments in patients with stable ankle fractures (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these promising results, the long-term effects of reducing surgical treatment for lateral malleolar fractures remain unknown. Therefore, the primary objective of the current study is to evaluate the long-term effects and safety of this treatment algorithm in terms of reoperations, complications and delayed surgeries due to non-union.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe present study is a long-term follow-up of the same two patient cohorts as investigated in the study by Rydberg et al. from 2022. Both cohorts consist of patients with lateral malleolar fractures registered as AO/OTA44-B1 in the SFR at the SU. The first cohort, referred to as the Pre-TA cohort, consists of patients treated between 1 April 2012 and 31 March 2014 (n\u0026thinsp;=\u0026thinsp;410), before the introduction of the TA. The second cohort consists of patients who were treated after the introduction of the TA between 1 September 2017 and 31 August 2019 (n\u0026thinsp;=\u0026thinsp;333). The follow-up time for both groups continued until 13 September 2023, when the follow-up time for all patients had reached at least four years (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe outcome of the present study was reoperation. Reoperation was defined as an unplanned surgical procedure occurring 30 days or more after the injury. Planned surgical procedures, such as removal of a syndesmotic screw, have not been considered as reoperations. Information regarding reoperations was extracted from the digital operating planning systems used at the SU. Medical records were further analysed to understand the reason behind each reoperation. The statistical software used was IBM SPSS Statistics version 29. The pre-TA and post-Ta cohorts were compared with respect to time to reoperation using Cox-regression with factors for cohort, sex and age group. Continuous variables are presented with mean and standard deviation, whereas categorical data are presented with frequency and percentages. P-values below 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 410 patients in the pre-TA cohort and 333 in the post-TA cohort. Both cohorts contained more women (56.0%) than men (44.0%). The mean age at the time of injury was 52.1 years in the pre-TA cohort and 52.6 years in the post-TA cohort. In total, women had a higher mean age at the time of injury, with a mean injury age of 54.5 years for women and 49.7 years for men (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of patients with ankle fractures before (pre-TA) and after (post-TA) the introduction of a structured TA*.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal \u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;743\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-TA\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;410\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-TA\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;333\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e327 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e189 (46.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e138 (41.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e416 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e221 (53.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e195 (58.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean injury age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.3 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.1 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.6 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.7 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.2 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.6 (20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54.5 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.5 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.3 (18.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;39 years, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e203 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90 (27.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;59 years, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e259 (34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e141 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e118 (35.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;99 years, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e281 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e156 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e125 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the pre-TA cohort, 161 (39.3%) of patients had positive clinical findings indicating medial ligament injury, while 167 (40.8%) did not. In the post-TA cohort, 95 (28.5%) patients had clinical findings suggestive of medial ligament injury, and 193 (58.0%) patients did not have any such findings.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eReoperations\u003c/h2\u003e \u003cp\u003e131 (31.9%) patients were surgically treated within the pre-TA cohort. Of these, 27 (20.6%) had a later reoperation. Two patients (0.8%) who were initially non-surgically treated had to undergo a surgical procedure at a later stage (defined herein as a reoperation) due to non-union. Hence, 29 patients (7.1%) out of 410 in the pre-TA cohort required a procedure defined as reoperation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the post-TA cohort, 34 (11.3%) patients underwent initial surgical treatment, and five (14.7%) of those patients later needed reoperation. Additionally, three patients (1.0%) treated non-surgically had late surgery due to non-union. Hence, in total, eight patients (2.4%) out of the 333 in the post-TA cohort underwent reoperation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive analysis of the number of reoperations with regard to the initial treatment method\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo reoperation, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReoperation, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eNon-surgical treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e277 (99.