Tibiotalocalcaneal Arthrodesis vs Open Reduction Internal Fixation for Trimalleolar Ankle Fractures in High-Risk Patients: A National Database Analysis

Abstract

Background: Trimalleolar ankle fractures pose a challenge for surgical management, especially in high-risk populations such as the elderly and patients with comorbidities. Surgeons traditionally employ open reduction internal fixation (ORIF) to manage these injuries; however, some recent studies advocate for tibiotalocalcaneal arthrodesis (TTCA) as an alternative that minimizes soft tissue disruption and facilitates earlier weightbearing. This study compares complication and readmission rates associated with ORIF and TTCA in managing trimalleolar fractures, providing insight on complication risks throughout this patient population.

Methods: A retrospective analysis was performed using the 2016-2021 Nationwide Readmissions Database. Adult patients (≥18 years) diagnosed with trimalleolar ankle fractures who underwent either ORIF or TTCA were identified. To balance the cohorts, propensity score matching based on key comorbidities (defined as diabetes, hypertension, chronic kidney disease, osteoporosis, obesity, morbid obesity, or heart failure), age, and sex was performed. Primary outcomes included 30- and 90-day readmissions and complication rates; secondary outcomes were specific complications, including infection, nonunion, and malunion, assessed only in patients with ≥90 days' follow-up.

Results: A total of 602 patients were analyzed after propensity score matching (307 ORIF, 295 TTCA). TTCA patients experienced significantly higher overall complication rates compared to ORIF patients (35% [95% CI: 30.67%-41.56%] vs 13% [95% CI: 9.15%-16.53%], P < .001). Specifically, TTCA was associated with increased nonunion (10% [95% CI: 8.37%-15.67%] vs 2% [95% CI: 1.11%-4.63%], P < .001) and malunion rates (13% [95% CI: 9.53%-17.19%] vs 1% [95% CI: 0.06%-1.82%], P < .001). TTCA patients also demonstrated higher 30-day readmission rates (25% [95% CI: 21.42%-31.40%] vs 13% [95% CI: 10%-17.62%], P < .001) and 90-day readmission rates (20% [95% CI: 15.83%-24.94%] vs 10% [95% CI: 7.21%-13.98%], P < .001). In multivariable analysis, TTCA remained independently associated with higher complication risk (adjusted odds ratio: 4.10, 95% CI: 2.29-7.33, P < .001). Complication rate differences persisted across both high- and low-risk patient subgroups.

Conclusion: In this national database analysis, ORIF was associated with significantly lower complication and readmission rates compared with TTCA for trimalleolar ankle fractures. Despite theoretical advantages of TTCA in high-risk populations, these findings suggest ORIF may be preferable for most patients, with TTCA reserved for carefully selected cases where conventional fixation is unlikely to succeed. Given the limitations of administrative data, prospective randomized trials with longer follow-up are needed to definitively establish optimal treatment algorithms for this challenging patient population.

Level of evidence: Level III, prognostic.

Keywords: ORIF; TTC; ankle fracture; outcome studies; tibiotalocalcaneal arthrodesis.

Figure 1.

Complications rates by risk category. Dashed lines signify statistical significance between groups at P < .05. ORIF, open reduction internal fixation; TTC, tibiotalocalcaneal arthrodesis.