LAUSR

We read with great interest an article titled “Intramedullary fixation versus anatomically contoured plating of unstable fractures: a randomized control trial” by Badenhorst et al. [1] published in the March 2020 issue of the journal and would like to extend our gratitude to the authors for the study. They have researched a great topic in a scientific manner; however, we wish to get the answer to some of our queries to enhance our understanding of the matter. The study mentions that the Burwell and Charnley criteria was used to assess the syndesmotic stability in order to assess the need for syndesmotic screw placement but does not mention the exact point in time during the surgerywhen the criteria is applied. This is relevant as posterior malleolus fixation is known to provide syndesmotic stability [2], and all fractures may not have required syndesmotic fixation if posterior malleolus fixation was undertaken. So, it would be prudent to note as to how many of the total patients in each group required posterior malleolar fixation and how it affected the decision to put in syndesmotic screws in the study. Also, what fixation method was used for the same?Was it standardized in all patients or else could it have been a confounding variable especially with regards to the length of scar as it could have varied depending upon the choice of method used to fix posterior malleolus. The nail group mentions that a posterior lateral approach was used to address the posterior malleolus when needed, but no such approach is defined for the plate group. Was posterior malleolus addressed through the same incision or a separate incision was given for it in the plate group? This is relevant as one of the outcome variables used was the length of incision and scar [1]. Also, no mention is made of the effect of using a separate approach for posterior malleolus in the nail group to the scar/incision length. Although statistically found not to be significant, the demographic data shows higher females in plate group and higher smokers and co-morbid patients in the nail group. How do the authors explain this finding? Smoking has been shown to be an important risk factor in ankle fractures and is known to be associated with significant complications [3]. An equal number of smokers in either group could have therefore resulted in a fairer comparison between the two groups. A higher number of smokers in the nail group may cancel out any outcome benefit achieved due to minimal soft tissue disruption. Although the distribution of the smokers may not have been statistically significant, but any complications arisen from the same could have been. Therefore, it is a confounding variable to say the least. The study had a disproportionately higher number of patients withWeber B fracture type in the plate group andWeber C in the nail group. How do the authors explain this finding? Weber B fractures itself represent a heterogeneous group of fractures [4, 5], and there is considerable debate as to what constitutes instability in this regard. No mention is made regarding criteria used to assess stability. Hence, such a heterogeneous group especially when the two groups have disproportionate fracture classification is not a valid comparison to begin with. How many of each group’s patients had medial malleolus fractures? No mention is made of it in the supplementary table provided. This is important to know as it would have a direct effect on the screening time, scar length, and post-operative circumference, all of which have been used as outcome measures [1].