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

Christian Harter; Thomas Cho; Jiayong Liu

doi:10.1016/j.jor.2024.12.047

View/Download PDF

Buy Reprints

PDF

Translate this page into:

67 (); 1-6

doi:

10.1016/j.jor.2024.12.047

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

Christian Harter, Thomas Cho, Jiayong Liu

University of Toledo Medical Center, Department of Orthopaedic Surgery, USA

⁎Corresponding author: Jiayong Liu. jiayong.liu@utoledo.edu

Received: 2024-11-17, Accepted: 2024-12-29, Published: 2024-12-31

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

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.

Keywords

Ankle

Fractures

Elderly population

Tibiotalocalcaneal (TTC) nailing

Outcomes

Show Related Articles from PubMed

1 Introduction

Ankle fractures are the third most common injury in the elderly population following the hip and distal radius.¹ Low energy ankle fractures are most often seen in elderly, osteoporotic females, and the incidence is projected to triple over the next 30 years.²^,³ These fractures pose a great risk to this demographic as poor results are often seen following traditional treatment methods. This can be due to the long healing time, poor soft tissue, and bone quality in the elderly. They may also put this population at risk of perioperative complications, repeat surgeries, and increased mortality due to longer healing times that keep patients immobilized, as well as the fact that many patients in this demographic often have multiple comorbidities.⁴ This is exacerbated by many patients' inability to limit weight-bearing postoperatively. In elderly populations, maintaining mobility and independence in daily activities is of utmost importance, as loss of mobilization is associated with increased mortality. Tibiotalocalcaneal (TTC) nailing has long existed as a treatment option for fractures of the ankle. It was first used in 1906 when Lexer utilized a boiled corpse fibula inserted through the calcaneus, talus, and into the tibia to achieve tibiotalocalcaneal arthrodesis.⁵ The popularity of the nailing technique has grown in the past twenty years as a treatment option for certain demographics and surgical indications. The technique of tibiotalocalcaneal nailing involves making a 2 cm longitudinal incision in the plantar surface of the heel, and then advancing a percutaneous guidewire from the calcaneus, through the talus, and into the tibia. Reaming is then performed and a TTC nail is inserted and secured with usually two screws proximally and two screws distally.^6–14 This technique immobilizes the ankle and subtalar joints.¹⁵ The use of TTC nailing has increased in popularity as a treatment option for the elderly population because it has the advantages of being a relatively quick and easy surgical option that is minimally invasive and avoids extensive soft tissue dissection. TTC nailing provides more stability in patients with poor bone quality and allows patients to mobilize immediately. It also allows for a quick return to weight bearing compared to traditional treatment methods and has been reported to have a low complication rate. These advantages come at the expense of the movement of the ankle and subtalar joint, which can impact patients’ freedom of movement in some areas such as running, jumping, and squatting. However, elderly patients are already often limited in these activities. In a population with a limited life expectancy, it is more important to maintain their weight-bearing and walking ability for their morbidity and mortality. Currently there are no systematic reviews on this topic with large elderly patient populations. The aim of this study is to analyze the outcomes of the treatment of ankle fractures in the elderly population with tibiotalocalcaneal nailing. The primary outcome measurements included are complication rate, time to weight-bearing, return to baseline, functional scores, revision rate, union rate, length of hospital stay, and healing time.

2 Methods

2.1

2.1 Search strategy

This systematic review was carried out utilizing PubMed and Google Scholar as a database to identify potential studies. The key search terms used were variations of the criteria “tibiotalocalcaneal nail”, “ankle fracture”, “TTC arthrodesis”, “geriatric”, “elderly” and “hindfoot nail” to identify studies published from 2000 to the present that investigated ankle fractures treated with TTC nailing.

