CME ARTICLE

Retrograde Intramedullary Tibiotalocalcaneal

(Hindfoot) Arthrodesis With Concomitant Midfoot
and Forefoot Corrections
Nicholas B. Jorgensen, MBBS, BSc*wzy and Michael Lutz, FRACS, MBBSwz8

Abstract: Tibiotalocalcaneal arthrodesis is a salvage procedure. We
report on the operative technique, the importance of addressing con-
comitant ankle and foot deformities when present and the outcomes
(radiologic fusion rate, limb salvage rate, and global patient
satisfaction) with a hindfoot arthrodesis nail. It was used for tibiota-
localcaneal arthrodesis on 63 consecutive patients (6 bilateral proce-
dures). The minimum follow-up was 12 months; the mean age was 59
(range, 24 to 87) years, with 69% male. At 3 months, the fusion rate
was 77.7% (49/63); 6-month fusion rate was 95% (60/63). The overall
complication rate was 12.6% (8/63). There was a 100% limb salvage
rate. Fifty-seven concomitant procedures were performed on 38
patients at time of nail insertion.
Level of Evidence: Diagnostic Level 4. See Instructions for Authors
for a complete description of levels of evidence.
Key Words: tibiotalocalcaneal arthrodesis, hindfoot arthrodesis,
intramedullary nail, ankle and subtalar arthritis, hindfoot deformity
(Tech Foot & Ankle 2015;14: 146–155)
LEARNING OBJECTIVES
After completing this activity, the learner should be better
able to:
 Select and recognize patient-specific treatment approaches
for concomitant foot and ankle procedures.
 Identify patients at risk of complications from Tibiotalo-
calcaneal Arthrodesis (TTCA).
 Understand the aims of Tibiotalocalcaneal Arthrodesis
(TTCA).
HISTORICAL PERSPECTIVE
Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure.
It is an alternative to amputation in nonbraceable hindfoot
deformities, disabling fixed deformities, failed ankle arthrod-
esis, failed total ankle arthroplasty, talar osteonecrosis and
avascular necrosis, severe combined ankle and subtalar
arthritis, neurological deficit, and tumor.1–4
Historically, a solid, functional, pain-free arthrodesis is
difficult to achieve. Previous studies have demonstrated non-
union rates as high as 10% to 25%.5–9 Screws, plates, external
fixators, and intramedullary nails (IMN) (both hindfoot fusion
specific and otherwise) have been used, with the aim of surgery
being the provision of a stable, well aligned, pain-free, shoe-
able, and ambulatory foot.
More recently use of IMN designed for TTCA have
shown very high fusion rates.10,11 Intramedullary fusion tech-
niques in comparison with other constructs have the advan-
tages of being load-sharing, have greater rotational stability
and bending stiffness, have rigid and stable fixation, allow for
sequential compression, have an anatomic design with valgus
curve, and can be percutaneously inserted.4,10–13
Multiple biomechanical studies have compared intra-
medullary nailing to other fusion devices in TTCA. Screw
configurations, blade and locked plates, and external fixators
have been used. Intramedullary nailing has demonstrated
greater rigidity, final stiffness, less deformity with com-
pression, and higher load-to-failure stressors in biomechanical
and cadaveric models.3,12,14–16 Progress of IMN design to
incorporate angle-stable locking screws has also increased
biomechanical advantages to earlier nail designs with only

