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Surgical enhancement of fracture healing – operative vs. nonoperative treatment

Open AccessPublished:November 16, 2020DOI:https://doi.org/10.1016/j.injury.2020.11.049

      Highlights

      • High-level of evidence studies comparing treatment outcomes in fractures with controversial debates on the value of surgical treatment in clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fractures are discussed in this narrative review.
      • From the mentioned fracture types, only in Jones fractures literature provides evidence that surgical treatment is superior to conservative treatment in terms of functional outcome and patient-related quality of life.
      • Lower nonunion rates after surgical fracture treatment were often offset by complications due to the surgical procedure, while nonunions after conservative treatment seem only to have limited impact on functional results.

      Abstract

      Although the success story of surgical fracture treatment led to a tremendous improvement of treatment outcome for certain fractures such as femur or tibia shaft fractures, the overall benefit of surgical versus conservative treatment remains controversial for several types of fractures. For this sake, we carried out a narrative review of high-level of evidence studies comparing treatment outcomes in fractures with controversial debates on the value of surgical therapy in clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fractures. We identified eight studies (Level-I and -2) with functional and quality of life outcomes in these fractures.
      Only in Jones fractures of the fifth metatarsal bone, bone healing and functional outcomes were significantly better after surgical compared to conservative treatment. In terms of patient-related quality of life, surgical treatment was not found to be superior compared to conservative treatment in all the above-mentioned fractures. In many trials, lower nonunion rates after surgical treatment were offset by complications due to the surgical procedure. Nonunion after conservative treatment often seemed to have only limited impact on functional results.
      However, the comparability of studies was limited due to age-differences between patients. Therefore, we emphasize the need for further investigations to determine which patient-related factors favor a conservative treatment approach and for whom surgery is the best option.