2.2

2.2 Inclusion and exclusion criteria

Included study types for this review were randomized control studies and retrospective cohort studies. Inclusion criteria included a patient population >65 years old, ankle fractures, and treatment utilizing a nail through the tibia, talus, and calcaneus. Exclusion criteria included young patient populations, nails that did not extend through the tibia and talus and calcaneus, fibula involvement, and TTC nails for indications other than ankle fracture. Studies that were meta-analyses or systematic reviews were excluded. Studies with limited data or unclear patient demographics were excluded. Data was extracted and input into an Excel spreadsheet split into separate categories. Categories for data analysis included patient demographics, study characteristics, functional outcomes, radiographic outcomes, postoperative complications, and revisions.

2.3

2.3 Data analysis

Relevant qualitative and quantitative data were compiled in an Excel sheet, and values for quantitative data were rounded to three significant figures. For quantitative data, the mean and standard deviation were calculated. Pre- and post-operative scores were assessed utilizing an unpaired two-sample t-test. The rates of total infection among all patients were compared to those of diabetic patients using a two-sample t-test. A P-value of 0.05 was used.

3 Results

3.1

3.1 Demographics

A total of 3009 studies were initially identified for further analysis. After applying inclusion and exclusion criteria, twenty-four studies were appropriate for review^6–14^,^16–30 (Fig. 1). This includes a total of 657 patients, making this the largest study to analyze this demographic (Table 1). The mean age of the patients was 78 ( ± 6.3) years. With this review focusing on elderly patient populations, a relatively high comorbidity rate was assumed across all patients. While most of the studies discussed the high comorbidity rate as an implicit factor influencing the indication for TTC nail, only eight studies reported the number of patient comorbidities, with the average being 3 ( ± 1.38) per patient. Some studies used the Charlson Comorbidity Index (CCI) instead of reporting comorbidity numbers. A total of four studies reported the CCI with an average of 5.7 ( ± 1.05). The American Society of Anesthesiologists class was reported by twelve studies with an average of 2.82 ( ± 0.33). A total of fifteen studies reported the percentage of diabetics in their cohorts, with three studies including only diabetics and six having greater than 50 % diabetics. The average proportion of diabetics was 47.29 % ( ± 0.33).

The PRISMA flowchart. Prisma = preferred reporting items for systematic reviews and meta-analyses.

Table 1 Patient demographics.

Author	Year published	Study level	Patients included	Mean Age	Comorbidities	Diabetics
Al-Nammari	2014	RCS	48	82	3.3	15
Amirfeyz	2008	RCS	13	78.9
Armstrong	2018	RCS	20	76	2.9	5
Baig	2023	RCS	30	70	5.6	30
Baker	2018	RCS	16	73	4
Balziano	2023	RCS	18	88.6		5
Cay	2023	RCS	34	87	3
Corin	2023	RCS	70	80
DeGenova	2024	RCS	32	74.3		32
Duvvuri	2023	RCS	22	80.8		2
Ebaugh	2019	RCS	27	66		27
Eyre-Brook	2021	RCS	68	77.4
Georgiannos	2017	RCT	43	78
Herrera-Perez	2020	RCS	17	81.5		11
Jonas	2013	RCS	31	77		31
Kotsarinis	2024	RCS	32	80.2
Kulakli-Inceleme	2021	RCS	10	85.2		1
Large	2023	RCS	14	68	1.5	11
Lemon	2005	RCS	12	84
Lu	2021	RCS	20	77.82		5
O'Daly	2010	RCS	9	81
Ou	2023	RCS	26	84		8
Persigant	2018	RCS	14	79.6	2.4
Taylor	2016	RCS	31	63	1.3	17

