Ankle Fractures That Act Like Hip Fractures, and a New Treatment for Them — What Now?

Minimalist approaches can work for some patients, you just have to know which ones

I read the CORRelations post “Ankle Fractures That Act Like Hip Fractures, and a New Treatment for Them” with significant interest. This post points out the substantial morbidity associated with open ankle fractures in frail, older patients and the very real issues associated with placement of a long tibiotalocalcaneal (TTC) nail without preparation of the ankle or the subtalar joint for fusion. Although I’m an experienced, subspecialty trauma surgeon, prior to reading that post, I had never considered how similar these patients are to older patients with hip fractures in terms of what to expect after surgery — more than half of these patients with ankle fractures lost mobility, and more than 1 in 20 died within 3 months.

By contrast, I have noticed that the number of frail, older patients with complex ankle fractures seems to be increasing, and that locked fixation has not solved all our problems when it comes to treating them. The combination of poor-quality bone, confused patients who have trouble with recommendations to restrict weightbearing, and the many issues associated with loss of ambulation make these injuries in these patients tough to manage.

As Dr. Guyton pointed out in that CORRelations post, there are real problems associated with just throwing a TTC nail across an unprepared subtalar and ankle joint, and certainly we can’t expect those joints to fuse. But there are some patients in this frail group for whom this kind of minimalist approach is likely to work, and for them, it certainly beats the high risk of wound complications and reoperations we see when we perform ORIF in this setting, and it’s certainly the fastest way to get them walking again. There are no easy or obvious answers here.

I’m sure that future studies will try to help us identify which of these fractures (and which of these patients) are best treated primarily with a long TTC nail and without preparation of those joints for fusion, and this may reduce the long-term morbidity associated with these injuries.

Most importantly, all of us need to slow down and ask “what is best for this specific patient” when faced with an older patient who has an open ankle fracture rather than simply defaulting to ORIF. If the injury is severe, the patient is frail, and we know that conventional ORIF is likely to result in complications (as though it were a hip fracture!), we should be open to treatments like a long TTC nail, as suggested.