      Key words

      Introduction

      Treatment options for fractures are numerous, ranging from conservative treatment methods to various internal or external fixation procedures as well as partial or complete joint replacement. Between 2005 and 2013, an increase of 21% in the number of internal fixation procedures was recorded in Germany, partly due to introductions of technical innovations such as locking plates [
      • Garcia P.
      • Domnick C.
      • Lodde G.
      • Raschke M.J
      Operative Versorgung in Orthopädie und Unfallchirurgie: wird in Deutschland immer mehr operiert?.
      ,
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      . Nevertheless, consensus among surgeons is still lacking as to which fractures and for which patient surgical treatment is beneficial. Nowak et al. surveyed 134 orthopedic surgeons about their opinion regarding appropriate treatment of proximal humeral fractures. While consensus on minimally dislocated fractures was high, a strong disagreement in more complex fractures was found. In three-part fractures, treatment strategies varied between plate fixation, hemiarthroplasty and total reverse shoulder arthroplasty, whereby approximately one third each preferred one of the methods mentioned above [
      • Nowak L.L.
      • Vicente M.R.
      • McKee M.D.
      • Hall J.A.
      • Nauth A.
      • EmilH Schemitsch
      Orthopaedic surgeons’ opinions surrounding the management of proximal humerus fractures: an international survey.
      ].
      Although several studies compared the possible procedures in terms of functional outcomes and their complications, the resulting information were frequently limited due to lack of evidence as well as methodical issues. [
      • Griffin D.
      • Parsons N.
      • Shaw E.
      • Kulikov Y.
      • Hutchinson C.
      • Thorogood M.
      • et al.
      Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.
      ]. However, recent high-quality studies have highlighted these issues and have given some evidence-based answers comparing functional outcome, quality of life and complication rates. For this purpose, this article provides an overview of the current state of evidence of surgical versus conservative treatment of fractures in which appropriate treatment is still controversially discussed (Table 1).
      Table 1Characteristics of included studies. =not significant.
      AuthorsAnatomical areaPatients (n)UnionPost-operative functionComplicationsMean follow-up period (months)
      OperativeNon-operativeOperativeNon-operativeScoreOperativeNon-operativestatItemOperativeNon-operative
      Axelrod et al. 2019
      • Axelrod D.E.
      • Ekhtiari S.
      • Bozzo A.
      • Bhandari M.
      • Johal H
      What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures?.
      Displaced mid-third clavicle fractures138058596.7%88.9%Constant scoremean difference of 4.5 points95% CI 0.62 to 8.3revision surgeryodds ratio of 0.85 (95% CI 0.31 to 2.5) favoring operative management12
      DASH scoremean difference of 3.8 points95% CI 0.43 to 8.1
      Rangan et al. 2015
      • Rangan A.
      • Handoll H.
      • Brealey S.
      • Jefferson L.
      • Keding A.
      • Martin B.C.
      • et al.
      Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: the PROFHER Randomized Clinical Trial.
      Proximal humerus fractures12512596.8%96.0%Oxford Shoulder Score39.138.3p = 0.48total24.0%18.4%24
      Launonen et al. 2019
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      Displaced two-part proximal humerus fractures in patients aged > 60 years4444100%100%DASH score18.517.4p = 0.81total6.8%024
      Constant–Murley score68.066.0p = 0.60
      Oxford Shoulder Score40.241.5p = 0.54
      Visual analogue scale (0 to 100)11.509.9p = 0.72
      Duckworth et al. 2017
      • Duckworth A.D.
      • Clement N.D.
      • McEachan J.E.
      • White T.O.
      • Court-Brown C.M.
      • McQueen M.M
      Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly.
      Displaced fractures of the olecranon in patients aged ≥ 75 years11781.8%22.2%DASH score22.023.0p = 0.763total81.8%14.3%12
      Broberg and Morrey score94.088p = 0.285
      Mayo Elbow Score95.095.0p = 0.906
      Willet et al. 2016
      • Willett K.
      • Keene D.J.
      • Mistry D.
      • Nam J.
      • Tutton E.
      • Handley R.
      • et al.
      Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: a Randomized Clinical Trial.
      Unstable ankle fractures in patients aged > 60 years30931198.9%89.5%Olerud-Molander Ankle Score66.064.5n.sinfection and/or wound breakdown10.0%1.0%6
      Timed Up and Go mobility test18.018.4n.sadditional operating room procedures6.0%1.0%
      van Leeuwen et al. 2019
      • van Leeuwen C.A.T.
      • Hoffman R.P.C.
      • Hoogendoorn J.M
      Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures.
      Type B fibula fractures99130Olerud-Molander Ankle Score84.084.0p = 0.988total3.0%0.8%63.6
      American Academy of Orthopaedic Surgeons90.093.0p = 0.281
      Visual Analogue Scale (1 to 10)1.30.8p = 0.281
      Griffin et al. 2014
      • Griffin D.
      • Parsons N.
      • Shaw E.
      • Kulikov Y.
      • Hutchinson C.
      • Thorogood M.
      • et al.
      Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.
      Displaced, intra-articular calcaneal fractures7378Kerr-Atkins score for pain and function69.865.7p = 0.993total23.0%4.0%24
      American Orthopaedic Foot and Ankle Society score79.276.8p = 0.976
      Yates et al. 2015
      • Yates J.
      • Feeley I.
      • Sasikumar S.
      • Rattan G.
      • Hannigan A.
      • Sheehan E
      Jones fracture of the fifth metatarsal: is operative intervention justified? A systematic review of the literature and meta-analysis of results.
      Jones fracture12211597.4%76.2%Return to sports (weeks)10.218.735.9

      Methods

      The PubMed/Medline database was searched for clinical trials, randomized controlled studies, meta-analyses and systematic reviews. The following keywords were used for the search on 19th November 2019: “bone fracture”, “management”, “outcome”, “treatment” in combination with the affected anatomical area or fracture entity (clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fracture). The exclusion criteria were articles for which full text was not available, were not in English, were gray literature or which were published before 2010.
      The inclusion criteria were: all types of articles related to humans and adults and in which two study arms (surgical versus conservative treatment) were included. One or two representative articles were selected for each anatomical region, with preference given to randomized controlled trials (RCT), systematic reviews and meta-analyses.

