Outcomes from tibiotalocalcaneal nailing versus open reduction internal fixation for high-risk fragility ankle fractures: a single-centre matched retrospective cohort study

A. Hrycaiczuk, K. Oochit, A. Imran, E. Murray, P. Chan, R. Carter, B. Jamal

Introduction: Tibiotalocalcaneal nailing (HFN) is a proposed solution to successfully treating high-risk ankle fragility fractures. We aimed to determine whether outcomes in our trauma centre reflect those previously reported and support that HFN and open reduction internal fixation (ORIF) demonstrate equal results in this demographic.

Methods: Outcomes for fragility ankle fractures treated with HFN (without joint preparation) or ORIF were compared via retrospective cohort study. 64 patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA. Fracture classification, complications, discharge destination, union rates, FADI scores and patient mobility were recorded.

Results: Cohorts were well matched; mean age was 78.4 (HFN) versus 78.3 (ORIF), ASA 2.9 (HFN) versus 2.8 (ORIF) and CCI equal at 5.9. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (HFN) versus 3.3 days (ORIF). There was no difference in 30-day, 1-year, or overall mortality. Kaplan-Meier survivorship analysis showed the mean time to mortality in deceased patients was shorter in the HFN group (20.3 months versus 38.2 months, p=0.013). There was no significant difference in the overall complication rate (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in HFN patients; however, this was not statistically significant. There was no statistical difference in FADI scores 72.1±12.9 (HFN) versus 67.9±13.9 (ORIF) nor post-operative mobility status.

Conclusion: HFN demonstrated broadly equivalent results to ORIF in high-risk ankle fragility fractures. Mean survival was however shorter in the HFN group. This may be due in part, to delay to theatre, as HFN was treated as a sub-specialist operation in our unit at the time. We propose that both HFN and ORIF are satisfactory options in frail patients and the priority should be expedient operating. Further randomised control studies are needed to guide a working consensus.