Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre

Tibiotalocalcaneal nailing as a treatment for ankle fractures in the elderly population: A systematic review

This study evaluated patient outcomes of tibiotalocalcaneal (TTC) nailing for ankle fractures in an elderly population. A systematic literature search of PubMed and Google Scholar identified 24 studies involving 657 patients aged over 65. Key outcome measures included union rates, healing time, functional scores, and complications. The average union rate for TTC nail patients was 88.36 % (±12 %), with a healing time of 17.8 weeks (±4.68). Post-operatively, 77.16 % (±17 %) of patients returned to or exceeded their baseline ambulatory function. Pre-injury Olerud-Molander Ankle Scores averaged 63.1 (±5.00), compared to 50.43 (±8.59) post-surgery. Infection rates were reported in 10.51 % (±0.07) of patients (60/571), with superficial and deep infection rates of 6.83 % (±8 %) and 3.68 % (±6 %), respectively. Nail failure occurred in 4.7 % (12/255) of cases, and the average revision rate was 13.36 % (±7 %). In conclusion, TTC nailing is a viable treatment for elderly patients with ankle fractures. It offers satisfactory functional outcomes and an acceptable complication risk. It is particularly beneficial for those unable to undergo multiple surgeries or with significant comorbidities, providing a quick and effective means to restore mobility.

Biomechanical design considerations of a 3D-printed tibiotalocalcaneal nail for ankle joint fusion

Tibiotalocalcaneal (TTC) arthrodesis treatment using intramedullary nails faces significant challenges due to inadequate bone integration and mechanical stability. This study developed a novel 3D-printed long titanium TTC intramedullary nail incorporating diamond lattice structures and differential thread leads to enhance biological fixation and compression. Four 3D-printed TTC nails (5 mm diameter, 70 mm length) with solid (TTC 1), lattice structure (TTC 2), lattice with longitudinal ribs (TTC 3), and lattice with both longitudinal and transverse ribs (TTC 4) were designed and manufactured. The lattice region featured a diamond array (70% porosity, 650 μm pore size, 1.2 mm unit length) with 2.5 mm thickness surrounding a 2.5 mm solid core. Static four-point bending tests assessed mechanical strength following ASTM F1264 protocols. Six skeletally mature Yorkshire pigs underwent TTC arthrodesis using TTC 1, 2, and 4 designs. Outcomes were evaluated using radiographic imaging and micro-CT analysis at 12 weeks post-surgery. All 3D-printed nails demonstrated acceptable precision with errors below 5% for straightness, circularity, and pitch distance. Mechanical testing revealed fracture strengths of 2387.33 ± 32.88 N, 435.00 ± 50.00 N, 849.17 ± 63.98 N, and 1133.67 ± 81.28 N for TTC 1-4, respectively. The differential thread design achieved significant compression ratios (81-82.5%) at fusion sites. Micro-CT analysis showed significantly higher bone formation in lattice designs (TTC 2: 145.37 ± 37.35 mm³, TTC 4: 137.81 ± 9.52 mm³) compared to the solid design (TTC 1: 28.085 ± 3.21 mm³). However, TTC 2 experienced two implant fractures, while TTC 4 maintained structural integrity while promoting substantial bone growth. This study concluded that titanium 3D printing technology can be applied for manufacturing long TTC intramedullary nails with surface lattice design but reinforcing ribs need to be added to provide enough mechanical strength.

Open Reduction and Internal Fixation vs Primary Tibiotalocalcaneal Hindfoot Nailing for Ankle Fractures in Elderly Patients: A Systematic Review and Meta-analysis

BACKGROUND

Current literature lacks comprehensive information comparing primary tibiotalocalcaneal (TTC) hindfoot nailing and open reduction internal fixation (ORIF) in the ankle fractures in the elderly population. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of 2 surgical techniques, primary TTC nailing and ORIF, for ankle fractures in the elderly.

METHODS

Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and used databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included total infection, deep infection, superficial infection, hardware problems such as painful hardware, and hardware protrusion/pullout, nonunion/delayed union, reoperation, length of stay, and return to preoperative mobility level.

RESULTS

Total 5 studies were included in this study. In aggregate, 127 patients (42.9%) underwent TTC nailing, whereas 169/296 patients (57.1%) underwent ORIF. A lower rate of superficial infection was reported for the TTC nailing group: 2.1% (2/95) in TTC nailing vs 10.2% (14/137) in ORIF, with a relative ratio of 0.26 (95% CI, 0.08-0.85). The other outcome measures were not significantly different between groups.

CONCLUSION

Based on our review of these studies that reported mostly early follow-up data, it appears that primary TTC nailing may be a viable alternative to ORIF for ankle fracture fixation in the elderly population. However, these findings should be interpreted cautiously because of heterogeneity across the included studies.

The outcomes of the management of complex distal tibia and ankle fractures in elderly with tibiotalocalcaneal nail in a minimum 12-month follow-up period

PURPOSE

To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre.

METHODS

Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate. Exclusion criteria were patients that died or were lost to follow-up and cases in which the nail was used in a chronic setting, such as malunion and non-union. Main parameters evaluated were fracture union, complications and functional outcomes. The functional outcome was assessed using the Olerud-Molander Ankle Score (OMAS). The minimum follow-up was 12 months.

RESULTS

Thirty-two consecutive patients (12 males) with a mean age of 80.2 years (range 66-98) met the inclusion criteria and formed the basis of this study. Fracture union was achieved in 93.8% of the cases at a mean time of 3.9 months (range 2-8). Two patients developed surgical site infections and underwent reoperation before union. The overall complication rate was 25.1%, while the respective reintervention rate was 18.8%. In terms of functional outcomes, the mean OMAS score was 45, ranging from 20 to 70.

