Fixation of ankle fractures - a major trauma centre's experience in improving quality.

Background: Ankle fracture malreduction has been shown to result in poor long-term functional outcomes. Varying methods can be used to change practice and thereby outcomes. We present over four years' worth of results with the effects of different techniques for change.

Methods: Two audit cycles were performed incorporating three audit data collections; an initial standard setting audit 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 the hospital picture archiving and communication system, by at least two blinded observers in each cycle. These were scored based on the criteria published by Pettrone .

Results: In the initial audit in 2013, there were 94 patients, with a malreduction rate of 33%. In the second audit in 2015, there were 68 patients, with an increase in malreduction rate to 43.8%. In the third audit in 2017, there were 205 patients, with a significant decrease in malreduction rate to 2.4%. The final major complication rate was 0.98%. The rate of deep infection was 0.5%.

Conclusions: By recognising and addressing the need to improve the quality of ankle fracture fixation, we have made significant improvements in radiological outcomes. Education alone, without system change, was not successful in our department in achieving improved outcomes.