Juliet Fink, Dr. Jacobson, Dr. Kadakia, Dr. Coleman, and Dr. Barreto, my team at Emory Orthopedics. Ankle fractures are a fairly common orthopedic injury observed in many different patient populations with as many as 130,000 or more occurring per year. Most patients follow a predictable course of care after their initial injury. Typically, they present to an emergency department or urgent care where they're given an X-ray that confirms a fracture. If they are malreduced, there is often some reduction attempted and they're given a follow-up appointment with an orthopedic specialist within a few days. The orthopedic specialist will then proceed with operative or non-operative care as indicated. Paradigm exists that near anatomic reduction improves outcomes in non-urgent ankle fractures, which is why reduction is usually attempted by emergency or urgent care caretakers. This makes sense from a logical perspective that we would want the bone to be as anatomically aligned as possible. However, no study to date has shown objective evidence that near anatomic reduction in the preoperative setting for ankle fractures is critical for good patient outcomes. For this study, all non-emergent ankle fractures treated by one fellowship-trained foot and ankle surgeon were queried over a five-year period and evaluated using the electronic medical record. Patients with major tibial pathology, such as a pilon fracture, were excluded, and 97 patients over the age of 18 years with various traumatic ankle fracture etiologies were considered. Emory electronic medical record and state imaging databases were reviewed in order to evaluate preoperative films both before and after visiting the orthopedic specialist. The AP and lateral views were assessed for adequate reduction after initial presentation to urgent care or emergency department. Using the results of this evaluation and or the patient's operative date, the number of days until adequate reduction for each patient was calculated. Each patient also completed VAS and SF-36 surveys preoperatively and postoperatively. Non-continuous data was compared with chi-squared tests, and continuous non-normally distributed data was compared using a Mann-Whitney U-test. In our results, the average age of our 97 patient population was 46, with 68.9% of the population female and 31.1% male. 51 patients were found to be adequately reduced within 24 hours, 39 were inadequately reduced. No differences were found in preoperative or postoperative VAS, SF-36, physical, or mental scores. VAS pain scores in both cohorts improved similarly over the preoperative to final postoperative follow-up. Average time to final follow-up was a little over one year. The results, including tourniquet and operative time obtained are depicted here on the table, with the relative P values on the far right column and zero representing an inadequately reduced patient group while one represents an adequately reduced patient group in the second column on the left. Based on this data, the state of the injured ankle prior to going to the operating room may not be of much significance. If a patient is ultimately undergoing definitive surgical fixation, we show that their postoperative physical and mental wellbeing is not significantly different regardless of the preoperative reduction status. An interesting finding is that preoperatively, the physical and mental wellbeing scores were also not significantly different across adequate and inadequate reduction populations, which leads us to assert that the pain and discomfort associated with the procedure of reduction may not be worth it in patients who are neurovascularly intact. Pain relief is often one of the stated reasons reduction is performed in the emergency department. Although this may be true, the preoperative wellbeing scores indicate that either the pain relief is not great enough or it is overshadowed by the pain of reduction. To add to this, in our patient population, the attempt at reduction was not very effective with only 52.6% of patients actually presenting to the orthopedic specialist in a state of adequate reduction. This number may be misrepresented as several fractures in the population likely did not require any reduction at all as they were not displaced. However, that would still point to a high rate of failed reduction attempts. With this information in mind and knowing that orthopedic trauma is both physically and psychologically distressing, performing excessive manipulation of the injured but neurovascularly intact ankle after traumatic injury may not be indicated because ultimately there will be no significant change in the patient's postoperative outcome if near anatomic reduction is not achieved. In conclusion, we contend that one year after surgical correction and hematic reduction following traumatic non-emergent ankle fracture does not significantly affect overall patient outcomes. While satisfying, near anatomic reduction may not be critical to good patient outcomes after surgery in neurovascularly intact non-urgent ankle fractures. Below here are our citations and we appreciate Dr. Barreto, Dr. Coleman, and Dr. Kadakia for their mentorship and oversight. Specifically, we thank Dr. Barreto for his time reviewing x-rays and the use of his clinic.

ankle fractures

treatment

outcomes

X-ray

reduction attempts