SLR - October 2017 - Geoffrey B. Cady

Fragility Fractures of the Ankle in the Elderly: Open Reduction and Internal Fixation Versus Tibio-Talo-Calcaneal Nailing: Short-Term Results of a Prospective Randomized-Controlled Study

Reference: D. Georgiannos, V. Lampridis, I. Bisbinas. Fragility Fractures of the Ankle in the Elderly: Open Reduction and Internal Fixation Versus Tibio-Talo-Calcaneal Nailing: Short-Term Results of a Prospective Randomized-Controlled Study. Injury, International Journal of the Care of the Injured. 2017; 48, 519–524.

Scientific Literature Review

Reviewed By: Geoffrey B. Cady, DPM
Residency Program: The Western Pennsylvania Hospital, Pittsburgh, PA

Podiatric Relevance: Unstable ankle fractures are one of the most commonly managed injuries by foot and ankle surgeons. In young patients, open reduction and internal fixation (ORIF) is relatively predictable with excellent outcomes. However, the management of these injuries in the elderly is less predictable due to the various comorbidities present in this patient population. Tibiotalocalcaneal (TTC) nailing has been shown to be an effective option for arthrodesis of the hindfoot; however, there are few reports of their use in treatment of ankle fractures. This study compares the results of 44 elderly patients treated with ORIF versus 43 elderly patients treated with TTC nailing.

Methods: A prospective, randomized-controlled, comparative study was performed. A total of 87 patients with unstable ankle fractures were identified and met criteria. Inclusion criteria included patients over 70 years of age and closed bimalleolar or trimalleolar ankle fractures. Exclusion criteria included open fractures, severe peripheral vascular disease and diabetic angiopathy. Nail fixation was performed after closed reduction with TrigenR hindfoot nail and locked with two screws proximally and two screws distally. ORIF was performed with 1/3 tubular plate and 3.5 mm screws for the fibula and two 4.0 mm screws for the medial malleolus. Postoperatively, no immobilization was applied to the nail group, and patients were encouraged to weightbear as tolerated. The ORIF group was placed into a cast for six weeks with nonweightbearing. Olerud-Molander ankle score (OMAS) pre/postoperatively, complications, length of stay and mobility status were obtained. The follow-up was 12 months.

Results: There was no significant difference in mobility, OMAS or mortality at 12 months between the two groups. However, the TTC nail group had a significantly shorter hospital stay compared to ORIF group. Also, the total number of complications for the ORIF group was higher and statistically significant. The ORIF group also had a statistically significant number of deep vein thrombosis compared to the TTC nail group.

Conclusions: There were no statistically significant difference found in functional outcomes, including mobility, OMAS and mortality. However, the TTC nail group had significantly less complications. Maintaining mobility in elderly patients helps prevent comorbidities and loss of independence. TTC nailing is an effective method of treatment for unstable fractures in the elderly. It may allow for early mobilization and help prevent soft-tissue complications associated with traditional ORIF. There were a number of limitations, including the short follow-up period. Additionally, the authors did not record the time postoperatively at which the TTC nail group began weightbearing so their claim of early mobilization cannot be evaluated.

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