1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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.

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

10. 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Fibular nails to be withdrawn from use in department

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

12. 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

13. 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.

14. 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.