The AOFAS Orthopod-Cast

Episode: How I Treat This: Ankle Fractures – Part 1 – The UK Experience

Date: November 6, 2024

Host: AOFAS Podcast Committee
Guest: Andy Malloy (Liverpool, UK)

Episode Overview

This episode dives into the UK approach to treating ankle fractures, spotlighting system-level changes and treatment philosophies that have improved outcomes for patients. Dr. Andy Malloy shares the evolution of Liverpool's ankle fracture management, emphasizing data-driven protocols, the centralization of care, and nuanced surgical decision-making. The discussion contrasts UK protocols with trends in the US and explores when to operate, how to evaluate instability, and the importance of specialist involvement.

Key Discussion Points and Insights

Evolution of the UK System for Ankle Fracture Care

• Centralization and Systemic Change

  • In Liverpool, a move to designate the hospital as a major trauma center led to subspecialized trauma teams.
  • System improvement originated from a retrospective audit in 2012, revealing poor reduction rates and suboptimal hardware placement.
  • "What we found is that 33% of them were not reduced ideally or the hardware was in the wrong place." – Andy Malloy [01:40]
  • After implementing a protocol inspired by 'nudge theory,' including independent review of all ankle fracture reductions, the malreduction rate dropped from 33–44% to 3% [03:55].
  • All trauma is now reviewed by a foot and ankle subspecialist the next day, no formal referral required — improving results by ensuring those with specific interest and expertise treat these injuries.

• Systemic Implementation Across the UK

  • Similar results observed nationwide; multiple studies confirmed ankle malreductions weren’t unique to Liverpool [04:45].
  • Shift toward subspecialists and interest-based treatment rather than general trauma or random assignment.

Importance of Specialist Involvement and Audit

• "You want to be doing a good job. And if you're not doing a good job, you either change what you're doing or you don't do that thing." – Andy Malloy [07:58]
  • Emphasis on regularly auditing outcomes, seeing data as a quality assurance tool.
  • Patient-reported outcome measures (PROMs) are used to assess departmental performance.
  • Data supports that dedicated foot and ankle surgeons yield better ankle fracture outcomes.

Decision-Making: Operative vs Non-Operative

• Case Example: Healthy, active 48-year-old with lateral malleolus fracture and 6mm medial clear space widening.
  • Initial Approach: Immobilization in a well-fitted cast or backslab, review in specialist clinic, consider weight-bearing X-rays [09:01].
  • Operative Threshold: Preference is for surgery due to predictable outcomes and faster rehab unless the patient strongly prefers to avoid an operation.
  • "If it can be reduced in the plaster...then you could try a trial of conservative treatments." – Andy Malloy [09:55]
  • Discusses trend towards more aggressive operative treatment due to chronic medial-sided pain and flatfoot concerns with conservative management [13:09].

Modern Trends and Surgical Technique Insights

• Addressing the Deltoid Ligament

  • "I would have a really low threshold for doing it...I would go into the operation planning that this is going to happen unless it is just absolutely rigid." – Andy Malloy [15:26]
  • Experiences of syndesmosis screw failure often traced back to unaddressed deltoid ruptures.
  • Strong advocacy for checking and repairing the deltoid to prevent instability and revision surgeries.

• Syndesmosis Management

  • Visual confirmation during surgery is key - "you need to see the anterior aspect and you need to feel that that fibula is keyed into the incisura..." [19:50]
  • Preference for flexible fixation (tightrope, suture button, or internal brace) over rigid screws, but still surgeon-dependent
  • Outmoded reliance on stress X-rays is discouraged in favor of direct visualization for detecting subtle syndesmotic instability [21:11].

Imaging and Assessment

• The Role of CT Scans

  • Every posterior malleolar (post mal) fracture or comminuted ankle fracture warrants a CT: "The diagnostic accuracy of a lateral radiograph...is about 23%. There's no other test that you'd accept a 23% accuracy on." – Andy Malloy [22:33]
  • CT determines fragment size and guides whether direct or indirect reduction is needed.

