Abstract
Purpose
Geriatric ankle fractures present a clinical challenge due to frailty and poor bone quality. Unstable injuries often require prolonged non-weightbearing after traditional fixation, a limitation that may exacerbate sarcopenia, medical complications, and functional decline in the elderly. Tibiotalocalcaneal (TTC) nailing has emerged as an alternative that may permit earlier weightbearing. This study investigates complications and discharge disposition in geriatric patients who undergo fixation with TTC and conventional constructs.
Methods
A retrospective review was conducted of patients ≥ 60 years who underwent operative fixation of rotational ankle fractures with radiographic tibiotalar instability at an academic trauma center. Patients with tibial plafond fractures or < 6 weeks of follow-up were excluded. Demographics, complications, reoperations, and discharge disposition were analyzed. Multivariate logistic regression and propensity score–matched cohorts were employed to compare complication rates and discharge disposition between cohorts.
Results
130 geriatric patients underwent operative fixation with TTC (39) or traditional (91) constructs. Patients who underwent TTC nailing were likely to be older, have higher Charlson Comorbidity Index (CCI), and neuropathy. Patients with TTC fixation were allowed to weight bear sooner (1.6 weeks) than conventional constructs (9.8 weeks; p < 0.001). No differences were observed between groups in rates of reoperation, implant failure, or deep infection. Construct choice had no effect on discharge disposition among patients treated during inpatient admission.
Conclusion
Among geriatric patients with higher medical complexity, TTC fixation provides an early complication profile comparable to traditional fixation while allowing early weightbearing. However, TTC fixation may not independently improve rates of home discharge. While there are similar rates of short-term complications, long-term sequelae and functional repercussions of acute hindfoot fixation of geriatric malleolar ankle fractures remain unknown.
Keywords: Ankle fractures, Geriatric, Weight-bearing, Post-operative complications
Introduction
Geriatric ankle fractures are associated with high complication rates [1, 2]. Many comorbidities have been identified as predictors of surgical complications [2]. Additionally, high one-year mortality rates have been reported, with some literature suggesting comparable rates to that of geriatric hip fractures [3, 4]. While operative intervention has been found to have a protective effect, there is no strong consensus on the optimal surgical technique or fixation construct [3]. With increasing numbers of geriatric patients and an increasing number of associated fractures, the overall burden to the healthcare system is expected to rise [3, 5, 6]. The use of tibiotalocalcaneal intramedullary nail fixation (TTC) to stabilize ankle fractures has garnered recent interest in the management of this complex and increasingly important problem.
One of the goals of surgical fixation of ankle fractures in the elderly is to return them to performing their activities of daily living. Early weight bearing is associated with better quality of life and functional independence following a geriatric ankle fracture [7]. Patients may require a prolonged period of non-weightbearing following traditional fracture fixation, but immobilization has been associated with the development of many associated medical complications. Additionally, low compliance in the elderly to maintain postoperative weight bearing restrictions is common, which may compromise traditional fixation methods [8]. TTC nailing offers potential benefits including a minimally invasive technique and early weight bearing.
Early weightbearing following a geriatric ankle fracture has been shown to significantly affect a patient’s ability to maintain independence and likelihood of returning home [9]. There is a current sparsity in the literature that investigates the effect on mobilization between conventional open fixation methods and TTC nail fixation for acute geriatric ankle fractures. Consequently, this study aims to compare the complication profile in geriatric patients who undergo unstable ankle fracture fixation with both conventional constructs and TTC fixation, as well as investigate the effect of TTC nail fixation on postoperative disposition in geriatric patients.
Methods
This is a retrospective review of adult patients over 60 years of age who underwent operative fixation of rotational malleolar ankle fractures with evidence of tibiotalar instability at an academic practice by one of five fellowship trained orthopaedic trauma surgeons. Patients were identified by Common Procedural Terminology (CPT) codes 27792, 27814, 27822, 27823, and 27829, which were queried from the electronic medical record from June 2020 to June 2024. Radiographs were reviewed and classified according to the OTA/AO classification. Two cohort were defined: (1) patients treated with traditional plate and screw constructs (ORIF) (Fig. 1), and (2) patients treated with hindfoot nail constructs (TTC) (Fig. 2). Patients with TTC nail fixation in this series did not undergo a formal arthrodesis procedure (no cartilage preparation). Fixation type was determined by surgeon preference. During the study’s collection period, the general indication for the use of TTC nail fixation in geriatric patients was:
Elderly patients that the surgeon believed would benefit from higher immediate weight bearing potential, and/or had concerns regarding the healing of open surgical approaches.
