Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.
We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.
Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.
The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18).
When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.
Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040
Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation. Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of TTC nailing for fragility ankle fractures.
A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, and Web of Science, identifying 14 studies for inclusion. Studies including patients with a fragility ankle fracture, defined according to NICE guidelines as a low-energy fracture obtained following a fall from standing height or less, that were treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. This review was registered in PROSPERO (ID: CRD42021258893).
A total of 312 ankle fractures were included. The mean age was 77.3 years old. In this study, 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection was 10% (95% CI: 0.06–0.16), deep infection 8% (95% CI: 0.06–0.11), implant failure 11% (95% CI: 0.07–0.15), malunion 11% (95% CI: 0.06–0.18), and all-cause mortality 27% (95% CI: 0.20–0.34). The pooled mean post-operative Olerud–Molander ankle score was 54.07 (95% CI: 48.98–59.16). 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 post-operative rehabilitation protocols. Prospective randomised control trials with long follow-up times and large cohort sizes are needed to guide the use of TTC nailing for ankle fractures.