3.2

3.2 Outcomes

The quality of outcomes of TTC nails was assessed by several measures, including functional outcomes, radiographic union, healing time, hospital stay, time to weight-bearing, and return to baseline. Only two studies reported AOFAS scores (average 52.8). Functional outcomes were most assessed using Olerud-Molander Ankle Scores, a self-administered patient questionnaire that measures ankle function across multiple categories on a scale of 1–100, with higher scores correlating with higher function.³¹ Pre-injury OMAS was reported in 5 studies and post-operative in 9 studies, with a mean score of 63.1 ( ± 5.00) pre-operatively and 50.43 ( ± 8.59) post-operatively. Post-operative OMAS was measured at an average of 10.14 months after surgery (range = 6–16.75 months). The post-operative OMAS was significantly lower than pre-injury OMAS. These scores demonstrate fair maintenance of ankle function, but it is inherently flawed in its assessment due to the nature of the OMAS scoring categorization.³¹ Several of the categories evaluated in the OMAS are severely impacted by TTC arthrodesis, including running, jumping, squatting, and climbing.⁶^,¹⁴ Compared to open reduction and internal fixation (ORIF), the most common method of ankle fracture treatment, TTC nailing is at a disadvantage in terms of OMAS scores due to the preservation of mobility in the ankle joints in ORIF. Furthermore, due to the geriatric nature of this population, TTC patients generally have lower baseline scores to begin with.

The average rate of radiographic union was 88.36 % ( ± 0.12) across all studies, with the average healing time being 17.8 ( ± 4.68) weeks. Eleven of the studies specified that the ankle joints were not prepared prior to treatment.⁷^,⁹^,¹⁰^,¹³^,¹⁴^,¹⁶^,¹⁷^,²²^,²³^,²⁶^,³⁰ This decision was made to minimize the invasiveness, healing time, and wound complications.⁹ Some surgeons also feel that joint preparation would devascularize the talar fragments, introducing healing issues.²¹ Other authors suggest that joint preparation is an important factor contributing to the union rate.²⁶^,³² However, with such a low proportion of non-union observed, joint preparation may not be necessary in this patient population.

Fifteen studies reported hospital stays with an average of 12.77 ( ± 8.12) days. The average time to weight-bearing across the eight studies that reported it was 28.25 ( ± 25.5) days, although three of these studies reported all patients weight-bearing one day post-operatively. Additionally, ten of the studies allowed immediate weight-bearing as tolerated but did not specify the average return to weight-bearing among the patients. The number of patients that returned to or exceeded their baseline level of ambulatory function post-operatively was reported in sixteen studies with an average of 77.16 % ( ± 0.17), which is favorable compared to reported ORIF return to baseline.⁶^,²⁷ There were two studies that reported 100 % of patients returning to baseline. Some studies specified that the majority of TTC patients had poorer baseline ambulatory function, which was an indication noted by the surgeons for them to receive TTC over ORIF.¹⁰ This may explain some discrepancies in PROMs (Table 2).

Table 2 Complications.

Author	Superficial infections	Deep infections	All infections	Symptomatic removal	Implant failure	Revised cases	Overall Complications
Al-Nammari	2	2	4	1	0	3	9
Amirfeyz	1	0	1			1	3
Armstrong	6	0	6				7
Baig	5		5	6		6	13
Baker			0		0		0
Balziano			0			2	4
Cay	1	2	3			4	5
Corin	5		5			10	17
DeGenova	2	3	5		1	3	8
Duvvuri	1		1			2	3
Ebaugh	1	3	4	2		4	5
Eyre-Brook	1	1	2	10	5	12	23
Georgiannos	1		1	1		1	3
Herrera-Perez	1	0	1				4
Jonas			0	5	2	5	7
Kotsarinis	5		5	6		6	8
Kulakli-Inceleme	1	0	1			2	4
Large	0	2	2				4
Lemon			0				0
Lu	4	0	4		0	4	8
O'Daly			0				0
Ou	0	4	4		4	7	12
Persigant		1	1		0	1	2
Taylor	2	3	5	3		3	8

