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Comparative efficacy of cast immobilization versus removable braces in patients with ankle fractures: a systematic review and meta-analysis

BMC Musculoskeletal Disorders volume 26, Article number: 243 (2025) Cite this article

Abstract

Background

An effective and appropriate method to support the ankle joint optimally is particularly important during the healing phase of ankle fractures. The purpose of this review was to assess the functional outcomes, ankle-related quality of life, and associated complications of cast immobilization versus removable braces for the treatment of adult ankle fractures.

Methods

Studies comparing cast immobilization and removable braces after ankle fracture were included by systematic searches of PubMed/MEDLINE, Web of Science, Scopus, and EMBASE databases according to PRISMA (Preferred Reporting Items for Systematic Evaluation and Meta-Analysis Statements) guidelines. Primary outcome measures included early to mid-late Olerud Molander Ankle Score (OMAS). Secondary outcomes were ankle dorsiflexion and plantarflexion, swelling, pain, time to return to work, calf muscle atrophy, and complications. Subgroup analysis was performed. Risk of bias was assessed in both randomized controlled trials and cohort studies.

Results

Eleven studies including 1485 patients met the eligibility criteria. The fracture types of the study included Weber A/B/C and Lauge-Hansen supination external rotation (SER), supination-adduction (SA), pronation-external rotation (PER) and pronation-abduction (PA). The results of the meta-analysis showed that removable braces had better early (mean difference (MD) -2.14; 95% confidence interval (CI) -4.26, 0.00) and mid-term functional outcomes (MD -5.81; 95% CI -10.35, -1.27) after ankle fracture compared with cast immobilization. In addition, removable braces caused significantly more wound breakdown (Odds ratio (OR) 0.39; 95% CI 0.17, 0.90) and wound infections (OR 0.32; 95% CI 0.17, 0.58) than cast immobilization.

Conclusion

Compared with cast immobilization, removable braces had better functional outcomes in the early and mid-term periods after ankle fractures and were less likely to result in deep vein thrombosis (DVT). Overall, the removable brace is a comfortable ankle fracture option that might improve functional outcomes.

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Introduction

Ankle fractures are one of the most common and serious injuries, accounting for approximately 17.6% of lower extremity fractures [1,2,3]. The incidence of ankle fractures ranges from 100 to 150 per 100,000 people per year and is increasing explosively every year [4]. In the United Kingdom, more than 120,000 people suffer from ankle fractures every year [5]. In the populous country of China, a national survey found the incidence of ankle fractures to be 37.1 per 100,000 people per year. In general, the incidence of ankle fractures is on the rise with the increasing aging of the global population, especially in the elderly and female populations [6].

The most commonly used classification systems for ankle fractures include the Danis-Weber and Lauge-Hansen classification [7]. Studies have shown that 70% of ankle fractures are typically Weber type B fractures or supination-external rotation (SER) fractures [4]. One study showed that approximately 25% of ankle fractures require surgical treatment and the rates of emergency surgery and reoperation within 30 days were at low levels [7]. Stable ankle fractures could be treated with non-operative methods including cast immobilization or removable braces, and a multicenter randomized controlled trial (RCT) with a five-year follow-up demonstrated that there was no significant difference between surgical and non-surgical treatment in terms of ankle functional outcomes [8].

It is well recognized that fractures in adults require approximately 6 weeks to achieve sufficient healing to resist the stresses induced by weight bearing [9,10,11,12]. The most traditional and commonly used form of external immobilization after ankle fracture is below-knee cast immobilization for 4–6 weeks [13,14,15]. The protective and supportive properties of cast immobilization promote early fracture healing, but traditional casting techniques have been associated with complications such as skin ulcers, ankle stiffness, and deep vein thrombosis (DVT) [16,17,18]. Removable braces appear to be an alternative means of immobilization for shorter durations, allowing for early mobility and cleaning of the ankle surface compared with casts [19]. A Cochrane review suggested that removable braces have better elasticity and greater mobility, and may alleviate ankle stiffness and calf muscle atrophy [16]. However, most of the studies comparing casts and removable braces were conducted before 2010, and there is a need to further evaluate the merits of casts and braces in the treatment of ankle fractures. In recent years, two large multicenter RCTs have compared cast immobilization and removable braces in ankle fractures [20, 21]. Kearney et al. [5] demonstrated that there was no significant difference in ankle functional scores between cast immobilization and removable braces, whereas Kortekangas et al. [22] found that the use of a functional orthosis resulted in higher functional scores than casts and reduced the incidence of deep venous thrombosis.

