Purpose of the study: To establish the difference between AO plate osteosynthesis and Elastic Stable Intramedullary Nailing and the long-term outcome. Design: Prospective randomised study. Material: During 2000 and 2002 prospective randomised study was carried out where children with diaphysial fracture of long bone was either treated with osteosynthesis with AO plate or ESIN. 32 children had AO plate osteosynthesis and 34 children had ESIN procedure. Methods: In our series of patients managed with ESIN Nailing 24 had forearm fracture 6 had femur fracture 2 had humeral and 2 had tibial fracture. The other group with AO plate osteosynthesis had 25-forearm fracture 1 humeral fracture 4 tibial fractures and 2 femoral fractures. Results: The group treated with AO plate osteosynthesis 2 had rotational deformity and rest did well. The recovery period after removal of metal work was longer. The group treated with ESIN procedure 1 patient fell down and bend the C-Nail, which was straightened in situ, and the fracture healed with slight curvature of the femur, which corrected slowly with growth. The forearm fractures did not have any rotational deformity. The recovery period post removal of the ESIN was very short. Conclusion: We find that ESIN is a superior procedure for diaphysial fractures of long bone in children and AO plating should only be done in cases where ESIN is not possible

Abstract

The authors describe a new, original technique of intra-medullary nailing (originally designed for the Gamma nail system, now also suitable for other nailing systems) for the management of pertrochanteric and subtrochanteric fractures using a minimally invasive approach to the proximal femur. In this approach, the intramedullary nail is placed using a percutaneous Kirschner wire as a guide, so that the procedure has been called “Percutaneous Nailing System” (PNS). The entry portal is selected at the proximal femur using the Kirschner wire, then a series of cannulae is placed through a small cutaneous incision (15 mm). This dilatator system protects the soft tissue during the reaming procedure (usually only necessary in the proximal femur, not in the diaphysis) and the insertion of the femoral nail. From April 2001 to January 2004, 120 patients were treated with this new technique. They have been followed up and retrospectively compared to 60 patients operated with the standard technique. The comparison between the two groups was based on the surgical procedure (operation time and total blood loss) and the post-operative period (complications, length of hospitalisation). With the minimally invasive technique the operation time was on average 15 min and the blood loss, measured as the difference in pre- and postoperative haemoglobinaemia, was on average 1 point, with no need for blood transfusion: these values were less than half in comparison to the standard technique. The study shows the advantages of this minimally invasive technique, which can also be applied to fractures of the femoral diaphysis

Introduction: The present study was performed to compare the mechanical properties and fixation stability of tibial nails of the newest generation used in the management of distal metaphyseal fractures. Furthermore, we tried to evaluate whether distal locking with 4 locking screws might increase load-sharing after stabilization of distal metaphyseal tibial fractures. Methods: We used 16 Sawbones third generation large left tibiae (Sawbones Inc., Sweden) to create an unstable distal metaphyseal fracture model (AO type 43-A3). In 8 specimens the fracture was stabilized with 2 nails with 3 distal locking options (4x VersaNail™, DePuy Orthopaedics, Johnson& Johnson, Warsaw, IN; 4x T2 Tibial Nailing System™, Stryker, Kiel, Germany) and in 8 specimens with 2 nails with 4 locking options (4x Connex™, ITS Spectromed, Lassnitzhöhe, Austria; 4x Expert Tibial Nail™, Synthes, Switzerland). Each specimen was loaded cyclically with three loading sequences over a period of 40,000 cycles in each series (700N, 1,500N, 1,800N). Implant stiffnes during axial cyclic loading series in 7° valgus alignement was recorded as well as cycles until failure of the bone-implant-construct. Results: In the second loading series, implant failure was observed in all tibial nails with 3 distal locking screws after a mean period of 57,196.7 cycles. If distal locking was performed with 4 screws, implant failure was recorded in the third and last loading series after a mean period of 87,518.3 cycles (p< 0.001). If distal locking was performed with 3 distal locking screws, implant stiffness was 1776 (±99) N/mm. If distal locking was performed with 4 locking screws, implant stiffness was 2674 (±208) N/mm (p< 0.001). Conclusion: Distal locking with 4 screws improves implant-bone stability. Stability is influenced by the number of locking screws and not by screw diameter. In these fracture type, nails with 4 distal locking options should be used

