Audit changes practice-a simple education intervention can lead to better outcome in ankle fracture surgery

Unstable ankle fractures are common, and majority requires open reduction and internal fixation (ORIF). There is emerging evidence that the rate of malreduction has remained high despite advances in surgical techniques and implants. Malreduced ankle is a prominent cause of post-traumatic ankle arthritis leading to poor patient reported outcome. The aim of this study was to investigate the quality of anatomical reduction and surgical fixation of ankle fractures and the impact of simple education intervention on the quality of reduction of these fractures.

An audit cycle was completed in two phases; retrospective review (phase 1) of 114 cases operated prior to an education intervention using infographic posters and then a prospective (phase 2) review of 96 consecutive cases operated after the education intervention. Data including age, fracture morphology, time to surgery, and the quality of reduction were assessed. The quality of anatomical reduction was evaluated using radiological parameters described by Pettrone. Paediatric, Weber A, pathological and open fractures were excluded. Education interventions included regional teaching and dissemination of infographic posters. Mann- Whitney U test and Chi-squared test were used to compare continuous and categorical data between phase 1 and 2 respectively. P value < 0.05 was considered significant.

Phase one cohort showed malreduced fixation in 25% of cases. Inadequate restoration of fibular length was the most common type of malreduction. After implementation of education intervention, malreduction rate reduced to 9.4% in phase 2 (p = 0.015). There were no significant differences between age, gender, and time to surgery between phase one and two.

This study demonstrates that simple education intervention can lead to better understanding of fixation and decrease the rate of malreduction of these fractures. We recommend that using Pettrone's radiological criteria in correction of corresponding anatomy of ankle fracture is a useful tool to avoid malreduction.