Ankle tibiotalocalcaneal nailing in elderly ankle fractures as an alternative to open reduction internal fixation: technique and literature review

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.

Distal Femoral Nail as a Cost-Effective Alternative to Tibiotalocalcaneal Nail for Ankle Fracture Non-Union in an Elderly Patient: A Case Report

Introduction

Ankle fracture non-union in elderly patients is challenging due to osteoporotic bone, comorbidities, and risks associated with open reduction and internal fixation (ORIF). Tibiotalocalcaneal (TTC) nail fixation enables early weight-bearing but is costly and not widely available in resource-limited settings.

Case Report

We present an 83-year-old male with a painful, deformed left ankle and non-union of a bimalleolar fracture treated conservatively. Comorbidities included diabetes mellitus and hypertension. Due to fragile skin and high ORIF-associated risks, a distal femoral nail (DFN) was used as a substitute for a TTC nail. A minimally invasive technique was performed, including joint preparation and medial malleolar bone grafting. Weight-bearing was initiated postoperatively.

Conclusion

DFN offered comparable fixation with reduced cost and acceptable complications. This case highlights DFN's utility as a TTC nail substitute in elderly patients, ensuring stability, early mobilization, and functional recovery in low-resource settings.

Syndesmotic Screw Fixation Versus Suture Button Versus Tibiotalocalcaneal Nail Treatment in Syndesmotic Ankle Fractures: A Meta-Analysis

BACKGROUND

Syndesmotic ankle fractures occur when damage to the syndesmosis complex is combined with a malleolar fracture. This can result in severe pain, weakness, and instability. Surgical interventions include syndesmotic screw fixation (SS), suture button fixation (SB), and tibiotalocalcaneal nail (TTC). This meta-analysis aims to compare the outcomes of these treatment methods for syndesmotic ankle fractures.

METHODS

A literature search was conducted on PubMed and Embase for comparison studies that included at least 2 surgical interventions and at least one of the relevant functional outcomes and/or complication metrics until June 2024. The Olerud-Molander Ankle Score (OMAS) was used to compare functional outcomes, and it is a self-reported outcome measure that evaluates the symptoms and function of those with ankle fractures, while infections and reoperations were reported to compare complication outcomes. Statistical analyses were performed using Review Manager 5.4. A P-value ≤ .05 was considered statistically significant. The risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale.

RESULTS

A total of 18 studies with a total of 1,040 patients were ultimately included in this study. The SS had a significantly higher OMAS 2-year follow-up compared to TTC. The TTC had a significantly lower infection rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than SS. The SB had a significantly lower reoperation rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than TTC. The SB had a significantly lower infection rate compared to TTC.

CONCLUSION

The SB emerges as the preferred treatment method for syndesmotic ankle fractures, while TTC stands as a viable alternative. The SB is recommended as the primary surgical intervention for patients with syndesmotic ankle fractures due to its superior clinical benefits when compared to TTC and SS.

LEVELS OF EVIDENCE

3.

The Impact of Diabetes on Outcomes for Tibiotalocalcaneal Arthrodesis: A Systematic Review of Available Comparative Studies

Background/Objectives: Tibiotalocalcaneal (TTC) arthrodesis is commonly used in salvage situations involving the ankle and subtalar joint, often in patients with concomitant diabetes mellitus (DM). Across orthopedics, DM presents an overall increased risk of developing complications post-surgically. In this systematic review, the primary aim was to summarize the outcomes and complications of patients undergoing TTC arthrodesis with DM. Methods: A qualitative systematic review was conducted, with an initial search performed on 30 August 2023, using PubMed, SPORTDiscus, CINAHL, and MEDLINE. The search algorithm "tibiotalocalcaneal" AND (nail OR nails) AND (fusion OR arthrodesis) was applied, following PRISMA guidelines. Inclusion criteria encompassed articles examining the impact of diabetes on TTC arthrodesis outcomes. Data extraction involved patient demographics, complication rates, and surgical outcomes. Due to data heterogeneity, a narrative approach was utilized to describe results across studies. Results: Four articles met the inclusion criteria. These observational comparative studies were of moderate quality, with a mean MINORS score of 20.5 ± 1.9 points. The combined patient cohort included 162 patients, evenly split between diabetic and non-diabetic groups, with a mean age of 58.2 ± 2.7 years and a follow-up duration of 35.0 ± 7.4 months. Diabetic patients exhibited higher rates of superficial infection, though functional outcomes and fusion rates were generally favorable. Conclusions: TTC arthrodesis in diabetic patients was associated with an increased risk of superficial infections and various other complications. Despite these risks, functional outcomes and rates of successful fusion were comparable to non-diabetic patients undergoing TTC arthrodesis. This review highlights the need for standardized definitions of surgical success.

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.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

Ankle fractures in the elderly: Do we have new concepts?

The relevance of geriatric ankle fractures is continuously increasing. Treatment of these patients remains challenging and requires adapted diagnostic and therapeutic strategies, as compliance to partial weight bearing is difficult to maintain compared to younger patients. In addition, in the elderly even low impact injuries may lead to severe soft tissue trauma, influencing timing and operative strategies. Recently, the direct posterolateral approach and plate fixation techniques, angular stable implants as well as intramedullary nailing of the distal fibula have been found to improve stategical concepts. This article aims to provide a comprehensive overview of the diagnostic and recent aspects with respect to how this difficult entity of injuries should be approached.