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e296 (99.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e573 (99.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSurgical treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104 (79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27 (20.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (85.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e133 (80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e381 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-TA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e325 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e706 (95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37 (5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo summarise, 29 (7.1%) patients in the pre-TA cohort and 8 (2.4%) of patients in the post-TA cohort underwent reoperation. There was a statistically significant difference in the number of reoperations between the pre-TA (20.6%) and post-TA (14.7%) cohorts (HR\u0026thinsp;=\u0026thinsp;0.33; p\u0026thinsp;=\u0026thinsp;0.006). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows a Kaplan-Meier plot of time to reoperation. Event is defined as reoperation (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimated hazard ratio from cox regression for time to reoperation using group, sex, and age group as factors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHazard Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95.0% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup Pre-TA REF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex male REF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group 16\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eREF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group 40\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.838\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group 60\u0026ndash;99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree major reoperations were performed, all of which were recorded in the Pre-TA cohort. In two of these patients, a review of radiographic images from the time of injury revealed a medial clear space of 14.5 mm and 9 mm, respectively, indicating incorrect fracture classification as AO/OTA-B1 in the SFR. The third patient underwent a major reoperation due to a severe infection at the operation site after the primary surgery. The patient was treated with antibiotics and hospitalised, and the plate and screws were removed.\u003c/p\u003e \u003cp\u003eNo major reoperations were observed in the post-TA cohort.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this long-term follow-up study is that treating stable ankle fractures non-surgically is safe and does not lead to an increased risk of non-union, mal-union or increased reoperation rates. The current study builds upon the findings of a previous study by Rydberg et al. that demonstrated that implementing a standardised treatment algorithm for lateral malleolar ankle fractures led to a considerable decrease in surgical intervention (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The present study can conclude that this approach is safe and reliable long term. With a minimum follow-up time of four years, the present study demonstrates that the rate of reoperations did not increase; in fact, it significantly decreased after the introduction of a TA. The present study also demonstrates no increase in the frequency of late surgeries due to non-union. The results of this study provide insight into the effectiveness and safety of implementing a standardised treatment algorithm for lateral malleolar fractures. Adhering to treatment guidelines can significantly reduce the number of surgeries required without increasing the risk of reoperations or the need for later surgical treatment. This highlights the importance of evidence-based treatment approaches to improve patient outcomes and optimise healthcare resource utilisation (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present study, a reoperation was defined as an unplanned surgical treatment occurring 30 days or more after the injury, for both surgically and non-surgically treated patients. Planned procedures, such as removal of a syndesmotic screw, were not considered reoperations. Results demonstrate that the risk of reoperation for those who underwent surgery in each group respectively decreased from 20.6% pre-TA to 14.7% post-TA. As planned secondary procedures were not considered reoperation, the higher number of reoperations found in the pre-TA cohort can not be explained by a higher degree of patients receiving primary surgical treatment before introducing the TA.