From the *Orthopaedic Registrar, Department of Orthopaedics, Mackay Base Hospital, West Mackay; wOrthopaedic Surgeon, Visiting Medical Officer,
Department of Orthopaedics, Princess Alexandra Hospital, Woolloongabba; zUniversity of Queensland, St Lucia; yOrthopaedic Principal House Officer,
Department of Orthopaedics, Ipswich General Hospital, Ipswich; and 8Visiting Medical Officer, St Andrews War Memorial Hospital, Brisbane, Qld,
Australia.
Dr. Lutz has disclosed that he is a member of the speaker’s bureau for Stryker and his spouse/life partner (if any) has no financial relationships with or
financial interests in, any commercial companies pertaining to this educational activity. Dr. Jorgensen and LCMEI staff are in a position to control the
content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in,
any commercial organizations pertaining to this educational activity.
Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.
INSTRUCTIONS FOR OBTAINING AMA PRA CATEGORY 1 CREDITt
Techniques in Foot & Ankle Surgery includes CME-certified content that is designed to meet the educational needs of its readers. This activity is available for
credit through December 31, 2015.
Earn CME credit by completing a quiz about this article. You may read the article here, on the TFAS website, or in the TFAS iPad app, and then complete the
quiz, answering at least 80 percent of the questions correctly to earn CME credit. The cost of the CME exam is $10. The payment covers processing and
certificate fees. If you wish to submit the test by mail, send the completed quiz with a check or money order for the $10.00 processing fee to the
Lippincott CME Institute, Inc., Wolters Kluwer Health, Two Commerce Square, 2001 Market Street, 3rd Floor, Philadelphia, PA 19103. Only the first
entry will be considered for credit, and must be postmarked by the expiration date. Answer sheets will be graded and certificates will be mailed to each
participant within 6 to 8 weeks of participation.
Need CME STAT? Visit http://cme.lww.com for immediate results, other CME activities, and your personalized CME planner tool.
Accreditation Statement
Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Credit Designation Statement
Lippincott Continuing Medical Education Institute, Inc., designates this journal-based CME activity for a maximum of 1 (one) AMA PRA Category 1
Creditt. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Address correspondence and reprint requests to Nicholas B. Jorgensen, MBBS, BSc, Department of Orthopaedics, Ipswich General Hospital, Chelmsford
Avenue, Ipswich, 4305, Qld, Australia. E-mail: jorgensen.nicholas@gmail.com.
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Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015 Hindfoot Fusion With Concomitant Corrections

TABLE 1. Recent Tibiotalocalcaneal Arthrodesis Studies With More Than 20 Patients

Age
(Range) Follow-up % Time to Union AOFAS Score Complication Satisfaction
References N (y) (Range) (mo) Nail Used Union (Range) (wk)* (Range) Rate (%) (%)
Chou et al6 37 53 (19-79) 26 (12-168) NS 86 19 (12-65) 66 35 87
Anderson 25 56.6 (17-82) 40.9 5 designs 96 NS 66 (39-84) 44 92
et al18
Niinimaki 34 57 (25-77) 24 (6-43) NS (Biomet) 75 16 NS 35 90
et al9
Boer et al19 50 57.6 (22-82) 51 (12-84) Orthofix 96 20 (12-72) 70 (32-86) 20 92
Mückley 55 55 (27-78) 16 (7-27) T2AAN 96 NS 67 (38-86) 25 93
et al10 (Stryker)
Taylor 52 61 (22-89) 23.5 (3-72) T2AAN 84 15 NS 17 84
et al11 (Stryker)
Budnar 45 61.3 (40-76) 48 (10-74) TTC Fusion 89 14 (10-24) 69 80 (45) 82
et al20 (DePuy)
Hammett 52 57 34 (8-73) ACE Humeral 87 NS 63 59 (25 major) 82
et al21 (DePuy)
This study 63 59 (24-87) 29 (12-60) T2AAN 95 14 (6-24) NS 13 93
(Stryker)
AAN indicates ankle arthrodesis nail; AOFAS, American Orthopaedic Foot and Ankle Score; NS, not stated.