      Fractures of the clavicle shaft

      Clavicular fractures account for 4% of all fractures, affecting most frequently young men with high functional demands [
      • Amin S.
      • Achenbach S.J.
      • Atkinson E.J.
      • Khosla S.
      • Melton L.J
      Trends in Fracture Incidence: a Population-Based Study Over 20 Years: FRACTURE TRENDS.
      ]. Various options for managing these fractures are provided, whether conservative treatment (mostly sling or figure-of-eight bandage) (Fig. 1) or surgical treatment with open reduction and plate fixation or intramedullary devices [
      • Zlowodzki M.
      • Zelle B.A.
      • Cole P.A.
      • Jeray K.
      • McKee M.D
      Treatment of Acute Midshaft Clavicle Fractures: systematic Review of 2144 Fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group.
      ]. Axelrod and colleagues included 22 RCT in a meta-analysis regarding union after one year, revision surgery and functional outcome of different surgical procedures and conservative treatment of displaced mid-third clavicle fractures. The included studies were reviewed using the Cochrane Collaboration's Tool for Assessing Risk of Bias [
      • Higgins J.P.T.
      • Altman D.G.
      • Gøtzsche P.C.
      • Jüni P.
      • Moher D.
      • Oxman A.D.
      • et al.
      The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
      ] and 18 out of 22 were deemed „low“ risk of bias. In the studies included, 1002 patients were treated with a plate construct, 378 with an intramedullary device and 585 patients underwent a nonoperative treatment. Surgical procedures were sub-specified, including anterior plating, anterosuperior plating, superior plating, locked intramedullary devices, and unlocked intramedullary devices. Union achievement was decreased in non-surgical patients (88.7%) compared to surgical treated patients (96.7%) (relative risk (RR) 1.128; 95% CI 1.1 to 1.17; p < 0.001), resulting in a number needed to treat (NNT) of ten. Anterior or anterosuperior plates performed best, resulting in union in 99.3% of cases and NNT of eight. No differences were detected between the treatment methods with regard to reoperation rates including hardware removal [
      • Axelrod D.E.
      • Ekhtiari S.
      • Bozzo A.
      • Bhandari M.
      • Johal H
      What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures?.
      ].
      Fig. 1:
      Fig. 1Non-operative treatment of a midshaft clavicle fracture of a 49-year old man after a motorcycle accident: x-rays anteroposterior (AP) (A1) and 45° cephalic tilt view (A2) on the day of accident, AP (B1) and 45° cephalic tilt view (B2) two months after trauma and AP (C1) and 45° cephalic tilt view (C2) eight months after trauma.
      Functional outcome was assessed using Constant score and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Minor improvements were found in surgically treated individuals. However, the minimal clinical difference (MCID) was not reached. Comparing surgical strategies, anterosuperior plate construction resulted in best functional outcome, reaching the MCID in the constant score. Although there was a higher chance of fracture union in the operatively treated group, there were no benefits concerning risk of revision surgery or in functional outcome scores compared to conservative treatment. Unfortunately, no information in the included studies was given about complications, such as fracture related infections or complications in wound healing. Furthermore, patient related data such as age or comorbidities are lacking, which are known to have considerable influence on healing progress.