\u003c/p\u003e \u003cp\u003eThe majority of reoperations in both groups were minor reoperations. A minor reoperation was defined as a surgical procedure due to patient complaints, usually hardware-related pain. Even though minor reoperations are generally simple, routine procedures, they often require the patient to be under general anaesthesia and be conducted in an operating theatre. Reith et al. conducted a survey among patients with hardware-related pain. The most frequent indications for metal implant removal in the ankle were pain, personal preference, professional recommendation or impairment of function. After hardware removal, 52% of the patients experienced pain relief, and 52% experienced better function (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). All surgical procedures carry a risk of complications such as infections. Andersen et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) concluded that there was a 5% risk of wound infections after syndesmotic screw removal. By reducing unnecessary surgical procedures for ankle fractures, both primary and planned secondary surgical procedures such as the removal of syndesmotic screws, the risk of complications can be minimised, leading to greater patient satisfaction and fewer complications. Avoiding unnecessary complications and reoperations can further save valuable healthcare resources.\u003c/p\u003e \u003cp\u003eThree major reoperations were found in this study, all in the Pre-TA cohort. Upon evaluation of their radiological images, it was discovered that one patient had a medial clear space of 9 mm, and the second patient had a 14.5 mm medial clear space. For the medial clear space to increase this much, a medial ligament injury has to be present, indicating that these patients were, in fact, not type B1 fractures but misclassified. AO/OTA44-B1 should not have any significant medial ligament injuries, and the correct classification for these fractures should be AO/OTA44-B2.1 for which primary surgical treatment was recommended. It can be concluded that these ankle fractures were incorrectly classified at a group level in the AO/OTA classification in the SFR. A previous study by Juto et al. suggested that the SFR classification of ankle fractures is accurate but pointed out that classification at a group level can be challenging (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The study by Juto et al. evaluated the accuracy of ankle fracture classifications in the SFR by applying strict AO/OTA classification guidelines on random samples. The results showed an accuracy of 88% for the AO/OTA type. However, the group level accuracy was slightly lower at 74%. Thus, it is more challenging to differentiate the different groups within type B injuries. This is in line with the findings of the present study where the two major reoperations found were probably due to misclassified fractures leading to the wrong treatment method.\u003c/p\u003e \u003cp\u003eFor the third major reoperation revealed in the current study the fracture was correctly classified in the SFR as an AO/OTA44-B1 fracture. The reason behind this reoperation was a deep infection after the primary surgery. The patient had to undergo hospitalisation with i.v. antibiotics, and it was decided to remove the plate and screws to help eliminate the infection. Serious infections are not uncommon after surgery. A study by Cammas et al. identified it as the second most common complication (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A retrospective observational study at SU by Bergstr\u0026ouml;m et al. studied the incidence of surgical site infections (SSI) for surgically treated ankle fractures (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The study included 480 patients who underwent primary surgery and revealed that 10.2% developed an SSI. In the study by Bergstr\u0026ouml;m et al., the patients who underwent a reoperation due to infection usually had one to four reoperations before the infection resolved. In addition, the infected patients had more medical follow-ups and a more extended hospital stay. Hence, surgery has substantial risks, and the best way to reduce these risks is to avoid unnecessary surgeries.\u003c/p\u003e \u003cp\u003eIn the present study, five patients required surgery at a later stage due to non-union. Two patients were found in the pre-TA cohort and three in the post-TA cohort. The mean age of injury for these patients was 45 years, which is younger than the overall mean age in the study. This finding is consistent with the literature, which suggests that non-union is more common among younger patients. According to Mills et al., the highest risk of non-union occurs in individuals aged 25\u0026ndash;44 years (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). For the five non-unions in this study, the primary assessment at the A\u0026amp;E (Accident \u0026amp; Emergency Department) correctly suggested no indication for surgery, and the patients were treated with orthosis according to the TA. However, the fractures did not heal properly, and the patients sought care for pain and discomfort. A radiographic examination confirmed that the fractures had not healed properly and required surgical intervention. Finding an apparent reason for the failure of healing was impossible in all five patients. Non-union is a known orthopaedic problem. A study by Mills et al. suggested that 1% of all ankle fractures result in non-union (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This is consistent with the findings in this study, where the total non-union risk was 0.9%, with 0.8% in the pre-TA cohort and 1.1% in the post-TA cohort. Hence, the risk of non-union is the same regardless of the TA, suggesting that there is no increased risk of non-union with fewer primary surgeries.\u003c/p\u003e \u003cp\u003eThe main strength of this study is the size of the cohorts studied, 743 patients with lateral malleolar ankle fractures, and the long follow-up period of at least four years for all patients. Another strength is that medical records were thoroughly reviewed for all reoperations found to understand the underlying causes.