Primary Tibiotalocalcaneal Nailing Versus Open Reduction and Internal Fixation for Unstable Ankle Fractures in Older and High-Risk Adults: A Systematic Review and Meta-Analysis

Background: Primary tibiotalocalcaneal (TTC) nailing has been proposed as an alternative to open reduction and internal fixation (ORIF) for unstable ankle fractures in older and medically high-risk adults, particularly when poor bone quality, frailty, soft-tissue compromise, or inability to comply with non-weight-bearing restrictions make conventional fixation less suitable.This systematic review and meta-analysis compared primary TTC nailing or tibiotalocalcaneal arthrodesis (TTCA) with ORIF in this population.Methods: PubMed, Scopus, Web of Science, Embase, and Google Scholar were searched from inception to June 2026.Eligible studies directly compared primary TTC nailing/TTCA with ORIF for unstable ankle fractures in older or high-risk adults and reported extractable quantitative outcomes.Risk ratios were used for dichotomous outcomes and mean differences for continuous outcomes.Study quality was assessed using the modified Downs and Black Checklist.Results: Eight comparative studies involving 1,443 treatment episodes were included.Pooled analysis showed no statistically significant difference between TTC nailing/TTCA and ORIF in length of hospital stay, overall postoperative infection, implant-related complications, nonunion, reoperation, or mortality.Superficial infection was significantly lower after TTC nailing, and individual studies consistently reported earlier postoperative weight-bearing with TTC fixation.However, some database and cohort studies reported higher readmission, malunion/nonunion, or secondary surgery after TTCA.Conclusion: Primary TTC nailing may be a reasonable alternative to ORIF for carefully selected older or highrisk patients, especially when early weight-bearing and reduced soft-tissue exposure are priorities.Current evidence does not demonstrate clear overall superiority over ORIF and remains limited by heterogeneity and residual confounding.