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin. We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution. All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks. The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening. Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%. We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws

Aims. To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures. Method. A retrospective, consecutive series study of 60 patients treated with ESIN between February 1996 and July 2005. Results. There were 43 (72%) boys and 17 (28%) girls with median age of 11.5 years (range: 2.6-15.9). 54 (90%) patients had a closed injury and 6 (10%) sustained a Grade I open injury. Seven patients had an isolated radius fracture. 49 (82%) fractures were stabilised with both bone ESIN, 10 (16%) with radial and one with isolated ulnar ESIN by standard technique under tourniquet control. All but two patients were protected with an above elbow cast. Thirty-six cases (60%) were primary procedures and 24 (40%) were performed due to re-displacement following a MUA. 36 patients (60%) required a minimal open reduction. Average hospital stay was 1.8 days (1-8 days). Average length of immobilisation was 5.4 weeks (3-9 weeks). Average time for clinical fracture union was 5.7 weeks (3-13 weeks). ESIN were removed after mean period of 33.8 weeks (approx: 7.9 months). One patient had a forearm compartment syndrome and required formal fasciotomy. One patient had ulnar delayed union and one had ulnar non-union. Five patients had transient superficial radial nerve neuropraxia. Ten had soft tissue irritation leading to early nail removal in two patients and two had superficial wound infection. Three patients sustained a re-fracture with the nail in situ following a new injury. 53 (88%) patients had full elbow and wrist movements on discharge. Seven patients had restriction of forearm rotations of less than 15°. Conclusion. Good clinical outcome, transitory and modest complications; quick and safe nail removal; and better cosmesis compared to plating makes ESIN an attractive treatment option for displaced, unstable paediatric forearm diaphyseal fractures

Introduction: Nailing of the femoral shaft fractures has almost exclusively been done through the antegrade approach. This involves the use of a traction table and location of the entry point piriform fossa can be difficult especially in the obese or well-built patient. The set-up and operative time and blood loss can be considerable. We conducted a prospective study of nailing of femoral fractures, using the retrograde approach (through the knee joint) to measure the operating time, blood loss and knee function. A purpose built retrograde system was used (ART Nail ® ACE Medical Company-El Segundo, California). Materials & Methods: Seventeen patients who had a femoral shaft fracture, either as an isolated injury, or with associated with other injuries were nailed using the Art Nail, using the retrograde approach. The patients were placed on a radiolucent table, with a bolster place under the knee joint. A stienmann pin was inserted into the ipsilateral tibia 1” inferior and posterior to the tibial tubercle. This was used to apply traction manually by an assistant. The surgical approach was to split the patella tendon and the knee joint was entered. Using a light source, the nail entry point at the intercondylar notch, 7mm anterior to the PCL, is located. The rest of the operative procedure was done according to the operative manual. Blood loss was estimated by the anaesthesiologist. A drain was inserted into the knee joint after a through wash-out and continuos passive motion was started when the drain was removed on the 2nd postoperative day. Results: Fourteen had a single fracture while 3 had other associated fractures. The age range of was 28 to 67 years. Operative time was 60–100 minutes with blood loss ranging from 50–600 mls,with the median at 200mls. Post-operative drainage was 10–335 mls with median at 100mls. One patient developed distal deep vein thrombosis. Two patients were lost to follow-up. Union occurred at 12–20 weeks in fourteen patients, Two patients had to undergo dynamisation of the nail, one of which required a bone grafting to achieve union at 24 weeks. Two patients had a 1cm shortening of the limb and there were no malrotations. Two patients had < 5 degree medial–lateral angulation, on X-ray. At six months follow-up, fourteen patients had full range of motion at the knee joint, while one patient who had chondrocalcinosis had range of motion from 0 to 90 degrees. . The follow-up period is from 10–26 months. No patient complained of pain or instability of the knee joint. Conclusion: The retrograde approach is a safe and quick method of nailing femoral shaft fractures with no medium term effects on the knee joint