      Proximal humerus fractures

      Fractures of the proximal humerus are common, especially in older individuals. They account for 5 to 6% of all adult fractures. The surgical neck is usually involved, since osteoporosis is one of the main risk factors for those typically metaphyseal fractures [
      • Court-Brown C.M.
      • Caesar B.
      Epidemiology of adult fractures: a review.
      ]. In Germany, an increase of 39% in surgical procedures for fractures of the proximal humerus was recorded from 2005 to 2013 [
      • Garcia P.
      • Domnick C.
      • Lodde G.
      • Raschke M.J
      Operative Versorgung in Orthopädie und Unfallchirurgie: wird in Deutschland immer mehr operiert?.
      ]. In contrast to increasing surgery rates, a Cochrane review from 2015 still emphasizes limited evidence base regarding the treatment of choice, especially in complex fractures. Furthermore, the included studies did not show superiority of surgical versus conservative treatment. The authors could not provide clear recommendations on the type of conservative and surgical care [
      • Handoll H.H.
      • Brorson S.
      Interventions for treating proximal humeral fractures in adults.
      ]. The Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) study group compared conservative and surgical treatment for displaced humeral fractures in a prospective RCT. 258 patients were eligible, including 18 Neer one-part fractures with nine patients each in surgical group (SG) and nonsurgical group (NSG), 128 Neer two-part fractures (65 SG vs. 63 NSG), 93 Neer three-part fractures (46 SG vs. 47 NSG), and 11 Neer four-part fractures (5 SG vs. 6 NSG). Surgical treatment most often involved locking plates (n = 90), followed by hemiarthroplasty (n = 10), intramedullary nails (n = 4), and other surgery (n = 5). Conservative treatment consisted of broad arm type sling (n = 82) or collar and cuff (n = 35) with three patients receiving a hanging cast. The functional outcome measured by the Oxford shoulder score (OSS) did not differ significantly between the two groups at any point of time (6, 12, and 24 months post-injury). Furthermore, the comparative groups ranked equal in the Short Form 12 (SF-12) mental and physical component scores. Slightly more surgical treated patients (24.0% vs. 18.4%) experienced complications. However, these results were not statistically significant. Assuming that age and tuberosity involvement would have significant impact on the outcome, subgroup analyses evaluated the impact of age or fracture type on functional outcome. However, no differences emerged between the subgroups of patients aged >65 years and <65 years, as well as between tuberosity involvement and no tuberosity involvement, respectively [
      • Rangan A.
      • Handoll H.
      • Brealey S.
      • Jefferson L.
      • Keding A.
      • Martin B.C.
      • et al.
      Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: the PROFHER Randomized Clinical Trial.
      ]. With reference to the above-mentioned study, another research group allocated 88 patients either to surgical treatment using a Philos locking plate (Depuy-Synthes, Solothurn, Switzerland) or non-operative treatment consisting of wearing a collar-cuff sling for 3 weeks. The rehab protocol was identical for both groups. In contrast to the PROFHER-Trial this study focused on displaced two-part proximal humerus fractures in patients aged ≥60 years. Outcome measurement was conducted by blinded assessors evaluating the DASH score for primary outcome in addition to the Constant score, the visual analogue scale for pain (VAS), the quality of life questionnaire 15D, the EuroQol Group's 5-dimension self-reported questionnaire EQ-5D and OSS. In line with the PROFHER study, there were no statistical or clinically significant between-group differences at any point of assessment (3, 6, 12, and 24 months post-injury) [
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      ]. After 24 months, in both studies the patients achieved similar results in the OSS [
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      ,
      • Rangan A.
      • Handoll H.
      • Brealey S.
      • Jefferson L.
      • Keding A.
      • Martin B.C.
      • et al.
      Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: the PROFHER Randomized Clinical Trial.
      . The complication rate in this trial was quite low (3.4%) and all of them concerned surgical treated patients [
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      ]. There was a considerable lower complication rate in this trial compared to the PROFHER trial, which is most likely attributable to the fact that mainly experienced upper limb surgeons performed the interventions compared to 66 different surgeons of 30 centers in the PROFHER trial [
      • Launonen A.P.
      • Sumrein B.O.
      • Reito A.
      • Lepola V.
      • Paloneva J.
      • Jonsson K.B.
      • et al.
      Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial.
      ,
      • Rangan A.
      • Handoll H.
      • Brealey S.
      • Jefferson L.
      • Keding A.
      • Martin B.C.
      • et al.
      Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: the PROFHER Randomized Clinical Trial.
      . Despite the overall good quality of these RCTs, some severe limitations remain. On the one hand, the PROFHER study considered only diabetes among comorbidities, while Launonen et al. included neurological diseases as well. On the other hand, no information about osteoporosis as well as other comorbidities was given, which would be expected to influence fracture healing and functional outcome. Further, long-term outcome data are missing, which is an often-encountered problem in clinical studies, not only in the orthopedic field. Nevertheless, both trials were designed as prospective RCTs, providing some high-quality evidence that surgical treatment is not superior to non-surgical. Therefore, the existing literature does not support the trend of increased surgical interventions in proximal humeral fractures.

