EARLY SURGICAL STABLISATION PATHWAY FOR ISOLATED UNSTABLE ANKLE FRACTURES

S. Yousaf, M. Edmondson, C. Lee, S. Bellringer, DM. Crone, BA. Rogers

~150 ankle fractures per 100,000 people per year 1

~9% of all traumatic fractures 2

Narrow timeframe for early definitive surgical fixation due to swelling / blisters.

Early stablisation may expedite early return to function and reduce hospital stay.3, 4

OUR STANDARD PROTOCAL

Within 24 hours from injury

AIM: Audit and analyse the outcome of our patients treated for unstable ankle fractures in this early fixation pathway.

ORIF Ex-fix with staged ORIF

METHODS

Exclusion - Age <18- Polytrauma- Pilon fractures

End-point - Compliance to protocol- Length of hospital stay - Post operative complications

April 2012 April 2013

All isolated unstable ankle fractures

Retrospective study

Unstable ankle fractures- Lateral malleolus # with talar

shift- Bimalleolar/ Trimalleolar #- Isolated medial malleolus # with

maisonneuve or syndesmotic injury

LEVEL 1 MAJOR TRAUMA CENTRE

Early fixation = ORIF within first 24 hours post presentation

RESULTS

172 consecutive unstable ankle fractures

62% 38%

Mean age 51 (range 18-89)

lateral malleolus # with talar shift

Bimalleolar #

Trimalleolar #

medial malleolus / maisonneuve #

Other # dislocation

0 10 20 30 40 50 60 70

60

55

38

17

2

91% (n = 156)

9% (n = 16)

ORIF Ex-fix

n = 172

Mode 8 days (2-17)

ORIF Ex-Fix42%

of patients received surgery within 24

hours

No statistical significance in the length of stay post

ORIF (p=0.36)

<1 day46%

(n = 73) >1 day

54% (n = 83)

75% of ex-fix were applied

within 24 hours (0-5 days)

Mode 1 day Mode 1 day

3 (12%)

6 (24%)

2 (8%)4 (16%)

10 (40%) failed operation infections wound breakdown non-union metal irriation

ORIF Ex-FixComplications13% (n=22)

21 1

Type of complications

157Age range 20-88Mean = 56

Further surgery (n=18)

Debridement

Re-ORIF

Removal of metalwork

0 2 4 6 8 10 12 14

2

3

13

no of pts

ORIF Complication rates

Early (n=73)

Delayed (n=83)

0 2 4 6 8 10 12 14

13

8

P = 0.16

• Gender (p=0.64)• Laterality (p=0.17)• Grade of surgeon• Type of injury

No correlation with:

52

1

Fibular locking

DCP

Tubular non-locking

Soft tissue complications (n=8) 4.65% of all cases

6 deep wound infections2 wound breakdown

CONCLUSION

Matched population required for comparison of implants in our second phase audit

No significant difference in complication rates and post-operative length of stay between early vs delayed ORIF

Whilst maintaining health economy is important , the long term clinical benefits of early ORIF pathway is unclear

REFERENCES

1. T. P. Van Staa, E. M. Dennison, H. G. M. Leufkens, and C. Cooper. Epidemiology of Fractures in England and Wales. Bone Vol. 29, No. 6 December 2001:517–522

2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691-7

3. Pietzik P, Qureshi I, Langdon J, Molloy S, Solan M. The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature. Ann R Coll Surg Engl. 2006 Jul;88(4):405-7.

4. Schepers T, De Vries MR, Van Lieshout EM, Van der Elst M. The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature. International Orthopaedics (SICOT) (2013) 37:489–494

The author(s) declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest

Sohail YousafST4 Trauma and OrthopaedicsBrighton and Sussex University Hospitalssohail.yousaf@bsuh.nhs.uk

FOR FURTHER INFORMATION