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Weight-bearing Radiographs to Evaluate Stability in Ankles With Isolated Weber Type B Fractures.

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ClinicalTrials.gov Identifier: NCT03831009
Recruitment Status : Recruiting
First Posted : February 5, 2019
Last Update Posted : February 15, 2019
Sponsor:
Information provided by (Responsible Party):
Ostfold Hospital Trust

Brief Summary:
The investigators will conduct a prospective cohort study on the use of weight-bearing radiographs to evaluate stability in ankles with isolated, trans-syndesmotic (Weber type B) fibular fractures. Stable fractures will be treated conservatively using a functional brace, unstable fractures will undergo surgical fixation.

Condition or disease Intervention/treatment Phase
Lateral Malleolus Fractures Ankle Fractures Procedure: Open reduction internal fixation (ORIF) Other: Conservative treatment Not Applicable

Detailed Description:

It is widely accepted that fractures in stable ankles can be treated non-operatively and fractures in unstable ankles needs internal fixation surgery (Michelson, Magid & McHale, 2007, Gougoulias, Khanna, Seellariou, Maffulli, 2010). Clinical decision-making is thus based on ankle stability evaluation. The integrity of medial structures, mainly the deep deltoid ligament, is considered the most important determinant for stability of the ankle mortise (Michelson, Magid & McHale, 2007, Gougoulias, Khanna, Seellariou, Maffulli, 2010). Weber B fractures, with no obvious sign of medial side injury on initial plain radiographs, have to be considered of uncertain stability until adequate stress testing is performed.

Currently there is no definite consensus on what test(s) best determines stability in ankles with undisplaced, isolated lateral malleolar fractures. Much used methods comprises manual stress radiographs and gravity stress radiographs (McConnel, Creevy & Tornetta, 2004). However recent studies have shown that such methods overestimate the need for surgical fixation indicating the need for a different method to make up the basis for surgical indication (Dawe, Shafafy, Quayle, Gougoulias, Wee & Sakellariou, 2015, Hastie, Akhtar, Butt, Baumann & Barrie, 2015, Holmes, Acker, Murphy, McKinney, Kadakia & Irwin, 2016, Hoshino, Nomoto, Norheim & Harris, 2012, Koval, Egol, Cheung, Goodwin & Spratt (2007), Seidel et al., 2017, Weber, Burmeister, Flueckiger & Krause, 2010). Authors of recent studies have proposed weightbearing radiographs as an alternative method to distinguish stable and unstable fractures, significantly reducing the need for operative treatment (Dawe et al., 2015, Hastie et al., 2015, Hoshino et al, 2012, Holmes et al., 2016, Seidel et al., 2017, Weber et al. 2010).

To evaluate weight-bearing radiographs ability to determine stability our primary focus is to evaluate if conservative treatment for "gravity unstable/weightbearing stable" ankles produces different outcomes than conservative treatment for "gravity stable/weightbearing stable" ankles.

Participants will be assigned to non-operative or surgical treatment based on ankle stability evaluation using results from weightbearing radiographs consistently. Stable ankles will be treated non-operatively with a functional brace (AirCast) for 6 weeks. Participants will be instructed to bear weight as tolerated and to actively do standardized range-of-motion exercises. Standard operative treatment is open reduction and internal fixation of the fracture using plate and screws.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 100 participants
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: Two-arm parallel assignment. Based on stability evaluation using weight-bearing adiographs one group recieves surgery, one group recieves non-surgical treatment.
Masking: None (Open Label)
Primary Purpose: Diagnostic
Official Title: Weight-bearing Radiographs to Evaluate Stability in Ankles With Isolated Trans-syndesmotic Lateral Malleolar (Weber Type B) Fractures. A Pilot Study.
Actual Study Start Date : January 1, 2019
Estimated Primary Completion Date : December 31, 2021
Estimated Study Completion Date : December 31, 2021

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Active Comparator: Weight-bearing stable/Gravity stable
Ankles that are considered stable using weight-bearing radiographs AND gravity stress test will be assigned to conservative treatment
Other: Conservative treatment
Conservative treatment involves ankle protection with a functional brace (AirCast) for 6 weeks. Participants will be instructed to bear weight as tolerated and to actively do standardized range-of-motion exercises.

Active Comparator: Weight-bearing stable/Gravity unstable
Ankles that are considered stable using weight-bearing radiographs but unstable using gravity stress test will be assigned to conservative treatment
Other: Conservative treatment
Conservative treatment involves ankle protection with a functional brace (AirCast) for 6 weeks. Participants will be instructed to bear weight as tolerated and to actively do standardized range-of-motion exercises.

