Foot and Ankle Surgery 29 (2023) 588–592

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Foot and Ankle Surgery

journal homepage: www.journals.elsevier.com/foot-and-ankle-surgery

Hindfoot nailing without joint preparation for ankle fractures in

extremely elderly patients: Comparison of clinical and patient-reported ]]
]]]]]]
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outcomes with standard ORIF

⁎
Snir Balziano, Isaac Baran, Dan Prat
Department of Orthopaedic Surgery, Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel, Affiliated with the Faculty of Medicine of Tel-Aviv
University, Ramat-Aviv, Tel-Aviv, Israel

a r t i cl e i nfo a bstr ac t

Article history: Introduction: Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative
Received 12 May 2023 to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We
Received in revised form 25 June 2023 hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can
Accepted 2 July 2023
provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF.
Methods: A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in
Keywords:
patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique:
Tibiotalocalcaneal nail
TTC ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the pa­
Ankle fracture tients’ charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires
PROMs included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS).
Fragility Results: Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28
Elderly in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the
TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of
stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the
TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups
respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as
well as the OMAS (60.0 versus 32.8, p = 0.029).
Conclusion: TTC nailing without joint preparation for unstable fragility fractures of the ankle in the ex­
tremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were
inferior.
© 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction retrograde intramedullary nail without joint preparation has been

Clinical reports have demonstrated a considerable increase in the
incidence of unstable ankle fractures in the elderly over the previous
few decades [1]. Compared to the young population treated with
conventional open reduction and internal fixation (ORIF), managing
ankle fractures in the elderly is challenging and less predictable [2].
Owing to multiple comorbidities and decreased bone density, com­
plication rates are high and include surgical wound infection and
failure of fixation [3]. Tibiotalocalcaneal (TTC) stabilization with a
⁎
Correspondence to: Department of Orthopaedic Surgery, Chaim Sheba Medical
Center, Tel-Hashomer, Ramat Gan, Israel, 52621, Affiliated with the Faculty of
Medicine of Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
E-mail address: prat.dan@gmail.com (D. Prat).
described as a primary surgical option for fragility fractures of the
ankle. On the one hand, it employs a less invasive method that
avoids substantial soft tissue dissection, while on the other hand, it
provides stiff internal fixation permitting early weight-bearing. The
latter may improve functional outcomes [4], and reduce the risk of
potential issues induced by prolonged bed rest. Recent work on TTC
nailing without joint preparation has mostly consisted of small study
series [5–8], of which only a few included a comparison group [9].
The evidence supporting TTC nailing in certain subgroups is still
lacking, especially in direct comparison to ORIF. Furthermore, the
present study aims to shed light on the outcome of ORIF and TTC
nailing in the extremely elderly age group [10]. In the present study,
we compared perioperative parameters, clinical outcomes, and pa­
tient-reported outcomes (PROMs). We referred to the “biological
age” rather than only the chronological age and included a

https://doi.org/10.1016/j.fas.2023.07.001
1268-7731/© 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

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S. Balziano, I. Baran and D. Prat Foot and Ankle Surgery 29 (2023) 588–592

comorbidity index [11]. We hypothesized that primary hindfoot

nailing without joint preparation, and immediate weight bearing can
provide a safe and effective treatment for unstable fragility fractures
of the ankle compared to ORIF.

2. Methods

A retrospective, single-center, comparative study. Institutional

review board approval was obtained by the institutional Helsinki
committee before the study began.

