Clinical outcomes of closed versus open simple ankle fractures patterns requiring soft tissue reconstruction: A prospective comparative observational study

Background: Contemporary guidelines advocate for initial debridement and single-stage definitive fixation with immediate soft tissue reconstruction for open fractures. This study aims to evaluate the effectiveness of single-stage stabilization and immediate definitive soft tissue coverage in open ankle fractures compared to closed fractures.

Methods: We compared all isolated open ankle fractures (OF) treated between January 2017 and June 2019 to a control group of operatively managed closed ankle fractures (CF). The OF group included patients with extensive soft tissue injury loss with periosteal stripping and bone exposure (Gustilo and Anderson IIIB) requiring split skin graft, rotational flap or free flap. Clinical outcomes assessed included infection rates, amputation, revision hardware surgery, surgical reduction, non-union rates, and functional outcomes (assessed using the MOXFQ and EQ-5D-5L questionnaires). Health provider matrices were utilized to evaluate cost-benefit parameters, such as length of stay (LOS). Statistical analysis was performed with a significance level set at P < 0.05.

Results: A total of 27 OF and 35 CF cases with AO classification 44 A-C fractures were analyzed following standard treatment protocols. No amputations were reported, but deep/superficial infections occurred in 3 patients in the OF group compared to 2 in the CF group. There was a three-folds increase in mal-union (P = .11), rates of additional surgeries and discharge times in the OF group. (P < 0.05). However, return to functional weight bearing between OF (mean 10.6 weeks) and CF (mean 7.2 weeks) was similar (P = 0.06), and there were no significant differences in EQ-5D-5L and MOXFQ scores at the end of orthopaedic treatment p = 0.5 and 0.16 respectively. The mean hospital LOS was significantly longer for OF (15.6 days) compared to CF (5.4 days) (P < 0.05).

Conclusion: Definitive stabilization and immediate soft tissue reconstruction in the management of open ankle fractures result in high rates of limb salvage and achieve functional outcomes similar to those seen in matched closed ankle fractures upon completion of orthopedic treatment. Although the patient journey is extended, soft tissue and infective complications do not significantly differ. This calls for further investigation to establish the long-term cost-benefit implications of this approach.