Evaluation of Minimally Invasive Hindfoot Nails for the Treatment of Complex and Fragility Acute Ankle Fractures

Research Type: Level 4 – Case series Introduction/Purpose: Fragility and complex ankle fractures are common amongst certain populations and are associated with high rates of disability and morbidity. The most utilized surgical treatment for these injuries is ORIF. However, this procedure requires delayed weightbearing and bestows a certain risk of complications, such as hardware prominence. infections and failure secondary to the significant osteoporotic bone. Meanwhile, minimally invasive ankle internal fixation utilizing a hindfoot nail, without joint preparation, allows for less invasive treatment of fragility ankle fractures and immediate weightbearing. While this application of the hindfoot nail has gained popularity in the field, the associated outcomes and complications remain unclear in the current literature. Accordingly, the current retrospective case series analyzed outcomes and complications with hindfoot nails for the treatment of acute ankle fractures. Methods: Patients who underwent hindfoot nailing for acute ankle fractures between January 2021 and January 2025 at a single institution were identified and retrospectively reviewed. All included patients in the current study were > 18 years of age at time of surgery and were followed for > 3 months after their procedure. Twenty-two patients met the inclusion criteria; patients were of a mean 65.55 ± 14.71 (range, 39-94) years of age and were followed for 11.38 ± 6.08 (range, 3.11-24.46) months. Fifteen fractures were open (68.2%); the remaining 7 were closed injuries. Patient Reported Outcome Measurement Information System (PROMIS) scores, patient demographic, and complications were recorded for each patient. Preoperative and final follow-up PROMIS scores were analyzed by paired t-test; all p< 0.05 (*) were considered to be significant. Results: Following hindfoot nail placement for acute ankle fractures, patients had a significant improvement in PROMIS function (p=0.033*) and mobility scores (p=0.002*). One patient with a closed injury had a wound complication over the heel screw insertion site (4.5%). One patient experienced painful hardware and underwent nail removal at one year post operation (4.5%). There were no cases of nonunion observed following hindfoot nail placement. Six patients, all of whom had open fractures, experienced wound complications directly related to the open nature of their original injury. Two of these patients ultimately underwent below knee amputation. Conclusion: An improvement in patient reported outcome measures and a low rate of complications were observed following hindfoot nailing for treatment of acute ankle fractures, especially in patients with closed injuries. Findings from the current study indicate hindfoot nailing is a safe and effective surgical management strategy for acute fragility and complex ankle fractures. The current, small case series is limited in nature; future expansion these findings may provide comparisons of hindfoot nailing to ORIF and allow for longer duration follow-up. Evaluation of the benefits of early weightbearing in the geriatric population will also require study in a larger prospective series.