Diabetic patients who were unable to comply with WB restrictions (neuropathy) leading to significant concerns regarding fracture healing and implant failure.
Diabetic patients in whom wound healing is a significant concern with open surgical approaches
Fig. 1.
Initial injury mortise (a) and lateral (b) radiographs of a 70-year-old. Intraoperative mortise (c) and lateral (d) radiographs following acute ankle fracture fixation with conventional lateral plate and medial bicortical screw fixation construct, with syndesmotic suture button fixation. Eight-month postoperative mortise (e) and lateral (f) radiographs demonstrating healed fractures are shown
Fig. 2.
Initial injury mortise (a) and lateral (b) radiographs of a 75-year-old female with severe Parkinson’s disease. Intraoperative mortise (c) and lateral (d) radiographs following acute ankle fracture fixation with a tibiotalocalcaneal nail. Ten-month postoperative mortise (e) and lateral (f) radiographs demonstrating healed fractures are shown
After radiographic review, patients with tibial plafond/pilon fractures or less than 6 weeks of radiographic follow-up were excluded. Demographic data were reviewed for Charlson Comorbidity Index (CCI), smoking status, BMI, diagnosis of peripheral neuropathy, and admission status at time of surgery (inpatient or outpatient surgery). Chi-square test was utilized to compare categorical variables. Wilcoxon rank sum test was utilized to compare nonparametric data.
Primary outcome measures included complications including reoperation, implant failure, culture positive infection, and death within 90 days. Propensity matching was utilized to adjust for covariates of Charlson Comorbidity Index, neuropathy, and admission status to minimize confounding. For secondary outcome measures, absolute risk and risk ratios were calculated for each adverse outcome, along with their respective confidence intervals. Patients in each cohort were matched 1:1 using a nearest-neighbor strategy without replacement and a caliper of 0.2. Propensity scores were estimated with logistic regression. The secondary outcome of interest was postoperative discharge disposition in all patients who received inpatient surgery. Ordinal regression analysis was employed to compare constructs and their association with discharge disposition, with ranking assigned to each discharge destination (1—home, 2—inpatient rehab facility, 3—skilled nursing facility, 4—long term acute care). All statistical analysis was performed in R 4.3.1 with the MatchIt (v4.5.4) and cobalt (v4.5.1) packages.
Results
After inclusion and exclusion criteria, a total of 130 patients over 60 years of age were identified with operative fixation of rotational ankle fractures. 91 patients were treated with ORIF, with a mean age of 67 years, CCI of 3.44, and 38% male. 39 patients were treated with TTC, with a mean age of 79 years, CCI of 6.36, and 30% male. A significantly higher number of TTC patients were older (p < 0.001), had more comorbidities (p < 0.001), and were treated with surgery requiring admission (10% versus 62%; p < 0.001). More patients with neuropathy were treated with TTC over ORIF (23% versus 7%; p = 0.017) (Table 1).
Table 1.
Demographics. All counts are represented as n (%), unless otherwise specified
| ORIF (n = 91) | TTC (n = 39) | p | |
|---|---|---|---|
| Outpatient Surgery | 56 (61.5) | 4 (10.3) | < 0.001 |
| Male sex | 33 (37.9) | 11 (29.7) | 0.504 |
| Age, years | 66.99 (6.32) | 79.36 (10.41) | < 0.001 |
| Time to Surgery, days [mean (SD)] | 6.62 (7.92) | 4.54 (4.98) | 0.142 |
| Length of Stay, days [mean (SD)] | 15.65 (65.06) | 5.26 (4.91) | 0.376 |
| Time to WBAT, weeks [mean (SD)] | 9.89 (3.12) | 1.62 (2.76) | < 0.001 |
| Follow-up, weeks [mean (SD)] | 33.98 (36.26) | 33.90 (37.72) | 0.991 |