      Olecranon fractures

      Olecranon fractures are intra-articular fractures. Thus, anatomical reduction of the articular surface and internal fixation is generally recommended [
      • Perren S.M.
      Basic Aspects of Internal Fixation.
      ]. Several surgical techniques are available: tension band fixation, intramedullary fixation and plate fixation. Non-operative treatment is commonly restricted to non-displaced fractures. A maximum of two millimeter displacement is commonly accepted for conservative treatment [
      • Newman S.D.S.
      • Mauffrey C.
      • Krikler S
      Olecranon fractures.
      ]. In elderly patients, olecranon fractures should be regarded as predominantly osteoporotic [
      • Court-Brown C.M.
      • Caesar B.
      Epidemiology of adult fractures: a review.
      ]. In those patients, increased rates of surgery related complications, such as wound healing disorders, loss of reduction, and infections occur. In contrast, satisfactory short- and long-term outcomes following non-operative treatment are reported. Retrospective studies and case series doubt benefit of surgical treatment [
      • Gallucci G.L.
      • Piuzzi N.S.
      • Slullitel P.a.I.
      • Boretto J.G.
      • Alfie V.A.
      • Donndorff A.
      • et al.
      Non-surgical functional treatment for displaced olecranon fractures in the elderly.
      ,
      • Veras Del Monte L.
      • Sirera Vercher M.
      • Busquets Net R.
      • Castellanos Robles J.
      • Carrera Calderer L.
      • Mir Bullo X
      Conservative treatment of displaced fractures of the olecranon in the elderly.
      ,
      • Mj P.
      • Pw R.
      • Ta A.
      • Pc B
      A review of displaced olecranon fractures treated conservatively.
      ]. Duckworth et al. performed a prospective RCT of non-operative versus operative management of olecranon fractures in individuals aged ≥75 years. Half of the patients suffering from a stable displaced olecranon fracture (Mayo type 2) were treated operatively either with tension band wiring (n = 9) or using plates (n = 2). Conservative treatment (n = 8) with collar and cuff sling for two weeks with subsequent physiotherapy. No significant differences were found for all timepoints, neither in the Mayo Elbow Score, Broberg and Morrey score nor in the DASH score, which was defined as primary outcome. Better range of motion could be demonstrated for the operative group compared to the non-operative group (mean arc of flexion: 106° vs. 129°, p = 0.049), while both groups showed similar results in forearm rotation. Follow-up data were obtained at 6, 12, 26, and 52 weeks after injury by physiotherapists. The number of randomized patients (n = 19) was low due to prematurely termination of patient recruitment based on unequally higher complication rates in the operative group (81.8% vs. 14.3%, p = 0.013). A total of 13 complications occurred in ten patients. Of these, seven were due to loss of reduction, four to subsequent surgery due to removal of metalwork or revision and two to infections. Nine out of 11 operatively treated patients experienced at least one complication, while just one patient of the non-operative group developed complications due to a missed Mayo type 3 fracture. In radiographs, all non-operatively and two operatively treated patients developed nonunion, which were painless and did not seem to compromise functional outcome [
      • Duckworth A.D.
      • Clement N.D.
      • McEachan J.E.
      • White T.O.
      • Court-Brown C.M.
      • McQueen M.M
      Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly.
      ]. Based on the small sample size, these results are not generalizable and have to be considered of limited value. Nevertheless, these findings are in line with former conducted case studies and provide primary non-operative procedure in elderly patients suffering from isolated displaced olecranon fractures [
      • Gallucci G.L.
      • Piuzzi N.S.
      • Slullitel P.a.I.
      • Boretto J.G.
      • Alfie V.A.
      • Donndorff A.
      • et al.
      Non-surgical functional treatment for displaced olecranon fractures in the elderly.
      ,
      • Veras Del Monte L.
      • Sirera Vercher M.
      • Busquets Net R.
      • Castellanos Robles J.
      • Carrera Calderer L.
      • Mir Bullo X
      Conservative treatment of displaced fractures of the olecranon in the elderly.
      ,
      • Duckworth A.D.
      • Clement N.D.
      • McEachan J.E.
      • White T.O.
      • Court-Brown C.M.
      • McQueen M.M
      Prospective randomised trial of non-operative versus operative management of olecranon fractures in the elderly.
      . With high complication rates in the use of tension band wiring, it remains unclear whether plate osteosynthesis would have a greater benefit, since only two patients received this procedure. Reviewing the existing studies regarding olecranon fractures highlights the need for RCTs in this field [
      • Lenz M.
      • Wegmann K.
      • Müller L.P.
      • Hackl M
      Nonoperative treatment of olecranon fractures in the elderly—A systematic review.
      ].

