Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired.

We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility.

This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile.

Introduction

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. The incidence of fragility ankle fractures is currently estimated to be around 150 per 100,000 people annually and is anticipated to rise to around 269 per 100,000 by 2030. The aim of surgery is to restore mobility, preserve function and to prevent complications related to non-weight-bearing and the application of hind foot nail (HFN) seems to provide these advantages. This systematic review aims to investigate the role of HFN in the treatment of fragility ankle fractures. We aim to review the available evidence published on the functional recovery observed in patients following treatment with HFN and the observed complications in the literature.

Ankle osteomyelitis after open pilon-fractures remain one of the most challenging scenarios. Ankle-fusion using an external frame is a classical option but in some cases of non-compliance patients could be not ideal. The purpose of this report was to evaluate our results using a new staged salvage protocol in cases where an external-frame arthrodesis is not recommended due to the issue of a non-compliance patient. During the first stage we resect all the infected tissues and an antibiotic-loaded cement spacer is used to obliterate the dead space, to reach some kind of stability and to achieve a high concentration of local antibiotic. A free or keystone flap is used if needed and a posterior splint is placed. After a course of targeted systemic antibiotics the second stage is schedule. During the second stage after the spacer removal, a self-made antibiotic coating retrograde hindfoot arthrodesis nail is used in order to achieve ankle fusion. We use a bone-substitute loaded with gentamicin (Cerament-G®) to fill the bone defects and to achieve high concentration of local gentamicin, to protect bone healing and to decrease the risk of relapse. We present four patients with ankle-osteomyelitis after open pilon fracture treated by such protocol. We receive all patients > 6 months after the initial fracture. In all cases type III-B open pilon fracture was the initial injury. All the patients presented psychological disturbances and the possibility of perform an external frame reconstruction was considered not indicated. At presentation, all patients have compromised skin around the distal tibia area. According to the Cierny/Mader osteomyelitis classification all patients were Type IV-Blocal. Compromises soft tissues were treated with an ALT free flap in two cases and with a Keystone flap in two cases. 10 mL paste of Cerament-G® was used in each case with a single case where a white-draining event was present without further complication. Tibiotalocalcaneal fusion was achieved after 4 months in all cases. At average of 7 months of follow-up, none of the four fused ankles has required further surgery and no infection relapse was observed. The use of this salvage treatment protocol has proven safe and useful for such difficult problem in these difficult patients, with a relatively low associated complication rate. Cerament-G® is a useful tool in order to fill all the bone voids, promote bone healing and simultaneously to protect the surgical area due to the high local concentration of gentamicin

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures

Introduction. Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC). Materials & Methods. This cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed. Weightbearing status over the treatment course was monitored. Patient frailty was measured using the clinical frailty score (CFS). Results. There were 35 patients, mean age 77 years (range 65–97 years), 86% female. Mean length of admission in the MTC was 26.4 days (range 3–78). Most (94%) had a low-energy mechanism of injury. Only 57% of patients underwent one-stage surgery (ORIF n=15, hindfoot nail n=1, external frame n=4) with 45% being permitted to fully weightbear (FWB). Eleven (31.4%) underwent two-stage surgery (external fixator; ORIF), with 18% permitted to FWB. Of those patients with pre-injury mobility, 12 (66%) patients were able to FWB following definitive fixation. Delay in weightbearing ranged from 2–8weeks post-operatively. Seven patients (20%) underwent an initial Orthoplastic wound debridement. Ten patients (28.6%) required plastic surgery input (split-skin grafts n=9, local or free flaps n=3), whereby four patients (40%) underwent one stage Orthoplastic surgery. Eighteen (51.4%) patients had a CFS ≥5. Patients with a CFS of ≥7 had 60% 90-day mortality. Only 17% patients had orthogeriatrician input during admission. Conclusions. These patients have high frailty scores, utilise a relatively large portion of resources with multiple theatre attendances and protracted ward occupancy in an MTC. Early FWB status needs to be the goal of treatment, ideally in a single-staged procedure. Poor access to orthogeriatric care for these frail patients may represent healthcare inequality

Introduction. Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame. Materials and Methods. We treated 4 geriatric (3 female and 1 male) patients with Gustillo-Anderson III B fractures of the tibia between 2017–18. All were unfit to undergo orthoplastic procedures (free flap or local flaps). The age range is 69 yrs to 92 years. Co-morbidities included severe rheumatoid arthritis, multiple sclerosis and heart failure. The procedure involved wound debridement, application of two ring Taylor Spatial Frame, acute deformation of the limb on the table to achieve soft-tissue closure/approximation. Regular neurovascular assessments were performed in the immediate post-operative period to monitor for compartment syndrome and nerve compression symptoms. After 7–10 days of latent period, the frame was gradually manipulated, according to a method we had previously published, to achieve anatomical alignment. The frame was removed in clinic after fracture healing. Results. Time in frame ranged from 1.5 months to 7 months. In one patient (92 yr old with an open fracture of the ankle) hindfoot nail was inserted after soft-tissue closure was achieved at 1.5 months, and frame removed. We achieved complete healing of soft tissue wounds without any input from plastic surgeons in all patients. All fractures healed in anatomical alignment. 3 patients had one episode of superficial pin infection each requiring 5 days of oral antibiotics. None of the patients developed a deep infection. Conclusions. Acute intentional deformation (AID) with Taylor Spatial Frame achieves good closure of soft tissues in physiologically compromised geriatric patients who were deemed unfit for plastic surgery. We also achieved fracture healing in all four cases without any major complications

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study. All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability