A multi-centre assessment of hind foot nail or fibula protubule screw fixation in complex ankle fractures. Low energy ankle fractures sustained in elderly patients draw parallels with elderly hip fractures. Early post-op ambulation is key. To achieve this there needs to be surgical techniques that achieve strong robust fixation with a high degree of stability. Traditional standard AO fracture fixation may not be able to achieve adequate hold. Our aim was to review the outcomes of patients with complex ankle fractures which were treated with either a hind foot nail or fibula protubule screws. We carried out retrospective evaluation of patients from four large trauma centres in the UK. These patients had sustained AO44A, B or C ankle fractures which required fixation with either a hind foot nail or protubule screws. Protubule screws was defined as three or more screws crossing the fibula into the tibia. Pelon fractures, standard AO fixation and conservative management were excluded. The following patient outcomes were collected undergoing subgroup analysis. Our results were as follows. Looking first at overall demographics. Of the 135 patients, 87 were fixed with a hind foot nail and 48 with protubule screws. Hind foot nail patients were older, had a higher Charleston index score and a lower estimated 10 year survival rate. Most patients sustained an AO type B fracture pattern. When comparing genders, protubule screw fixation was not selected for those with dementia. Hind foot nail fixation was selected for those with a greater Charleston index score regardless of their gender, consequently resulting in a lower 10 year survival rate. A greater number of open fractures were fixed with a hind foot nail with an older female predominance. Females fixed with a hind foot nail had the greatest reduction in independent mobility. Protubule screw patients were more likely to be independently mobilising pre-operatively. Hind foot nail fixation results in a quicker return to fully weight bearing in both males and females when compared to protubule screws. We then specifically looked at the role of diabetes. When compared to their protubule screw counterparts, both diabetic and non-diabetic patients fixed with a hind foot nail were older, more cognitively impaired and had a higher Charleston index score. Diabetes was noted to be the single largest comorbidity. Superficial infections were more likely in diabetics fixed with a hind foot nail. However, non-diabetic patients fixed with protubule screws had a greater number of superficial and deep infections compared to non-diabetic patients fixed with a hind foot nail. Metalwork failure and wound breakdown were observed to be greater in diabetic patients fixed with a hind foot nail. VTE is a specific technique risk of hind foot nail fixation that is more common in diabetics. Open and closed fractures were then compared. Open fractures with protubule screw fixation had a higher rate of metalwork failure. There was a greater VTE risk in both open and closed hind foot nails fixation method. Patients with age and frailty matched. Firstly, 75 to 89 years old with a Charleston index score of 3 to 8. Hind foot nail fixation carried a higher rate of post-op mortality in those over to 75 years old. We then matched for the younger age group of 60 to 75 years old, again with a Charleston index score of 3 to 8. In this match group, fixation with a hind foot nail carried an increased risk of superficial infections and mortality. On reviewing mortality, it should be noted that there were no post-operative deaths in the protubule screw group. Fractures, both open and closed, fixed with a hind foot nail carried a greater than 30% mortality within 18 months. Patients with open fractures, dementia and a higher Charleston index score were more likely to die. To summarise, complex fractures are more likely to occur in elderly female patients, usually being an Aotype B fracture. Diabetes and open fractures had a significant prevalence. Hind foot nail fixation was more likely in older comorbid patients, with fixation resulting in a higher rate of superficial infections, VTE and post-operative mortality. The increased morbidity risks were found to be independent of age. Early post-op weight bearing and return to mobility was seen in hind foot nail fixations, and a greater metalwork failure was seen in open fractures affixed with protubule screws. In conclusion, fixation using a hind foot nail carries a higher risk of morbidity and mortality. The presence of diabetes leads to an even greater risk of deep infection and wound breakdown. Based on our current findings, we would consider carefully the use of a hind foot nail as a first-line method of fixation for closed ankle fractures, where an alternative fixation is possible. Further prospective or randomised controlled studies are needed to help define the best practice in complex ankle fractures. Thank you for listening.

hind foot nail

complex ankle fractures

superficial infections

venous thromboembolism

alternative fixation methods