Removable brace as a viable alternative to cast immobilization for ankle fractures-a meta-analysis of randomized controlled trials.

Background: Recent years have seen continuous debate over the preferred method of immobilization for ankle fractures, especially between removable braces and cast immobilization. To address this, we conducted a meta-analysis of prospective randomized controlled trials (RCTs) to compare the two approaches and assess the feasibility of using a removable brace as an alternative to cast immobilization.

Methods: PubMed, Cochrane Library, Embase, and Web of Science were last searched on January 18, 2025, to identify comparative studies evaluating removable braces vs. cast immobilization. Data were extracted and pooled, and a meta-analysis was conducted using Review Manager 5.4 (RevMan 5.4), The Cochrane Collaboration. Functional scores, complications, and time to return to work (RTW) were analyzed to assess the efficacy, safety, and cost of the two groups.

Results: We included 11 RCTs with a total sample size of 1,472 participants. There were no significant differences in the Olerud-Molander Ankle Score (OMAS) between the removable brace and cast immobilization groups, both in the short term at 6 weeks [mean differences (MD): 7.18, 95% confidence interval (CI): -5.77 to 20.12,  = 0.28], 12 weeks (MD: 6.02, 95% CI: -0.22 to 12.26,  = 0.06), and in the long term at 24 weeks (MD: 2.25, 95% CI: -2.78 to 7.27,  = 0.38), as well as beyond 1 year (MD: 0.82, 95% CI: -1.75 to 3.39,  = 0.53). Compared to the cast immobilization group, the removable brace group showed similar rates of chronic regional pain [risk ratio (RR): 0.74, 95% CI: 0.14-3.94,  = 0.73], non-union (RR: 0.96, 95% CI: 0.17-5.46,  = 0.96), and thrombosis (RR: 0.46, 95% CI: 0.20-1.10,  = 0.08). Additionally, there was no significant difference in the incidence of wound infections when the brace was applied after primary wound healing (RR: 1.63, 95% CI: 0.87-3.03,  = 0.13). In terms of return to work (RTW), the removable brace group showed a significantly shorter mean time to return to work (MD: -17.17, 95% CI: -33.00 to -1.34,  = 0.03). Subgroup analysis revealed that the brace group achieved a better OMAS score at 12 weeks when early weight-bearing was permitted (MD: 9.00, 95% CI: 1.47-16.53,  = 0.02).

Conclusion: Overall, both braces and casts demonstrated comparable effectiveness in postoperative ankle function recovery and wound complications. However, braces offered an advantage in promoting early weight-bearing, which contributed to improved recovery of ankle function. Additionally, the use of braces allowed patients to return to work earlier.