\u003c/p\u003e \u003cp\u003eOne limitation of this study is that it only includes reoperations performed at SU in patients who sought medical care on their own accord. Hence, the study does not include patients who might have undergone reoperations at other facilities within Sweden or abroad, and no information is present on the well-being of patients who did not seek medical care after the initial follow-up period. Moreover, this study does not consider complications that did not require surgical intervention.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates treating stable ankle fractures non-surgically does not lead to an increase in reoperations or late surgeries due to non-union. In fact, a structured treatment algorithm that reduce the number of primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 also led to a significant reduction 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sahlgrenska University Hospital\u003c/p\u003e\n\u003cp\u003eTA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Treatment algorithm\u003c/p\u003e\n\u003cp\u003eAO\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Arbeitsgemeinschaft für Osteosynthesefragen\u003c/p\u003e\n\u003cp\u003eOTA\u0026nbsp; \u0026nbsp;\u0026nbsp;Orthopaedic Trauma Association\u003c/p\u003e\n\u003cp\u003eSFR\u0026nbsp; \u0026nbsp; \u0026nbsp;Swedish Fracture Register\u003c/p\u003e\n\u003cp\u003eMRI \u0026nbsp; \u0026nbsp; Magnetic resonance imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study was approved by the Swedish Ethical Review Authority (reference number 2023-03400-01- 441331). All patients were informed at registration in the Swedish Fracture Register that they had the right to withdraw. According to Swedish legislation, National Quality Registers do not require signed consent from the individual registered patient\u0026nbsp;(24). All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen access funding was provided by the University of Gothenburg.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all our colleagues at the orthopaedic department at Sahlgrenska University Hospital for providing detailed data in the Swedish Fracture Register on busy working days.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCourt-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691-7.\u003c/li\u003e\n\u003cli\u003eBergh C, Wennergren D, Moller M, Brisby H. Fracture incidence in adults in relation to age and gender: A study of 27,169 fractures in the Swedish Fracture Register in a well-defined catchment area. PLoS One. 2020;15(12):e0244291.\u003c/li\u003e\n\u003cli\u003eRydberg EM, Wennergren D, Stigevall C, Ekelund J, M\u0026ouml;ller M. Epidemiology of more than 50,000 ankle fractures in the Swedish Fracture Register during a period of 10 years. J Orthop Surg Res. 2023;18(1):79.\u003c/li\u003e\n\u003cli\u003eNasrallah K, Haim S, Einal B. Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review. Orthop Rev (Pavia). 2021;13(1):8987.\u003c/li\u003e\n\u003cli\u003eDietrich A, Lill H, Engel T, Schonfelder M, Josten C. Conservative functional treatment of ankle fractures. Arch Orthop Trauma Surg. 2002;122(3):165-8.\u003c/li\u003e\n\u003cli\u003eJain N, Symes T, Doorgakant A, Dawson M. Clinical audit of the management of stable ankle fractures. Ann R Coll Surg Engl. 2008;90(6):483-7.\u003c/li\u003e\n\u003cli\u003ePakarinen HJ, Flinkkil\u0026auml; TE, Ohtonen PP, Ristiniemi JY. Stability Criteria for Nonoperative Ankle Fracture Management. Foot \u0026amp; Ankle International. 2011;32(2):141-7.\u003c/li\u003e\n\u003cli\u003eMittal R, Harris IA, Adie S, Naylor JM. Surgery for Type B Ankle Fracture Treatment: a Combined Randomised and Observational Study (CROSSBAT). BMJ Open. 2017;7(3):e013298.\u003c/li\u003e\n\u003cli\u003eChen X, Lim JA, Zhou A, Thahir A. Current concepts of the perioperative management of closed ankle fractures. J Perioper Pract. 2022;32(11):295-300.\u003c/li\u003e\n\u003cli\u003ePakarinen H, Laine HJ, Ristiniemi J. [When is ankle fracture treatable without surgery?]. Duodecim. 2012;128(17):1770-6.\u003c/li\u003e\n\u003cli\u003eBurke FD. Classification of Fractures of Long Bones by M. E. Muller, S. Nazarian, P. Koch, J. Schatzker. Springer-Verlag. 1990. \u0026pound;45.50. Journal of Hand Surgery. 1991;16(2):228-9.\u003c/li\u003e\n\u003cli\u003eJuto H. Studies of Ankle Fractures: Classification, Epidemiology, Complications and Results: Ume\u0026aring; University; 2022. \u003c/li\u003e\n\u003cli\u003eWennergren D, Ekholm C, Sundfeldt M, Karlsson J, Bhandari M, M\u0026ouml;ller M. High reliability in classification of tibia fractures in the Swedish Fracture Register. Injury. 2016;47(2):478-82.\u003c/li\u003e\n\u003cli\u003eJuto H, M\u0026ouml;ller M, Wennergren D, Edin K, Apelqvist I, Morberg P. Substantial accuracy of fracture classification in the Swedish Fracture Register: Evaluation of AO/OTA-classification in 152 ankle fractures. Injury. 2016;47(11):2579-83.\u003c/li\u003e\n\u003cli\u003eRydberg EM, Zorko T, Sundfeldt M, M\u0026ouml;ller M, Wennergren D. Classification and treatment of lateral malleolar fractures - a single-centre analysis of 439 ankle fractures using the Swedish Fracture Register. BMC musculoskeletal disorders. 2020;21(1):521-.\u003c/li\u003e\n\u003cli\u003eRydberg EM, Skoglund J, Brezicka H, Ekelund J, Sundfeldt M, Moller M, et al. Fractures of the lateral malleolus - a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm. BMC musculoskeletal disorders. 2022;23(1):401-.\u003c/li\u003e\n\u003cli\u003eRydberg EM, Skoglund J, Brezicka H, Ekelund J, Sundfeldt M, M\u0026ouml;ller M, et al. Fractures of the lateral malleolus \u0026ndash; a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm. BMC Musculoskeletal Disorders. 