Fixation of ankle fractures: a major trauma centre’s experience in improving quality

L. Jayatilaka, S. Whitehouse, L. Mason, A. Molloy

Introduction: Ankle fracture mal-reduction results in poor long-term functional outcomes. Varying methods can be used to change practise and thereby outcomes. We present over 4 years-worth of results with the effects of different techniques for change.

Methods: 2 audit cycles were performed incorporating 3 audit data collections; an initial standard setting in 2013, with re-audits in 2015 and 2017. Between the first and second audit was a period of education and reflection. Between the second and third audit there was a change in process in ankle fracture management supported by education. 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, with an additional criteria of incorrect placement of fixation

Results: In the initial audit cycle in 2013 there were 94 patients, with a mal-reduction rate of 33%. In the second audit, there were 68 patients, with an unchanged mal-reduction rate of 34%. In the third audit, there were 207 patients, with a significant decrease in mal-reduction rate to 2.4%. The final revision rate was 1.4%. The rate of deep infection was 0.5%.

Conclusion: By recognising and addressing the need to improve the quality of ankle fracture fixation we have made significant improvements. Initial intradepartmental education was not successful, even with constant consultant presence in theatre. The results of the second audit brought about system changes within the department, including the appointment of a foot and ankle trauma lead, dedicated foot and ankle trauma clinics and operating lists together with the development of treatment algorithms for complex ankle fractures. Education alone, without system change, is not successful in achieving improved outcomes. Our combined approach of education and system change led to a reduction of mal-reduction from 33% to 2.4%.