A meta-analysis by Spierings et al. in 2022 stated that removable braces were a safe non-operative treatment for Weber type B ankle fractures because of the lower number of complications. With regard to functional results, removable braces are on par with casts [23]. A meta-analysis by Li et al. in 2023 found that short- and long-term functional outcomes of postoperative ankle fractures treated with a removable brace were not significantly different from those treated with a cast. Although the range of motion of the ankle was better in the brace group than in the cast group, wound complications were three times higher in the brace group [24]. Considering the inconsistencies in the results between these two meta-analyses, it is particularly important to further compare the functional outcomes and safety between cast immobilization versus removable braces of patients with ankle fractures.

High-quality evidence is still urgently required to determine the optimal form of ankle support for fracture healing. Therefore, this review aimed to compare the functional outcomes and safety of cast immobilization with removable braces in the treatment of ankle fractures.

Methods

Ethics committee approval was not required for this study. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis Statements (PRISMA) [25]. The PRISMA checklist was revealed in Supplementary file.

Search strategy and literature screening

Two authors (Zhou and Zheng) independently searched PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from database creation to October 1, 2024. The search strategy was conducted using a broad combination of free text keywords and subject headings. References from relevant RCTs, observational studies, review articles, and systematic reviews were also reviewed and screened. The language of publication was limited to English. Screening was carried out in two main stages. Initially, two independent investigators (Zhou and Zheng) screened titles and abstracts and excluded ineligible articles after removing duplicates. The full texts were then perused to assess whether the studies met the inclusion criteria, and disagreements were resolved by consensus when encountered. A detailed search strategy was presented in Supplementary Text 1.

The inclusion and exclusion criteria were listed in Table 1. The primary outcome was early to mid-late Olerud Molander Ankle Score (OMAS). Secondary outcomes included ankle dorsiflexion/plantarflexion, pain VAS (visual analogue scale), quality of life, radiographic results, return to work, swelling, and adverse events/complications. Complications included wound infection, wound breakdown, reoperation, pressure sore/ulcer, DVT, pulmonary embolism and non-union/delayed-union of fracture. Case series were excluded due to their inability to set a control group and low level of evidence.

Table 1 Inclusion and exclusion criteria
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Data extraction

One author of the review (Zhou) independently extracted data from each included study using a specific tabulation. Another author (Zheng) independently extracted a randomized 10% sample of these data to test for consistency. Continuous data were extracted as mean and standard deviation (SD), and dichotomous variables were extracted as frequency or percentage.

Assessment of risk of bias

Two authors (Chen and Jiang) used the Cochrane Risk of Bias Assessment Tool to assess the reporting quality and risk of bias of the included RCTs independently. The Cochrane Risk of Bias Assessment Tool essentially evaluated selection bias, performance bias, detection bias, attrition bias, reporting bias, and other sources of bias. The Newcastle–Ottawa Scale (NOS) was adopted to evaluate the quality of retrospective cohort studies.

Evaluation of certainty of evidence and TIDieR

The certainty of evidence was evaluated through the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system [26]. For outcomes that included only RCTs, the ratings started at a high level of certainty. For the outcomes that included both RCTs and observational studies, we conducted subgroup analysis based on study design, and assessed the certainty of evidence for the RCT and observational study subgroups respectively. Two of the authors downgraded the evidence from five aspects: inconsistency, indirectness, risk of bias, imprecision, and publication bias.

The TIDieR (Template for Intervention Description and Replication) checklist was adopted to evaluate the content regarding the interventions in the included RCTs [27]. Each study was assessed using the 12 items to show the reporting of the interventions.

