OBJECTIVE: To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre.
METHODS: Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate. Exclusion criteria were patients that died or were lost to follow-up and cases in which the nail was used in a chronic setting, such as malunion and non-union. Main parameters evaluated were fracture union, complications and functional outcomes. The functional outcome was assessed using the Olerud-Molander Ankle Score (OMAS). The minimum follow-up was 12 months.
RESULTS: Thirty-two consecutive patients (12 males) with a mean age of 80.2 years (range 66-98) met the inclusion criteria and formed the basis of this study. Fracture union was achieved in 93.8% of the cases at a mean time of 3.9 months (range 2-8). Two patients developed surgical site infections and underwent reoperation before union. The overall complication rate was 25.1%, while the respective reintervention rate was 18.8%. In terms of functional outcomes, the mean OMAS score was 45, ranging from 20 to 70.
CONCLUSIONS: Tibiotalocalcaneal nailing can be considered as an acceptable less invasive option with good functional outcomes for the treatment of complex distal tibia and ankle fractures in frail patients with problematic local soft tissues.

Reconstruction options for giant cell tumors (GCTs) of bone are limited and challenging due to the amount of structural compromise and the high recurrence rates. This is especially true for GCTs of the foot and ankle, as the area is vital for weight bearing and function. The typical treatment for GCTs is currently excision, curettage, and cementation, although that is not always effective. A 36-year-old otherwise healthy female presented with an original diagnosis of a large aneurysmal bone cyst (ABC) of the distal tibia that had recurred despite two previous attempts at treatment with resection and cementation. She was treated with surgical resection of the lesion, reconstruction, and ankle and subtalar joint arthrodesis with a tibiotalocalcaneal intramedullary nail in combination with a trabecular metal cone. The final pathology of the intraoperative samples was consistent with GCT. Postoperatively, she recovered well, and her imaging was consistent with a successful fusion. This case report provides evidence that tibiotalocalcaneal fusion with a unique combination of hindfoot nail and trabecular metal cone construct in a single procedure is a successful option for the treatment of large, recurrent GCT lesions in the distal tibia.

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.

UNASSIGNED: Ankle fractures are a common orthopedic injury traditionally treated with open reduction and internal fixation or conservative management. One complication introduced with open reduction and internal fixation is the requirement for non or partial weight bearing in the post-operative period. This requirement poses a unique challenge for patients who may not comply with these weight-bearing restrictions. This case is the first known article that specifically illustrates the validity and effectiveness of retrograde tibiotalocalcaneal (TTC) nailing for patients who are unlikely to follow weight-bearing restrictions.
UNASSIGNED: An 83-year-old Caucasian female with idiopathic mild mental retardation and Alzheimer\'s presented with a minimally displaced trimalleolar ankle fracture and was treated at a single urban hospital with a retrograde TTC nail secondary to her inability to adhere to weight-bearing restrictions post-operatively. Pertinent demographic, clinical, radiographic, and surgical data were collected. The patient had minimal post-operative pain, was able to bear weight on the day of surgery, and had no post-operative complications.
UNASSIGNED: This case report demonstrates that the use of a TTC nail is a safe and effective mode of fixation for ankle fractures in patient populations who may not adhere to weight-bearing restrictions post-operatively. The main benefits of fixation with a TTC nail are the ability to weight bear as tolerated post-operatively and decreased wound complications while having similar functional outcomes to open reduction and internal fixation. We suggest the use of TTC nails for ankle fractures in select patients who may not adhere to weight-bearing restrictions post-operatively.

BACKGROUND: Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. 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.
METHODS: A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients\' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS).
RESULTS: Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 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).
CONCLUSIONS: TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.

Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weightbearing. We performed a retrospective observational review of patients >65 years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, postoperative mortality, complications, and further treatment. The primary outcome was reoperation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty-three out of 70 patients were female. The average age of those who died within 1 year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days postsurgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.

There has been increasing interest in the use of hindfoot tibiotalocalcaneal (TTC) nails to treat ankle and distal tibia fractures in select patient populations who are at increased risk for soft tissue complications after open reduction and internal fixation with traditional plate and screw constructs. We describe a technique which uses a retrograde femoral nail as a custom length TTC nail. By using a simple modification of the insertion jig, we are able to achieve safe screw trajectories that allow for robust distal interlocking fixation. Review of implantation in multiple cadaveric specimens demonstrates safe placement of distal screw fixation in the calcaneus without risking injury to important neurovascular structures. Because of the 2-cm incremental length options of this particular device, we are able to achieve supraisthmal fixation in the tibia which may lessen the risk for fracture that may be more likely to occur at the tip of a short TTC nail option. Furthermore, a custom length TTC nail is more costly and also requires advanced notice to acquire for the case; retrograde femoral nails are readily stocked and accessible at our level 1 trauma center. This TTC technique offers anatomic restoration while also offering convenience, instrument familiarity, cost savings, and increased patient safety.

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.

OBJECTIVE: Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up.
METHODS: We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70).
RESULTS: The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) - Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS).
CONCLUSIONS: The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190-6.