Title : A meta-analysis of proportions of single-arm studies comparing Tibio Talo Calcaneal (TTC) nailing to Open Reduction & Internal Fixation (ORIF) in ankle fractures in the elderly
Abstract:
Introduction: Ankle fractures are a common injury in the elderly population. Due to osteoporosis, poor soft tissues, and frequent comorbidities, fixation is often challenging and carries high failure rates. Tibio Talo Calcaneal nailing (TTC), also known as hindfoot nailing, has been used as an alternative to Open Reduction and Internal Fixation (ORIF), but few studies have directly compared outcomes between these two interventions.
Methods: A systematic literature search was performed from January 1990 to January 2025 for studies involving TTC or ORIF in patients over 50 years of age with ankle fractures requiring operative intervention utilising PRISMA guidelines. Outcomes included malunion/non-union, mortality, Surgical Site Infection (SSI), overall complication rate, re-operation rate, return to previous activity level, length of hospital stay, and Olerud and Molander (O&M) functional scores. As the studies included did not directly compare these interventions, meta-analysis of proportions for single-arm observational studies was performed in RStudios; proportional outcomes were logit-transformed, and continuous outcomes were pooled using random-effects models. Heterogeneity was assessed using the tau2 and I² statistics.
Results: A total of 24 studies were included, consisting of 29,351 patients in the ORIF group, and 301 patients in the TTC group. TTC was associated with significantly higher mortality (25.7% vs 7.3%, p < 0.001), surgical site infection (11.9% vs 4.4%, p < 0.001), and overall complication rates (32.5% vs 6.4%, p < 0.001) compared to ORIF. Functional outcomes were better following ORIF (O&M score: 64.5 vs 50.1, p=0.037). Although TTC patients had a longer length of hospital stay (pooled mean difference +2.50 days), the difference was not statistically significant (p=0.710). Substantial heterogeneity (I² > 80%) was observed across several outcomes.
Conclusion: Compared to ORIF, TTC nailing is associated with higher mortality, complication rates, and inferior functional outcomes. ORIF may be preferable when clinically feasible. Future prospective studies, particularly randomised controlled trials, are needed to further clarify optimal treatment strategies for ankle fractures in the elderly population.