Statistical analyses

All statistical analyses and forest plots for this study were provided through Review Manager (version 5.4, Cochrane Collaboration). Baseline characteristics of this study are presented using mean, median (interquartile range (IQR)), or frequency. Weighted mean difference (MD) and 95% confidence interval (CI) were used to report continuous variables. Odds ratio (OR) and 95% CI were used to report dichotomous variables. Based on the Cochrane Evaluation Handbook, variability between studies was assessed based on P-values and I2 values. If heterogeneity was found to be high, a random-effects model was used (P < 0.05, I2 > 50%); when heterogeneity was found to be low, a fixed-effects model was used (P > 0.05, I2 < 50%). A P ≤ 0.05 was considered statistically significant as calculated by the Z-test. In case of high heterogeneity, subgroup analysis was performed in terms of undergo surgery or not, ankle fracture type, stable/unstable fractures, study design and sample size. Publication bias was assessed by funnel plot. Funnel plots for the results of the fixed- and random-effect model was plotted using Review Manager and STATA (version 17, StataCorp LP) respectively. Egger's test was also used to evaluate the publication bias. Sensitivity analysis was performed to evaluate the stability of the combined effect size, which was conducted by STATA.

Results

Selection of studies

Figure 1 summarized the search and screening process. A search based on four databases identified 4348 studies for potential inclusion. The number of records searched by PubMed/MEDLINE, Web of Science, Scopus and EMBASE were 1571, 1354, 840, and 583 respectively. Duplicates were removed and further screened through titles and abstracts, at which stage 3232 articles were excluded. The main reasons for excluding these studies were the wrong type of study, interventions that did not meet inclusion criteria and non-English language. All the records excluded by screening title/abstract were listed in Supplementary file 2. Nineteen studies potentially met the eligibility criteria and were reviewed for full-text eligibility. After a thorough screening of the articles, two articles not in English and one secondary analysis were excluded first. Three studies were excluded due to their outcomes were unable to be combined with the results of other studies. One article was excluded because it used ASKp scores to evaluate ankle function instead of using OMAS. Another study failed to present the continuous variables with standard deviations SD. Ultimately, a total of eight RCTs and three retrospective cohort studies were included in the meta-analysis.

Fig. 1
figure 1

Flowchart showing the study selection process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)

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Study characteristics

The specific characteristics of the included studies and participants were shown in Table 2. The 11 studies were published in two main periods, 1989–2007 and 2018–2021, and all of them were from Europe and the United States. All studies compared the therapeutic effects and complications of cast immobilization with removable braces in patients with ankle fractures [5, 22, 28,29,30,31,32,33,34,35,36]. A total of 1485 patients were included in this meta-analysis, with a total of 784 patients receiving cast immobilization and 701 patients receiving removable brace immobilization. The fracture types of the study included Weber A/B/C and Lauge-Hansen supination external rotation (SER)/supination-adduction (SA)/pronation-external rotation (PER)/pronation-abduction (PA). All the eight studies that used Weber classifications included Weber B ankle fractures, and Weber B accounted for more than 80% of the participants in seven of them. Seven included studies revealed the stability of patients' fractures, five of which had only stable fractures and two of which were unstable fractures. Five studies only included operative patients and five studies only contained non-operative participants, and the remaining one study included both operative and non-operative patients. Three studies used elastic braces (glass fiber elastic braces, elastic bandages, and removable inflatable air hoops), and eight studies used functional braces. Ten of the included studies mentioned the choice of weight bearing, and eight of them chose weight bearing. Among these eight studies, two used weight bearing from partial to full, and the other six did not reveal the detailed information in the degree of weight bearing. Four studies mentioned the duration of weight bearing, two of these studies chose two weeks and the other two studies chose six weeks. All the studies that mentioned about early mobilization and physiotherapy chose to use early mobilization/physiotherapy. Additional information of the included trials and participants was revealed in Supplementary Table 1.

Table 2 Characteristics of the included trials and participants
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Risk of bias

On the assessment of the risk of bias, two authors reached a consensus on all items after discussion. The risk of bias for RCTs was illustrated in Fig. 2. All RCTs had a low risk of selection bias, attrition bias, and reporting bias, whereas performance bias and detection bias were high. Supplementary Table 2 summarized the assessment of the risk of bias for retrospective cohort studies. Publication bias was shown in supplementary Fig. 1–2. For DVT, since all the data points lie in the region of 95% confidence interval, no significant publication bias was observed. For mid-term OMAS, no significant publication bias was detected, as the significance of Egger's test was more than 0.05 (P = 0.119).

