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Foot and Ankle Surgery xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Tibiotalocalcaneal nail xation and soft tissue coverage of

GustiloAnderson grade 3B open unstable ankle fractures in a frail
population; a case series in a major trauma centre
Lesley Armstrong, BA MBBS MRCS* , John Jackson, MBBCh BSc MRCS1,
Andrew Riddick, MBBCh FRCS Ed
Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: GustiloAnderson grade 3B open ankle fracture-dislocations requiring stable xation and
Received 2 December 2016 soft tissue coverage are increasingly common in frail populations.
Received in revised form 20 March 2017 Methods: We identied all patients with open ankle fracture-dislocations treated with a tibiotalocalca-
Accepted 29 March 2017
neal nail and soft tissue coverage over a ve-year period. We retrospectively recorded pre-morbid status,
Available online xxx
fracture and soft tissue injury pattern, surgical details, post-operative mobility, length of hospital stay,
complication and re-operation rate and survival.
Keywords:
Results: 21 ankles (20 patients) are included, all grade 3B open fractures. All patients were permitted to
Ambulation
Frail elderly
mobilise by one to six weeks post-surgery. One patient required further soft tissue surgery. Six patients
Intramedullary nailing had supercial wound colonization/infection, none developed deep infections. None of the nails have
Open fracture required removal. We observed a 15% three-month mortality rate.
Orthopaedic surgery Conclusion: Tibiotalocalcaneal nail xation and soft tissue coverage of unstable open ankle fractures in
Soft tissue injuries frail patients facilitates early return to ambulation with a low complication and re-operation rate.
Survival rate 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction This can be difcult for frail patients, in whom ambulation is

Open fracture-dislocations of the ankle are challenging injuries
to treat in the frail and elderly population. They often occur
following low-energy injuries. Soft tissues around the ankle fail
when the fracture-dislocation occurs, resulting in signicant soft
tissue stripping. These injuries pose a challenge to the surgeon in
view of poor quality bone and soft tissues [1]. This group of
patients frequently have poor pre-operative health [2] in terms of
medical co-morbidities, such as diabetes mellitus and circulatory
disease, which further increase the risk of surgical complication.
Their overall pre-morbid state can be compared to the neck of
femur fracture patient population, and the priority as in patients
with neck of femur fractures is to provide a surgical treatment
that minimizes the complication rate and facilitates early
ambulation. Traditional open reduction internal xation in
osteoporotic bone can involve a period of non-weight-bearing.
paramount to managing their activities of daily living [3]. Poor hold
in osteoporotic bone, and the need for further soft tissue insult in a
heavily traumatized area can make plate and screw xation an
unattractive option in elderly co-morbid patients, and for this
reason surgical treatment with a tibiotalocalcaneal nail has
become more popular in the treatment of closed unstable fractures
in frail elderly patients [1]. Emphasis is placed on achieving good
xation that allows the patient to mobilise as quickly as possible,
and less on longer term outcomes in a population with a limited
life expectancy. Here we present a case series of patients who have
been successfully treated with a primary tibiotalocalcaneal nail in
the context of open fracture-dislocation of the ankle, with a low
rate of post-operative complication and a timely return to
ambulation.
2. Methods

2.1. Participants
* Corresponding author.
E-mail addresses: lesley.armstrong@doctors.org.uk (L. Armstrong), 35 ankles were treated with a tibiotalocalcaneal nail for
john.jackson1@nhs.net (J. Jackson), andrew.riddick@nbt.nhs.uk (A. Riddick). unstable ankle fractures between 1 July 2011 and 30 June 2016.
1
Present address: North Devon District Hospital, Raleigh Park, Barnstaple EX31
22 of these ankle fractures were open fractures requiring soft
4JB, United Kingdom.

