Why Fibular Nailing Can Be an Efficient Treatment Strategy for AO Type 44-B Ankle Fractures in the Elderly

The reference standard treatment of unstable AO type 44-B ankle fractures is open reduction and internal fixation. However, delayed-staged surgery because of compromised soft tissues results in prolonged hospitalization and increased total healthcare costs in the elderly (age ≥65 years). The aim of the present study was to measure the efficiency of intramedullary fibular nailing (IMFN) in the elderly. A prospective series of 15 elderly patients with an AO type 44-B ankle fracture treated with IMFN were compared with a retrospective cohort of 97 elderly patients treated with plate and screw osteosynthesis (PSOS). Clinical and process-related variables and total healthcare costs, including 5 cost categories, were assessed. Functional outcomes, general health status, and quality of life were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot and EuroQol 5-dimension 3-level visual analog scales. Although the preoperative length of stay was significantly shorter for the patients treated with IMFN, the total length of stay and total healthcare costs were not significantly different between the 2 groups. The complication and reintervention rates were similar in both groups, with improved American Orthopaedic Foot and Ankle Society scale scores in the IMFN group. Compared with delayed-staged surgery, early IMFN led to a significant reduction in total healthcare costs. We could not prove significant cost savings for IMFN compared with PSOS for the treatment of AO type 44-B ankle fractures. However, early IMFN was financially beneficial compared with a delayed-staged (IMFN and PSOS) surgery protocol. Because, ultimately, IMFN allows for early percutaneous fixation in most cases, IMFN is a potentially profitable treatment strategy for AO type 44-B ankle fractures in the elderly with good outcomes.