Percutaneous Gallagher nail stabilization for fragility ankle fracture
Reference: O’Daly, B. J., Harty, J. A., O’Malley, N., O’Rourke S. K, Quinlan, W. R. Percutaneous Gallagher Nail Stabilization for fragility ankle fracture. Euro J Orthop Surg Traumatol. (2010). 20:651-655.
Scientific Literature Review
Reviewed by: Alex Scholl, DPM
Residency Program: St. John Hospital and Medical Center. Detroit, MI
Osteoporotic fragility ankle fractures in the elderly are difficult and can be fraught with complications. A fragility fracture is defined as a fracture that affects a person over the age of 60 resulting from minimal trauma. The inherent instability of osteopenic fractures, along with physical limitations and co-morbidities of the patients involved necessitate minimally invasive techniques for stable fixation.
Nine cases of fragility fractures treated from 1996 to 2005 were examined. All patients failed closed reduction with plaster cast immobilization and percutaneous Gallagher nail stabilization performed by the same surgeon. ORIF was contraindicated in all patients. Failure of reduction under anesthesia with subsequent cast application was classified “early” if failure occurred in less than one week, and “late/salvage” if greater than 1 week. The Gallagher nail used was a 4.7mm X 27cm nail, with a distal end that is expanded as a screw to prevent proximal migration of the nail by anchoring into the plantar cortex of the calcaneus. It is also further supplemented with a washer.
Patients were positioned prone, with the foot in slight equinus. After the ankle fracture was reduced, the foot was held in slight equinus to allow the nail to penetrate the posterior articular surface of the talus and tibial plafond. When normal weight bearing is resumed the nail hole is orientated posterior to the articulating surfaces. When the lateral malleolar fracture could not be reduced, intramedullary Kirschener wires were utilized for enhanced stabilization. The patients were placed in a posterior splint until wounds were healed, at which point weight bearing was allowed as tolerated with 2 crutches.
Nine total patients, 8 females and 1 male, were examined. The mean age was 81 years (range 60-101) and the mean follow-up was 34 months. Five patients had bimalleolar fractures, three had tri-malleolar fractures, and one had a fracture dislocation of the ankle. All patients had poor soft tissue envelopes preoperatively. Four of the patients were considered salvage procedures due to late failure of conservative closed reduction and immobilization. The other five were treated as early failure of reduction. No intraoperative complications or postoperative soft tissue complications occurred. All patients were able to weight bear with assist one day postoperatively. Nails were removed at a mean of 6 weeks in 8 patients. One patient refused nail removal, and one patient was not able to attend final clinical and radiographic evaluation due to medical co-morbidity. No cases of delayed union or talar shift were observed radiographically. Pain-free, assisted transfer with all patients was achieved at 8 weeks postoperatively. Six of the nine patients returned to pre-fracture mobility status. Two of the three remaining required a walker for mobility who used a cane prior. The last patient went from walker to needing a nurse assist for mobilization.
Percutaneous Gallagher nail stabilization is a viable option when dealing with difficult osteoporotic fragility ankle fractures. It is a minimally invasive procedure accepting poor soft tissue envelopes and co-morbidities of the patient population involved. The ability to immediately weight-bear also accommodates for this population’s physical limitations.