| Mechanism of Injury | NA | ||
| High energy blunt (vehicular, fall from height, etc.) | 19 (20.9) | 4 (10.2) | |
| Low energy blunt (ground level fall, assault, etc.) | 72 (79.1) | 35 (89.8) | |
| Open Fracture | 11 (12.1) | 10 (25.6) | 0.096 |
| Anatomic Description | NA | ||
| Bimalleolar | 43 (47.3) | 11 (28.2) | |
| Lateral Malleolus | 14 (15.4) | 1 (2.6) | |
| Medial Malleolus | 2 (2.2) | 0 (0.0) | |
| Trimalleolar | 32 (35.2) | 27 (69.2) | |
| Fracture Dislocation | 32 (36.0) | 21 (53.8) | 0.090 |
| AO/OTA Classification | NA | ||
| 44A1 | 1 (1.1) | 0 (0.0) | |
| 44A2 | 2 (2.2) | 0 (0.0) | |
| 44B1 | 12 (13.2) | 0 (0.0) | |
| 44B2 | 34 (37.4) | 6 (15.4) | |
| 44B3 | 28 (30.8) | 26 (66.7) | |
| 44C1 | 1 (1.1) | 4 (10.3) | |
| 44C2 | 6 (6.6) | 3 (7.7) | |
| 44C3 | 7 (7.7) | 0 (0.0) | |
| Smoker | 15 (16.5) | 2 (5.1) | 0.140 |
| BMI [mean (SD)] | 29.27 (6.42) | 28.65 (5.82) | 0.611 |
| Neuropathy | 6 (6.6) | 9 (23.1) | 0.017 |
| Charlson Comorbidity Index [mean (SD)] | 3.44 (1.94) | 6.36 (2.05) | < 0.001 |
WBAT, weightbearing as tolerated prescription; EBL, estimated blood loss; BMI, body mass index
P values in bold indicate statistical significance (p ≤ 0.05)
35 patients in each group were treated with surgery requiring postoperative admission. In the ORIF group, 29% were discharged home, 37% to inpatient rehabilitation, 9% to skilled nursing facilities, and 14% to long term acute care facilities. In the TTC group, 9% were discharged home, 23% to inpatient rehabilitation, 60% to skilled nursing facilities, and 9% to long term acute care facilities. After adjusting for CCI, there was no difference in discharge destination based on fixation construct (p = 0.532). (Table 2).
Table 2.
Discharge destination following surgical admission, with ordinal Regression analysis by construct and Charlson Comorbidity Index
| Discharge destination | ORIF (n = 35) | TTC (n = 35) | ||
|---|---|---|---|---|
| Home | 10 (28.6) | 3 (8.6) | ||
| Inpatient rehabilitation | 13 (37.1) | 8 (22.9) | ||
| Skilled nursing facility | 3 (8.6) | 21 (60.0) | ||
| Long term acute care | 5 (14.3) | 3 (8.6) |
| Adjusted OR | 95% Lower CI | 95% Upper CI | P | |
|---|---|---|---|---|
| TTC construct | 1.425892 | 0.4800544 | 4.235284 | 0.532 |
Overall covariate balance was improved after adjustment for confounders utilizing 1:1 matching for outpatient surgery status, neuropathy, and CCI (Fig. 3). 21 patients were included in each cohort for final analysis. The matched cohort characteristics are presented in Table 3. There were no significant differences between matched groups except for time to weightbearing status. Patients with TTC were allowed to weight bear sooner than ORIF (1.5 wks versus 9.7 wks; p < 0.001). There were two nonunions in the ORIF group and none in the TTC group (p = 0.469). There was one instance of implant failure in the ORIF group and none in the TTC group (p = 0.999). There were two reoperations in both the ORIF group and TTC group (RR 1 [95% CI 0.155, 6.451], p = 0.999). Deep infection occurred in one patient in the ORIF group and two in the TTC group (RR 0.5 [95% CI 0.049, 5.103], p = 0.999). Mortality within 90 days occurred in one patient in both the ORIF group and TTC group (RR 1 [95% CI 0.067, 14.954], p = 0.999) (Table 4). Of the four reoperations in the matched cohort, both TTC reoperations were debridement with implant retention for deep infection. One patient in the ORIF group underwent multiple debridements for infection and ultimately transtibial amputation. One patient in the ORIF group underwent hardware removal for screw loosening and implant irritation.
Fig. 3.
Love plot demonstrating improved covariate balance after propensity score matching with a threshold standardized mean difference of 0.2
Table 3.
