Tibiotalocalcaneal Arthrodesis Versus Open Reduction and Internal Fixation in Treatment of Trimalleolar Ankle Fractures: A Propensity-Matched TriNetX Database Study

ABSTRACT Background Trimalleolar ankle fractures are complex injuries associated with high complication rates and poorer outcomes, particularly in elderly and medically comorbid patients. While open reduction and internal fixation (ORIF) remains the standard treatment, alternative strategies such as tibiotalocalcaneal arthrodesis (TTCA) have been increasingly explored for high-risk populations. Methods A retrospective cohort study was performed using the TriNetX Research Network. Adult patients undergoing operative treatment for trimalleolar fractures were identified and stratified by procedure (TTCA versus ORIF). Propensity score matching (1:1) was performed to balance demographics and comorbidities, including age, sex, obesity, tobacco use, osteoporosis, diabetes, dementia, and peripheral vascular disease. Outcomes were assessed at 90 days, 1 year, and 2 years. Primary outcomes included secondary surgery (revision procedures, irrigation and debridement, hardware removal, and below-knee amputation). Secondary outcomes included 90-day infection and wound dehiscence. Risk ratios with 95% confidence intervals were calculated, with p<0.05 considered significant. Results After matching, 210 patients were included in each group. At 90 days, infection and wound complication rates were similar between TTCA and ORIF cohorts. TTCA was associated with significantly higher rates of secondary surgery at 1 year (28.1% vs 17.1%; RR 1.64, p=0.007) and 2 years (31.4% vs 21.0%; RR 1.50, p=0.015). Irrigation and debridement was also more frequent in the TTCA cohort at 1 year (RR 2.25, p=0.012) and 2 years (RR 2.23, p=0.009). In sensitivity analysis of closed fractures, findings remained consistent, with higher secondary surgery rates in the TTCA group. Conclusion In this large propensity-matched study, TTCA may be associated with a higher incidence of secondary surgery—particularly irrigation and debridement—compared with ORIF at one and two years postoperatively, while early wound complication rates were similar. These findings may be influenced by residual confounding despite propensity matching.