Fig. 2
figure 2

Risk of bias included in the randomized controlled trials (A). Risk of bias graph (B)

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GRADE and TIDieR

For outcomes that only included RCTs and outcomes of the RCT subgroups, the initial certainty of evidence was evaluated as high. Then, the evidence was downgraded for various reasons, and the ratings of certainty were moderate and low. For outcomes of the observational study subgroups, the initial certainty of evidence was rated as low at the first place, and evidence for each outcome was evaluated as very low. The detailed results of GRADE were revealed in Supplementary Table 3 and Supplementary Table 4 in the supplementary file. The TIDieR checklists of eight included RCTs were shown in the supplementary file.

Functional outcomes

OMAS

For early-stage OMAS (6w), a meta-analysis of 4 studies (n = 812) showed that those treated with removable braces were higher than those treated with casts, with a significant difference between the two groups: MD, −2.14; 95% CI, −4.28 ~ 0.00; fixed effects model (Fig. 3A). There was low heterogeneity between studies (P > 0.05, I2 < 50%).

Fig. 3
figure 3

Forest plots showing OMAS of Early Stage (A), Medium Stage (B), and Late Stage (C). Abbreviations: SD: Standard deviation; CI: Confidence interval; df: Degree of freedom

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For mid-term OMAS (12w), a meta-analysis of 8 studies (n = 962) showed that those fixed in removable braces were higher than those fixed in casts, with a significant difference between the two groups: MD, −5.81; 95% CI, −10.35 ~ −1.27; random-effects model (Fig. 3B). There was significant heterogeneity between studies (P < 0.05, I2 > 50%). Subgroup analysis was performed to analyze whether surgery affected mid-term outcomes. A meta-analysis of 5 postoperative studies showed no significant difference in OMAS between the two groups: MD, −4.79; 95% CI, −9.59 ~ 0.01. A meta-analysis of three conservative treatment studies showed no significant difference in OMAS between the two groups: MD, −7.84; 95% CI, −17.48 ~ 1.79. Further subgroup analysis on ankle fracture type, stable/unstable fractures, study design and sample size were also performed (Supplementary Fig. 3–6). Subgroup analysis suggested that study type and sample size might be the source of heterogeneity in OMAS results. For subgroup analysis of fracture types and stable/unstable fractures, no subgroup differences were observed. The sensitivity analysis of mid-term OMAS was also shown in Supplementary Fig. 7.

For late-stage OMAS (52w), a meta-analysis of 4 studies (n = 320) showed no significant difference in OMAS between the two groups: MD, 0.20; 95% CI, −2.15 ~ 2.56; fixed-effects model (Fig. 3C). There was low heterogeneity between studies (P > 0.05, I2 < 50%).

Ankle dorsiflexion and plantar flexion

A meta-analysis of 4 studies (n = 322) showed no significant difference in ankle dorsiflexion between the two groups: MD, −0.19; 95% CI, −1.77 ~ 1.40; fixed-effects model (Fig. 4A). There was low heterogeneity between studies (P > 0.05, I2 < 50%). A meta-analysis of 4 studies (n = 322) demonstrated no significant difference in plantarflexion between the two groups: MD,0.30; 95% CI, −1.97 ~ 2.56; fixed-effects model (Fig. 4B). There was low heterogeneity between studies (P > 0.05, I2 < 50%).

Fig. 4
figure 4

Forest plots showing functional outcomes: Ankle Dorsiflexion (A) and Ankle Plantar Flexion (B). Abbreviations: SD: Standard deviation; CI: Confidence interval; df: Degree of freedom

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Ankle-related quality of life

Swelling

A meta-analysis of 4 studies (n = 228) showed that the degree of swelling was lower in the removable brace group than in the cast group, with a significant difference between the two groups: MD,0.34; 95% CI, 0.17 ~ 0.51; fixed-effects model (Fig. 5A). There was no between-study heterogeneity (P > 0.05, I2 = 0%).

