Hindfoot nail for acute management of the elderly ankle and distal tibia fragility fractures - a safe and effective treatment

F. Ashouri, M. Al-Maiyah

Introduction: Fragility ankle fractures in the elderly are usually of complex pattern, intra-articular, unstable and the surrounding soft tissues are compromised. In this study, we looked at our cohort of the ankle fragility fractures that were managed acutely with a hindfoot nail to assess the outcomes and efficacy of this method of fixation.

Methods: We retrospectively reviewed the surgical logbooks of ankle fracture fixation performed in our department from February 2015- July 2016. Inclusion criteria were elderly patients who underwent a hindfoot nail for an ankle or distal tibia metaphyseal fracture, with poor soft tissue condition or open fractures, poor pre-injury mobility and multiple co-morbidities. Outcomes were analysed with emphasis on post-operative wound complications, post-operative infection, peri-prosthetic fractures, fracture healing and mal-union, metal ware failure and functional outcomes.

Results: We identified 18 patients who matched the inclusion criteria, 5 men and 13 women. Age ranged between 65 and 93. Follow up 2 to 17 months. Five patients had open ankle fractures, of which one was complicated with wound infection post-operatively. 17 patients had a VALOR® hindfoot nail implant. One was managed with a short femoral nail, as a hindfoot nail, due to the limitation of available VALOR® nail lengths. All patients returned to pre-injury functional status within 3 weeks. One patient had malunion. One patient died 6 months post-operatively due to cardiac disease. No patients had peri-prosthetic fractures or metal-ware failure.

Conclusion: Our cohort of patients had good short term outcomes with early return to pre-injury functional status, reducing the risk of prolonged hospitalisation and complications. Malunion and non-union, stress proximal fractures and late infection are all long-term potential risks. We conclude that hindfoot nail is a safe and effective method of treatment of complex ankle and distal tibia metaphyseal fractures in this age group.