The use of tibiotalocalcaneal nails for unstable ankle fractures in low demand elderly patients has been introduced as an alternative to open reduction internal fixation to allow early weight-bearing and to decrease soft tissue complications and mechanical failures. This paper describes the technique of hindfoot nailing and reviews the current literature. Overall, it is a minimally invasive and expeditious procedure that provides stable fixation to withstand immediate ambulation of the frail elderly patient. Future high-quality randomized controlled trials will determine if complications and outcomes compare favorably to open reduction and internal fixation.

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.