Fig. 5
figure 5

Forest plots showing Swelling (A), VAS Pain (B), Time Return to Work (C), and Calf Muscle Atrophy (D). Abbreviations: SD: Standard deviation; CI: Confidence interval; df: Degree of freedom

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Pain VAS

A meta-analysis of 2 studies (n = 209) demonstrated no significant difference in VAS between the two groups: MD, −1.54; 95% CI, −8.13 ~ 5.06; random-effects model (Fig. 5B). A significant heterogeneity was found between studies (P < 0.05, I2 > 50%).

Time to return to work

A meta-analysis of 2 studies (n = 162) showed no significant difference in time to return to work between the two groups: MD,12.61; 95% CI, −16.69 ~ 41.90; random-effects model (Fig. 5C). A significant heterogeneity existed between studies (P < 0.05, I2 > 50%).

Calf muscle atrophy

A meta-analysis of 2 studies (n = 129) showed no significant difference in the degree of calf muscle atrophy between the two groups: MD,1.64; 95% CI, −1.51 ~ 4.78; fixed-effects model (Fig. 5D). No heterogeneity was observed between studies (P > 0.05, I2 = 0%).

Complications

A meta-analysis of 11 studies (n = 1401) demonstrated no significant difference in total complications between the two groups: OR, 0.70; 95% CI, 0.28 ~ 1.74; random-effects model (Fig. 6). There was significant heterogeneity between studies (P < 0.05, I2 > 50%). Subgroup analysis indicated that there were no significant subgroup differences (P > 0.05; I2 < 50%). A meta-analysis of six postoperative studies showed no significant difference in the total number of complications between the two groups: OR, 0.48; 95% CI, 0.15 ~ 1.53. A meta-analysis of five studies of conservative treatments showed no significant difference in the total number of complications between the two groups: OR, 1.50; 95% CI, 0.29 ~ 7.74. Further subgroup analysis on ankle fracture type, stable/unstable fractures, study design and sample size were also conducted (Supplementary Fig. 8–11). No subgroup differences were detected.

Fig. 6
figure 6

Forest plots of subgroup analysis showing Complications. Abbreviations: M-H: Mantel–Haenszel; CI: Confidence interval; df: Degree of freedom

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Wound infection

A meta-analysis of 4 studies (n = 884) demonstrated that incidents of wound infection were significantly higher with removable braces than with cast immobilization: OR, 0.32; 95% CI, 0.17 ~ 0.58; fixed-effects model (Fig. 7A). There was no significant heterogeneity between studies (P > 0.05, I2 < 50%).

Fig. 7
figure 7

Forest plots showing complications: Wound Infection (A), Wound Breakdown (B), Reoperation (C), and Pressure Sore/ulcer (D). Abbreviations: M-H: Mantel–Haenszel; CI: Confidence interval; df: Degree of freedom

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Wound breakdown

A meta-analysis of 3 studies (n = 831) showed that wound breakdown occurred significantly more often with removable braces than with cast immobilization: OR, 0.39; 95% CI, 0.17 ~ 0.90; fixed-effects model (Fig. 7B). There was no interstudy heterogeneity (P > 0.05, I2 = 0%).

Reoperation

A meta-analysis of 2 studies (n = 792) revealed no significant difference in patients requiring reoperation between the two groups: OR,1.34; 95% CI, 0.10 ~ 17.90; random-effects model (Fig. 7C). Significant heterogeneity existed between studies (P < 0.05, I2 > 50%).

Pressure sores and ulcers

A meta-analysis of 2 studies (n = 706) showed no significant difference in pressure sores and ulcers between the two groups: OR,1.43; 95% CI, 0.55 ~ 3.68; fixed-effects model (Fig. 7D). No inter-study heterogeneity was observed (P > 0.05, I2 = 0%).

DVT

A meta-analysis of 6 studies (n = 1154) showed that DVT occurred significantly less frequently with removable braces than with cast immobilization: OR,2.93; 95% CI, 1.10 ~ 7.79; fixed-effects model (Fig. 8A). There was no interstudy heterogeneity (P > 0.05, I2 = 0%).