2.1. Patients

The data on patients over 75 years of age who were surgically

treated for unstable ankle fractures between January 1, 2016, and
December 31, 2021, were reviewed. Exclusion criteria included re­
vision surgeries, high-energy mechanism of injury, and oncologic Fig. 1. Flowchart of dataset selection, inclusion, and exclusion. Abbreviations: ORIF –
pathological fractures. Unstable ankle fractures were defined as bi- Open reduction internal fixation; TTC – Tibiotalocalcaneal nailing.
malleolar or bi-malleolar equivalent fractures and tri-malleolar
fractures, with disruption of the ankle mortise on plain x-rays and/or
on stress images [12]. We identified patients using the International
Classification of Diseases, 9th Revision, Clinical Model (ICD-9-CM)
coding for ankle fractures (Code 824) and derivatives. We confirmed
the diagnosis with a review of medical records and preoperative
radiographs. Fractures were classified according to the 2007 AO/OTA
fracture classification [13]. We confirmed the surgical treatment by
comparing the Current Procedural Terminology (CPT) codes, surgical
notes, and intraoperative and postoperative radiographs. Patient
demographics including age, sex, Charlson-Comorbidity-Index CCI
[11], and the American Society of Anesthesiologists Physical Status
Classification System (ASA), were collected. Other categorical vari­
ables included pre-operative ambulation and BMI. Outcome para­
meters included complication rates, revision rates, and PROMs. Fig. 2. Ankle radiographs of an 82-year-old female patient following hindfoot nailing
of a fracture dislocation of the right ankle.
2.2. Surgical technique

Fellowship-trained orthopedic trauma surgeons or fellowship-

trained foot and ankle surgeons performed all surgeries. All proce­
dures were performed with the patient in a supine position and a
bumper under the ipsilateral hip, intravenous administration of
antibiotic (2 g Cefazolin or 1 g of Vancomycin), and a thigh tourni­
quet at 270–300 mm Hg. General anesthesia or spinal anesthesia
was selected according to the anesthesiologist’s recommendation.
Nail fixation was performed with the use of the Stryker T2™ Ankle
Arthrodesis Nail (Stryker, Kalamazoo, MI, USA) after closed reduction
under image intensifier guidance, percutaneously, a guide wire was
inserted into the tibial medullary canal from the plantar surface of
the heel, through the subtalar and tibiotalar joints. The tibial canal Fig. 3. Ankle radiographs of an 88-year-old female patient following hindfoot nailing
was reamed, but joint preparation was not performed. The TTC nail of a fracture dislocation of the left ankle.
was placed and secured with two screws proximally and two screws
distally, one fixed to the talus and the other to the calcaneus. A soft protected weight bearing in a controlled ankle motion (CAM) boot
dressing was applied (Figs. 2 and 3). Open reduction and internal for another four to six weeks.
fixation were carried out under the AO’s guiding principles, using a
medial and lateral ankle approach. With the use of an Arthrex
stainless steel ankle set (Arthrex, Naples, FL, USA), the medial mal­ 2.4. Assessment and outcomes
leolar fractures were reduced and fixed with two 4.0 mm cannulated
screws or with a combination of a buttress plate, and the fibular Major Complications included deep infection, hardware pullout,
fractures were fixed with an anatomic locking plate and 3.5 mm and nonunion, venous thromboembolic event (VTE), myocardial infarc­
2.7 mm screws. Below knee splint was applied. tion (MI), cerebrovascular accident (CVA), Arrhythmia (i.e., Atrial
flutter, atrial fibrillation), small bowel obstruction (SBO), excess
2.3. Post-operative care bleeding, and congestive heart failure (CHF). Minor complications
included superficial wound infection, painful hardware, residual
Weight-bearing, as tolerated immediately after surgery, was en­ hypoesthesia, delirium, pneumonia, urinary tract infection (UTI), and
couraged in the TTC group. In the ORIF group, patients remained bedsores. The following perioperative variables were also analyzed:
non-weight-bearing for two to six weeks followed by conversion to surgery time, postoperative ambulation status at discharge (data

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S. Balziano, I. Baran and D. Prat Foot and Ankle Surgery 29 (2023) 588–592

was extracted from physical therapy reports), and postoperative Table 2

length of stay. Fracture types. *p < 0.05.

