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AFTER (Ankle Fracture Treatment Enhanced Recovery) Project: A Multi-Disciplinary and Cost Effective Approach to Improve Patient Outcome with Ankle Fractures

Introduction: Ankle fractures often pose significant challenges to the healthcare system in United Kingdom. Increased soft tissue swelling together with limited theatre space lead to a delayed surgery and an increased hospital stay which causes poor outcome and decrease patient satisfaction. The aim of this project was to improve the decision making for unstable ankle fractures, reduce in-hospital stay and improve patient outcome.

Assessment of the problem: Initially, we retrospectively collected data from 2018-19 for all unstable ankle fracture who underwent surgery and we analysed the reasons for the delay in surgery, time from injury till surgery and measured outcome score.

We found out that 73.4% of ankle surgeries are getting delayed. The average stay in hospital for ankle fracture patient was about 4.5 days and the average delay in surgery was 3.4 days resulting in an estimated loss of £1,50,000 a year for delayed surgeries only.

Intervention: We implemented the AFTER pathway in 2019 to expedite the decision making for surgery and early physiotherapy input. If surgery is not possible immediately, the patient will be assessed by the IDT team and encouraged to go home with a leg elevator (OrthoLove) and clinic follow up in 72 hours for swelling as-sessment, the decision regarding the date and time of surgery. Finally, the surgery is done as a daycare admis-sion and then discharged with the elevation pillow. Post-surgery, a team of dedicated foot and ankle physiothe-rapist will guide these patients for early weight-bearing and rehabilitation and follow up in the clinic for 6 months.

Result: We measured the outcomes in terms of total in-hospital stay, time from ED presentation to surgery and post-surgery OMAS score at 6 months follow up. We have seen a significant reduction in hospital stay from 4.5 days to 1.4 days. And a reduction in healthcare cost without any increase in the complication rate. Patient satis-faction also increased significantly because of reduced hospital stay (average OMAS score 78).

Conclusion and significance: AFTER project is a dedicated and cost-effective pathway to treat unstable ankle fractures, however, structured rehabilitation and a multi-disciplinary team approach are essential for its success.


Rajib Naskar*, Gabriel Omogra, Nigel Katandawa, Baljinder Dhinsa

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