Hindfoot nails or protibial screw fixation: what is the best option for a complex ankle fracture?

J. Bethel, A.-A. Najefi, M. Davies, E. Gosney, K. Patel, R. Ahluwalia

Introduction: Surgical options for ankle fractures in patients with multiple co-morbidities (including osteoporosis) include hind-foot intramedullary nail fixation (HFN) or fibula pro-tibia screw fixation (PTS) to retain function. We compared their outcomes.

Methods: 31 patients identified with AO44 fractures underwent HFN (17) and PTS (14) fixation. Patient demographic data, co-morbidities, Charlson Co-morbidity Index Score (CCIS), weightbearing status, peri-operative information and post-operative complications were recorded. Radiographs were assessed for metalwork breakage, non-union, and anatomical reduction.

Results: The mean age between fixation groups was different 77 (HFN) vs. 63 (PTS) (p=0.03). Estimated 10-year survival was 22.4±25.5% for the HFN group and 54.6±38.7% for the PTS group (p=0.001). There were 12 open-fractures in the HFN group (71%) and 8 in the PTS group (57%). Eight open fractures had an in-situ fixation without joint preparation, 4 had joint preparation with shortening. Mean time to full weightbearing was 2.1±3.8 in HFN and 9.9±3.8 weeks in PTS-pts (p<0.001); but more patients were independently weightbearing after an HFN (24% vs. 29%). Closed fractures had no metalwork failures or infection. Two open fractures (12%) in the HFN group had superficial infection and 1(6%) had metalwork failure. One patient (7%) in the PTS open-fracture group developed a deep infection, two patients (14%) had metalwork failure. There were 4 non-unions in each surgical group. In the HFN group 4 patients (24%) had a venous thromboembolism (VTE) post-operatively and 3 patients(18%) with open fractures in the HFN group died within 1-year of surgery.

Discussion: HFN allows earlier weightbearing in patients with a higher CCIS with accepted functional loss, but higher intraoperative blood-loss, mortality and VTE than PTS fixation. Further studies to stratify utilisation of these technique in both open and closed fractures is required, as similar union rates, metalwork/wound complications rates are only observed in closed fractures.