Open Ankle fragility fractures in elderly patients treated with subtalar joint-sparing primary ankle fusion: An Evolving Treatment Option

Siddharth Khadilkar, Yousufuddin Shaik

Introduction: Open ankle fractures in elderly patients are associated with significant morbidity due to complex fracture patterns, compromised soft tissue, and multimorbidity. Traditional staged fixation may lead to delayed mobility and higher complication rates. Primary ankle fusion offers an alternative, but conventional tibiotalocalcaneal (TTC) fusion compromises subtalar motion, impacting functional outcomes. To evaluate the outcomes of subtalar joint-sparing primary ankle fusion using either an anterograde tibial nail or cannulated screws in elderly patients with open ankle fractures.

Method: This retrospective study included 14 patients aged ≥60 years with open ankle fractures treated at two UK centres. Patients underwent primary ankle fusion using either an anterograde tibial nail or cannulated screws, preserving the subtalar joint. All surgeries were performed within 12–24 hours of injury, adhering to BOAST with plastic surgery input for soft tissue management. Patients followed a standardized rehabilitation protocol allowing early full weight-bearing. Radiological union was assessed at a minimum follow-up of 1 year and at 18 months.

Results: Radiological union was achieved in the majority of patients by final follow-up. Early full weight-bearing was well tolerated, with most patients returning to their baseline level of mobility. No deep infections, implant failures, or revision surgeries were recorded. Subtalar joint motion was preserved in all cases.

Conclusion: Subtalar joint-sparing primary ankle fusion is a safe and effective treatment for open ankle fractures in elderly patients. It enables early mobilization, preserves hindfoot function, and ensures reliable bone union with low complication rates. Given these outcomes, this technique should be considered a preferred alternative to traditional TTC fusion, offering clear functional benefits for this vulnerable population.