Transarticular tibio-talo-calcaneal nailing versus open reduction and internal fixation for treatment of the elderly ankle fracture: a multi-centre, prospective, randomised controlled trial.

Intervention name: Transarticular Tibio-talo-calcaneal (TTC) nailing TTC nailing will be performed using the Styker T2 Ankle Arthrodesis Nail. The patient’s foot is positioned in neutral dorso-plantar flexion, five to ten degrees of external rotation and 5 degrees of hindfoot valgus. Closed reduction of the fracture is performed under image intensifier (ii) guidance. The longitudinal axis of the calcaneus and tibia are marked on the patient using a Kirschner wire (K-wire) and a marking pen. A 2-3 cm longitudinal incision is made at the intersection of the marked lines, followed by soft tissue dissection to gain access to the plantar aspect of the calcaneus. A K-wire is then inserted through the incision, and after confirmation of positioning with ii is progressed through the calcaneus, across the subtalar and talocrural joints and into the tibial medullary canal. A rigid reamer is used over the wire and reamed until it reaches the medullary canal of the tibia. A ball-tipped guide is then passed into the tibia with sequential reaming over the wire to 1-1.5mm greater than the nail diameter previously selected. The nail is then locked with two screws proximally through the tibial shaft, and two distally in the calcaneus in orthogonal planes. Skin will be closed with 3.0 nylon interrupted sutures. Patients will be placed in a cam walker and allowed to full weight bear day one post-operatively. All operations are to be performed by consultant orthopaedic surgeons or their trainees under direct supervision. Patients are positioned supine on a radiolucent table with a sandbag under the ipsilateral hip. All patients will receive intravenous antibiotics. A tourniquet will be used for all operations.. Operations approximate 60-120min in duration.