3.3

3.3 Complications

Infections were reported in nineteen studies. The overall rate of infection across all studies that reported it was 10.51 % ( ± 0.07) (60/571 patients) and the overall complication rate was 24.00 % ( ± 0.13)(157/657 patients), showing comparable results to traditional repair with ORIF. Studies have reported ORIF complication rates of 21.5 % and infection rates of 13.8 %.³³ Sixteen studies reported rates of superficial infection with an average of 6.83 % ( ± 0.08) (39/571 patients). Nine studies reported on deep infection with an average of 3.68 % ( ± 0.06) (21/571 patients). Superficial infections were treated with antibiotics while deep infection required surgical revision with formal debridement. Medical comorbidities also are driving factors in complication rates, and among these studies, the average number of comorbidities per patient was three.¹⁸^,³⁴ Among the studies, the most common complications seen were infection, loosening of the distal locking screws, breaking of the distal locking screws, and amputation due to wound complications. Some previous studies have suggested that patients demonstrating poorly controlled diabetes such as those with peripheral neuropathy, peripheral artery disease, or diabetic neuropathy have complication rates greater than twice that of patients without these comorbidities.³⁵ This systematic review examined the studies containing greater than 50 % diabetics and compared the rates of infection in this group to the overall infection rate. There were six studies that contained a majority of diabetics, including three studies that contained exclusively diabetics. The overall infection rate across all studies was 10.51 %, while the rate of infection in studies with most diabetic patients was 14.56 % (22/151 patients), demonstrating no significant difference in infection rates between diabetic patients and all patients. The average revision rate was 12.60 % ( ± 0.07) (76/603 patients), with the most common indications for revision being deep infection, periprosthetic fractures, broken or loose distal locking screws, and non-union. Some authors opted to use a longer tibiotalocalcaneal nail that crosses the isthmus of the tibia to avoid risking periprosthetic fractures.¹²^,¹³ Nail failures were reported in eight studies at a rate of 4.70 % (12/255 patients). The average rate of implant removal was 11.61 % ( ± 0.06) (36/310). Of the 36 nail removals reported, 2 were elective removals, while the other 34 were due to symptomatic issues (Table 3).

Table 3 Patient outcomes.

Author	OMAS pre-op	OMAS post-op	Healing time (weeks)	Union	Hospital Stay (days)	Return to baseline	Time to weight-bearing (weeks)	Immediate full weight-bearing allowed post-op
Al-Nammari	62	5 7	9	1		0.9		Yes
Amirfeyz		50		1		1	42
Armstrong					18			No (2 weeks)
Baig					5	0.8
Baker						1		No (1 week)
Balziano		32.8			10.7			Yes
Cay					21	0.44		Yes
Corin								Yes
DeGenova			23.1	1		0.781	45.5
Duvvuri			19.4	0.727	7
Ebaugh			18	0.88	6	0.815	47
Eyre-Brook				0.74	29	0.81
Georgiannos	63.4	56.9			5.2	0.756		Yes
Herrera-Perez	64.1	55.3		1		0.8824		Yes
Jonas	56	45		0.619		0.9355		Yes
Kotsarinis		45	16	0.938	28.8		1
Kulakli-Inceleme				0.7	15.4	0.5		Yes
Large				0.857	8		66.5
Lemon	70	61		1		0.8182	1
Lu		50.9	17	1	10.8	0.65
O'Daly				0.889		0.667	1
Ou				0.885	13	0.59	22
Persigant					6			Yes
Taylor			22.2	0.903	7.6			Yes