http://dx.doi.org/10.1016/j.fas.2017.03.015
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
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FAS 1037 No. of Pages 6
2 L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
tissue coverage. All the open fractures were grade 3B as per the
GustiloAnderson classication. One ankle was a revision
procedure following failed open reduction internal xation and
was excluded from this study. In the remaining 21 ankles
(in 20 patients), a tibiotalocalcaneal nail was used for primary
xation. Three patients were male and 17 female. The average age
was 76 (range 4898). Mechanisms of injury were a combination of
low- and high-energy. Two patients (three ankles) had concomi-
tant signicant injuries. 18 patients had isolated injuries.
11 fractures were trimalleolar, four bimalleolar (medial and
lateral), two bimalleolar (lateral and posterior), two lateral
malleolus fractures, one lateral malleolus with anterior tibial
Tillaux fractures and one lateral malleolus with ipsilateral talar
neck fracture. See Table 1 for a summary of patient demographics
and results.
2.2. Data collection
We retrospectively identied all patients on our trauma
database (Bluespier International, Droitwich UK) who had been
treated surgically for an ankle fracture within this time frame. We
reviewed the ward-round entries and operation notes for all of
these patients to establish which patients had an open ankle
fracture and had been treated with a tibiotalocalcaneal nail and
soft tissue coverage. We reviewed each patients radiographs pre-
and post-xation, discharge summaries, Trauma & Orthopaedic
follow-up clinic letters, and letters from the Plastic Surgery
database. From these sources in combination, we ascertained
patient age and comorbidities, pre-injury residence, mechanism of
injury, concomitant injuries, fracture conguration, date of initial
debridement, date of tibiotalocalcaneal nail, details of all surgeries,
grade of open fracture, method of soft tissue coverage, post-op
weight-bearing status, length of hospital stay, discharge destina-
tion, follow-up details, post-op complications, details of further
surgery, and death rate. We cross-referenced our software sources
to ensure accuracy of data.
2.3. Staging of surgery
All patients received treatment as per the British Orthopaedic
Association Standards for Trauma 4 [4] for open fracture
management. The decision on whether to stage the surgery or
carry out debridement, xation and soft tissue coverage in a single
sitting was made during the rst visit to theatre. Two ankles were
treated in a single stage, having debridement, tibiotalocalcaneal
nail and coverage with a medial plantar ap and split skin grafting
in the same session. The remaining 19 open ankle fractures had an
initial washout, debridement and stabilization followed by
denitive xation and coverage on average 1.5 days later (range
04 days). Three of our patients had the primary debridement
performed before transfer to our major trauma centre, and one of
these had a further debridement (and application of external
xation) before the denitive surgery. Of the 19 ankles having
staged surgery, six were stabilised with temporary external
xation, one with a tibiotalocalcaneal Steinman pin, one with
Kirschner wires and a bula nail and 11 with plaster applied in
theatre. Nine ankles had vacuum-dressings applied, and ten had
standard dressings.
2.4. Operative technique
Three different tibiotalocalcaneal nails were used in total over
the ve years; xation was achieved in 10 ankles with the T2 Ankle
Arthrodesis Nail (Stryker Trauma GmbH, Schnkirchen, Germany),
nine with the Versanail (DePuy ACE Orthopaedics, Inc., Warsaw,
USA) and two with the Titanium Cannulated Hindfoot Arthodesis
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
Nail (Synthes, West Chester, PA, USA). The diameter of nail ranged
from 10 to 12 mm and the length 150 to 300 mm. All nails were
locked proximally and distally. None of the ankles had joint surface
preparation before nailing. All required soft tissue coverage
performed by a Plastic Surgeon, and this was achieved with either
a local ap or free ap and split skin graft (SSG). 12 ankles had a
medial plantar ap, two dorsalis pedis ap, two free gracillis ap,
one free anterolateral thigh ap, one free scapula ap, one
myocutaneous ap, one bilobed transposition ap, and one patient
had SSG alone without a ap. Intravenous antibiotics were started
on admission. Patients having coverage with local aps had the ap
raised prior to the tibiotalocalcaneal nailing. After the ap was
raised, the nail was inserted by the Trauma & Orthopaedic Surgeon
using the technique recommended by the implant manufacturer.
Patients having coverage with an anterolateral thigh free ap had
the ap raised from the contralateral thigh at the same time as the
nailing. A below-knee backslab was applied to limit movement to
protect the ap. The patients were transferred post-operatively to
the Plastic Surgery ward, where they were monitored on a strict
ap protocol. Please see Figs. 1 and 2.
2.5. Ethical approval
We referred to the NHS Health Research Authority online
information and decision-making tool. We did not require ethical
approval from the NHS Research and Ethics Committee (NHS REC)
for this study.
3. Results
3.1. Return to ambulation and discharge destination
15 patients (16 ankles) lived in their own home prior to their
injury, one in a warden-controlled at, two in a residential home,
one in a care home and one in a nursing home. 14 patients
(15 ankles) were repatriated to their local hospitals for ongoing
rehabilitation, two were transferred to community hospitals, one
to a care home and three discharged home. Only two patients from
home managed to return home directly from our hospital. The
average length of stay in the major trauma centre was 18 days. The
majority of our patients were non-weight-bearing through the
operative ankle for two weeks to allow ap healing (range one to
six weeks). After this weight-bearing as tolerated was advised. One
patient had limited mobility at four months post-operatively, but
this was related to frailty rather than to ankle xation complica-
tions.
3.2. Complications and re-operation
One patient required further surgery to their ankle. This was
undertaken during the same admission as their ankle fracture
surgery and was a soft tissue procedure to re-perfuse a
threatened ap. To date, none of the patients included in this
series have required re-operation for implant-related reasons
(mean time from surgery 13 months; range 535 months, four
patients died with the implants in situ) and none have undergone
amputation. One patient developed cellulitis over the apthis
was successfully treated with antibiotics. Five other patients had
wound swabs taken from the operative leg, which were positive
for various bacteria. This gives an overall supercial post-op
wound colonisation/infection rate of 29%. One patient had a
positive wound swab from the donor site on the contralateral leg.
None of our patients required return to theatre due to deep
infection. One patient had failure of the SSG over donor site of the
dorsalis pedis ap, but went on to heal following a period of
observation.
 FAS 1037 No. of Pages 6
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Table 1
fas.2017.03.015
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B