• Fixation Philosophy for Posterior Malleolar Fractures

  • Dr. Malloy describes his and Linda Mason's classification system, prioritizing the fracture pattern over fragment size [26:15].
  • "The size of it actually doesn't matter particularly. We want to determine what the size because that will tell us what type of posterior malleolus fracture it is." – Andy Malloy [24:59]
  • True posterior pilon (Type 3): needs direct fixation; likens it to hanging a picture from the correct wall [28:26].
  • In elderly or comorbid patients, weigh the risks — may opt for syndesmotic fixation only, accepting anticipated arthritis [29:59].

Surgical Approaches and Techniques

• Medial and Posteromedial Fractures

  • Medial posteromedial approach recommended for access and visualization, especially to check for tibialis posterior tendon entrapment [33:31].
  • Plates preferred for fixation if available (recognized bias due to involvement in implant design) [35:40].
  • Careful prone positioning: semi-prone ("recovery position") makes access easier [36:00].

• Lateral Malleolus and Plating

  • Single longer incision in small patients; two incisions in heavier individuals [37:29].
  • Strong preference for lateral plating over posterior plating due to concerns of peroneal tendon irritation.

Individualized Practice & Avoiding Dogma

• Both speakers stress "flexible thinking": All techniques must be adapted to patient needs, surgeon experience, and intraoperative findings [38:47].
• "Rigid fixation, but flexible thinking." (Attributed to Dr. Armin Kalikin) [32:25]

High Weber C Fractures (Proximal Fibula)

• General threshold to avoid plating above 10-12 cm from ankle (too thin, tricky to plate) [39:55].
• In such cases, prefer rigid syndesmotic stabilization and fixation of the deltoid; willingness to reconsider approach as new evidence emerges.

Notable Quotes & Memorable Moments

• On system change:
  “The normalization of poor behavior...what we found is it needed entire system change to get the best results for our patients.” – Andy Malloy [01:40]

• On auditing outcomes:
  “Any surgeon should want to know what their results are. And you want to be doing a good job.” – Andy Malloy [07:58]

• On when the deltoid should be fixed:
  “I would go into the operation planning that this [deltoid repair] is going to happen unless it is just absolutely rigid as hell and there’s no evidence.” – Andy Malloy [15:26]

• On importance of direct reduction:
  “If you were going to hang a picture on a wall, you'd hang it directly in the wall...You wouldn't go to the other side of the wall and then try and knock your nail through.” – Andy Malloy [28:26]

• On imaging:
  “The diagnostic accuracy of a lateral radiograph...is about 23%. There's no other test that you'd accept a 23% accuracy on.” – Andy Malloy [22:33]

• On dogma:
  “Dogmatic thought process never works...It's rigid fixation, but flexible thinking.” – [32:25]

• On the principle of treatment:
  “The principle is you fix these anatomically by whatever means necessary.” – [39:24]

Timestamps for Key Segments

• 08:30 – Importance of data, audit, and outcome measurement in surgical practice
• 09:01 – Non-operative vs. operative management in active, healthy patients
• 13:09 – Shift towards more aggressive surgical intervention in mild displacement
• 15:26 – Approach to the deltoid ligament: threshold for repair
• 19:50 – Management of the anterior inferior tibiofibular ligament (AITFL) and syndesmosis
• 22:33 – Use of CT for assessment of posterior malleolus
• 26:15 – Treatment algorithm based on post mal fracture pattern
• 33:31 – Surgical approach for posteromedial fractures
• 37:29 – Incision and plating strategies for the lateral malleolus
• 39:55 – Management of high (Weber C) fibula fractures

Conclusion

The episode advocates for a data-driven, systematic, and specialist-led approach to ankle fracture care. Key takeaways include the necessity of careful patient selection, detailed assessment (including liberal CT use), specialist involvement, surgical flexibility, and continuous outcome measurement. Above all, individualized treatment and the avoidance of dogmatic thinking are essential for optimal patient outcomes.