CONCLUSION

Tibiotalocalcaneal nailing can be considered as an acceptable less invasive option with good functional outcomes for the treatment of complex distal tibia and ankle fractures in frail patients with problematic local soft tissues.

Reaming for Tibiotalocalcaneal Nailing Removes Only 10% of the Ankle and Subtalar Joints

OBJECTIVES

Tibiotalocalcaneal (TTC) nailing in the setting of acute ankle trauma has become increasingly popular. No consensus exists as to whether formal joint preparation is necessary, although there is some concern that residual motion at unprepared joints may lead to implant loosening and/or breakage. The objective of this study was to quantify the proportion of tibiotalar and subtalar articular surface destruction that occurs during reaming for TTC nail fixation.

METHODS

Twelve cadaver lower extremities were procured. The specimens were pinned into neutral ankle and hindfoot alignment. A guidewire was inserted under fluoroscopy, followed by a 12-mm opening reamer. The specimens were then dissected, exposing the tibial plafond, talar dome, posterior facet of the talus, and posterior facet of the calcaneus. Images of each joint were obtained, and ImageJ software was used to calculate the total joint surface area and the area of articular destruction.

RESULTS

The mean proportion of articular cartilage destruction was 9.3%, 10.3%, 8.9%, and 10.3% for the tibial plafond, talar dome, posterior facets of the talus, and posterior facets of the calcaneus, respectively. No joint destruction was observed in the middle facets of the subtalar joint.

CONCLUSIONS

Reaming for TTC nail placement violates approximately 10% of each articular surface of the tibiotalar and subtalar joints. Retention of 90% of the articular surface may allow for residual motion at the joints and therefore potentially substantial stress on the implant. Formal joint preparation for the purposes of achieving fusion during TTC nail placement may be beneficial to prevent implant loosening or breakage.

Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: Comparison of clinical and patient-reported outcomes with standard ORIF

INTRODUCTION

Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF.

METHODS

A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS).

RESULTS

Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as well as the OMAS (60.0 versus 32.8, p = 0.029).

CONCLUSION

TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.

Treatment strategies for complex ankle fractures-current developments summarized in a narrative review

Background and Objective

Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature.

Methods

We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study.

Key Contents and Findings

Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results.

Conclusions

However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

Primary Retrograde Tibiotalocalcaneal Nailing in an Elderly Osteoporotic Patient With Ankle Fracture: A Case Report

Introduction

Ankle fractures are a common orthopedic injury traditionally treated with open reduction and internal fixation or conservative management. One complication introduced with open reduction and internal fixation is the requirement for non or partial weight bearing in the post-operative period. This requirement poses a unique challenge for patients who may not comply with these weight-bearing restrictions. This case is the first known article that specifically illustrates the validity and effectiveness of retrograde tibiotalocalcaneal (TTC) nailing for patients who are unlikely to follow weight-bearing restrictions.

Case Report

An 83-year-old Caucasian female with idiopathic mild mental retardation and Alzheimer's presented with a minimally displaced trimalleolar ankle fracture and was treated at a single urban hospital with a retrograde TTC nail secondary to her inability to adhere to weight-bearing restrictions post-operatively. Pertinent demographic, clinical, radiographic, and surgical data were collected. The patient had minimal post-operative pain, was able to bear weight on the day of surgery, and had no post-operative complications.

Conclusion

This case report demonstrates that the use of a TTC nail is a safe and effective mode of fixation for ankle fractures in patient populations who may not adhere to weight-bearing restrictions post-operatively. The main benefits of fixation with a TTC nail are the ability to weight bear as tolerated post-operatively and decreased wound complications while having similar functional outcomes to open reduction and internal fixation. We suggest the use of TTC nails for ankle fractures in select patients who may not adhere to weight-bearing restrictions post-operatively.

Hindfoot nailing for displaced ankle fractures in the elderly: A case-control analysis

INTRODUCTION

Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a hindfoot nail compared to patients who underwent an ORIF.

METHODS

A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021. Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS). Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure and infections.

RESULTS

Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who underwent ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11 complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant differences in length of stay (P = 0.58) and operation time (P = 0.19).

CONCLUSION

Hindfoot nailing was associated with an increased risk of complications and higher risk of return to the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be aware of these potential pitfalls.

Preservation of the Subtalar Joint Determines Outcomes in a 10-Year Evaluation of Ankle Arthrodesis

Posttraumatic osteoarthritis may lead to surgical fusion of the ankle joint if non-surgical therapy fails. The indication for a fusion of the joint is based on the pain and disability of the patient, radiographic imaging, and surgeon experience, with no strict guidelines. We aimed to compare outcomes after tibiotalocalcaneal arthrodesis (TTCA) and tibiotalar arthrodesis (TTA) to highlight the functional importance of the subtalar joint. In total, 432 patients with ankle arthrodesis were retrospectively enrolled. Group A (n = 216) underwent TTCA; group B (n = 216) underwent TTA. Demographics, Olerud & Molander Ankle Score (OMAS), Foot Function Index (FFI-D), and Short Form-12 Questionnaire (SF-12) were recorded at a mean follow-up of 6.2 years. The mean OMAS was 50.7; the mean FFI-D was 68.9; the mean SF-12 physical component summary was 39.1. These scores differed significantly between the groups (p < 0.001). The overall revision rate was 18%, primarily for revision of non-union and infection (p < 0.001). Approximately 16% of group A and 26% of group B were able to return to previous work (p < 0.001). Based on significantly worse clinical scores of TTCA compared to TTA and the prolonged downtime and permanent incapacity, the indication for a generous subtalar joint arthrodesis with planned ankle arthrodesis should always be critically examined.