Tibiotalocalcaneal Fusion Using Hindfoot Nailing Versus Open Reduction and Internal Fixation for Fragility Ankle Fractures in Older Adults: A Prospective Randomized Comparative Study
In brief
Hindfoot nailing gets older fracture patients walking 7 weeks earlier than ORIF
In a 60-patient randomized trial, older adults treated with a hindfoot nail began weight bearing at about 2 weeks, compared with 9 weeks after open reduction and internal fixation, and had better ankle function at 12 months. Bone union was also faster, but the rate of union and complications did not differ significantly; permanent loss of ankle and subtalar motion and limited follow-up matter when weighing the trade-offs.
- Journal
- Orthopaedics & traumatology, surgery & research : OTSR (Q1)
- Published
- 3 November 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Yasser Osman Sorour, Amr Abdel Gawad Mahmoud, Ahmed Saleh Shaker, Wael Adel Salama
- PMID
- 42977155
- DOI
- 10.1016/j.otsr.2026.104984
Why clinicians should know about it
- Picked for Orthopedics and Sports Medicine (paper of the day, 4 November 2026): Randomized comparison of fixation strategies for fragility ankle fractures
Abstract
BACKGROUND: Fragility ankle fractures in older adults are challenging because poor bone quality, medical comorbidities, and vulnerable soft tissues increase the risk of fixation failure, wound complications, and prolonged immobilization after conventional open reduction and internal fixation (ORIF). Tibiotalocalcaneal (TTC) fusion using a hindfoot intramedullary nail may provide stable load-sharing fixation while allowing earlier weight bearing. HYPOTHESIS: TTC fusion using a hindfoot nail would provide better 12-month functional outcomes, earlier weight bearing and radiological union, and fewer fixation-related complications than ORIF in older adults with fragility ankle fractures. PATIENTS AND METHODS: This prospective, single-center, parallel-group randomized controlled study included 60 patients aged ≥65 years with fragility ankle fractures, with 30 patients treated by TTC fusion and 30 by ORIF. Each participant was followed for 12 months. The primary outcome was the Olerud-Molander Ankle Score (OMAS) at 12 months. Secondary outcomes included the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, time to weight bearing, radiological union and time to union, midfoot range of motion, and postoperative complications. The trial was registered at ClinicalTrials.gov (NCT06709365). RESULTS: The TTC group had a significantly shorter operative time than the ORIF group (62.4 ± 9.8 vs. 89.7 ± 12.3 min; p < 0.001) and achieved earlier weight bearing (2.1 ± 1.3 vs. 9.2 ± 2.4 weeks; p < 0.001). At 12 months, OMAS was significantly higher in the TTC group (75.77 ± 4.02 vs. 65.57 ± 4.54; p < 0.001), as was the AOFAS score (80.17 ± 4.95 vs. 69.00 ± 4.94; p < 0.001). Radiological union occurred in 28/30 patients (93.3%) after TTC fusion and 26/30 (86.7%) after ORIF (p = 0.67), while time to union was significantly shorter after TTC fusion (12.1 ± 2.3 vs. 14.6 ± 3.1 weeks; p = 0.0008). Postoperative midfoot range of motion was also greater in the TTC group (36.8 ± 6.4 ° vs. 31.4 ± 5.8 °; p = 0.001). DISCUSSION: TTC fusion with a hindfoot nail provided superior 12-month functional outcomes, earlier weight bearing, shorter operative time, and faster radiological union than ORIF in selected older adults with fragility ankle fractures. However, the observed reduction in individual complications was not statistically significant, and the permanent loss of ankle and subtalar motion together with the limited 12-month follow-up should be considered when selecting treatment. LEVEL OF EVIDENCE: I; randomized controlled therapeutic study.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.