      Ankle fractures

      The incidence of ankle fractures is reported as about 100.8 fractures per 100,000 individuals affecting most commonly young men and elderly women [
      • Court-Brown C.M.
      • McBirnie J.
      • Wilson G
      Adult ankle fractures—An increasing problem?.
      ,

      Donken C.C., Al-Khateeb H., Verhofstad M.H., van Laarhoven C.J. Surgical versus conservative interventions for treating ankle fractures in adults 2012:39.

      . Operative treatment is recommended for unstable fractures, which include bi- or trimalleolar fractures, subluxation of the talus or fracture dislocation as well as open fractures. Treatment options consist of open or closed reduction followed by surgical fixation using screws, plates, or wires. Fractures without signs of instability can be treated conservatively by closed reduction followed by immobilization in a plaster cast [

      Donken C.C., Al-Khateeb H., Verhofstad M.H., van Laarhoven C.J. Surgical versus conservative interventions for treating ankle fractures in adults 2012:39.

      ,
      • Willett K.
      • Keene D.J.
      • Mistry D.
      • Nam J.
      • Tutton E.
      • Handley R.
      • et al.
      Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: a Randomized Clinical Trial.
      ,
      • Arastu M.H.
      • Demcoe R.
      • Buckley R.E
      Current concepts review: ankle fractures.
      ]. The mortise radiograph is commonly chosen as a diagnostic tool to assess the stability of the fracture. A medial clear space (MCS) <4 mm or a fibula dislocation <2 mm is generally considered to be stable and therefore can be treated conservatively. When MCS >6 mm, an unstable fracture is assumed, for which surgical treatment is recommended. In case of an MCS between 2 and 4 mm, further diagnostic tools are recommended to test for medial instability. However, recent data showed that most surgeons chose operative treatment at a cut-off of 4 mm MCS [
      • van Leeuwen C.A.T.
      • Hoffman R.P.C.
      • Donken C.C.M.A.
      • van der Plaat L.W.
      • Schepers T.
      • Hoogendoorn J.M
      The diagnosis and treatment of isolated type B fibular fractures: results of a nationwide survey.
      ].
      The Cochrane working group reviewed present data concerning treatment strategies of ankle fractures [

      Donken C.C., Al-Khateeb H., Verhofstad M.H., van Laarhoven C.J. Surgical versus conservative interventions for treating ankle fractures in adults 2012:39.

      ]. Three RCTs and one quasi-randomized trial met the inclusion criteria, while comparable metanalyses were compromised by different approaches measuring functional outcome. In addition, all trials were at high risk of bias due to lack of blinding and incomplete outcome data. Therefore, the reviewer concluded that evidence is scarce whether surgical or non-surgical treatment is superior in treating ankle fractures in adults [

      Donken C.C., Al-Khateeb H., Verhofstad M.H., van Laarhoven C.J. Surgical versus conservative interventions for treating ankle fractures in adults 2012:39.

      ]. To answer this question and avoid the mentioned flaws, Willet et al. performed a multicenter (24 UK trauma centers) RCT with blinded outcome assessors. Patients older than 60 years, suffering of an acute malleolar fracture and an unstable ankle joint normally treated with surgery were included in this study. Out of 620 eligible patients, 309 were randomized to surgical treatment, while 311 were allocated to conservative treatment. Conservative treatment consisted of closed fracture reduction followed by close contact casting in anesthesia. Olerud-Molander Ankle Score (OMAS) was set as primary outcome. No significant between-groups differences were observed at follow-up (six weeks and six months), respectively. Furthermore, no differences emerged between the secondary outcomes of quality of life (mental and physical), ankle pain, and patient satisfaction as well as in the Time Up and Go mobility test. After six weeks there were slight between-group differences in ankle movement, but these were no longer noticed after six months. With regard to equal functionality, conservative treatment had lower complications and was more cost-effective. Even though the malunion rate was also higher, this seems to have a negligible effect on the functional outcome in elderly patients [
      • Willett K.
      • Keene D.J.
      • Mistry D.
      • Nam J.
      • Tutton E.
      • Handley R.
      • et al.
      Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: a Randomized Clinical Trial.
      ]. Similar results have been reported by van Leeuwen et al. who retrospectively investigated conservative and operative treatment of isolated trans-syndesmotic (type B) fibula fractures [
      • van Leeuwen C.A.T.
      • Hoffman R.P.C.
      • Hoogendoorn J.M
      Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures.
      ]. In total, 229 patients were long-term followed up, subdivided in non-operatively treated cohort (n = 130) and an operatively treated cohort (n = 99). Mean length of follow-up was 5.3 years using a questionnaire to assess functional outcome and patient related lifetime quality. No significant differences between groups were reported. The EQ-5D quality of life score was 0.8 vs. 0.9 (p = 0.72), mean VAS pain score 0.8 vs. 1.3 (p = 0.09), OMAS 84 vs. 84 (p = 0.98) and for the American Orthopaedic Foot & Ankle Society score 93 vs. 90 (p = 0.28). Furthermore, subgroups with an MCS of 4–6 mm and a fibula dislocation >2 mm were formed and compared in terms of these parameters. Again, no superiority of surgical treatment was shown in subgroup comparison. Metal removal was necessary in almost 35% after initial surgical treatment. Thus, in the case of a questionable instability, gravity stress radiographs are recommended so that surgery can be avoided in stable fractures[24]. Comparing base line characteristics, operatively treated patients were significantly younger. In line with the study of Willet et al., the favorable outcome of conservative fracture treatment in older patients may also be influenced by their lower life expectancy and lower functional demands.

      Calcaneal fractures

      Calcaneal fractures are known to be debilitating and very complicated injuries. Incidence is estimated to be approximately 11.5 per 100,000 population. Young men are more often affected, thus resulting in a male to female ratio of 2.4:1. The most common injury mechanism consists of a fall from a height (71.5%) [
      • Mitchell M.J.
      • McKinley J.C.
      • Robinson C.M
      The epidemiology of calcaneal fractures.
      ]. Calcaneal fractures are usually classified into four types according to Sanders: 1 = non-displaced fractures (displacement <2 mm); 2 = two-part or split fractures of the subtalar joint; 3 = three-part or split depression fractures; and 4 = four-part or highly comminuted articular fractures [
      • Sanders R.
      • Fortin P.
      • DiPasquale T.
      • Walling A
      Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification.
      ]. In the last two decades, treatment has evolved to plate and screw fixation of intra-articular displaced calcaneal fractures to restore the subtalar joint. On the other hand, high complication rates after surgery due to frequently critical soft tissue conditions have been reported. Griffin et al. conducted a large multicenter assessor blinded RCT to provide some evidence on decision-making in displaced calcaneal fractures. Two treatment arms were formed from 151 patients (73 operative vs. 78 non-operative); non-displaced fractures and gross deformities of the hindfoot (also called “fibula impingement”) were excluded. Open reduction and internal fixation with plates and screws via extensive lateral approach was the surgical intervention performed within three weeks after injury. Non-operative treatment consisted of careful pain-adapted mobilization of the ankle and subtalar, and the fitting of a removable splint. Both groups were mobilized with non-weight bearing for six weeks, followed by six weeks partial weight bearing. Primary outcome was the Kerr-Atkins calcaneal fracture score as a patient reported outcome instrument assessing pain and function after calcaneal fracture. Secondary outcome measures were the EQ-5D and SF-36 for life time quality as well as the American Orthopaedic Foot and Ankle Society score to assess global hindfoot function. Follow-up period was set at two years, with follow-up examinations at 6 weeks, 6, 12, 18 and 24 months post-surgery. No significant differences in both primary and secondary outcomes could be evidenced between the treatment groups. Furthermore, no positive treatment effects of surgery for heel width, range of motion and walking speed were observed. Complications and/or reoperations affected significantly more patients of the operative cohort (23% operative vs. 4% non-operative). The estimated OR was 7.5 (95% CI 2.0 to 41.8, p<0.001), while the most common complication was surgical site infection. Three patients had to undergo subtalar arthrodesis due to painful arthrosis, all of them were previously treated non-operatively [
      • Griffin D.
      • Parsons N.
      • Shaw E.
      • Kulikov Y.
      • Hutchinson C.
      • Thorogood M.
      • et al.
      Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.
      ]. Probably a longer-term follow-up would point out a better outcome of surgery treatment with regards to prevention of secondary arthrosis of the subtalar joint. Even after two years, there were still considerable deficiencies for patients in the functionality and quality of life. Therefore, a longer observation period could also provide important information regarding patient-related long-term outcomes. Advantages of recent less invasive surgical procedures such as percutaneous fixation will have to be tested in RCTs in the future as well [
      • Griffin D.
      • Parsons N.
      • Shaw E.
      • Kulikov Y.
      • Hutchinson C.
      • Thorogood M.
      • et al.
      Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial.
      ].