4 Discussion

This systematic review aims to provide an overview of the technique, the indications, the limitations, and the expected outcomes of tibiotalocalcaneal nailing ankle fractures in an elderly population. This study focuses on major outcomes: time to weight-bearing, complication rate, return to baseline, and patient-reported outcome measures (PROMs). Tibiotalocalcaneal nailing has existed as a surgical technique for many years. However, over the past 10 years, this treatment method's popularity has soared dramatically. This is demonstrated in that fourteen out of the twenty-four studies have been published in the past five years. The reason for this increase in utilization is a greater understanding of the indications for use and increased evidence of its merits. The major indications for use of TTC nailing include fragility fractures occurring from a low energy mechanism such as a fall from standing height, advanced patient age, poor bone quality, and poor pre-operative baseline mobility. The advantages of using TTC nailing in the treatment of ankle fractures are that it is less invasive, has a quick recovery time, has a low complication rate, and has early mobilization. Disadvantages of TTC are limited mobility in the tibiotalar and subtalar joints, long-term complications that include arthritis of the tibiotalar and subtalar joints, and periprosthetic fractures.⁶ TTC nailing is generally contraindicated in a younger population with otherwise uncompromised mobility and a lack of comorbidities as it will detract from the functionality and mobility of the ankle joints that is imperative to movements such as squatting, jumping, and running. However, in the elderly population, this is not a concern because these patients have a limited baseline mobility and largely cannot perform these movements prior to injury. TTC's advantages are highly relevant in this patient population because elderly individuals rely on ambulation for independent living and everyday activities. Generally, the geriatric population has a limited life expectancy, limited activity, high comorbidity profile, and poor bone and soft tissue quality.

The most widely used alternative to TTC nailing is open reduction internal fixation (ORIF) which involves reducing ankle fractures utilizing a plate and screws. ORIF has been and remains the standard of care for ankle fractures. Although it has been reported that ORIF can have healing times of up to 12 weeks, it also has the potential to achieve near baseline levels of ambulation following treatment. However, ORIF is limited in its efficacy in patient populations with osteoporosis, peripheral vascular disease, diabetes, or other comorbidities.⁶ Compared to standard treatment with ORIF, TTC has been shown by some studies to be less invasive, have a decreased risk of wound complications, and a faster time to weight-bearing.⁶^,¹⁰ In an elderly patient population, a fast time to weight-bearing is especially beneficial, as it has been reported that patients older than 65 years are only compliant with non-weight bearing restrictions about 22 % of the time.³⁶ TTC has the additional benefit of being a one time surgery while ORIF often involves multiple surgeries.

The main limitations of this study are the small sample size, the retrospective nature of the study, and the lack of control groups to compare outcomes to. There was also a prevalent non-uniformity of patient demographics and outcomes reported among the studies. Furthermore, the decision to perform tibiotalocalcaneal nailing versus an alternative treatment option was left to the discrepancy of the operating surgeons in most of the studies, and as such, the indications may have varied from surgeon to surgeon. This study's aim was to provide a systemic view of the technique of tibiotalocalcaneal nailing for ankle fractures in geriatric populations. In future reviews, a more pointed comparison of the efficacies of differing treatment methods is called for. Despite this systematic review including the largest sample size of this patient population to this point, larger sample sizes, as well as RCTs with extended follow-up times and more detailed results, are needed in future studies.

5 Conclusion

TTC is a reasonable treatment option for ankle fractures in elderly populations especially in patients with multiple comorbidities that cannot tolerate multiple invasive surgeries. In cases where complete function of the ankle joints is not the greatest concern whether due to limited life expectancy or pre-existing limited function, TTC provides a quick and reliable method of ankle fixation that allows a rapid return to weight-bearing and potentially prolonged independent living with an acceptable complication profile.

CRediT authorship contribution statement

Christian Harter: Data curation, Formal analysis, interpretation, Writing – original draft, Writing – review & editing. Thomas Cho: Data curation, Formal analysis, interpretation, Writing – original draft. Jiayong Liu: Conceptualization, Methodology, Software, Formal analysis, interpretation, Writing – review & editing, Supervision.

Guardian/Patient's consent

N/A.

Ethical statement

Not applicable.

Financial support and sponsorship

No.