ORIF TTC
2.5. PROMs n = 28 n = 18
N (%) N (%) p-value

We used two validated PROMs: The Foot and Ankle-Ability Open fractures 3 (10.7 %) 1 (5.6 %) 0.545
Measure Activity of Daily Living (FAAM-ADL) [14], and the Olerud- AO/OTA 0.594
A 2 (7.1 %) 1 (5.6 %)
Molander Ankle Score (OMAS) [15]. The questionnaires were con­
B 24 (85.7 %) 14 (77.8 %)
ducted over the phone with patients who are still alive and who C 2 (7.1 %) 3 (16.7 %)
have provided their informed consent.
Abbreviations: AO/OTA – Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic
Trauma Association Classification.
2.6. Statistical analysis
Table 3
Bivariate analysis of the two groups was performed using in­ Postoperative ambulation status.
dependent sample T-tests for the continuous variables and Pearson
Total (available) ORIF TTC
chi-square and Fisher exact test for the categorical variables. The p- n = 28(27) n = 18(15)
value of < 0.05 was considered significant. Statistical analysis was N (%) N (%) p-value
performed using the SPSS software package, version 26.0 (SPSS, IBM.
Postoperative ambulatory Ability 0.001*
Armonk, NY, USA). Free 11 (40.7 %) 0 (0.0 %)
Cane 6 (22.2 %) 1 (6.7 %)
3. Results Walker 9 (33.3 %) 8 (53.3 %)
Wheelchair 1 (3.7 %) 6 (40.0 %)

A total of 409 individuals were surgically treated for unstable *

p < 0.05.
ankle fractures within the studied period. A total of 46 patients were
included in the study after accounting for miss-coded cases, and ages versus 85.1 min (Range 20–200, SD ± 45) in the ORIF group
below 75 years old. Eighteen patients were treated by TTC nailing (p = 0.452). The difference in length of stay between the groups was
and 28 patients by ORIF (Fig. 1). The mean age of the TTC group was not statistically significant (10.7 days in the TTC group versus 7.0
significantly higher (88.6, Range 80–96, SD ± 4.6 versus 81.8, Range days in the ORIF group, p = 0.081).
75–91, SD ± 4.8. p < 0.001). Female gender was dominant in both The postoperative ambulation status of the groups was sig­
groups but with a higher rate of female patients in the TTC group nificantly different in favor of the ORIF group (Table 3). Within each
(p = 0.021). The mean CCI was higher in the TTC group: 5.3 (SD ± 0.9) group, the preoperative and postoperative ambulation status did not
versus 4.6 (SD ± 1.1) (p = 0.012). Moreover, the mean ASA score was change significantly (p = 0.158 in the TTC group and p = 0.537 in the
higher within the TTC group (3, SD ± 0.26 versus 2.6, SD ± 0.55) ORIF group).
(p = 0.014) The preoperative walking ability of the ORIF group was The overall complication rate was 50.0% in the ORIF group versus
significantly better than the TTC group (p = 0.010). (Table 1). The 22.2% in the TTC group (p = 0.060). The major complication rate was
average follow-up period was of 46.4 months (Median 49.5, found to be 5.6% in the TTC group versus 28.6% in the ORIF group
SD ± 25.3). (p = 0.055). Minor complication rates were 16.7% and 21.4% for the
Most fractures were closed fractures (90 % versus 85 %). The was a TTC and ORIF groups, respectively (p = 0.691) The revision rates were
similar distribution of fracture patterns in the two groups (p = 0.160) not statistically different. (p = 0.161) (Table 4).
(Table 2) The most common fracture pattern within both groups was
AO 44-B with 61.1 % within the TTC group and 85.7 % within the ORIF
group. 3.1. PROMs
The mean surgery time was statistically similar between the
groups with 84.8 min (Range 41–139, SD ± 27) in the TTC group In the ORIF group, four patients (14.2 %) had died and another
nine (32 %) were either unreachable or reluctant to take part. Five
Table 1 (27.7 %) patients passed away in the TTC group, and another seven
Demographics and baseline functional status. (38.8 %) were inaccessible. The patient characteristics of those who
ORIF TTC had lost to follow-up or were reluctant to participate were similar
n = 28 n = 18 between groups. OMAS was significantly higher in the ORIF group
N (%) N (%) p-value (60, SD ± 29) compared to the TTC group (32.8, SD ± 9.9) (p = 0.029).
Gender FAAM-ADL was 62 % on average (SD ± 28.9) in the ORIF group versus
Female 21 (75.0 %) 18 (100.0 %) 0.021* 32 % (SD ± 19.1) in the TTC group (p = 0.020).
ASA 0.009*
2 10 (37.0 %) 0 (0.0 %)
3+ 17 (63.0 %) 14 (100.0 %)
Diabetes Mellitus 5 (17.9 %) 5 (27.8 %) 0.426 Table 4
CCI 0.012* Revisions and complications rates. *p < 0.05.
3–4 15 (53.6 %) 3 (16.7 %)
ORIF TTC
5+ 13 (46.4 %) 15 (83.3 %)
n = 28 n = 18
Preop ambulatory Status 0.010*
N (%) N (%) p-value
Free 16 (59.3 %) 3 (18.8 %)
Cane 3 (11.1 %) 0 (0.0 %) Complications
Walker 7 (25.9 %) 10 (62.5 %) Minora 6 (21.4 %) 3 (16.7 %) 0.691
Wheelchair 1 (3.7 %) 3 (18.8 %) Majora 8 (28.6 %) 1 (5.6 %) 0.055
Total 14 (50 %) 4 (22.2 %) 0.060
Abbreviations: ASA – American Society of Anesthesiologists Physical Status
Revisions 8 (28.6 %) 2 (11.1 %) 0.161
Classification System; CCI – Charlson Comorbidity Index.
* a
p < 0.05. See text for minor and major complications definitions.