Purpose of the study: Fractures of the metacarpals are common injuries generally observed in young males. Nailing, either with a centromedullary configuration or intermetacarpal construction is generally proposed. The nailing procedure nevertheless has its drawbacks: fracture instability, secondary displacement, pin migration, infection, requirement to remove material, injury to the cutaneous dorsal branch of the ulnar nerve, and most importantly, immobilisation for several weeks which is a major inconvenience for these young active patients. In this context, we wanted to compare two fixation systems: a locked plate versus centromedullary nailing. Material and methods: This was a retrospective comparison of consecutive patients from September 2007 to December 2008. The series included 39 cervical fractures of the fifth metacarpal in 39 patients aged 31 years on average. The first 19 patients were treated with a locked plate (Médartis. ®. ) (group A) and the 20 others with descending centromedullary nailing (group B). In group A, a dorsal approach respecting the dorsal cutaneous branch of the ulnar nerve was used. The technique consisted in insertion of distal locking screws enabling fracture reduction on the plate. No postoperative immobilisation was proposed and rapid mobilisation was encouraged. In group B, classical centromedullary nailing was performed with immobilisation with a short Thomine brace and syndactylisation of the last two fingers. Outcome was based on objective criteria (Jamar. ®. force, joint motion, duration of sick leave) and subjective assessment (DASH, VAS). Results: Mean follow-up was 12 months in group A and 8 months in group B. Depending on the type of fracture, plates with different shapes and lengths were used in group A; a single pin was used in group B (16/10 or 20/10). Secondary displacement was more frequent in group B, but the results in recovered motion were better in group B. The only parameter better in group A was length of sick leave; four patients in group A underwent reoperation to remove the plate and for tenoarthrolysis. In all, the outcomes for cervical fractures of the fifth metatarsal were better in group B. Discussion: Our preliminary results in group A show lesser complications and earlier return to work compared with better motion at last follow-up in group B. Centromedullary nailing remains the better treatment for cervical fractures of the fifth metatarsal. The extra cost of the plates does not appear to be warranted for the treatment of neck fractures of the fifth even though the patient can resume occupational activities earlier

Complex injuries of upper extremity are among the most challenging cases for the treating physician, especially when comminuted fractures, neurovascular injuries or extensive soft tissue loss are accompanied with. Reconstruction of the skeleton is usually very difficult since plates, screws, or external fixation do not always provide sufficient stability. Recently, flexible titanium intramedullary nails that initially developed for pediatric trauma, were introduced in treatment of open and complex injuries of upper extremity. From 1995 – 2001 20 patients (16 male, 4 female) with a mean age 28 years (15–60 years) were managed at our department with flexible titanium intramedullary nailing. 12 sustained forearm fractures, humeral ones, as well as 4 concomitant fractures of forearm and humerus.Nailing was performed either closed with image intensifier or open through the wound with minimal stripping. Postoperatively a splint was applied. Rehabilitation regime was adjusted to soft tissue care; when severe soft tissue wasn’t encountered, early mobilization of the arm was applied. Union rate was conceivably high, in a relative short time. In 3 cases of segmental fractures of radius, nail removal and subsequent fixation with plate and screws due to nonunion of distal site, was necessitated. Operative technique is simple, fast and reliable providing satisfactory reduction, stable fixation with minimal further tissue trauma and mostly early mobilization

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. However, patients often report functional limitations even years after the injury. This study investigates the influence of the surgical approach (transpatellar vs. parapatellar) on gait performance and patient reported outcome six months after surgery.

Twenty-two patients with tibial shaft fractures treated by intramedullary nailing through a transpatellar approach (TP: n=15, age 41±15, BMI 24±3) or a parapatellar approach (PP: n=7, age 34±15, BMI 23±2) and healthy, matched controls (n=22, age 39±13, BMI 24±2) were assessed by instrumented motion analysis six months after intramedullary nailing. Short musculoskeletal function assessment questionnaire (SMFA) as well as kinematic and kinetic gait data were collected during level walking. Comparisons among approach methods and control group were performed by analysis of variance and Mann-Whitney test.

Six months after surgery, knee kinetics in both groups differed significantly compared to controls (p <.04). The approach method affected gait speed (TP: p = .002; PP: p = .08) and knee kinematics in the early stance phase (TP: p = .011; PP: p = .082), with the parapatellar approach showing a more favorable outcome. However, the difference between patient groups was not significant for any of the assessed gait parameters (p > .2). Also, no differences could be found in the bother index (BI) or function index (FI) of SMFA between surgical approach methods (BI: TP: Mdn = 7.2, PP: Mdn = 9.4; FI: TP: Mdn = 10.3, PP: Mdn = 9.2, p > .7).