static screw design.15,17 Our study suggests that the bio-
mechanical laboratory results are translated in the clinical
setting.
Clinical outcomes for intramedullary nailing for TTCA
have been previously investigated and provide a guide to
fusion rates and patient satisfaction. Shah et al’s 201112 review
of clinical trials suggested superior results in conditions with
impaired bone quality including rhuematoid arthritis, diabetes,
and neuroarthropathy. The ability to deliver compression and
rigid and stable fixation has allowed for more reliable fusion
rates and a higher limb salvage rate in late stage ankle insta-
bility hindfoot deformities.12,13,18 Other retrospective studies
using intramedullary nailing for TTCA have shown improved
patient outcomes (Table 1).6,10,18,19,22
Mückley et al,10 followed up 55 identical arthrodesis nails
for a mean of 16 months, achieving 96% fusion rate, sat-
isfaction (91%), and 25% complication rate (shaft fracture,
reoccurrence osteomyelitis, DVT, nonunion, and removal of
nail). Taylor et al11 achieved an 83.6% fusion rate at 3.7
months, with 83% good/excellent patient satisfaction and a
17% complication rate (2 below knee amputation, deep
infection, and removal of metal ware). Budnar et al20 reviewed
45 TTC fusion locking nails (Depuy) for a mean of 48 months,
achieving 89% fusion rate, improvement in clinical situation
(82%), increase in American Orthopaedic Foot and Ankle
Score of 37, and 45% complication rate (1 below knee
amputation, 1 nonunion, 3 delayed union, removal of metal
ware: 4 nails, 12 screws).
INDICATIONS/CONTRAINDICATIONS
Retrograde intramedullary TTCA is an alternative to amputation
in nonbraceable hindfoot deformities, disabling fixed deform-
ities, failed ankle arthrodesis, failed total ankle arthroplasty, talar
osteonecrosis and avascular necrosis, severe combined ankle and
subtalar arthritis, neurological deficit, and tumor.1–4 The most
common etiology in our experience is combined ankle and
subtalar arthritis and Charcot arthropathy (Table 2).
DeVries et al1 analyzed 179 TTCA using designs of IMN,
and showed a limb salvage rate of 88.2% (21 limbs ampu-
tated). From this study, DeVries et al1 developed an odds ratio
for risk of amputation, with diabetes (7.01), revision surgery
(6.23), preoperative ulceration (2.99), and increased age hav-
ing a correlation with amputation.

TABLE 2. Etiology of Patient Cohort Requiring Tibiotalocalcaneal PREOPERATIVE PLANNING

Arthrodesis A thorough orthopedic history and physical examination must
Diagnosis N (%) be performed on any patient when TTCA is considered. The
etiology of joint pathology must be identified and all
Ankle/subtalar arthritis 36 (57.1)
reasonable nonsurgical or more conservative surgical treatment
OA 19 (30.1)
Posttraumatic 13 (20.6) options have been exhausted. Weight-bearing anteroposterior
RA 4 (6.3) and lateral radiographs should be carefully evaluated for
Charcot arthropathy 12 (19) deformity and alignment, available bone stock, evidence of
Neurogenic-associated deformity 8 (12.7) hardware from previous surgery, and ensure any concomitant
Failed TAR 3 (4.8) foot and ankle pathology is identified.
Failed ankle joint fusion 2 (3.2) TTCA should be delayed if there is any concern of super-
Failed STJ fusion 1 (1.6) ficial infection. Appropriate antibiotic use, debridement, staged
Talus chrondosarcoma 1 (1.6) infection control (including removal of infected hardware) and soft
Total 63 (100)
tissue management needs to take place. In cases with pressure
OA indicates osteoarthritis; RA, rhuematoid arthritis; STJ, subtalar joint; areas and noninfected wounds, management in offloading foot-
TAR, total ankle replacement. wear including total contact casting should be completed before
surgical intervention, to at least, minimize wound size.

