Hindfoot Nails in Trauma


  • Primary arthrodesis or hindfoot nail stabilisation in the acute management of severe foot and ankle trauma is becoming increasingly popular
  • Candidates include those with irreversible cartilage injury, Pilon fractures, talus fracture-dislocations, calcaneal fractures, and fragility ankle fractures
  • There is a rising prevalence of fragility ankle fractures within the elderly population; these injuries are associated with significant morbidity and mortality and are most commonly seen in osteoporotic females
  • Both operative and non-operative techniques are associated with a high rate of complications
  • Non-operative treatment has been associated with a non-union rate of 48-73% and a malunion rate of 36-61%
  • The majority of evidence for hindfoot nails in trauma is for fragility ankle fractures in the elderly
  • Evidence supporting the use of tibio-talo-calcaneal (TTC) nails in the treatment of high-energy trauma is more limited, only small case series and case reports; this highlights the very selective nature of this technique in the active patient population

Rationale for Hindfoot Nails

  • Durable internal splints
  • Mechanically superior to extra-medullary implants in this application
  • More rigid, reliable(?) fixation
  • Consideration of early or immediate weight-bearing (particularly in non-compliant patients, already-impaired mobility, or those with impaired cognitive function)
  • Load-sharing constructs
  • Smaller incisions and limited exposure may prevent wound complications and soft tissue compromise, especially in severe injuries and patients with significant comorbidity

Evidence for Hindfoot Nails in Fragility Ankle Fractures

  • 7 studies (6 case series, 1 RCT) looking at the outcomes of hindfoot nails in elderly patients with ankle fractures
    • union rates of 85% to 100%
    • overall complication rates of 16.5%
    • mortality rates of 25% to 46% at the final follow up (considered to be multifactorial)
    • demonstrated that hindfoot nailing can be an effective treatment in elderly patients with fragility ankle fractures
  • This intervention is not without risks and therefore a careful, balanced approach should be taken



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Buckingham R, Hepple S, Winson I. Outcome of ankle fractures in the elderly. Foot Ankle Surg. 2000;6(3):175–178.

Willett K, Keene DJ, Morgan L, et al. Ankle Injury Management (AIM): design of a pragmatic multi-centre equivalence randomised controlled trial comparing Close Contact Casting (CCC) to Open surgical Reduction and Internal Fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years. BMC Muscoskel Disord. 2014;15(1):79.

Amirfeyz R, Bacon A, Ling J, et al. Fixation of ankle fragility fractures by tibiotalocalcaneal nail. Arch Orthop Trauma Surg. 2008;128(4):423–428.

Jordan R, Chapman A, Buchanan D, Makrides P. The role of intramedullary fixation in ankle fractures–a systematic review. Foot Ankle Surg. 2018;24(1):1–10.

Al-Nammari S, Dawson-Bowling S, Amin A, Nielsen D. Fragility fractures of the ankle in the frail elderly patient: treatment with a long calcaneotalotibial nail. J Bone Joint. 2014;96(6):817–822.

Baker G, Mayne A, Andrews C. Fixation of unstable ankle fractures using a long hindfoot nail. Injury. 2018;49(11):2083–2086.

Taylor BC, Hansen DC, Harrison R, Lucas DE, Degenova D. Primary retrograde tibiotalocalcaneal nailing for fragility ankle fractures. Iowa Orthop J. 2016;36:75.

Georgiannos D, Lampridis V, Bisbinas I. 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. 2017;48(2):519–524.