Our study demonstrates, that six months after surgery for tibial shaft fractures functional limitations remain. These limitations appear not to be different for either a trans- or a parapatellar approach for the insertion of the intramedullary nail. The findings of this study are limited by the relatively short follow up time period and small number of patients. Future studies should investigate the source of the functional limitation after intramedullary nailing of tibial shaft fractures.

Introduction: diaphyseal bone defect is one of the most difficult challenge in Orthopaedic and Traumatologic Surgery. One of the techniques for reconstruction of bone defect described by Masquelet is a two-stage procedure: induction of a membrane around a ciment spacer and autologous cancellous bone graft with external fixator. The aim of the study is to evaluate a modified technique with intramedullary nailing for tibial bone defect. Materials and Methods: between 2001 and 2006, 13 patients presented important tibial bone defect. On radiological examination, the mean size was 18,5 cm. 3. (12–30 cm. 3. ). Initially, there were 12 opened fractures (1 Gustilo 1, 2 Gustilo II, 9 fractures Gustilo III), and one osteomyelitis following a compartment syndrome. The mean age of the patients at the procedure was 41 years old (18–74). Our modified technique was as follows:. several debridment and stabilization of bone fragments with a temporary external fixator. first stage: removal of external fixator, intramedullary nailing, and filling of the bone defect with gentamycin cement spacer. Local or free muscular fiap to cover the soft tissue defect. second stage: removal of the spacer and placing autologous cancellous bone graft inside the induced membrane at 3 months. 10 patients had hyperbare oxygenotherapy. All patients were evaluated radiographically and by physical examination. using SF-36 questionnary. Results: There was no amputation but 4 complications. There were 3 deep infections: one just between the 2 stages and one 2 years after the second stage: both were treated by nail exchange and adapted intra-venous anti-biotherapy. The third one was the complete bone graft resorption because of an infection just after the second stage (the only failure of the method). The fourth complication is the nonunion 13 months after the second stage: nails has broken and has been changed. Bone healing was obtained in 12 patients at mean follow-up was 32 months (12–69). They were able to walk 4,3 months after bone grafting. 8 patients answered to the SF-36 questionnary: overall function was limited with a mean score of 99.8. Discussion: and conclusion: Our modified technique gave satisfactory results at medium term. Nailing, comparing to external fixator, offers a better stabilization of bone fragments, better control of axis and length of lower limb, and an easier access for plastic surgery and nurse care. Others bone reconstruction treatment like ilizarov bone transport, free vascularized fibula fiap or allograft are still possible if failure. However, the rate of deep infections are quite high (4/13) may be questionable. Sacrifice of intramedullary blood supply and the difficulties to confirm union on radiological exams are still problematics

Introduction

Cephalomedullary nailing (CMN) is commonly used for unstable pertrochanteric fracture. CMN is relatively safe method although various complications can potentially occur needing revision surgery. Commonly used salvage procedures such as renailing, hemiarthroplasty, conservative treatment or total hip arthroplasty (THA) are viable alternatives. The aim was to investigate the rate of THA after CMN and evaluate the performance on conversion total hip arthroplasty (cTHA) after failure of CMN.

Purpose: Femur fractures in children have a significant impact on families and the hospital system in Canada. There are several methods for treating femur fractures in children. The purpose of this study was to determine which of two techniques: Flexible Femoral Nailing (FFN) or Trochanteric Antegrade Nail (TAN), are the most safe and efficacious. Method: Hospital charts for all paediatric femur fracture patients between 1984 and 2006 treated with either FFN or TAN were reviewed. Demographic, clinical, radiographic and hospital stay data were collected and analyzed. Results: Ninety-seven children (100 fractures) were reviewed. The average age of patients was 11.9 years (SD = 4.4). Fifty-two fractures were treated with FFN and 48 fractures were treated with TAN. No serious complications were encountered in either group, including AVN. Minor complications in the FFN group included three patients with mal-alignment, and one with shortening of the limb. Two patients in the TAN group had shortening of the fractured limb. No radiographic differences were noted. The median length of stay for patients treated with FFN was 3 days (IQR = 2) and for patients treated with TAN was 3 days (IQR = 2). Overall, there were no significant differences in the clinical findings (including complications), radiographic evaluations, or length of stay between FFN and TAN cohorts. The only significant difference between the groups was length of surgical time (p value < 0.001). Conclusion: TAN is as safe and efficacious a treatment as FFN but requires addition operating room time, and hence hospital resources