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Jorgensen and Lutz Techniques in Foot & Ankle Surgery
FIGURE 1. Lateral incision with exposure of distal third of
(deformed) fibular, protected with retractors (A) and with
acetabular reamer (B).
TECHNIQUE
The T2 Ankle Arthrodesis Nail (Stryker) is a cannulated device
inserted in a retrograde manner and is made of titanium alloy
(Ti6A14V). Its design allows locking through the tibia, talus,
and calcaneus, with the ability to sequentially achieve
compression across each joint, if required.
Surgery takes place with informed consent and the patient
receives either general or spinal anesthesia. Patients are posi-
tioned supine, with a sandbag underneath their ipsilateral
buttock, with a thigh tourniquet and feet over the end of the
bed. Surgery is performed through a lateral transfibular
approach (a medial approach can be used, as required for
preoperative valgus deformity). Exposure of the distal fibular
is required. An acetabular reamer is used to obtain cancellous
bone graft from the distal fibular, with the fibular resected at
the level of the syndesmosis with an oscillating saw (Fig. 1).23
Laminar spreaders are positioned to provide exposure of
the articular surfaces of the tibia, talus, and calcaneus (Fig. 2).
These joint surfaces were denuded with osteotomes and cur-
ettes. Drilling of the subchondral surfaces occurs, with place-
ment of the fibular bone graft placed between the tibia, talus,
and calcaneus. In cases of severe deformity, partial or total
talectomy is performed to allow for alignment correction
without jeopardizing the soft tissue envelope. The lateral
incision is closed with subcutaneous braided polyglactin 910
(Vicryl) and interrupted nylon sutures, tourniquet deflated and
correction of deformity performed (Fig. 3).
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 Volume 14, Number 3, September 2015
FIGURE 2. Exposure of ankle joint (A) and talocalcaneal joint (B)
with laminar spreaders allows complete access to denude
articular surfaces of cartilage.
Using fluoroscopic guidance, the retrograde nail is
inserted percutaneously utilizing a guide wire technique
(Fig. 4). Key features of the procedure include positioning of
the guide wire to ensure the talus and calcaneum are translated
into the plane of the tibia. During reaming and nail insertion
foot positioning relative to the tibia needs careful attention.
With visual assessment an estimated 5 degrees valgus position
of the hindfoot in the coronal plane, plantigrade in the sagittal
plane, and 10 degrees of external rotation in the axial plane
was achieved at the time of nail insertion. The hindfoot
arthrodesis nail also allows compression across the subtalar
and ankle joints when desired by the surgeon.
Concomitant procedures were often performed at the time
of nail insertion, ranging from tibia, hindfoot, midfoot, and
forefoot corrections; removal of metal ware; and soft tissue
debridement and transfer (Fig. 5). Thirty-eight patients had 57
concomitant procedures performed (Table 3). Assessment of
midfoot and forefoot occurred preoperatively and intra-
operatively with the focus being a plantigrade foot and ankle.
As a significant number of patients have a concomitant
peripheral neuropathy, it is deemed essential that prevention of
asymmetric foot weight-bearing is avoided.
Tourniquet inflation time is limited to 120 minutes in
total as a principle. We had no instances of tourniquet inflation
duration breaching this limit. The tourniquet is released when
the initial lateral wound is closed and during nail insertion.
This allows the use of tourniquet during concomitant
Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015
FIGURE 3. Lateral incision closed after articular surfaces prepared
and alignment adjusted (A), in comparison to preoperative
alignment (B).
procedures without increased risk of ischemia and neurological
damage.
Common technical challenges include the potential for
the foot and ankle to adopt an equinus position during reaming;
this can be managed by ensuring an assistant holds the ankle in
a plantigrade position during the reaming process. The place-
ment of the talus screw needs to be centrally placed in the
sagittal plane; if it is too proximal, it can lead to fracture of the
talus during the compression process. Beware of the potential
difficulties of inserting titanium corticol locking screws in the
diaphyseal bone. This problem has been overcome by tapping
the screw holes after drilling occurs.
Similar to any unfamiliar procedure or implant use, a
learning curve exists. Familiarization with texts, operative
techniques, implant guides, and support of an experienced
colleague can aid in reducing this aspect of the procedure.
RESULTS
Between May 2009 and May 2013, 63 patients underwent
TTCA in 2 tertiary hospitals. Patients’ preoperative and
postoperative radiographs were evaluated for fusion rates
across both joints and a global satisfaction score. Operations
were performed by a single operator with no exclusion criteria
and a minimum follow-up of 6 months. No loss to follow-up
occurred to the 6-month radiologic follow-up.
Primary measurement outcome was of radiologic fusion
rates at 3 and 6 months. Fusion was defined as a measurement
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Hindfoot Fusion With Concomitant Corrections
FIGURE 4. The hindfoot arthrodesis nail being inserted
percutaneously with guide wire technique. The swivel action of
the aiming guide allows sequential placement of compression
and locking screws.
of greater than 50% of continuous trabeculae over both joint
surfaces by the primary operator on anterior-to-posterior and
lateral radiograph. Patient satisfaction was a secondary meas-
urement. A single, self-reported questionnaire was mailed out
to all patients as a once off postoperative status. Follow-up
phone calls were made if no response by mail was received.
The questionnaire combined 2 global questions relating to
satisfaction and whether the patient would repeat the surgery
and the Foot Function Index-Revised (FFI-R), a well-validated
evaluation tool for subjective patient function.24,25,26
The 63 nails were followed up for a minimum of 12
months. The mean follow-up was 29 (range, 12 to 60) mo;
mean age was 59 (range, 24 to 87) y, 69% were male and 6
procedures were bilateral. One patient passed away at 13
months postoperative time from unrelated causes. At 3 months,
the fusion rate was 77.7% (49/63); 6-month fusion rate was
95% (60/63). There was a 100% salvage rate of all limbs. The
overall complication rate was 12.6% (8 patients).
Response from the patient questionnaire (mail out and
phone call) was 29/63 (46%). One patient died at 13 months
postoperatively from cardiac reasons. Of the respondents, 86%
(25/29) stated they were better than their preoperative status,
and 93% (27/29) would repeat the surgery. Of the FFI-R
responses, the mean score was 29 (range, 2 to 122), with the
maximum possible score of 230, indicating poorest function.
COMPLICATIONS
The overall complication rate was 12.6% (8 patients)
(Table 4). We have had no instances of amputations in our
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Jorgensen and Lutz Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015