Overview of patient demographics and results.

Ankle Age Mechanism Wound Other regions injured Co-morbidities Residence Place of Length of Stages Nail Soft tissue Length of Re- Deep Survival
location pre-injury discharge stay in coverage time non- operation infection
major weight
trauma bearing
centre (weeks)
(days)
1 78 Fall Medial & None Diabetes Home Hospital 18 3 DePuy ACE Dorsalis pedis 2 No No Deceased
lateral transfer VersaNail ap & SSG
150  12 mm
2 91 Fall Medial & None Long-term catheter Residential Hospital 18 2 DePuy ACE Myocutaneous 6 No No
lateral home transfer VersaNail ap & SSG
180  10 mm
3 61 Fall Anteromedial None CVA, PE, asthma Home Home 27 2 DePuy ACE Medial plantar 2 No No Deceased
VersaNail ap & SSG
150  10 mm
4 79 Fall Medial None DM2,IHD, CABG, HTN, Home Hospital 7 2 Depuy ACE SSG 2 No No

L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

asthma transfer VersaNail
150  10 mm
5 91 Fall Medial None Dementia, Residential Hospital 11 2 DePuy ACE Medial plantar 2 No No
hypothyroidism, home transfer VersaNail ap ad SSG
intracerebral tumour 180  10 mm
excision
6 82 Fall Medial None Dementia Home Community 49 1 DePuy ACE Medial plantar 2 No No
hospital VersaNail ap & SSG
150  10 mm
7 84 Fall Medial None CKD 4, vascular Home Community 18 2 DePuy ACE Bilobed 1 No No Deceased
dementia, hospital VersaNail transposition
hypoalbuminaemia, 180  12 mm ao
chronic lymphoedema
8 65 Fall Medial None Partial paraplegia Home Hospital 15 2 Synthes Medial plantar 2 No No
following C1/2 fusion transfer HAN ap & SSG
150  10 mm
9 58 Fall Medial None Psychiatric illness Home Hospital 18 2 DePuy ACE Medial plantar 2 No No
transfer VersaNail ap & SSG
150  10 mm
10 84 Fall Anterolateral None Smoking, moderate Home Home 14 2 DePuy ACE Dorsalis pedis 1 No No
alcohol intake VersaNail ap & SSG
150  10 mm
11 83 RTC Lateral Thorax, pelvis, Hypothyroidism, vulval Nursing Hospital 24 2 Stryker Free scapular 4 No No
contralateral leg lichen sclerosis home transfer T2 ankle ap
(AKA) ipsilateral knee arthrodesis
soft tissue injury and nail
calcaneum fracture 150  12 mm
12 98 Fall Medial None Dementia, CKD 3, IND, Home Care home 31 2 Synthes Medial plantar 4 No No
eczema, THR, cervical HAN ap & SSG
spondylosis, iron- 180  10
deciency anaemia
13 79 Fall Medial None CVA, DM2, HTN, GORD Warden- Hospital 15 2 Stryker T2 Medial plantar 4 No No
controlled transfer ankle ap & SSG
at arthrodesis
nail 150  11
14 59 Absence Medial None Learning difculties, Care home Hospital 16 1 Stryker T2 Medial plantar 2 No No
seizure epilepsy (absence transfer ankle ap & SSG
seizures) arthrodesis
nail
150  11 mm

