Switching to non-surgical approach to ankle fractures in older people could save £1.5 million a year

  • 15 September 2020

If half of patients aged 60 and over who had surgery for an ankle fracture instead had a non-surgical treatment called close contact casting, the NHS could save around £1.5 million a year, according to a new analysis from researchers at NIHR Applied Collaboration West (ARC West) and the NIHR Bristol Biomedical Research Centre.

Using routinely collected data from hospitals in England between 2007/08 and 2016/17, researchers looked at how treatment for ankle fractures had changed over time for different patient groups.

They found that in 2016/17, the cost of hospital care for ankle fractures was more than £63.1 million. If half of the older patients who had surgery instead had non-invasive close contact casting, the researchers estimated this would have saved around £1.56 million.

There aren’t many studies on the best way to manage ankle fractures but in 2016 a large randomised control trial – the best test of a treatment – demonstrated the potential to use close contact casting for older patients, rather than surgery.

Close contact casting uses less padding than a traditional cast and holds fractures in position, even if they are unstable, by providing a close anatomical fit. In the trial, it was applied in an operating theatre under anaesthetic.

The trial found that using close contact casting for older patients with an unstable fracture, was cheaper than surgery and resulted in similar levels of function and pain for patients at six months and three years.

Over the 10-year period the researchers looked at, there were 223,465 hospital admissions where ankle fracture was the primary diagnosis. Use of surgical treatment for ankle fracture remained fairly consistent for both younger and older patients during that period, despite the emerging evidence for close contact casting, particularly among older age groups.

Lauren Scott, Senior Research Associate at NIHR ARC West and lead researcher on the project, said:

“Our research shows that savings could be made if treatment for ankle fractures switched from surgery to close contact casting for older people where appropriate. It wouldn’t be a suitable treatment for every patient, but even with conservative estimates of which patients could be switched to close contact casting, savings could be made.

“However, it’s likely that simply demonstrating the cost-effectiveness of close contact casting and including it in the guidelines for ankle fracture surgery won’t be enough to change practice.”

Will Hollingworth, Professor of Health Economics at the University of Bristol and principal investigator for the research, said:

“We recommend that clinical commissioning groups consider introducing local policies on who should receive surgery and who should receive close contact casting. This could be more effective at changing practice, alongside shared decision-making with patients, who could be presented with the benefits and drawbacks of both approaches to make an informed decision about their treatment.”


Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

by Lauren J. Scott, Tim Jones, Michael R. Whitehouse, Peter W. Robinson and William Hollingworth

Published in BMC Health Services Research