Locked fibular nailing in geriatric ankle fractures: A retrospective case series

INTRODUCTION: The incidence of ankle fragility fractures is increasing. These insufficiency fractures frequently occur in a frail geriatric population and are associated with an increased risk of skin complications. The objective of this study was to evaluate the clinical and radiological outcomes of geriatric ankle fracture fixation using locked fibular nailing. HYPOTHESIS: We hypothesized that fixation of geriatric ankle fractures with a locked fibular nail would allow bone union without skin complications or mechanical failure. METHODS: This retrospective single-center study included 21 patients with a mean age of 70.8 ± 5.2 years (range 65-85) who sustained an ankle fragility fracture treated with a locked fibular nail between January 2021 and August 2024. Fracture patterns included two isolated lateral malleolar fractures (9.5%), 17 bi-malleolar fractures (81%), one tri-malleolar fracture (4.8%), and one fracture of the distal quarter of the leg (4.8%). Pain was assessed using the Numerical Analog Scale (NAS), and functional outcomes were evaluated using the European Foot and Ankle Society (EFAS) questionnaire and the Olerud and Molander Score (OMS), with comparison to the contralateral ankle. Epidemiological and operative data, as well as complications (wound-healing disorders, mechanical failure, and non-union), were recorded. Fibular union was assessed according to the criteria described by McLennan and Ugersma. RESULTS: An anatomical or acceptable reduction of the fibula was achieved in 100% of patients. No wound-healing complications occurred, despite preoperative skin compromise in 17 patients (81%). No mechanical failures were observed at a mean follow-up of 13.6 months. The mean NAS score was 1.0 ± 1.2 (range 0-4). The mean EFAS score was 19.4 ± 2.4 (range 14-22), and the mean OMS score was 78.3 ± 19.1 (range 45-95). No statistically significant differences were found when compared with the contralateral ankle (p = 0.26 and p = 0.35, respectively). Complications included one early surgical site infection successfully treated with DAIR (debridement, antibiotics, and implant retention) and one secondary fracture involving both leg bones due to bone insufficiency. Mortality at final follow-up was 14.3% (3/21). CONCLUSION: Locked fibular nailing appears to be a reliable fixation technique for geriatric ankle fragility fractures, enabling bone union, restoration of anatomical alignment, and the absence of mechanical failure, while reducing the high rate of wound-related complications in this high-risk population. LEVEL OF EVIDENCE: IV; retrospective study.