References

Pearce O., Al-Hourani K., Kelly M., . Ankle fractures in the elderly: current concepts. Injury. 2020;51(12):2740-2747.
[Google Scholar]
Kannus P., Palvanen M., Niemi S., Parkkari J., Jrvinen M., . Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone. 2002;31(3):430-433.
[Google Scholar]
Kannus P., Palvanen M., Niemi S., Parkkari J., Jarvinen M., . Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone. 2002;31:430-433.
[Google Scholar]
Nilsson G., Jonsson K., Ekdahl C., Eneroth M., . Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Muscoskel Disord. 2007 Dec 20;8:127.
[Google Scholar]
Lexer E., . Versteifung paralytischer Gelenke mittels Knochenbolzen. Dtsch Med Wochenschr Vereinsber. 1906;8:321-322.
[Google Scholar]
Georgiannos D., Lampridis V., Bisbinas I., . Fragility fractures of the ankle in the elderly: open reduction and internal fixation versus tibiotalocalcaneal nailing: short-term results of a prospective randomized-controlled study. Injury. 2017 Feb;48(2):519-524.
[Google Scholar]
Taylor B.C., Hansen D.C., Harrison R., Lucas D.E., Degenova D., . Primary retrograde tibiotalocalcaneal nailing for fragility ankle fractures. Iowa Orthop J. 2016;36:75-78.
[Google Scholar]
O'Daly B.J., Harty J.A., O'Malley N., et al . Percutaneous Gallagher nail stabilisation for fragility ankle fracture. Eur J Orthop Surg Traumatol. 2010;20:651-655.
[Google Scholar]
Ebaugh M.P., Umbel B., Goss D., Taylor B.C., . Outcomes of primary tibiotalocalcaneal nailing for complicated diabetic ankle fractures. Foot Ankle Int. 2019 Dec;40(12):1382-1387.
[Google Scholar]
Balziano S., Baran I., Prat D., . Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: comparison of clinical and patient-reported outcomes with standard ORIF. Foot Ankle Surg. 2023 Dec;29(8):588-592.
[Google Scholar]
Lemon M., Somayaji H.S., Khaleel A., Elliott D.S., . Fragility fractures of the ankle: stabilisation with an expandable calcaneotalotibial nail. J Bone Joint Surg Br. 2005 Jun;87(6):809-813.
[Google Scholar]
Al-Nammari S.S., Dawson-Bowling S., Amin A., Nielsen D., . Fragility fractures of the ankle in the frail elderly patient: treatment with a long calcaneotalotibial nail. Bone Joint Lett J. 2014 Jun;96-B(6):817-822.
[Google Scholar]
Baker G., Mayne A.I.W., Andrews C., . Fixation of unstable ankle fractures using a long hindfoot nail. Injury. 2018 Nov;49(11):2083-2086.
[Google Scholar]
Amirfeyz R., Bacon A., Ling J., et al . Fixation of ankle fragility fractures by tibiotalocalcaneal nail. Arch Orthop Trauma Surg. 2008 Apr;128(4):423-428.
[Google Scholar]
Strauss E.J., Egol K.A., . The management of ankle fractures in the elderly. Injury. 2007 Sep;38(Suppl 3):S2-S9.
[Google Scholar]
Duvvuri P., Trout S.M., Bub C.D., Goldman A.T., . Use of a hindfoot nail without separate subtalar and tibiotalar joint preparation to treat geriatric ankle and distal tibia fractures: a case series. Geriatr Orthop Surg Rehabil. 2023 Aug 12;14
[Google Scholar]
Armstrong L., Jackson J., Riddick A., . Tibiotalocalcaneal nail fixation and soft tissue coverage of Gustilo-Anderson grade 3B open, unstable ankle fractures in a frail population; a case series in a major trauma center. Foot Ankle Surg. 2018 Aug;24(4):347-352.
[Google Scholar]
Large T.M., Kaufman A.M., Frisch H.M., Bankieris K.R., . High-risk ankle fractures in high-risk older patients: to fix or nail? Arch Orthop Trauma Surg. 2023 Jul;143(7):3725-3734.
[Google Scholar]
