Impact of Timing Surgical Fixation on Complications and Functional Outcomes in Ankle Fractures

Abstract

Introduction: This study aimed to assess whether adherence to the British Orthopaedic Association Standards for Trauma (BOAST) and National Institute for Health and Care Excellence (NICE) guidelines for ankle fractures is associated with reduced complication rates and improved functional outcomes. Methods: A retrospective analysis was conducted of all patients who underwent surgical fixation for ankle fractures in August 2023 to January 2024 from an acute hospital. Statistical analyses were performed using IBM SPSS Statistics software, version 29 (IBM Corp., Armonk, NY), to explore the relationship between BOAST and NICE guideline adherence and the study outcomes.

Results: The analysis revealed that only 10% of patients underwent ankle surgical fixation in accordance with the BOAST and NICE guidelines, with the mean time for surgery from injury as 10.7 days for the remaining cohort. Mental health effects were also recognised, with 26.7% due to waiting times. The association between BOAST and NICE compliance and complication incidence was found to be non-significant (p = 0.414). Mean Manchester-Oxford Foot Questionnaire (MOXFQ) scores were lower in the BOAST and NICE-compliant groups. The correlation coefficient between surgical waiting time and MOXFQ scores was r = 0.007, demonstrating no significant correlation between the time to surgery from injury and functional outcomes.

Conclusions: This study highlights the challenges in adhering to BOAST and NICE guidelines for timely surgical intervention in ankle fractures, with only a small proportion of patients receiving surgery within the recommended timeframe. Larger-scale studies are required to substantiate the hypothesis that early surgical intervention, as per the guidelines, leads to improved outcomes and whether achievement of the guidelines is feasible or requires re-examination.

Keywords: ankle and foot; ankle fracture; boast; guideline; manchester-oxford foot questionnaire; orthopaedic; the national institute for health and care excellence (nice); timing; trauma; waiting time.

Figure 1. Pie chart showing the reasons why there was a delay to surgery and therefore why the BOAST and NICE guidelines (early fixation on the day or day after injury) were not followed.

Values in the pie chart are presented as N, %. BOAST: British Orthopaedic Association Standards for Trauma; NICE: National Institute for Health and Care Excellence

Figure 2. Bar chart demonstrating the frequency and types of complications that occurred in patients post-operatively

DVT: deep vein thrombosis

Figure 3. Box and whisker plot representing the data of the MOXFQ scores for the patients whose surgeries were BOAST and NICE compliant compared against those that were BOAST and NICE non-compliant.

MOXFQ: Manchester-Oxford Foot Questionnaire; BOAST: British Orthopaedic Association Standards for Trauma; NICE: National Institute for Health and Care Excellence

Figure 4. A simple scatterplot with the number of days from the date of injury to the date of surgery on the x-axis and the MOXFQ scores on the y-axis. It is used to illustrate whether there is a correlation between waiting times for surgery and functional recovery.

MOXFQ: Manchester-Oxford Foot Questionnaire

Figure 5. The Manchester-Oxford Foot Questionnaire (MOXFQ) printed survey form for patient reported outcomes: page 1

Figure 5 and Figure 6 were reprinted from [10]. They have been used in this study to calculate the function and pain of the patient's ankle following surgery. The MOXFQ also considers the effects that this has on the patient's day-to-day life.

Figure 6. The Manchester-Oxford Foot Questionnaire (MOXFQ) printed survey form for patient reported outcomes: page 2

Figure 5 and Figure 6 were reprinted from [10]. They have been used in this study to calculate the function and pain of the patient's ankle following surgery. The MOXFQ also considers the effects that this has on the patient's day-to-day life.