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S. Balziano, I. Baran and D. Prat
Table 5
Mean age and complication rates in literature.
ORIF
Author N Mean age (years) Complication rate (%)
Amirfeyz et al. [7]
Jonas et al. [27]
Ebaugh et al. [8]
Schray et al. [2]
Taylor et al. [6]
Georgiannos et al. [9] 44 77 33.3
Large et al. [28] 47 71 31.9
White et al. [20] 100 74 16
Lynde et al. [19] 216 70 17.6
Current study* 28 81.8 28.6
*
Major complications were included.
4. Discussion
This study compares clinical outcomes and PROMs of two
treatment strategies for unstable ankle fractures in the elderly. We
compared two groups of patients by the type of surgery: conven­
tional ORIF versus TTC nailing without joint preparation. The mean
age of the TTC group at the time of injury was 88.6, which is almost
ten years older than in most studies (Table 5). On that note, the
dominance of the female sex in the study can be explained by the
higher prevalence of osteopenia and osteoporosis in elderly women,
and the higher life expectancy of women in the general population
[16]. Additionally, by using a comorbidity index, we could consider
the “biological age” rather than the chronological age.
Management of fragility fractures in the elderly is difficult, re­
sulting in unsatisfactory outcomes [17]. These results may be related
to the associated comorbidities that come with age, soft tissue
status, and bone quality [18]. Litchfield et al. and Beauchamp et al.,
found a 19 % non-union rate and 23 % wound complication rate
[17,19] in ankle fragility fractures ORIF. Similarly, Lynde et al. and
White et al. have found 9.7 % and 16 % of wound complications
[20,21]. Regarding TTC nailing, Ebaugh et al. have reported a surgical
complication rate of 18.5 %, without malunions [8], which is similar
to the 16–20 % overall complication rate reported by Schray et al. [2]
and to a systematic review published by Cinats et al. [22]. With a
pooled complication rate of 28 %, a recent meta-analysis likewise
supports the same magnitude of complications [23]. In the present
study, we found similar or higher complication and revision rates.
The overall complications and the rate of major complications were
higher in the ORIF group (p = 0.060 and p = 0.055 respectively),
though not statistically significant. Georgiannos et al. compared the
outcomes of TTC and ORIF for fragility ankle fractures and reported
an 8.1 % versus 33.3 % complication rate in the TTC group versus an
ORIF group [9]. These results correspond with our study. We found a
major complication rate of 5.6 % in the TTC group versus 28.6 % in the
ORIF group. The revision rate in our cohort was higher in the ORIF
group, but not statistically significant (Table 4).
Immediate weight-bearing internal fixation devices and pros­
theses are the mainstays of the treatment of fragility hip fractures.
Similarly, early mobilization following other orthopedic trauma in
the elderly is of utmost importance, as reduced mobilization can
result in complications and increased mortality [24]. On the same
note, TTC nailing provides a rigid stable fixation that allows im­
mediate weight bearing after an ankle fracture. Recent randomized
controlled trials encourage immediate weight bearing following
ankle fracture ORIF [25]. However, we believe that early weight
bearing in the context of fragility fractures and poor bone quality
should be pursued with caution.
Contrary to the better complication profile, we found inferior
PROMs in the TTC group. The OMAS and FAAM-ADL were sig­