      Jones fractures

      With an incidence of 6.7 per 10,000 population, metatarsal fractures are common injuries. Most frequently affected is the fifth metatarsal, in descending order the proximal metaphyseal part, followed by the diaphyseal part and the distal metaphysis [
      • Petrisor B.A.
      • Ekrol I.
      • Court-Brown C
      The Epidemiology of Metatarsal Fractures.
      ]. Jones fractures are defined as including all fractures of the proximal fifth metatarsal distal to the tuberosity and within 1.5 cm of this region [
      • Dean B.J.F.
      • Kothari A.
      • Uppal H.
      • Kankate R
      The Jones Fracture Classification, Management, Outcome, and Complications: a Systematic Review.
      ]. Standard procedure of operative treatment is fixation with cannulated intramedullary screws. Tension band wiring is a further available surgical option. Conservative treatment consists of no weight bearing for at least 5–8 weeks in a plaster cast [
      • Yates J.
      • Feeley I.
      • Sasikumar S.
      • Rattan G.
      • Hannigan A.
      • Sheehan E
      Jones fracture of the fifth metatarsal: is operative intervention justified? A systematic review of the literature and meta-analysis of results.
      ]. Even though this eponymous fracture was first described by Sir Robert Jones as early as 1902, its treatment remains controversial [
      • Dean B.J.F.
      • Kothari A.
      • Uppal H.
      • Kankate R
      The Jones Fracture Classification, Management, Outcome, and Complications: a Systematic Review.
      ]. Yates et al. reviewed current literature to meta-analyze outcome of operative versus conservative treatment in patients suffering from Jones fractures. Six relevant studies were included, the total number of patients was 237. Of these, 51% were treated non-operatively, while 49% were assigned to surgical treatment. Outcome measures consisted of non-union rates, delayed union rates, time to radiological union, and complication types as well as rates of occurrence. Metanalyses revealed an OR 5.74 (95% CI 2.65 – 12.40, p<0.001) with non-union rates for conservative treatment (3.8%) compared with those for surgical interventions (2.6%). Furthermore, a faster return to sports and to normal activity was reported in the surgical cohort. No superiority for return to work was shown. Patient satisfaction did no differ significantly in the two treatment arms. Nevertheless, surgical treated patients stated less pain in the VAS and sustained less complications than conservative treated patients (8.5% vs. 31%) [
      • Yates J.
      • Feeley I.
      • Sasikumar S.
      • Rattan G.
      • Hannigan A.
      • Sheehan E
      Jones fracture of the fifth metatarsal: is operative intervention justified? A systematic review of the literature and meta-analysis of results.
      ]. Thus, surgery seems to be superior in treatment of Jones fractures.

      Limitations

      This narrative review has several potential limitations worth mentioning. One potential limitation is publication bias because negative studies are less likely to have been published. Also, no systematic review of literature was performed and therefore some relevant studies could be missed. The search strategy was limited to the English language, to publications of the last decade and limited to adults because the intent of this review was to provide an overview of recent conducted studies.

      Conclusion

      Despite recent advances in operative fracture treatment, conservative treatment remains a viable option for fractures, in which appropriate treatment is still controversially discussed. This narrative review shows that treatment outcomes in conservatively treated midshaft clavicle, proximal humerus, olecranon, ankle and calcaneus fractures is not inferior in terms of function and patient satisfaction compared to surgical treatment. Classical Jones fractures of the fifth metatarsal bone benefit from surgical treatment with higher union rates and better functional outcome. However, most studies still exhibit considerable flaws, which limits the overall conclusion. Further studies with adequate patient selection, long-term follow-up and sufficient statistical robustness will be required to further improve treatment decision in certain fractures.

      Declaration of Competing Interest

      The authors declare no conflict of interest related to this paper.

      Appendix. Supplementary materials

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