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The Journal of Bone and Joint Surgery, Vol 67, Issue 1 67-78, Copyright © 1985 by Journal of Bone and Joint Surgery, Inc
A prospective, randomized study of the management of severe ankle fractures
WA Phillips, HS Schwartz, CS Keller, HR Woodward, WS Rudd, PG Spiegel and GS Laros
One hundred and thirty-eight patients with a closed grade-4
supination-external rotation or pronation-external rotation ankle fracture
(Lauge-Hansen classification) who were seen in the emergency room of the
University of Chicago Hospitals were entered into a randomized study of the
results of various methods of treatment. Ninety-six patients with
satisfactory initial closed reduction were randomized between continued
closed treatment in a plaster cast and open reduction with rigid internal
fixation according to the techniques of the Association for the Study of
Internal Fixation (ASIF). Forty-two patients with unsatisfactory closed
reduction were randomized between open reduction with internal fixation of
only the medial malleolus and open reduction with rigid internal fixation
according to the ASIF techniques. Of the 138 patients who were admitted to
the study, only seventy-one (51 per cent) could be followed for an average
of 3.5 years (a typical return rate of urban trauma centers). The outcomes
were evaluated by a scoring system that included clinical, anatomical, and
arthritis scores. Statistical analysis of the data showed that, of the
patients with initial satisfactory closed reduction, the ones treated by
open reduction and rigid internal fixation had significantly higher total
scores, particularly the patients who were more than fifty years old and
those with a medial malleolar fracture. The small number of patients with
unsatisfactory closed reduction who were treated by one of the two types of
open reduction and internal fixation and were available for follow-up
precluded drawing any conclusions about the superiority of one method of
internal fixation over the other in that group. The difference in the
talocrural angle between the injured and normal sides was the only
statistically significant radiographic indicator of a good prognosis.
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