Fixation of Ankle Fractures – A Major Trauma Centres Experience in Improving Quality L Jayatilaka Sam Whitehouse, A Kaye, L Mason, A Molloy Aintree University Hospital

Our Journey In 2013 an initial audit to look at the quality of our ankle fracture fixations Of 94 cases 33% were inadequately reduced Of these 50% needed revision and had worse clinical outcomes Of those reduced anatomically only 2% were revised

We are not alone Presented Powell (Leicester) – BOFAS 2015 Mushtaq (St Marys) – BOFAS 2015 Sinclair (North Bristol) – BOFAS 2016 Locally presented Chester - Ed Wood Portsmouth - Billy Jowett Sadly we are not alone on this. These results have been mirrored by studies in Leicester, London, Bristol, Chester and Portsmouth

Aim We present the results of 2 audit cycles in our department. Our aim was to improve the outcomes in our department for all ankle fractures

Methods All operatively treated ankle fractures presenting to our department were included 2nd Audit – January to August 2014 3rd Audit – January 2015 to September 2016 Image intensifier films were reviewed on PACS, by at least 2 blinded observers in each cycle. These were scored based on the criteria published by Pettrone et al. All surgery was performed under direct supervision of a consultant.

Assessment of reduction Pettrone et.al. JBJS Am 1983 This score has shown significant correlations with functional outcomes by an outcome study from Leicester and Aintree

Demographics Audit Year Age (mean) Age (range) Sex (M:F) 1st 2013 46.3 17-88 42:52 2nd 2015 48.8 19-82 30:34 3rd 2017 48.2 16-91 88:117

1st attempt at improvement Following the first audit in 2014, there was a period of intra-departmental education and reflection. 2nd audit was planned for following year to assess results of education.

2nd Audit 2014 2015 Number of patients 94 64 Mal-reduction 33% 44% Overall complication 9% 11%

2nd attempt at improvement System changes Foot and ankle trauma lead Dedicated foot and ankle trauma clinics and lists Institution of algorithms for posterior malleolar fractures CT scans being obtained for any suspected plafond injury Fibular nails to be withdrawn from use in department

2nd Audit 2014 2015 2017 Number of patients 94 64 207 Mal-reduction 33% 44% 3% Overall complication 9% 11% 1%

Complexity Standard: B2 and below including isolated medial malleolus 2013 2015 2017 F&A Other Number 39 55 21 43 118 87 Standard 67% 64% 42% 49% 32% 72% Complex 33% 36% 58% 51% 68% 28% This does not have to be foot and ankle but a trauma surgeon with an interest Standard: B2 and below including isolated medial malleolus Complex: B3 and above

Conclusions Thorough critique of ankle fracture fixation at the time of surgery to ensure adequate reduction is essential to obtain the best outcome for the patient. In our department, education was not successful in improving radiology or complication rate. The introduction of planned foot and ankle trauma lists for more complex fracture patterns as well as algorithms for specific fracture types have been shown to have a significant impact in our department.

The culture of it being “just an ankle fracture” is no longer acceptable. Education without system change is unlikely to change outcomes in the long term.