Abstract. Aim. To identify the difference in infection rates in ankle fracture surgery in Laminar and Non Laminar flow theatres. Background. The infection rates in ankle fracture surgery range between 1–8%. The risk factors include diabetes, alcoholism, smoking, open fractures, osteoporotic fractures in the elderly, and high BMI. Laminar flow has been shown to reduce infections in Arthroplasty surgeries. Therefore, it has become mandatory to use in those procedures. However, it's not the same with ankle fracture surgery. Materials and Methods. It was a retrospective study. The data was collected over a 5 year period between 2015 and 2020. It was collected from Blue spier, Panda, and theatre register. There were 536 cases in each group i.e. Laminar flow (LF) and Non-Laminar flow (NLF). The variables looked at were: 1. Superficial and deep infection rates in LF and NLF theatres, 2. The number of open fractures, 3. Type of ankle fractures (Bimalleolar, Trimalleolar), 4. The number of infected cases who had external fixation prior to ORIF, 5. The number of cases that had Plastics reconstructive procedures, and 6. The grade of the operating surgeon. Conclusions. Superficial infection rate between NLF and LF was not significantly different 11.5% vs 10.3%. The deep infection rate was statistically significant against NLF theatres at 6.34% vs 4.29%. The open fracture was a major contributing factor for deep SSI (14.7% vs 26%). The application of an external fixator in LF and NLF theatres did not alter the infection. rates. Bimalleolar fractures were associated with a higher infection rate

Aim. Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures. Method. A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University hospital in the period of 2015–2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients’ age and presence of one or more risk factors. Results. FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < 0.001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8–10.1) and 4.7 (95% CI 1.6–14.1) respectively. Conclusions. The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery

Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution. This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded. Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a cost savings of 35.9% in comparison to inpatient ankle fracture surgery (P < 0 .001). There were no significant differences in the rates of emergency room visits, readmissions, or complications between cohorts. Preliminary findings suggest that outpatient ankle fracture surgery is appropriate for most patients, requires less hospital resources and is associated with similar rates of readmission and complications as inpatient surgery. An established outpatient surgical pathway may offer significant cost savings in the treatment of the common closed ankle fracture that requires surgical intervention

Ankle fractures are common orthopedic injuries, often requiring operative intervention to restore joint stability, improve alignment, and reduce the risk of post-traumatic ankle arthritis. However, ankle fracture surgeries (AFSs) are associated with significant postoperative pain, typically requiring postoperative opioid analgesics. In addition to putting patients at risk of opioid dependence, the adverse effects of opioids include nausea, vomiting, and altered mental status which may delay recovery. Peripheral nerve blocks (PNBs) offer notable benefits to the postoperative pain profile when compared to general or spinal anaesthesia alone and may help improve recovery. The primary objective of this quality improvement (QI) study was to increase PNB administration for AFS at our institution to above 50% by January 2021. A root cause analysis was performed by a multidisciplinary team to identify barriers for PNB administration. Four interventions were chosen & implemented: recruitment and training of expert anesthesiologists in regional anesthesia techniques, procurement of additional ultrasound machines, implementation of a dedicated block room with training to create an enhanced learning environment, and the development of an educational pamphlet for patients outlining strategies to manage rebound pain, instructions around the use of oral multimodal analgesia, and the potential for transient motor block of the leg. The primary outcome was the percentage of patients who received PNB for AFS. Secondary outcome measures included total hospitalization length of stay (LOS), post-anesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients requiring opioid analgesic in PACU, and proportion of patients experiencing post-operative nausea and/or vomiting (PONV) requiring antiemetic in PACU. Thirty-day post-operative emergency department (ED) visits were collected as a balance measure. The groups receiving PNB and not receiving PNB included 78 & 157 patients, respectively, with no significant differences in age, gender, or ASA class between groups. PNB administration increased from less than 10% to 53% following implementation of the improvement bundle. Mean total hospital LOS did not vary significantly across the PNB and no PNB groups (1.04 days vs. 1.42 days, P = 0.410). Both mean PACU and mean 24-hour postoperative opioid analgesic consumption was significantly lower in the PNB group compared to the no PNB group (OME in PACU 38.96mg vs. 55.42mg [P = 0.001]; 24-hour OME 44.74mg vs. 37.71mg [P = .008]). A greater proportion of patients in the PNB group did not require any PACU opioid analgesics compared to those in the no PNB group (62.8% vs. 27.4%, P < 0.001). The proportion of patients experiencing PONV and requiring antiemetic both in the PACU did not vary significantly across groups. Thirty-day postoperative ED visits did not vary significantly across groups. By performing a root cause analysis and implementing a multidisciplinary, patient-centered QI bundle, we achieved significant increases in PNB administration for AFS. As a result, there were significant improvements in the recovery of patients following AFS, specifically reduced use of postoperative opioid analgesia. This multi-faceted approach provides a framework for an individualized QI approach to increase PNB administration and achieve improved patient outcomes following AFS

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Socially deprived patients face significant barriers that reduce their access to care, presenting unique challenges for orthopaedic surgeons. Few studies have investigated the outcomes of surgical fracture care among those socially deprived, despite the increased incidence of fractures, and the inequality of care received in this group. The purpose of this study was to evaluate whether social deprivation impacted the complications and subsequent management of marginalized/homeless patients following ankle fracture surgery. In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45,444 patients who underwent open reduction internal fixation for an ankle fracture performed by 710 different surgeons between January 1, 1994, and December 31, 2011. Socioeconomic deprivation was measured for each patient according to their residential location by using the “deprivation” component of the Ontario Marginalization Index (ON-MARG). Multivariable logistic regression models were used to assess the relationship between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and debridement due to infection, and amputation). Multivariable cox proportional hazards (CPH) models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty). A higher level of deprivation was associated with an increased risk of I&D (quintile 5 vs. quintile 1: odds ratio (OR) 2.14, 95% confidence interval (CI), 1.25–3.67, p = 0.0054) and amputation (quintile 4 vs. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed compared to more deprived patients (quintile 5 vs. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty. Marginalized patients are at a significantly increased risk of infection and amputation following operatively treated ankle fractures. However, these complications are still extremely rare among this group. Thus, socioeconomic deprivation should not prohibit marginalized patients from receiving operative management for unstable ankle fractures

Background. Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in-hospital mortality, in-hospital post-operative complications, length of stay and non-routine discharges. Aim. The purpose of this study was to retrospectively compare the complications associated with operatively treated ankle fractures in a group of patients with uncomplicated diabetes versus a group of patients with complicated diabetes. Complicated diabetes was defined as diabetes associated with end organ damage such as peripheral neuropathy, nephropathy and/or PAD. Uncomplicated diabetes was defined as diabetes without any of these associated conditions. Our hypothesis was that patients with uncomplicated diabetes would experience fewer complications than those patients with complicated diabetes. Methods. We compared the complication rates of ankle fracture repair in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes and calculated odds ratios (OR) for significant findings. At a mean follow up of 21.4 months we found that patients with complicated diabetes had 3.8 times increased risk of overall complications, 3.4 times increased risk of a non-infectious complication (malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis when compared to patients with uncomplicated diabetes. Open ankle fractures in this diabetic population were associated with a three times higher rate of complications and 3.7 times higher rate of infection. Conclusion. Patients with complicated diabetes have an increased risk of complications after ankle fracture surgery compared to patients with uncomplicated diabetes. Careful pre-operative evaluation of the neurovascular status is mandatory, since many patients with diabetes do not recognise that they have neuropathy and/or peripheral artery disease