Active Comparator: Weight-bearing unstable/Gravity unstable
Ankles that are considered unstable using weight-bearing radiographs AND gravity stress test will be assigned to open reduction internal fixation (ORIF)
Procedure: Open reduction internal fixation (ORIF)
Open fracture reduction followed by internal fixation using a plate and screws. The goal is an osteosynthesis that allow for early range-of-motion exercises, but weightbearing is usually not tolerated until 6 weeks postoperatively.

Active Comparator: Weight-bearing unstable/Gravity stable
Ankles that are considered unstable using weight-bearing radiographs but stable using gravity stress test will be assigned to open reduction internal fixation (ORIF)
Procedure: Open reduction internal fixation (ORIF)
Open fracture reduction followed by internal fixation using a plate and screws. The goal is an osteosynthesis that allow for early range-of-motion exercises, but weightbearing is usually not tolerated until 6 weeks postoperatively.




Primary Outcome Measures :
  1. The Manchester-Oxford Foot Questionnaire (MOxFQ) [ Time Frame: 24 months ]
    Ankle/foot specific patient-reported outcome measure


Secondary Outcome Measures :
  1. Olerud-Molander Ankle Score (OMAS) [ Time Frame: 24 months ]
    Ankle/foot specific patient-reported outcome measure. Maximum score (100) = best. Minimum score = 0 (worst). Poor = 0-30, Fair = 31-60, Good = 61-90, Excellent = 91-100. Presented as total score (0-100).

  2. AOFAS ankle-hindfoot [ Time Frame: 24 months ]
    Ankle/foot specific patient-reported outcome measure

  3. VAS/NRS of pain [ Time Frame: 24 months ]
    Visual analogue pain scale - patient reported. Scale 0-10. 10 = worst possible pain, 0 = no pain

  4. Eq-5d [ Time Frame: 24 months ]
    Genereic health related quality of life patient reported outcome measure

  5. Fracture healing [ Time Frame: 24 months ]
    Radiographic result

  6. Registration of complications [ Time Frame: 24 months ]
    Yes/No for malalignment, deep vein trobosis, nerve injury, wound infection, delayed wound healing and crossover to surgery (including reason for crossover).

  7. Bilateral ankle range-of-motion [ Time Frame: 24 months ]
    Measured in degrees with a goniometer ad modum Lindsjö.

  8. Bilateral calf circumference [ Time Frame: 24 months ]
    Calf circumference in centimeters measured 10 cm distal to the tibial tubercle Calf circumference in centimeters measured 10 cm distal to the tibial tubercle using measuring tape



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Ages Eligible for Study:   18 Years to 80 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Isolated Weber type B fractures without radiological signs of medial clear space widening on initial radiographs. Patients must be 18-80 years of age. Before the injury patients should be mobilized without walking aids. They should be compliant with good communication skills in the Norwegian or English languages. Patients must live in Østfold or nearby areas so they are able to meet to follow-up consultations.

Exclusion Criteria:

  • Patients presenting with any of the following will be excluded from the study: Fracture of the medial malleolus. Information about prehospital fracture closed reduction. Open fracture. Fracture resulting from high-energy trauma or multi-trauma. Pathologic fracture. Diabetes Mellitus type 1 and 2. Neuropathies. Cognitive disorders. Previous history of ankle fracture. Previous history of ankle-/foot surgery. Generalized joint disease such as RA. Patients with insufficient Norwegian or English language proficiency or lack of communication skills.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03831009


Contacts
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Contact: Martin Greger Gregersen +4748171718 martingjohansen@gmail.com
Contact: Marius Molund +4790093988 marius.molund@so-hf.no

Locations
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Norway
Østfold Hospital Trust Recruiting
Sarpsborg, Østfold, Norway, 1714
Contact: Martin Greger Gregersen    +4748171718    martingjohansen@gmail.com   
Contact: Marius Molund    +4790093988    marius.molund@so-hf.no   
Sponsors and Collaborators
Ostfold Hospital Trust
Investigators
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Principal Investigator: Marius Molund Østfold Hospital Trust

Additional Information:
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Responsible Party: Ostfold Hospital Trust
ClinicalTrials.gov Identifier: NCT03831009     History of Changes
Other Study ID Numbers: 18/07031-7
2018/1585/REK sør-øst B ( Other Grant/Funding Number: Regional Committees for Medical and Health Research Ethics )
First Posted: February 5, 2019    Key Record Dates
Last Update Posted: February 15, 2019
Last Verified: February 2019

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Fractures, Bone
Ankle Fractures
Wounds and Injuries