Long hindfoot nail fixation using standard tibial nails for elderly ankle and distal tibia fractures

Fragility ankle and distal tibia fractures in the elderly population present a complex clinical situation, due to the poor bone quality, soft tissue condition and medical comorbidities in this age group. This study aims to assess the outcome of long hindfoot nail fixation using standard tibial nails in managing these injuries. This is the largest and possibly first study to date of this implant used in ankle trauma hindfoot fixation.

This was a retrospective observational study across two level 1 major trauma centres in the United Kingdom, from January 2019 to December 2024. Patients included were above the age of 60 years, with acute ankle or distal tibia fractures and underwent long hindfoot nail fixation with standard tibial nails. Postoperative complications, early weightbearing and mortality rates were assessed.

A total of 36 patients were included, of which 44.4 % were malleolar fractures, 38.9 % distal tibia extra-articular fractures, and 16.7 % distal tibia intra-articular fractures. Half of the cases were open fractures. There were no cases of periprosthetic fracture, re-fracture, fixation or implant failure. There were six (16.7 %) postoperative complication cases, of which only one (2.8 %) was deemed a major complication; re-operation for removal of proximal locking bolt due to infection. 88.9 % were able to full weightbear within 30 days after surgery. The mortality rate was 8.3 % at 30 days and 16.7 % at 1 year.

The use of standard tibial nails, a universally available and feasible implant, for long hindfoot nail fixation in fragility ankle and distal tibia fractures is a safe and reliable treatment option, with a success rate of 97.2 % without major complications. They permit early weightbearing and provide a stable construct with reduced risk of periprosthetic fractures and fixation failure. The mortality rate was comparable to fragility hip fractures, highlighting the medical complexity of patients with these injuries.