Evaluating Compliance to Intra-operative Syndesmosis Stress Testing During Ankle Fracture Fixation: Are We Stressing It?

Introduction Ankle fractures are common injuries, and a proportion are complicated by syndesmotic instability. If left unrecognised or untreated, such instability can lead to poor functional outcomes, chronic pain and long-term joint degeneration. Intra-operative stress testing plays a vital role in detecting these injuries, and both radiographic evidence and clear documentation are key to ensuring safe and transparent surgical practice. Methods We conducted a retrospective closed-loop audit at a district general hospital to evaluate compliance documentation for intra-operative syndesmosis stress testing during ankle fracture fixation. Target compliance was set at 80% for both radiographic evidence saved and documentation in operative notes. The first audit cycle (November 2023-April 2024) identified gaps in practice and was followed by targeted educational interventions, including posters and dedicated teaching sessions. A second audit cycle was then performed (April-July 2025). Statistical comparison between the two cycles was performed using the Chi-squared test. Results Eighty-nine patient records were included in the first cycle and 50 in the second. Initial compliance for radiological evidence saved was 55% (n=49), and documentation was 71% (n=63). After intervention, both domains improved to 82% (n=41), achieving the audit target. The increase in radiological evidence saved was statistically significant (p=0.001), while the improvement in documentation was not (p=0.14). Importantly, the proportion of cases with no evidence saved fell from 25% (n=22) to 6% (n=3). Conclusion Targeted, low-cost interventions significantly improved compliance with British Orthopaedic Association Standard for Trauma (BOAST) standards for intra-operative syndesmosis testing. Embedding systematic stress testing, radiographic archiving and operative note documentation into routine practice enhances patient safety, reduces medico-legal risk and supports long-term ankle stability.