Hindfoot Nailing for Surgical Management of Open Ankle Fractures in the Elderly: A Systematic Review

Open ankle fractures in the elderly are increasingly common, with significant morbidity and mortality. Management is challenging due to poor soft tissue conditions, comorbidities, and limited functional independence. While traditional surgical options include external fixation or open reduction and internal fixation (ORIF), hindfoot nail (HFN) fixation may offer advantages, including immediate weight-bearing and reduced immobilisation complications. However, no systematic review has assessed the outcomes of HFNs in managing open ankle fractures in this population. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Comprehensive searches of the Medline, CINAHL, Embase, and Cochrane databases were conducted on September 24, 2024, with inclusion criteria focused on studies involving HFN for open ankle fractures in patients aged ≥60 years. Outcomes included union rates, infection, complications, and functional recovery. Two reviewers independently performed data extraction and quality assessment (using the Newcastle-Ottawa Scale), with narrative synthesis due to study heterogeneity.  Five retrospective studies were included where open ankle fractures were treated with HFNs. Across studies, immediate post-operative weight-bearing was allowed in most cases. Union rates ranged from 85% to 100%. Infection rates varied between 6.3% and 17.9%, with implant-related complications noted in 18.7% of cases. Functional outcomes, where reported, were moderate, with scores such as the Olerud-Molander Ankle Score (OMAS) averaging 45-57 (62 preoperatively). Mortality at six to 12 months ranged from 15% to 61%. Compared to ORIF, HFNs demonstrated no difference in union rates or complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). HFNs utilised in arthrodesis resulted in increased wound complications, and implant removal reoperations compared to ORIF (10%-20% vs. 5%-10%) in frail patients with compromised soft tissues. HFNs used for fixation only resulted in similar complication rates to ORIF.  HFNs appear to be a viable option for managing open ankle fractures in elderly patients. Offering advantages such as immediate weight-bearing and reduced immobilization risks. However, higher rates of implant-related complications and variable functional outcomes warrant caution. Prospective, comparative studies are needed to better delineate the role of HFNs in this complex patient population.