Hindfoot Nailing for Ankle Fractures in High-Risk Elderly Patients: A Retrospective Analysis of Clinical and Radiological Outcome

Background Hindfoot nailing (HFN) is an established surgical technique for ankle fractures, particularly in high-risk patients. Despite its advantages, outcomes can vary significantly based on patient factors and fracture characteristics. Objective The objective of this study is to evaluate short-term clinical and radiological outcomes of hindfoot nailing of ankle fractures in the frail elderly population, focusing on patient demographics, fracture characteristics, and complication rates to identify trends and areas for improvement. Methods A retrospective cohort study was conducted on 58 consecutive patients (mean age of 79.55 years; 47 (81%) women and 11 (19%) men) who underwent hindfoot nailing for ankle fractures between January 2020 and December 2024 at a tertiary trauma center. Patient demographics, fracture characteristics, and postoperative complications were analyzed. Primary outcomes included union rates and complication rates. Secondary outcomes included mortality, mobility changes, and the need for revision surgery. Statistical analysis employed Fisher's exact test and chi-square analysis to compare outcomes between open and closed fractures. Results The cohort demonstrated substantial frailty (mean Rockwood score of 5.38) and comorbidity burden (mean American Society of Anesthesiologists {ASA} grade of 3.10; 14 (24.6%) diabetics). Open fractures predominated (43, 63.3%). One-year mortality was 12 (20.7%) (95% confidence interval {CI}: 10.3%-31.1%). Among 30 patients with complete follow-up, the overall union rate was 24 (80.0%) (95% CI: 65.7%-94.3%), with comparable rates between open (16, 84.2%) and closed (nine, 81.8%) fractures (odds ratio {OR}: 1.19; p=0.986). However, open fractures demonstrated markedly elevated complication rates (12 {63.2%} versus two (18.2%); OR: 7.71; p=0.059). Joint preparation was associated with higher complication rates (11 {64.7%} versus three {23.1%}; OR: 6.11; p=0.077) but similar union rates. Functional mobility declined in 15 (50%) of patients, remained stable in 12 (40%), and improved in three (10%). Conclusions Hindfoot nailing in this high-risk population achieved acceptable union rates despite significant complication rates, particularly in open fractures. The findings support careful patient selection and highlight the need for enhanced perioperative protocols for open-fracture management.