Formal joint preparation appears to not be necessary for surgical treatment of ankle fractures with tibiotalocalcaneal nailing: a systematic review.

PURPOSE: The purpose of this study is to examine clinical outcomes among patients who underwent TTC nailing without any formal joint preparation to guide surgical decision-making.

METHODS

This study was a systematic review using three databases queried through December 27th, 2025. Articles were included if they reported outcomes for at least one cohort of patients undergoing TTC nail for ankle fractures without formal joint preparation. Clinical outcomes examined included reported fracture union rates, complications (infection, hardware related, and amputation), as well as the need for reoperation.

RESULTS

Seven articles were included out of 488 articles initially retrieved. Patients (n = 153) had a mean age of 73.8 (9.1) years old with a mean follow-up time of 22.2 (12.6) months. An overall fracture union rate of 85.7% was reported (n = 114 patients out of 133 patients). Studies reported a pooled total complication rate of 27.2% (n = 41 patients out of 151 patients), the most common being infection 17/34 (50%). Reoperation rates for unprepped TTC nailing was overall 17.4% (24/138), with only 1.5% of patients (2/138) reported across all studies requiring revision to formal ankle arthrodesis, suggesting treatment success irrespective of successful fusion.

CONCLUSION

TTC nailing without formal joint preparation may be a reasonable treatment option for ankle fractures in low demand patients with significant comorbidities, with minimal occurrence of reported nonunion requiring revision as well as the added benefit of minimizing incisions and wound complications. More research is needed for corroboration due to low evidence certainty.