3
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open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B

Table 1 (Continued)
Ankle Age Mechanism Wound Other regions injured Co-morbidities Residence Place of Length of Stages Nail Soft tissue Length of Re- Deep Survival
location pre-injury discharge stay in coverage time non- operation infection
major weight
trauma bearing
centre (weeks)
(days)
15 48 Fall Medial None Psoriasis, DM2, Home Home 13 2 Stryker Medial plantar 4 Yes No
hysterectomy, chronic T2 ankle ap & SSG
leg ulcers, unexplained arthrodesis
ts, smoking nail

L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

300  10 mm
16 93 Fall Medial None AF, COPD, HTN, dementia Home Hospital 10 2 Stryker Medial plantar 4 No No
transfer T2 ankle ap & SSG
arthrodesis
nail 200  12
17 73 Fall Medial/ None HTN, raised BMI, DM2 Home Hospital 11 2 Stryker Free gracilis 4 No No
circumferential transfer T2 ankle ap & SSG
arthrodesis
nail
150  11 mm
18 65 RTC Lateral None Palliative bladder cancer Home Hospital 12 2 Stryker Free ALT ap & 4 No No Deceased
transfer T2 ankle SSG
arthrodesis
nail
200  11 mm
19 77 RTC Posteromedial Spine, thorax Unknown Home Hospital 21 3 Stryker T2 Free gracilis 2 No No
transfer ankle ap
arthrodesis
nail
200  10 mm
20 77 RTC Medial Spine, thorax Unknown Home Hospital 21 2 Stryker T2 Medial plantar 2 No No
transfer ankle ap & SSG
arthrodesis
nail
200  10 mm
21 71 Twisted Anterior None IHD, bromyalgia, PMR, Home Hospital 9 2 Stryker Medial plantar 2 No No
ankle extending bilateral lymphedema, transfer T2 ankle ap & SSG
medial and bilateral TKR, raised BMI, arthrodesis
lateral PE, hiatus hernia, hip & nail
spine OA 150  11 mm
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FAS 1037 No. of Pages 6

L. Armstrong et al. / Foot and Ankle Surgery xxx (2017) xxxxxx 5

Fig. 1. Photographs of open unstable ankle fracture on arrival in the emergency department, following debridement and at 8 weeks post-op.

Fig. 2. Pre- and post-op radiographs.

ankle fractures following low-energy injuries. All the patients

3.3. Survival
Four of the 20 patients have died since their open ankle surgery
(20%). Three of these patients died within 3 months of their surgery
(15% three-month mortality). One patient died from metastatic
bladder cancer and had already been given a terminal prognosis
before the time of injury. Another patient died of multifocal
glioblastoma, which was picked up during the open ankle fracture
admission while being investigated for post-operative confusion.
We were not able to ascertain information on the cause of death for
the other two patients.
4. Discussion
We present the largest case series to date of patients receiving
treatment with a tibiotalocalcaneal nail and soft tissue coverage for
open unstable ankle fractures. Georgiannos et al. [5] have
published a recent prospective randomized-controlled study
comparing short-term results of ankle fractures in elderly patients
treated with open reduction internal xation compared to xation
with a tibiotalocalcaneal nail. They included 87 patients, and found
a signicant shorter hospital stay, a lower complication rate (which
reached statistical signicance) and a higher rate of return to
pre-injury mobility in the group treated with tibiotalocalcaneal
nail. This study supports the use of this technique in frail patients.
Ochman et al. [6] published a smaller case series in
2012 documenting the use of tibiotalocalcaneal nails as a limb
salvage procedure in three polytraumatised patients aged
1942 with bilateral talus, distal tibia or pilon injuries. These
three patients had non-reconstructable joints and signicant soft
tissue injury. They demonstrated moderate functional results and
return to former profession within a median follow-up of 5.4 years.
This patient group differs from those included in our series, as our
patients are frail and elderly, and the majority have sustained open
included in our series (irrespective of injury modality) were
functionally low-demand, or in the case of one patient, had a
terminal diagnosis and an expected decline in function over the
coming weeks. One of the patients in our study was 48 years old.
She sustained an open ankle fracture dislocation through a low-
energy injury (slip in the kitchen) and had signicant comorbid-
ities consistent with a biologically older patient. She also had poor
soft tissue integrity and multiple leg ulcers relating to her diabetes
mellitus, and we therefore felt it appropriate to include her.
Al-Nammari et al. [7] published a case series of elderly patients
with a combination of open and closed unstable ankle fractures
undergoing surgical treatment with long tibiotalocalcaneal nails
that bypass the isthmus of the tibia. Their study included 48 low-
demand patients with a mean age of 82. 19 had open fractures and
10 of these needed soft tissue coverage. They observed an average
time to mobility of 15 days. Several complications occurred within
the group, including two surgical site infections, two graft/ap-
related infections, two malunions, loosening or breaking of screws
in three, one deep infection requiring nail removal, one below knee
amputation four days following nailing and 14 signicant post-op
medical problems. The six-month mortality rate was found to be
35% [7].
Our patients were all mobilising by two to six weeks post-
operatively. The limitation on early mobility was the need for soft
tissue protection following local or free ap soft tissue coverage,
and all patients were permitted to mobilise weight-bearing as
tolerated as soon as their ap protocol had ended. Patients suitable
for xation with a tibiotalocalcanceal nail and soft tissue coverage
for open ankle fractures are generally frail and functionally low-
demand.
We have not, to date, removed any of these nails for any reason
including metalwork failure. 20% of the patients have died since
their surgery for reasons unrelated to their ankle injury, three
within three months resulting in a 15% three-month mortality rate.

Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
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This again reects the frailty of this group of patients. Two of our
patients (three ankles) had signicant concomitant injuries, which
limited their mobility. One patient has bilateral open ankle
fractures also with a talar neck fracture on the right (which was
treated with open reduction internal xation at the same time as
ankle xation). Their mobility was restricted to heel weight-
bearing on the right to protect the talar neck xation. The second
patient had an unstable pelvic fracture (requiring stabilization),
had a left above-knee amputation for unsalvageable leg injuries,
and a right calcaneum fracture on the same side as the open ankle
fracture. The patient was permitted to mobilise fully-weight-
bearing on the right after the ap protocol ended, but we
appreciate that their mobility may have been limited by these
other injuries.
We have shown an acceptable complication rate in our patients.
All supercial infections and colonisations were successfully
treated medically. None of patients had deep infections and the
only patient to undergo further surgery related to their ankle did so
for ap detachment. Pagliaro et al. [8] carried out a study on the
outcomes of patients over the age of 65 undergoing traditional
surgical xation. They included 23 ankles; 21 closed and two open
in patients with an average age of 72. Both open fractures had
complications; the wound dehiscence/deep infection occurred in a
patient with an open fracture (this required surgical debridement
but went on to union at 5 months) and a supercial infection. This
study did not comment on time to mobilisation. Taylor et al. [9]
have published a study on union rates in unstable ankle fractures
treated with a tibiotalocalcaneal nail. They also recorded infection
rate and implant-related complications. Of the 31 ankles included
in their series, 8 of these were open ankle fractures. They observed
three deep infections requiring surgical debridement, nail removal
and insertion of an antibiotic-impregnated rod. All of these
infections were in the open fracture group giving an overall deep
infection rate of 37.5%.
We accept that our series has several limitations. This is a non-
randomised retrospective study. We have included 21 ankles in
20 patients, which is a relatively small number, however, to our
knowledge, this is the largest case series of open ankle fractures
treated with a tibiotalocalcaneal nail reported to date. We have not
included a control group for comparison. The duration of follow-up
is short-term. Once stable for transfer, major trauma patients are
repatriated to their local hospitals. This has made following-up the
patients difcult, and we appreciate that this may lead to missing
data.
Please cite this article in press as: L. Armstrong, et al., Tibiotalocalcaneal nail xation and soft tissue coverage of GustiloAnderson grade 3B
open unstable ankle fractures in a frail population; a case series in a major trauma centre, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.
fas.2017.03.015
5. Conclusion
We have demonstrated a reliable technique for xation of open
unstable ankle fractures in an elderly frail population of patients
comparable to the neck of femur fracture population. Tibiotalocal-
caneal nail xation with ap coverage allows quick return to
mobility, limited only by the need for soft tissue protection
immediately post-operatively, and an acceptable complication rate.
Funding
We did not receive any funding for this work.
Conict of interest
The authors of this manuscript have no conicts of interest to
declare.
Acknowledgements
We have no further acknowledgements to include.
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