2.1

This systematic review and proportional meta-analysis followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist.

2.2

We included studies on patients presenting with talar neck fractures who underwent percutaneous fixation with or without arthroscopic assistance, aged 15–85 years, in which the surgical technique had been meticulously reported (including the direction of the screws, their size and their number) and the outcome (both clinical and/or radiographic) had been documented along with the assessment of the healing and complication rate (including re-operation) at a minimum follow-up of 6 months. All cohort studies (both prospective and retrospective) and case series were included, in any language. On the other side, we excluded studies in which talar fractures had been treated using different methods of fixation or on skeletally immature patients. Biomechanical studies, case reports, cadaveric studies, expert opinions, letters to the editor and instructional courses were excluded. Reviews already published on the topic were screened in order to include potentially eligible studies from the references.

2.3

A systematic search was conducted on multiple scientific databases (Pubmed, Web of Science, Cochrane Library and Scopus) from the first entry to January 2025. These key words and linking operators were adopted: ((talar) AND (fracture) AND (percutaneous) OR ((talar) AND (fracture) AND (minimally) AND (invasive)). Two reviewers (AI and CC) independently assessed the results and selected a list of studies. The two lists were then compared, and a senior author (AB) was contacted to sort disagreements. Data were recorded in a dedicated password-protected excel sheet, reporting cohort details, study design, surgical technique, measures of clinical and radiographic outcome at the latest follow-up.

2.4

The MINORS (Methodological index for non-randomized studies) criteria was used to evaluate the quality of studies . These eight categories were considered to assess non-randomized controlled trials (NRCTs): clearly stated objectives, the inclusion of consecutive subjects, prospective collection of data, appropriate endpoints, unbiased assessment of the study endpoints, an appropriate follow-up period (based on the objectives of the study), loss to follow-up less than 5 % and a prospective sample size calculation. For comparative studies four additional criteria were considered: balancing of groups, presence of contemporary groups, equivalent assessment of study groups, adequate statistical analyses. Each of these points could be deemed as “not indicated” (0 points), “indicated but insufficient” (1 point), or “indicated and sufficient” (2 points). The ideal score was 16 for non-comparative studies and 24 for comparative ones. The MINORS was recorded twice and independently by two authors (AI and AB) 10 days apart, then the scores were discussed whenever a difference was present until an agreement was found. The final MINORS scores were scored as follows: ‘poor quality’ (< 8), ‘moderate quality’ (between 9 and 14) and ‘good quality’ (between 15 and 16) for non-comparative studies. Cutoff points were < 14, 15–22, and 23–24, respectively, for comparative studies .

2.5

After running a Shapiro-Wilk test to test the distribution of variables included, continuous ones were reported as mean and, 95 % confidence interval (95 %CI) and range for normally distributed variables or as median and interquartile range (IQR) for non-normally distributed variables. Student-T test (for normally distributed variables) or Wilcoxon rank sum test (for non-normally distributed variables) were used to compare the two groups (ARIF and PF). A proportional meta-analysis was run to weigh data regarding the union, the complication and early (before 48 months) osteoarthritis rate. The ‘metaprop’ command was used to compute 95 % confidence intervals through the score statistic and the exact binomial method. The Freeman-Tukey double arcsine transformation of proportions was then incorporated. Heterogeneity among studies was assessed through the Higgins’ I² statistic and a random-effect model was applied in all cases. The significance level was p < 0.05. All analyses were performed using STATA statistical software package (Version 16.0, StataCorp, 2019).

3.1

The literature search yielded 1.309 papers, from which 882 were excluded because they were duplicates or for other reasons ( Fig. 1 ). At the end of the screening process, the full text of 18 articles was assessed for eligibility. Finally, 6 papers were included in the systematic review and meta-analysis, according to the inclusion and exclusion criteria ^,,,,, . One paper was analysed after translation from Chinese language ( Fig. 1 ) . The characteristics of the included studies have been depicted in Table 1 . All papers were retrospective and published between 2011 and 2023. Four studies reported outcomes after PF (51 cases) while two focused on ARIF (11 cases).

Flow-chart depicting studies included in this review.

In the two groups, the mean sample size (p = 0.88) and the mean age of patients (p = 0.24) were comparable. Patients were mostly males in the percutaneous fixation group (M/F: 36/15) and mostly females in the ARIF group (M/F: 4/7) ( Table 1 ). The mean follow-up in the ARIF group was 16 months (range, 12–18) and 31 months in the percutaneous fixation group (range, 20–48), but the difference was not significant (p = 0.09). All the talar fractures included in the ARIF group were classified as Hawkins II. In the PF group, 5 Hawkins I, 30 Hawkins II, 12 Hawkins III fractures and 3 Hawkins IV fractures were included Table 2 .

Table 2

Surgical details extracted from primary studies.

Authors	Treatment	Classification Method	Tourniquet	Method of reduction	Number of screws	Direction of screws	Size of screws	Surgical time
Fernandez et al.	PF	Hawkins I: 3 Hawkins II: 2 Hawkins III: 1	NA	Calcaneal transfixion pin	2	1 anteroposterior 1 posteroanterior	4.5 mm	102 min
Adbelgaid et al.	PF	Hawkins II: 10 Hawkins III: 4 Hawkins IV: 2	No	Calcaneal Steinmann pin + Schanz screws in talar body and talar neck	2	2 anteroposterior	3.5 mm	/
Wagener et al.	ARIF	Hawkins II: 7	Yes	2.5 k-wires in talar body and talar neck, Hintermann distractor over these 2	2	2 anteroposterior	4.3 mm	59 min
Bardas et al.	ARIF	Hawkins II: 4	NA	Instrumental manipulation with a hooked probe and trocar	2	2 anteroposterior	4.5 mm	/
Yang et al.	PF	Hawkins II: 9 Hawkins III: 5 Hawkins IV: 1	No	Calcaneal distraction, external pressure using fingers, K-wire into the fracture site as a joystick	2	2 posteroanterior	4.0 mm	46.9 min
Nie et al.	PF	Hawkins I: 2 Hawkins II: 9 Hawkins III: 2	NA	Calcaneal manual traction, external pressure on fragments, K-wire into the fracture site as a joystick	2	2 posteroanterior	NA	55.1 min

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