Fig. 8
figure 8

Forest plots showing complications: DVT (A), Pulmonary Embolism (B), Non-union/Delayed-union of Fracture (C). Abbreviations: M-H: Mantel–Haenszel; CI: Confidence interval; df: Degree of freedom

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Pulmonary embolism

A meta-analysis of 2 studies (n = 724) indicated no significant difference in pulmonary embolism between the two groups: OR,1.65; 95% CI, 0.22 to 12.72; fixed-effects model (Fig. 8B). There was no heterogeneity between studies (P > 0.05, I2 = 0%).

Fracture non-union/delayed healing

A meta-analysis of 3 studies (n = 1020) demonstrated no significant difference in fracture non-union/delayed healing between the 2 groups: OR,1.93; 95% CI, 0.46 ~ 7.80; fixed-effects model (Fig. 8C). No between-study heterogeneity was found (P > 0.05, I2 = 0%).

Discussion

The results of this systematic review and meta-analysis indicated that treatment with a removable brace after ankle fracture had better functional outcomes than cast immobilization in the early- to mid-term period. In addition, the degree of swelling after immobilization with removable braces was lower than with casts. However, removable braces induced significantly more wound complications than casts, while casts were associated with a higher risk of DVT. Moreover, no significant difference was detected between the two treatment options in long-term functional scores and total complications.

In our meta-analysis, casts and removable braces were compared in patients with ankle fractures. One study with at least five years of follow-up found that surgical treatment was not superior to nonoperative treatment in terms of ankle function and quality of life in patients with isolated type B ankle fractures [8]. In addition, a large RCT showed similar functional outcomes to surgery at six months when close contact casts were used to treat unstable ankle fractures [37]. Therefore, there is a need to explore and determine the optimal fixation of the ankle during the fracture healing phase. Traditionally, immobilization was performed with a below-knee cast for a duration of six weeks, which may be associated with potential disadvantages such as joint stiffness, muscle atrophy, lack of comfort, skin problems, and risk of thromboembolism [38]. In light of the growing emphasis on enhancing the quality of life after lower limb fractures in modern life [39,40,41], removable braces have been increasingly used in clinical practice as a form of immobilization that can permit early exercise and improve comfort [42]. In a recent RCT, the results showed that removable braces brought lower societal costs and improved patients' quality of life compared with casts [43].

In 2022, a meta-analysis showed that OMAS was better with removable braces than with casts at 26 weeks or more and that fewer complications occurred with removable braces. However, the study excluded additional medial or posterior injuries that could have introduced selection bias. In addition, this meta-analysis included only five studies with a total of 516 patients, and the small sample size also affected the strength of the evidence. In 2023, the results of another meta-analysis suggested that removable braces and casts had similar short- and long-term functional outcomes, while removable braces caused more wound complications. There was insufficient data for meta-analysis of their primary outcomes. Overall, with the increasing number of high-quality trials that have emerged in recent years, there is an urgent need for a high-quality meta-analysis to explore the efficacy and safety of removable braces and casts for ankle fracture immobilization.

Based on the results of this study, early and mid-term OMAS with removable braces is significantly better than cast immobilization, but no significant difference was detected between the two treatment options in late-stage OMAS. The early-stage improvement in ankle functional outcomes of brace group may be a multifactorial process, which is associated with early-stage activity, weight bearing and adverse events. The current consensus recommended that stable ankle fractures without medial injury could wear a functional brace for early-stage functional exercise [44]. Early ankle movement has been proven to restore joint range of motion and prevent muscle atrophy [45]. Furthermore, a study indicated that for ankle sprains, early mobilization is more effective than casting and reduces the incidence of recurrent ankle sprains [46]. This meta-analysis demonstrated better early-stage functional outcomes with the brace, further suggesting a strong link between early-stage activity and fracture healing. Results from a previous RCT study suggested that the use of a removable brace not only had better early functional outcomes than cast immobilization, but also contributed to improved ankle range of motion and mental health scores [47]. This suggested that the removable brace led to a rapid recovery of ankle function, improving the patient's subjective feeling without increasing the number of overall complications. Subgroup analysis also showed that removable braces provided better functional outcomes regardless of whether surgery was performed. This may be because the fracture types in the included studies were essentially stable fractures like Weber B fractures and SER fractures. Therefore, more detailed and rigorous preoperative planning and entire management are required for some severe fracture types such as ankle fractures combined with syndesmotic injuries or dislocations [41, 48].

