Frail Ankle Fractures: Walking Sooner With Intramedullary Nailing

 

Hindfoot nailing gets frail, elderly ankle-fracture patients’ weight-bearing early without added complications, according to two retrospective studies. Long-term function remains unproven.

 

The clinical gap

 

These patients often can’t comply with non-weight-bearing instructions, ORIF is frequently unsafe for them, and casting also requires non-weight-bearing.

 

Study 1: 22 patients (mean age 79, all ASA 3 or higher) were nailed without joint preparation.



• All patients (100%) were fully weight-bearing from day one.

• Mean FAAM-ADL score in survivors was 33.8% (n=6).

• Complication rate was 14%, with no wound complications requiring surgery.

• One-year mortality was 32%, with no deaths related to the procedure.

 

Study 2: 130 patients aged 60+ were compared, 39 with tibiotalocalcaneal (TTC) nails versus 91 traditional constructs.

 

• Weight-bearing began at 1.6 weeks versus 9.8 (p < 0.001).

• Reoperation, implant failure, or deep infection rates did not differ.

• Home discharge rates were similar.

 

The catch

 

Function was scored in only six patients, so the long-term benefit is still unknown. Study 1’s 32% one-year mortality reflects the frailty of this population, not the procedure.

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Complex Tibial Pilon Fractures May Be Another Good Indication for Hindfoot Nails

 

The trade-off

 

Tibiotalocalcaneal (TTC) nailing is increasingly used for comminuted pilon fractures, but it fuses the subtalar joint. That cost has been hard to weigh without knowing how often the joint degenerates anyway.

 

Inside the study

 

Researchers reviewed 473 patients treated with open reduction and internal fixation (ORIF). X-rays were graded with the Kellgren-Lawrence and NSS systems, and CT scans, when available, with the CT Ankle Osteoarthritis (CTAO) system. Patients were grouped by the time from injury to their latest X-ray, from under 12 months to more than 48 months.

 

What the imaging showed

 

• X-ray arthritis grades were linked to age, smoking, steroid use, comorbidity burden, fracture classification, and time since injury.

• Patients imaged 25 or more months after injury had significantly higher arthritis grades than those imaged within 24 months.

• CT scores also correlated with age.

 

The takeaway

 

The subtalar joint often deteriorates after pilon fractures treated with ORIF. Sacrificing it with early hindfoot nailing may therefore matter less clinically than feared.

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Frail Does Early Weight Bearing After Anterior Talofibular Ligament (ATFL) Repair Actually Improve Outcomes?

by Vince Vacketta, DPM

 

A retrospective study published this month compared two techniques in 65 patients who underwent open ATFL repair. Thirty-four patients received an internal brace and began weight bearing (WB) immediately. The other 31 patients had a traditional repair and began WB in a cast two weeks after surgery.

 

By the numbers

 

Complications were significantly higher in the internal brace group:

 

• Five patients (14.7%) in the internal brace group developed an infection.

• One patient (2.9%) in that group had persistent instability, and one (2.9%) had implant malposition.

• In the traditional repair group, no patients developed an infection.

• One patient (3.2%) in that group had symptomatic knot irritation.

 

Is faster really better?

 

These findings raise a broader question about early WB:

 

• Have we lost the plot with early WB? 

• Is it truly supported by clinical outcomes, or is it simply easier to market to patients?

• Early WB may speed short-term recovery, but its long-term superiority remains unproven. 

• It also carries additional risk, so surgeons should critically evaluate whether faster rehabilitation makes enough of a difference to a patient’s outcome to justify that risk.