Tibiotalar Nailing for Geriatric Pilon Fractures: Case Report and Review of the Literature.

Introduction: Tibial pilon fractures present a complex challenge, particularly in geriatric patients with comorbidities and compromised soft tissue. Traditional treatment options such as open reduction and internal fixation (ORIF) and tibiotalocalcaneal (TTC) nailing have shown variable outcomes, often complicated by infection, nonunion, and malunion. Tibiotalar nailing is an alternative approach that preserves subtalar joint motion while providing stable fixation, though, there is limited literature on its efficacy in geriatric pilon fractures. This report describes a case of a 64-year-old female with multiple comorbidities presenting with tibial pilon fracture successfully managed with antegrade tibiotalar intramedullary nailing, highlighting the potential advantages of this technique. Case Report: A 64-year-old female with a history of chronic obstructive pulmonary disease, hypertension, and a significant smoking history presented with a right tibial pilon and distal fibula fracture following a fall down the stairs. Due to her medical comorbidities and poor soft tissue envelope, she was at high risk for complications with ORIF. After discussing multiple treatment options, she elected to proceed with a tibiotalar intramedullary nail to optimize function while minimizing surgical morbidity. The procedure was performed using a suprapatellar approach, and an 8mm nail was inserted to preserve bone stock and future surgical options. Postoperatively, she progressed well, achieving full fracture healing by 9 months with minimal pain and functional independence. She declined further surgical intervention for hardware removal or ankle fusion, reporting satisfaction with her outcome. Conclusion: This case highlights the successful use of tibiotalar nailing as a viable alternative to ORIF and TTC nailing for managing geriatric pilon fractures with significant comorbidities. By preserving subtalar joint function, this approach offers potential advantages in mobility and quality of life while mitigating the risks associated with more invasive procedures. Given the limited existing literature on this technique, this report contributes to the growing body of evidence supporting its use. Further studies are warranted to compare tibiotalar nailing with conventional approaches in larger cohorts to refine its indications and optimize patient outcomes.