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patient-based outcomes measured at a mean follow up of
7.4 months.13 While 2 of 20 patients (10%) displayed residual MCS widening, only 1 patient was symptomatic at this
short-term point of follow-up.
Similarly, in the previously mentioned study by Koval
et al,28 the authors reported on a series of stress-positive
SER IV ankle fractures treated nonoperatively. Ninety percent of patients who had only partial tear of the deep deltoid
ligament as assessed by MRI (19 of 21) were treated conservatively and allowed to weight bear as tolerated. At final
evaluation, all fractures united without radiographic evidence of arthritis with American Orthopaedic Foot & Ankle
Society (AOFAS) and SF-36 scores demonstrating excellent results. Clements et al7 examined a similar cohort of 51
patients who underwent nonoperative treatment. While the
authors found decreasing (worsening) AOFAS hindfoot
scores with increasing MCS widening, patients with residual MCS widening of 4 and 5 mm demonstrated reasonably
good AOFAS scores of 90.2 and 89.4, respectively.
More recently, Holmes et al22 examined a cohort of
patients with both weight bearing and gravity stress views.
Fifty-one of these patients who demonstrated an anatomic
mortise on weight-bearing x-rays with MCS widening less
than 7 mm on gravity stress radiographs were treated nonoperatively in a pneumatic boot with full weight bearing.
Functional analysis of these patients at 1 year postinjury
was evaluated using the Foot and Ankle Ability Measure for
Activities of Daily Living (FAAM/ADL), the Olerud
Molander Ankle (OMA) score,48 the AOFAS score, and the
visual analog (VAS) pain score. Despite a mean MCS widening of 4.42 mm on initial gravity stress views, the final
mean MCS after nonoperative treatment on weight-bearing
x-rays was 2.64 mm. With regard to functional outcomes,
the mean value was greater than 90 for AOFAS, FAAM/
ADL, and OMA, indicating excellent functional results for
all patients.
Similarly, Seidel et al57 published a recent investigation
examining weight-bearing versus gravity stress views. Of
104 patients with isolated lateral malleolus fractures, 44
patients who had positive gravity stress radiographs but
anatomic weight-bearing x-rays were treated nonoperatively. When compared with the cohort who underwent surgery as well as 46 patients who had clearly stable ankles, all
patients healed with an anatomic mortise. The authors suggested that weight-bearing views may better guide treatment as reliance on gravity stress views may lead to
unnecessary surgery.
Two large-scale randomized prospective studies deserve
special consideration. In 2012, Sanders et al55 published
results of a level I multicenter study evaluating 81 patients
who met criteria for stress-positive SER IV equivalent
fractures. Forty-one were managed with operative reduction and fixation of the fibula, and 40 fractures were treated
nonoperatively. No statistically significant differences in

Foot & Ankle International 39(7)
functional outcomes were noted using the OMA and SF-36,
although the study was underpowered to find a functional
difference smaller than 15 points and follow-up was only
12 months. Of concern is the fact that 8 patients (20%) in
the nonoperative group developed a malaligned mortise
(MCS greater than or equal to 5 mm) and that 8 patients in
the nonoperative group developed delayed union or
nonunion.
In 2016, Willet et al65 published the results of a largescale randomized clinical trial examining casting versus
surgery for unstable ankle fractures in patients older than 60
years. A total of 309 patients underwent operative treatment, while 311 underwent close-contact casting. The
authors concluded that the use of close-contact casting
compared similarly to surgery, with patients displaying
equivalent functional outcomes at 6-month follow-up.
While the operative group displayed increased wound complications and the need for additional procedures, 15% of
the nonoperative group displayed radiographic malunion as
compared with 3% who underwent surgery.
Despite equivalent functional outcomes as assessed
using patient-based outcome measures with nonoperative
treatment, 3 specific points should be emphasized regarding
the current literature.
First, there appears to be a subset of patients with stresspositive SER IV fractures that will develop late displacement if treated nonoperatively, ranging from 10% to
20%.7,13,55 While previous works were not able to specifically identify which patients were more likely to displace,
the rate of a resultant malaligned mortise with nonoperative
treatment is not insignificant. Arguably, this needs to be
considered in the setting of increased risks of wound complications with operative treatment.
Second, the aforementioned investigations demonstrated
only short-term follow-up (range, 3-20 months).13,22,28,30,36
While orthopedic trauma populations have been demonstrated in previous investigations to have higher lost-tofollow-up rates, examination of functional outcomes at
short-term follow-up may be misleading. As previous studies have demonstrated the negative effects of mortise
malalignment on contact area, contact pressures, and the
development of posttraumatic arthritis, short-term assessments are unlikely to predict long-term functional outcomes.51,54 While these studies may represent the best
available evidence, longer-term follow-up of these cohorts
is required to definitively determine which treatment option
is best.
Third, in past studies, patients with MCS widening upon
initial presentation were near universally treated operatively, with attention of the investigations placed on the
cohort with stress-positive findings. However, recent literature has demonstrated that if weight-bearing radiographs
were obtained, then the widened mortise may have normalized based on joint congruency. As no current literature has

Table of Contents for the Digital Edition of Foot & Ankle International - July 2018