SLR - January 2022 - Dominick J. Casciato

Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures

Reference: Kulakli-Inceleme E, Tas DB, Smeeing DPJ, Houwert RM, van Veelen NM, Link BC, Iselin LD, Knobe M, Babst R, Beeres FJP. Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures. Geriatr Orthop Surg Rehabil. 2021 Jun 17;12:1-7.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Dominick J. Casciato, DPM
Residency Program: OhioHealth Grant Medical Center – Columbus, OH

Podiatric Relevance: With an aging population, the prevalence of fragility fractures among the elderly continues to grow. Unstable ankle fractures pose a particular challenge in this population as complications  ensue following traditional open reduction and internal fixation (ORIF). Namely, dissection around malleoli  with poor soft tissue coverage along with follow-up consisting of extended non-weightbearing precipitate poor outcomes. Tibiotalocalcaneal (TTC) intramedullary nailing reduces these complications due to its minimal incisional technique and ability to immediately bear weight.

Methods: A retrospective cohort study consisting of patients treated with a retrograde TTC nail at a Level I trauma center for unstable ankle fractures was conducted. Fusion without joint preparation was performed  for all patients in a similar surgical technique followed by immediate return to weightbearing as tolerated. Patients were followed for a minimum of six months. Patient demographics consisted of past medical history and pre-injury mobility. Fracture categorization included the AO/OTA and Gustillo and Anderson classification schemes. Primary outcomes assessed included fracture nonunion, implant complications, wound infection or healing disorder, and below the knee amputation. Secondary outcomes included mortality, patient-reported functional outcomes, return to pre-injury mobility, return to pre-injury care setting, and duration of hospital stay.

Results: Among the 365 patients presenting with unstable ankle fractures, 10 patients were treated with retrograde TTC nailing. The average patient age was 85.2±8.2 years, with one male and nine females comprising  the cohort. There were eight trimalleolar and two bimalleolar fractures. Eight patients were placed in a temporary external fixator prior to definitive nailing. Six patients placed weight immediately post-operatively  on the effected limb. Four post operative complications were experienced, including three fracture non-unions, two implant complications, and one wound infection. No below the knee amputations were performed though four patients died during the follow-period. The average Foot and Ankle Outcome Score was 52.6±14.2, with five patients able to return to pre-injury mobility and six able to return to the pre-injury  care setting. The average hospital stay was 15.4±3.9 days.

Conclusions: TTC intramedullary nailing proves to be an effective treatment option for geriatric patients with unstable ankle fractures. The minimal incision nature of the approach TTC nails lend themselves well  to older patients with a poor soft tissue envelope that would otherwise be dangerous when using a traditional ORIF approach through medial and lateral malleolar incisions. Furthermore, immediate weightbearing post operatively allows patients to return to a previous level of activity. As this investigation only examined ten patients, future studies assessing the efficacy of the TTC construct should include a greater cohort size along with further stratification of age groups. With an aging population, understanding how to treat the geriatric patient remains imperative to allow an acceptable quality of life.

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