2022;23(1):401.\u003c/li\u003e\n\u003cli\u003ePalm H, Posner E, Ahler-Tofteh\u0026oslash;j HU, Siesing P, Gylvin S, Aasvang T, et al. High reliability of an algorithm for choice of implants in hip fracture patients. Int Orthop. 2013;37(6):1121-6.\u003c/li\u003e\n\u003cli\u003eReith G, Schmitz-Greven V, Hensel KO, Schneider MM, Tinschmann T, Bouillon B, et al. Metal implant removal: benefits and drawbacks--a patient survey. BMC Surg. 2015;15:96.\u003c/li\u003e\n\u003cli\u003eAndersen MR, Frihagen F, Madsen JE, Figved W. High complication rate after syndesmotic screw removal. Injury. 2015;46(11):2283-7.\u003c/li\u003e\n\u003cli\u003eCammas C, Ancion A, Detrembleur C, Tribak K, Putineanu D, Cornu O. Frequency and risk factors of complications after surgical treatment of ankle fractures : a retrospective study of 433 patients. Acta Orthop Belg. 2020;86(3):563-74.\u003c/li\u003e\n\u003cli\u003eBergstr\u0026ouml;m J, M\u0026ouml;ller Rydberg E, Wennergren D, Svensson Malchau K. Incidence and Risk Factors for Surgical Site Infection in Ankle Fractures: An Observational Study of 480 Patients in Sweden. J Clin Med. 2023;12(20).\u003c/li\u003e\n\u003cli\u003eMills LA, Aitken SA, Simpson A. The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults. Acta Orthop. 2017;88(4):434-9.\u003c/li\u003e\n\u003cli\u003eSFS. SFS 2008:355 Patient Data Act (Swe). In: SFS, editor. 2008. p. Sect. Chapter 7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ankle fracture, Swedish fracture Register, Epidemiology, Fracture management, Treatment algorithm","lastPublishedDoi":"10.21203/rs.3.rs-4558150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4558150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: A previous study conducted at Sahlgrenska University Hospital (SU) revealed a significant variation in the treatment of ankle fractures, which resulted in the creation of a treatment algorithm (TA). The aim of TA was 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 introduction of the TA. However, the long-term effects of the TA and the reduced number of surgical procedures remained unclear.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To analyse the long-term effects of a structured TA for ankle fractures regarding complications and reoperation rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: 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 the introduction of the TA, the pre-TA cohort (n=410), with a group treated after the introduction of the TA, the post-TA cohort (n=333). Both groups were followed for a minimum of four years, and the outcomes were reoperation or complication. Reoperation was defined as any surgical procedure that occurred 30 days or more after the initial injury.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The results demonstrate a statistically significant reduction in the reoperation rate for lateral malleolar ankle fractures from 7.1% to 2.4% (p = 0.006) following the introduction of a TA that reduced the number of primary surgical procedures. Hardware-related complaints were the leading 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 late surgeries due to non-union.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Treating stable ankle fractures non-surgically does not lead to an increase in reoperations, complications or late surgeries due to non-union. In fact, a structured treatment algorithm that reduce the number of primary surgical procedures for lateral malleolar fractures of type AO/OTA44-B1 also led to a significant reduction 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.\u003c/p\u003e","manuscriptTitle":"Non-surgical treatment of lateral malleolar fractures is safe - Long-term follow-up of a comprehensive treatment algorithm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 18:21:41","doi":"10.21203/rs.3.rs-4558150/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-29T06:39:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"252690507623790298031655617896501797759","date":"2024-07-24T08:54:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T02:21:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T01:20:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116729125732063595420341119684619033518","date":"2024-07-13T01:20:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236820776908630005995085981554367011942","date":"2024-06-29T22:57:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-27T06:45:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77750087578671755655029767250565730108","date":"2024-06-26T15:23:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-25T14:23:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-20T12:10:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-20T10:46:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-20T10:45:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-06-10T12:53:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"00598fd2-d608-4633-a5f4-002f130ed784","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:00:14+00:00","versionOfRecord":{"articleIdentity":"rs-4558150","link":"https://doi.org/10.1186/s12891-024-07924-x","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2024-10-16 15:57:10","publishedOnDateReadable":"October 16th, 2024"},"versionCreatedAt":"2024-07-18 18:21:41","video":"","vorDoi":"10.1186/s12891-024-07924-x","vorDoiUrl":"https://doi.org/10.1186/s12891-024-07924-x","workflowStages":[]},"version":"v1","identity":"rs-4558150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4558150","identity":"rs-4558150","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}