In addition, there was no significant difference in late functional scores or time to return to work between the two immobilization modalities. Consistently, a systematic review found significant improvement in short- and medium-term outcomes after ankle fractures in adults, with little further improvement in long-term outcomes. This study concluded that the recovery rate after ankle fracture in adults approached 80% in the sixth month and reached stability in the 24th month. Moreover, activity limitations after fracture are more frequent in elderly and male patients [49]. Thus, the long-term functional outcome appeared to be slightly related to the method of fixation. Compared to braces, casts provide better immobilization in all directions [50]. The brace is removable and has appropriate fixation strength. Nevertheless, thanks to early mobilization, the removable brace significantly reduced ankle swelling. Even though removable braces enhance the comfort level of patients, the real concern of traumatologists is the possible risk of fracture migration [51]. To address this issue, our results demonstrated that there was no significant difference in terms of reoperation and bone non-union/delayed union between removable braces and casts. Additionally, there was no significant difference between the two fixation modalities in terms of pressure ulcers and pulmonary embolism. Therefore, the removable brace is a safe form of immobilization. As mentioned above, the complications of removable braces ought not be ignored.

Similar to previous meta-analyses, braces caused significantly more wound complications (wound rupture, wound infection) than cast immobilization. This may be due to the early activity affecting the postoperative wound and lack of soft tissue protection. It is noteworthy that the number of wound complications was particularly high in the RCT of 2003, with Lehtonen et al. suggesting that a brace with a pre-inflated airbag might increase the risk of wound complications [23]. Conformingly, another study also found that below-knee walking casts increased the risk of superficial wound infections [52]. Although wound complications do not appear to have an impact on long-term functional outcomes, all these studies recommend weight-bearing training to be initiated after initial wound healing. It has been observed that cast immobilization can lead to a higher incidence of deep vein thrombosis (DVT) compared to braces. This significant disadvantage of casts was highlighted in a multicenter RCT conducted in 2016 [37]. It is widely acknowledged that plaster immobilization hinders early ankle mobility and predisposes to thrombosis.

According to the results of subgroup analysis, fracture types and stable/unstable fractures did not show subgroup differences in mid-term OMAS and total complications, indicating that fracture types and stable/unstable fractures were not the main sources of heterogeneity. Since the study design and sample size showed huge subgroup differences in mid-term OMAS, it is suggested that study design and sample size may be the source of heterogeneity. In addition, sensitivity analysis indicated that the results have good stability. Funnel plot and Egger's test suggested that there is no significant publication bias in the main outcome of this paper.

The main significance of this study is listed as follows. Firstly, compared to previous researches, we included several recent RCTs to improve the level of evidence. Secondly, through careful data collection, we included comprehensive functional outcomes and complication outcomes, which evaluated the efficacy and safety of cast immobilization versus removable braces effectively. In terms of functional outcomes, this is the first meta-analysis to analyze OMAS at different stages of the two treatment options. For complication outcomes, we compared the total number of complications and seven major complications between casts and braces. Thirdly, we performed five subgroup analysis and sensitivity analyses to further explore the sources of heterogeneity, improving the reliability and stability of the results.

The main clinical implications of this study are as follows. First and foremost, in the early and middle stages of ankle fracture, a removable brace could be used if there is no contraindication. On the one hand, the removable brace is beneficial for micromobilization of the ankle joint in the early stage for the prevention of DVT. On the other hand, the brace is easy for observation of ankle swelling and skin condition as well as for cleaning. Moreover, when using the brace, the surgical wound should be carefully watched and high-quality care should be taken in order to avoid wound complications. Therefore, removable brace is an effective alternative to traditional cast immobilization for ankle fractures, which has some significance for early functional recovery and reducing the incidence of certain complications. Additionally, physical therapy and rehabilitation pathways are important for the recovery of motor function in patients with ankle fractures. The multidisciplinary approach should not be ignored, and the use of bone biomechanics and neuro electrophysiological evaluation is beneficial to provide accurate treatment for sports and non-sports population [53, 54].