Propensity matched cohort characteristics. All counts are represented as n (%), unless otherwise specified
| ORIF (n = 21) | TTC (n = 21) | p | |
|---|---|---|---|
| Outpatient Surgery | 5 (23.8) | 4 (19.0) | 1 |
| Male sex | 7 (33.3) | 4 (21.1) | 0.607 |
| Age, years | 70.01 (7.74) | 77.74 (10.29) | 0.009 |
| Time to Surgery, days [mean (SD)] | 3.48 (2.54) | 4.74 (5.01) | 0.315 |
| Length of Stay, days [mean (SD)] | 4.07 (1.69) | 6.06 (6.16) | 0.252 |
| Time to WBAT Rx, weeks [mean (SD)] | 9.66 (2.66) | 1.49 (2.58) | < 0.001 |
| Follow-up, weeks [mean (SD)] | 41.46 (51.59) | 25.56 (19.67) | 0.194 |
| Open Fracture | 2 (9.5) | 4 (19.0) | 0.659 |
| Fracture Dislocation | 10 (47.6) | 15 (71.4) | 0.209 |
| Smoker | 1 (4.8) | 1 (4.8) | 1 |
| BMI [mean (SD)] | 25.43 (7.72) | 28.36 (5.38) | 0.175 |
| Neuropathy | 2 (9.5) | 3 (14.3) | 1 |
| Charlson Comorbidity Index [mean (SD)] | 5.52 (2.14) | 5.33 (1.80) | 0.756 |
WBAT, weightbearing as tolerated prescription; EBL, estimated blood loss; BMI, body mass index
P values in bold indicate statistical significance (p ≤ 0.05)
Table 4.
Complications stratified by construct in propensity matched cohorts. RR – risk ratio
| ORIF (n = 21) | TTC (n = 21) | Lower | Upper | p | ||
|---|---|---|---|---|---|---|
| n (%) | n (%) | RR | ||||
| Nonunion | 2 (9.5) | 0 (0.0) | NA | 0.469 | ||
| Implant Failure | 1 (4.8) | 0 (0.0) | NA | 0.999 | ||
| Reoperation | 2 (9.5) | 2 (9.5) | 1 | 0.155 | 6.451 | 0.999 |
| Deep Infection | 1 (4.8) | 2 (9.5) | 0.5 | 0.049 | 5.103 | 0.999 |
| Death | 1 (4.8) | 1 (4.8) | 1 | 0.067 | 14.954 | 0.999 |
Discussion
The complication rate among geriatric patients undergoing surgical treatment for ankle fractures with traditional constructs is high [1, 2]. The purpose of this study was to compare outcomes between ORIF and TTC nailing in the treatment of acute, geriatric ankle fractures. One of principal goals in geriatric fracture care is early mobilization. Earlier weightbearing is often cited as an advantage of hindfoot nailing, yet many comparative studies do not include the time to weightbearing in their statistical analyses [10, 11]. Furthermore, while discharge disposition has been well studied in arthroplasty and hip fracture populations, there are no published studies evaluating discharge disposition between TTC nailing and ORIF in the treatment of geriatric ankle fractures. The current study found similar complication rates between the two constructs, despite allowing significantly earlier weightbearing in the TTC group, with patients in the TTC group initiating weightbearing at less than two weeks on average, while ORIF patients were delayed on average approximately 10 weeks. Patients who underwent TTC nail fixation in this study were older and had a higher burden of comorbidity. Despite earlier weightbearing, patients with TTC nail fixation did not have a higher rate of home discharge or improved discharge disposition. Many patients in either group were discharged to inpatient care facilities or long-term acute care facilities, indicating poor postoperative mobilization. It is possible that even a two-week delay on weightbearing prescriptions prevented these patients from achieving more favorable discharge dispositions with TTC nail fixation.
Regarding the use of TTC nail fixation in geriatric ankle fractures, varying complication rates have been cited in the literature, although much of the data remains heterogenous. A single published prospective, randomized controlled trial comparing these two fixation methods at this time reports favorable outcomes for hindfoot nail fixation, but excluded patients with open fractures, diabetic angiopathy, and severe peripheral vascular disease [11]. Peripheral vascular disease, venous insufficiency, and peripheral neuropathy are known predictors of high complication rates in patients over the age of 60 undergoing operative treatment of ankle fractures [2]. These were not exclusion criteria in the current study, as conditions associated with impaired healing and soft tissue compromise are often indications for hindfoot nailing. Large et al. reported no significant differences in complication rates between ORIF and TTC nailing but, unlike the current study population, observed no differences in medical risk factors between groups except for a higher prevalence of diabetes in the TTC group. Additionally, their median time to weightbearing was longer in the TTC group (9.5 weeks) compared with the ORIF group (8 weeks). Conversely, patients in this study were allowed to weight bear early without increased complications, despite being older and having a significantly higher Charlson Comorbidity Index (CCI).
