Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study

Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF).

A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching.

One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%).

Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation.

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