This study also had certain limitations. Firstly, we did not register this meta-analysis on an international registry platform prospectively, which is a limitation of this study. Secondly, the stiffness and elasticity of the brace has been correlated with early functional outcomes of the ankle, and this study did not further explore the effects of different brace types on early outcomes. Thirdly, our statistical analyses may not have been sufficiently precise because some of the studies involved relatively few patients, although the pooled analyses of these studies yielded low heterogeneity in the primary outcomes. Fourthly, we included three observational studies, which reduced the certainty of evidence of this study. Fifthly, as all the included studies were conducted in Europe and the United States, the generalizability of this study was limited. Therefore, further research in developing countries is required to increase the generalizability of these findings. Last but not least, due to the nature of post-fracture immobilization, all studies failed to achieve clinician and patient blinding, which could have introduced some bias. Due to these limitations, we eagerly anticipate that more high-quality RCTs will be carried out in the future to further confirm and update the findings of this research.

Conclusion

The results of the meta-analysis showed that removable braces had better functional outcomes and lower risk of DVT in the early and mid-term periods after ankle fracture compared to cast immobilization. Whereas, removable braces could increase the risk of wound complications. Moreover, there was no significant difference between the two treatment options in long-term functional scores and total complications. In the future, more high-quality RCTs should be conducted to confirm and update the findings of this study. Overall, removable braces represent a comfortable modality for post-fracture stabilization of the ankle that may improve early functional outcomes.

Data availability

This systematic review does not generate any new data. All data and materials are available publicly based on previous publications. All the records excluded during study selection are shown in supplementary file 2.

Abbreviations

SER:

Supination-external rotation

RCT:

Randomized controlled trial

DVT:

Deep vein thrombosis

PRISMA:

Preferred Reporting Items for Systematic Evaluation and Meta-Analysis Statements

OMAS:

Olerud Molander Ankle Score

VAS:

Visual analogue scale

SD:

Standard deviation

NOS:

Newcastle-Ottawa scale

GRADE:

Grading of Recommendations, Assessment, Development and Evaluation

TIDieR:

Template for Intervention Description and Replication

IQR:

Interquartile range

MD:

Mean difference

CI:

Confidence interval

OR:

Odds ratio

SER:

Supination external rotation

SA:

Supination-adduction

PER:

Pronation-external rotation

PA:

Pronation-abduction

Df:

Degree of freedom

M-H:

Mantel-Haenszel

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Acknowledgements

Not applicable.

Funding

This current study was supported by grants from Scientific Research Project of Nantong Health Bureau (MS2022098).

Author information

Author notes

  1. Shiran Zhou, Haotian Zheng and Mumin Cao contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopedic Surgery, Hai’an People’s Hospital, Zhongba Road 17, Hai’an, Nantong, Jiangsu, 226600, People’s Republic of China

    Shiran Zhou, Zubo Tu, Zhigang Chen, Dong Jiang, Shujun Lv & Haidong Cui

  2. School of Medicine, Southeast University, Nanjing, Jiangsu, PR China

    Haotian Zheng & Mumin Cao

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Contributions

S.Z., H.Z., and M.C. contributed equally to this study. S.Z. and H.Z. conceptualized the study, screened the literature, and wrote the first draft of the manuscript. M.C. performed the meta-analysis. Z.T., Z.C., and D.J. contributed to the advanced draft of the study. S.L. and H.C. revised the final draft of the manuscript and supervised the whole study. All authors approved the final version, and agree to be accountable for all aspects of the work.

Corresponding authors

Correspondence to Shujun Lv or Haidong Cui.

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Clinical trial number: Not applicable.

Statement of geographical limitations: The universality of this study might be limited, as all the eligible studies were conducted in Europe and the United States.

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Zhou, S., Zheng, H., Cao, M. et al. Comparative efficacy of cast immobilization versus removable braces in patients with ankle fractures: a systematic review and meta-analysis. BMC Musculoskelet Disord 26, 243 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08451-z

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BMC Musculoskeletal Disorders

ISSN: 1471-2474

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