The association between nonhome discharge and higher postoperative complication risk is well established in the arthroplasty and hip fracture literature but remains poorly studied in ankle fractures [12, 13]. Fibular nails have been associated with lower rates of increased care needs and higher likelihood of returning home compared with ORIF [9]. A study of one-year mortality in geriatric ankle fracture patients found no difference between those admitted to nursing homes and those who were not [14]. Immediate weightbearing following ORIF is increasingly being studied and has been associated with a lower rate of discharge to rehabilitation facilities compared with non-weightbearing patients [7, 15, 16]. However, the effect of immediate weightbearing on traditional plate and screw constructs in the setting of diabetes or osteoporosis has not been studied. While the TTC nail patients in this study were allowed to weightbear early at an average of 1.6 weeks, they did not have a significant difference in discharge disposition. Further study is required to determine if there is a correlation between early weightbearing in the geriatric population and postoperative functional or mobility outcomes.
There are significant limitations to this study. The retrospective nature and highly heterogenous population lead to significant selection bias. The authors acknowledge the significant differences in sample characteristics and attempted to combat this with propensity matched cohorts based on inpatient admissions, CCI, and neuropathy. However, propensity matching leads to diminished sample sizes, and thus the statistical analysis may be underpowered to detect a true difference in complication rates between groups. Specifically, this study is at risk for type II error and may be underpowered to detect clinically meaningful differences in complications, infection, or mortality. Additionally, only discharge destination was collected, but inpatient mobilization status with therapy, capability of ambulation and transfers, or patient reported outcome measures were not collected. TTC nail patients were often kept nonweightbearing for a two-week period to allow for plantar incision healing. This may have contributed to poor discharge disposition, as these patients would continue to require transfer assistance to maintain nonweightbearing status, similarly to the traditional fixation construct cohort. Further study is required to detect more subtle differences in postoperative outcomes regarding mobilization. Additionally, this study does not investigate long term functional outcomes or patient reported outcome measures. Thus, conclusions regarding the long-term safety of the use of unprepped hindfoot nail fixation cannot be made. More study is required to determine the sequelae or functional deficits induced by removing tibiotalar and subtalar motion from the geriatric ankle fracture population.
Despite these limitations, this study presents the results of an aggressive early weightbearing protocol for geriatric patients with rotational ankle fractures treated with TTC nail fixation. While frail patients at high risk for medical complications from immobilization may benefit from a more aggressive surgical approach to optimize weightbearing status, the current data did not demonstrate an improvement in discharge disposition with the use of TTC nail fixation. Patient wishes and limitations of TTC nail fixation must be carefully weighed and discussed with patients, as isolated TTC nail fixation does not allow for an anatomic reduction and eliminates tibiotalar and subtalar motion. Further study regarding the long term prognosis and functional outcomes of hindfoot nail fixation is required to elucidate the long term risks of this fixation strategy. A careful and thoughtful approach must be utilized when treating ankle fractures in an increasingly frail and comorbid elderly population.
Conclusion
TTC nailing in geriatric patients with unstable ankle fractures permits earlier weightbearing without increasing short-term complications compared to traditional fixation, despite being utilized in a more medically complex population. However, TTC fixation did not appear to independently influence discharge outcomes following inpatient admission, highlighting the multifactorial nature of postoperative recovery and disposition in this population. TTC fixation represents a viable alternative for select high-risk patients, though further investigation is needed to define its long-term outcomes.
Author contributions
D.H. contributed to study design, performed data collection, figure preparation, and authored the manuscript. L.V. contributed to study design, statistical analysis, tables and figure preparation, manuscript drafting, and data collection. A.W. and A.N. contributed to data collection. T.H. contributed to study design and reviewed the manuscript. R.K. contributed to study design and reviewed the manuscript. C.M. served as corresponding author and primary investigator. All authors reviewed and approved the final manuscript.
Data availability
The data supporting this study were obtained from de-identified protected health information within the electronic medical record and are not publicly available due to institutional restrictions.
Declarations
Conflict of interest
Ravi A. Karia is a paid consultant and speaker for Zimmer Biomet and Smith & Nephew. The remaining authors declare no conflicts of interest.
Footnotes
Publisher’s Note
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this study were obtained from de-identified protected health information within the electronic medical record and are not publicly available due to institutional restrictions.