Tibiotalocalcaneal nailing allows early weightbearing without increased early complication risk in unstable geriatric malleolar ankle fractures

PURPOSE: Geriatric ankle fractures present a clinical challenge due to frailty and poor bone quality. Unstable injuries often require prolonged non-weightbearing after traditional fixation, a limitation that may exacerbate sarcopenia, medical complications, and functional decline in the elderly. Tibiotalocalcaneal (TTC) nailing has emerged as an alternative that may permit earlier weightbearing. This study investigates complications and discharge disposition in geriatric patients who undergo fixation with TTC and conventional constructs. METHODS: A retrospective review was conducted of patients ≥ 60 years who underwent operative fixation of rotational ankle fractures with radiographic tibiotalar instability at an academic trauma center. Patients with tibial plafond fractures or < 6 weeks of follow-up were excluded. Demographics, complications, reoperations, and discharge disposition were analyzed. Multivariate logistic regression and propensity score-matched cohorts were employed to compare complication rates and discharge disposition between cohorts. RESULTS: 130 geriatric patients underwent operative fixation with TTC (39) or traditional (91) constructs. Patients who underwent TTC nailing were likely to be older, have higher Charlson Comorbidity Index (CCI), and neuropathy. Patients with TTC fixation were allowed to weight bear sooner (1.6 weeks) than conventional constructs (9.8 weeks; p < 0.001). No differences were observed between groups in rates of reoperation, implant failure, or deep infection. Construct choice had no effect on discharge disposition among patients treated during inpatient admission. CONCLUSION: Among geriatric patients with higher medical complexity, TTC fixation provides an early complication profile comparable to traditional fixation while allowing early weightbearing. However, TTC fixation may not independently improve rates of home discharge. While there are similar rates of short-term complications, long-term sequelae and functional repercussions of acute hindfoot fixation of geriatric malleolar ankle fractures remain unknown.