This randomized controlled study aimed to compare surgical duration, intra-operative blood loss, and fluoroscopy time between the suprapatellar and infrapatellar approaches for intramedullary interlocking nailing of tibia. We included 40 adult patients with tibial shaft fractures, excluding those with non-union, revision surgery, or polytrauma. Patients were divided equally into two groups using block randomization: Group A (20 patients) underwent the infrapatellar approach, and Group B (20 patients) underwent the suprapatellar approach. Blood loss was measured using gravimetric method and by changes in pre-operative and post operative haemoglobin levels. Surgical duration was estimated by calculating the time elapsed between the start and end of the procedure and fluoroscopy time was logged from the fluoroscopy machine.

In group A, blood loss averaged 154±30.98ml, slightly more than in group B (150±32.92ml), though the difference was not statistically significant (p>0.05). Group A also showed a higher difference in haemoglobin levels (2.20±1.13 gm/dl) compared to group B (1.15±0.93 gm/dl), which was statistically significant (p=0.02). Fluoroscopy time and surgery duration were slightly longer in group A compared to group B but not statistically significant(p=0.693).

The suprapatellar approach results in lesser blood loss, potentially promoting faster recovery, reduced need for blood transfusions and shorter hospital stays. It also entails shorter fluoroscopy time and surgical duration (though not statistically significant) which may reduce radiation exposure for the surgical team.

To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing.

This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score.

Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury.

Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures.

Introduction

The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection.

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Introduction

Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published.

Aims: The evaluation of the results of surgical treatment of humeral shaft fractures with intramedullary nailing (I.N.) after twelve month follow up. Methods: This study involves 18 patiens with fracture of the humeral shaft, treated operatively with I.N. of A.O. type, in a 4-year period (Jan 1998- Feb 2001). 17 were available to follow up examination. 16 men and 2 women with average 25 years of age were followed for a mean period of a year. Indication for the prosedure was the inability to maintain closed reduction. In 11 patiens the nail was inserted below the great tuberosity. The rest underwent retrograde I.N. All nails were proximally locked and x- were distally locked too. Closed reduction was achieved in 15 cases. The nail was inserted manually (with no hammer use) in all cases. Results: Clinical and radiological healing was apparent in all fractures between the 4th and 6th p.o. month. Full active motion was achieved in 8th p.o. week. There were 3 p.o. radial nerve palsies. Two of them resolved six months later. Residual pain of the shoulder was noted in one case. Conclusions: Nailing of the humeral shaft fractures using AO-type nail is a reliable method of treatment, giving very good final results. Advantages are: minimal surgical trauma, less blood loss, shorter operative time and earlier mobilization

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) fusion is an alternative option for the geriatric patient. This systematic review and meta-analysis provides a detailed analysis of the functional and clinical outcomes of hindfoot nailing for fragility ankle fractures presented so far in the literature.

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded.

Subgroup analyses were performed according to (1) open vs closed fractures, (2) immediate post-operative FWB vs post-operative NWB, (3) majority of cohort are diabetics vs minority of cohort are diabetics. Meta-regression analyses were done to explore sources of heterogeneity, and publication bias was assessed using Egger's test.

The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06-0.16; I2=44%), 0.08 (95%CI:0.06-0.11, I2=0%), 0.11 (95%CI:0.07-0.15, I2=0%), 0.11 (95%CI:0.06-0.18; I2=51%), and 0.27 (95%CI:0.20-0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98-59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores.

Subgroup analyses showed that studies with a majority of diabetics had a higher proportion of implant failure (p=0.0340) and surgical infection (p=0.0096), and a lower chance of returning to pre-injury mobility than studies with a minority of diabetics (p=0.0385). Egger's test (p=0.56) showed no significant publication bias.

TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.