Jonas S.C., Young A.F., Curwen C.H., McCann P.A., . Functional outcome following tibio-talar-calcaneal nailing for unstable osteoporotic ankle fractures. Injury. 2013 Jul;44(7):994-997.
[Google Scholar]
Persigant M., Colin F., Noailles T., Pietu G., Gouin F., . Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients. Orthop Traumatol Surg Res. 2018 Jun;104(4):507-510.
[Google Scholar]
Lu V., Tennyson M., Zhang J., Thahir A., Zhou A., Krkovic M., . Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre. Eur J Orthop Surg Traumatol. 2023 Jan;33(1):125-133.
[Google Scholar]
Eyre-Brook A.I., Ring J., Chadwick C., Davies H., Davies M., Blundell C., . A comparison of fibula pro-tibia fixation versus hindfoot nailing for unstable fractures of the ankle in those older than 60 years. Foot Ankle Spec. 2023 Apr;16(2):135-144.
[Google Scholar]
DeGenova D.T., Hill Z.P., Hoffman A.D., et al . Does the subtalar or tibiotalar joint need fused in primary retrograde tibiotalocalcaneal nailing for fragility ankle fractures? Foot Ankle Spec. 2024 May;10
[Google Scholar]
Kotsarinis G., Santolini E., Kanakaris N., Giannoudis P.V., . 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. Eur J Orthop Surg Traumatol. 2024 May;18
[Google Scholar]
Herrera-Perez M., Martín-Vélez P., Rendón-Díaz D., Pais-Brito J.L., . Acute retrograde tibiotalocalcaneal nailing in osteoporotic periarticular ankle fractures. Journal of the Foot & Ankle. 2020;14(2):117-122.
[Google Scholar]
Kulakli-Inceleme E., Tas D.B., Smeeing D.P.J., et al . Tibiotalocalcaneal intramedullary nailing for unstable geriatric ankle fractures. Geriatr Orthop Surg Rehabil. 2021 Jun 17;12
[Google Scholar]
Ou C., Baker J.F., . Hindfoot nailing for displaced ankle fractures in the elderly: a case-control analysis. Injury. 2023 Aug;54(8)
[Google Scholar]
Baig M.S., Mehta S., Morales D.S., Maniar H.H., Dahodwala T., Horwitz D.S., . Successful primary treatment of ankle fractures in diabetic patients with peripheral neuropathy using a tibiotalocalcaneal nail: a case series. Indian J Orthop. 2023 May 5;57(7):1068-1075.
[Google Scholar]
Corin N., Pearkes T., Hristova K., et al . The use of hindfoot nails for elderly complex distal tibial and ankle fractures. J Foot Ankle Surg. 2023 Sep-Oct;62(5):797-801.
[Google Scholar]
Cay P., Saad A., Bellringer S., Robertson A., Guryel E., . Tibiotalocalcaneal nail and primary closure for the management of open ankle fractures in the elderly patient; results from a major trauma centre. Foot Ankle Surg. 2024 Feb;30(2):123-128.
[Google Scholar]
Olerud C., Molander H., . A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg. 1984;103(3):190-194.
[Google Scholar]
Kim C., Catanzariti A.R., Mendicino R.W., . Tibiotalocalcaneal arthrodesis for salvage of severe ankle degeneration. Clin Podiatr Med Surg. 2009 Apr;26(2):283-302.
[Google Scholar]
Zaghloul A., Haddad B., Barksfield R., Davis B., . Early complications of surgery in operative treatment of ankle fractures in those over 60: a review of 186 cases. Injury. 2013;45:780-783.
[Google Scholar]
Olsen J.R., Hunter J., Baumhauer J.F., . Osteoporotic ankle fractures. Orthop Clin N Am. 2013 Apr;44(2):225-241.
[Google Scholar]
Wukich D.K., Joseph A., Ryan M., Ramirez C., Irrgang J.J., . Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011 Feb;32(2):120-130.
[Google Scholar]
Seo H., Lee G.J., Shon H.C., et al . Factors affecting compliance with weight-bearing restriction and the amount of weight-bearing in the elderly with femur or pelvic fractures. Ann Rehabil Med. 2020 Apr;44(2):109-116.
[Google Scholar]