Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures

Abstract

Background: Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes. Methods: A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications. Results: A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8). Conclusion: Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.

Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre

“…Perhaps due to our high percentage of open fractures, superficial infection rate was higher than the range of 0-6.5% quoted in the literature [8,22]. We report no cases of deep infection or non-unions, which is very favourable compared to other management options such as ORIF [4,27], as well as other studies utilising TTC nailing [8,20,22], with non-union rates of 30% being reported [20]. We also report no periprosthetic fractures, even though a long nail was not used, which was suggested to prevent periprosthetic fractures [22].…”

“…Studies mention that preparing the subtalar joint reduces non-union rate [20,34]; nevertheless, whether or not subtalar joint needs open debridement remains a contentious point. The surgeons who elected to not prepare the joints felt that doing so would devascularise the talar fragments excessively, increase surgical insult and create an unnecessarily invasive procedure that would introduce wound healing issues, in return for arthrodesis union which is hard to achieve in a host with multiple co-morbidities.…”

“…Since 2005, the literature contains optimistic reports of using tibiotalocalcaneal (TTC) nails for treatment, with no non-union [18] and immediate weight-bearing post-operatively [19]. However, few studies assessed functional outcomes with adequate follow-up times [18][19][20][21][22].…”

Retrograde tibiotalocalcaneal nailing for the treatment of acute ankle fractures in the elderly: a systematic review and meta-analysis

“…To estimate interobserver reliability, a kappa coefficient of 0.84 was obtained, suggesting excellent agreement between reviewers. Twelve studies were retrospective case series ( 1 , 2 , 3 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ), one was a prospective case series ( 30 ), and one was a randomised control trial ( 31 ). Figure 1 presents a PRISMA flowchart.…”

“…Table 1 presents the study characteristics and patient demographics. Seven studies were performed in the UK ( 2 , 3 , 22 , 23 , 24 , 25 , 28 ) and the majority were published in the last 5 years ( 1 , 3 , 21 , 25 , 26 , 27 , 28 , 30 , 31 ). Apart from 2 studies ( 22 , 30 ), all studies collected patient data over a span of at least 3 years.…”