HINDFOOT NAILING WITHOUT FUSION FOR FRAIL ELDERLY ANKLE FRACTURES: A SINGLE-SURGEON SERIES FROM A DISTRICT GENERAL HOSPITAL

Displaced ankle fractures in frail elderly patients carry morbidity and mortality comparable to neck-of-femur (NOF) fractures. Open reduction and internal fixation (ORIF) is frequently unsafe due to poor bone quality, compromised soft tissues, and systemic comorbidity. Close contact casting, recommended by the AIM trial, excludes patients with insulin-dependent diabetes, peripheral vascular compromise, active ulceration, and cognitive impairment — our exact cohort. We applied a NOF-equivalent philosophy: hindfoot nailing as a spanning construct permitting immediate weight-bearing without joint preparation. Retrospective review of 22 consecutive patients by a single senior surgeon at Ysbyty Gwynedd, Bangor (2015–2025). All were ASA grade 3 or above with significant comorbidities, poor soft tissues, and inability to comply with non-weight-bearing. The mortise was reduced closed over a Steinmann pin; a straight hindfoot nail inserted with oblique calcaneal screws for subchondral purchase, talar locking, and all holes filled. No joint preparation was performed. Patients were fully weight-bearing from day one. Eighteen female and four male patients; mean age 79 years (60–95). Mean Charlson Comorbidity Index-predicted 10-year survival was 30.5%. Frank dislocation at presentation in 15 patients (68%). All 22 (100%) achieved immediate full weight-bearing. No wound complication requiring operative management occurred. Three procedure-related complications (14%): periprosthetic fracture managed conservatively, nail removal with arthroscopic fusion, and screw removal with tendo-Achilles lengthening. Seven patients (32%) died within one year; overall mortality 59%. No death was attributable to the procedure. FAAM-ADL in survivors: mean 33.8% (2–61%, n=6). Hindfoot nailing without joint preparation achieves immediate mobilisation in frail elderly patients unsuitable for conventional management. The 14% complication rate and zero wound complications compare favourably with published series. The 32% one-year mortality reflects systemic frailty rather than operative morbidity. We advocate recognition of the frail elderly ankle fracture as a NOF-equivalent injury requiring a mobilisation-first pathway, supported by prospective multicentre evaluation and formal meta-analysis.