nificantly better in the ORIF group in the present study as in previous
591
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Foot and Ankle Surgery 29 (2023) 588–592
TTC
N Mean age (years) Complication rate (%)
13 78.9 7.6
31 77 0
27 66 18.5
58 77.7 20
31 63 9.7
43 78 8.1
14 68 21.4
18 88.6 5.6
publications. [9,26] However, in the TTC group, OMAS was lower
than previously reported [9,23,27], possibly because of the sig­
nificantly older age of our study group. In a recent study by Lu et al.
of TTC with joint fusion, OMAS scores were even lower [28].
It is worth noting that there was a significant difference in the
ambulation status of the two groups before the operation. A larger
number of patients in the TTC group used a wheelchair or walker
before surgery. Consequently, it can be observed that during the last
follow-up, 40.7 % of patients in the ORIF group were able to walk
without any aid (as opposed to 0 % in the TTC group), while only
3.7 % were confined to a wheelchair (compared to 40.0 % in the TTC
group) (Table 3). This may also assist in understanding some of the
differences in PROMs. Nevertheless, within each group, the pre­
operative and postoperative ambulation status did not change sig­
nificantly. The present study has several limitations. First, this study
is a retrospective single-center study with the inherited methodical
flaws of that design. Second, the low incidence of ankle fractures in
the extremely elderly population (10 % of all ankle fractures treated
in our institution during the study period) yielded a small number of
cases in both study groups. Moreover, the indication for choosing the
surgical technique may have been influenced by the surgeons’ pre­
ferences rather than clear clinical justification. Our inability to show
statistical significance in certain clinical outcomes is related to this
limitation and warrants further investigation. In total, only 54 % of
the patients in the ORIF group and 34 % in the TTC group completed
their PROM questionnaires. Drawing clear conclusions becomes
challenging with high dropout rates in extremely elderly patients.
This study is among the first to address medium-term clinical out­
comes and PROMs of ankle fractures in the extremely elderly po­
pulation. We believe that the present study sheds another light on
the debate in the management of fragility ankle fractures. The better
complication profile but the inferior PROMs of TTC versus ORIF
should be acknowledged in the decision-making process when
treating these patients.
5. Conclusion
In extremely elderly patients with unstable fragility ankle frac­
tures, early weight bearing, and minimal iatrogenic soft tissue injury
are important. TTC nailing without joint preparation offered better
mid-term outcomes compared to ORIF in terms of complications and
revision rates. However, PROMs were found to be inferior. These
findings provide valuable insights into surgical decision-making in
this unique subgroup.
Level of evidence III
Retrospective cohort study.
S. Balziano, I. Baran and D. Prat
Ethical approval
Institutional review board approval was obtained.
Informed consent
Informed consent was waived by the IRB.
Funding
None.
Conflict of Interest
All authors, their immediate family, and any research foundation
with which they are affiliated did not receive any financial payments
or other benefits from any commercial entity related to the subject
of this article.
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