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.

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.

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).

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).

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.

I; randomized controlled therapeutic study.