Surgical versus non-surgical treatment of ankle fractures in patients above the age of 50: A systematic review and meta-analysis

Ankle fractures management in old individuals has been discussed controversially. We aimed to assess clinical outcomes in patients undergoing surgery and those receiving non-surgical treatment. MEDLINE, PubMed, EMBASE, Google Scholar, and Cochrane databases were searched in June 2019. In the synthesized analyses, patients above 50 years of age who received surgical treatment through open reduction and internal fixation (ORIF) were compared to those who underwent non-surgical treatment through closed reduction and casting for relevant clinical outcome parameters. We identified 12 eligible studies with a total of 54,699 patients. Of these, 27,110 received surgical and 27,588 non-surgical treatment. Surgical treatment was associated with a lower risk of non-unions (odds ratio [OR]: 0.127; 95% confidence interval [CI]: 0.055, 0.292, P < 0.001) as well as mal-unions (OR: 0.128, 95% CI: [0.063, 0.262], [P < 0.001]), and mortality at 1-year post-treatment (OR: 0.509, 95% CI: [0.266, 0.975], [P = 0.042]). Similarly, the duration of return to pre-injury activity was significantly shorter in a surgical group whereas skin complications were associated with a higher risk in the surgical group (OR: 4.923, 95% CI: [3.720, 6.515], [P < 0.001]). Neither rates of satisfaction and re-admission nor duration of hospital stay and period in cast differed between surgical and non-surgical treatment groups. In patients above the age of 50 years, ORIF seems to be superior to non-surgical treatment for relevant clinical outcomes such as non-union, mal-union, and mortality rates; as well as return to pre-injury level was better in the surgical group.