Reducing the Risk: How Surgeon Expertise Influences Post-Traumatic Osteoarthritis in Ankle Fractures

A Jaques, K Abdelghafour, S Mordecai, R Deol, K Johal

Anatomical reduction and restoration of the articular congruity for the trimalleolar ankle fractures are key to avoiding Post-Traumatic Osteoarthritits (PTOA) of the ankle. The literature suggests that these complex injuries should ideally be managed by specialised Foot & Ankle (F&A) surgeons. We aimed to assess the quality of fracture reduction and the association with PTOA in trimalleolar ankle fractures operated on by F&A and General Trauma Surgeons in a UK District General Hospital.

Single-centre Retrospective Cohort study assessing preoperative and post-operative radiographs of trimalleolar ankle fractures between May 2017 and June 2023 with a minimum of one year follow-up. Quality of reduction was determined by assessing articular step-off, measuring the talocrural angle and the incidence of PTOA among patients operated by F&A surgeons and general trauma surgeons. Radiological evaluation was done by 2 independent assessors.

364 patients underwent definitive fixation of trimalleolar fractures, of which, 177 patients (48.6%) were operated on by general trauma surgeons and 187 (51.4%) by F&A surgeons. 54/177 patients from the general trauma surgeons group and 64/187 patients from the F&A group had arthritic changes on follow-up radiographs. 47/54 (87%) from trauma surgeons group who developed PTOA were found to have an intraarticular step off, which was significantly higher than the 38/64 (59%) in the F& A group (χ2(1)=6.3, p<0.05) and step-off was strongly associated with the development of postoperative arthritis (χ2(1)=180.98, p<0.001). There was no statistically significant difference between the talocrural angles of F&A (82.41±1.62) and trauma groups (82.21±1.84) (p=0.268); However, Point Biserial Correlation showed a significant association between Talocrural angle and PTOA (rpb=0.25, n=364, p<0.001).

F&A surgeons had improved quality of reduction and lower rates of residual articular step-off and, consequently, significantly lower risks of post-traumatic osteoarthritis in patients with trimalleolar fractures. Talocrural angle had a strong association with the development of PTOA.