FIGURE 5. Lateral ankle (A) and weight-bearing anteroposterior (AP) foot (B) radiographs of a 60-year-old male with severe hindfoot
and talonavicular joint arthritis. Weight-bearing lateral ankle (C) and weight-bearing AP foot (D) radiographs after hindfoot and
talonavicular joint fusions.

series of patients. Of our patients that have nonunions (3 successful limb salvage has been achieved through ongoing
patients, 5%), all are diabetic with Charcot arthropathy customized, immobilizing footwear.
affecting the hindfoot and aged 53, 63, and 73 years. The There was no correlation between nail dimensions and the
tibiotalar joint failed to fuse in all 3 instances. However, need for removal of the hindfoot arthrodesis nail for tibial

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Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015 Hindfoot Fusion With Concomitant Corrections

patients had peripheral neuropathy and/or diabetic angiopathy

TABLE 3. Details of 57 Concomitant Procedures Performed on that would tend to mask any iatrogenic damage from retro-
38 Patients at Time of Tibiotalocalcaneal Arthrodesis
grade nailing.
Concomitant Procedures Number
Talectomy 10 POSTOPERATIVE MANAGEMENT
Removal of metal 13 All patients were placed in a Below Knee Plaster of Paris
Tibial osteotomy 3 Backslab (Gypsona BP, BSN Medical) at the conclusion of the
Hindfoot osteotomy 2 case. Wound review occurred 2 weeks postoperatively and all
Midfoot osteotomy 1
TNJ arthrodesis 5
patients continued immobolization in a cast (Nemoa Polyester
Forefoot correction 7 Casting Tape, T&L) non–weight-bearing. If the patient was
Tendon transfer/debride 5 diabetic and/or neuropathic, the patient had weekly wound
AT tenotomy 6 reviews and Total Contact Casting techniques were used [under
Forefoot amputation 2 cast padding (Webril, Coviden; Plaster of Paris (Gypsona);
ORIF 2 Polyester Casting Tape overlay (Nemoa)]. Weight-bearing
Arthroscopy 1 commenced at 6 weeks after surgery in a Nextep Contour
Total 57 (Walker, DJO). Diabetic and neuropathic patients commenced
AT indicates Achilles tendon; ORIF, open reduction internal fixation; TNJ, their weight-bearing in a Total Contact Casting. Progression to off
talonavicular joint. the shelf shoe wear commenced at 3 months after surgery.
Diabetic and neuropathic patients were provided with customized
medical grade footwear. Radiologic follow-up occurred at 6
diaphyseal pain. Of the 3 nails removed for pain, the dimen- weeks, 3, 6, and 12 months. Computerized tomography was
sions measured 10  150 mm and two 11 200 mm. For all performed after the 6-month assessment if there was clinical or
reasons, there was a 6% (4/64) rate of nail removal in our radiographic concern of delayed union.
study, which is comparable with those presented in the liter-
ature. Niinimaki et al9 had an 11.7% (4/34) and Mückley
et al10 had a 2% (1/55) rate of removal for tibial diaphyseal POSSIBLE CONCERNS, FUTURE OF THE
pain. We had no instances of tibial fracture, although this is a TECHNIQUE
recognized complication.10,21 Although the use of FFI-R scores in our study as a single
Damage to the lateral plantar and calcaneal nerve upon retrospective analysis does not display significance in oper-
plantar incision and nail insertion is possible, although inci- ative success, the mean score was 29 (range, 2 to 122), with
dence is rare.9,18,21,27 We had no occurrences of plantar or 230 indicating poorest outcome. This does suggest a good
calcaneal nerve damage in our study. This may also mean that functional outcome in our patients’ series. Furthermore, 83%
the damage is limited or not clinically significant. Many of our (25/29) respondents felt they were better than their

TABLE 4. Summary of Patient Details and Complications

Complications
Nonunion
Removal locking screws
Removal nail (Infection)
Removal nail (Pain)
N Patient Details Outcomes
3 73 male, Charcot Arthropathy Psuedoarthrosis, pain free, weight-bearing
Concomitant procedure: talonavicular joint arthrodesis
Psuedoarthrosis tibiotalar joint
53 male, chronic osteomyelitis fibula, Charcot arthropathy Dynamized nail (removal of locking screw),
Nonunion tibiotalar joint ongoing review
63 male, Charcot arthropathy, medial approach for Talus screw removed
severe valgus hindfoot deformity Fusion 8 mo
Concomitant procedure: talectomy, midfoot osteotomy
Infected talus screw, nonunion tibiotalar joint
2 Same patient (above line) as nonunion, Talus screw removed
infected screw Fusion 8 mo
65 male, posttraumatic OA Talus screw removed
Concomitant procedure: talonavicular joint arthrodesis
Talus locking screw backed out, wound present
1 73 male, posttraumatic OA Fusion remains, nail removed
Revision nail (from previous surgeon)
Infected and removed for pain
3 73 male, failed TAR Removal 18 mo
Concomitant procedure: R/O TAR, tibial osteotomy, talectomy Fused at 3 mo
Nail movement, no fracture
56 female, OA Removal 5 mo
Concomitant procedure: first metatarsal dorsiflexing Fused at 3 mo
osteotomy, fifth metatarsal ORIF and bone graft
(stress fracture) and bunionectomy
Tibial diaphyseal pain, nail movement, no fracture
41 male, equinovarus contracture (Neurogenic) Removal 6 mo
Concomitant procedure: Achilles tendon lengthening, Fused at 3 mo
tibialis posterior tendon transfer
Tibial diaphyseal pain

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Jorgensen and Lutz Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015

FIGURE 6. Preoperative anteroposterior (AP) ankle (A) and lateral ankle (B) radiograph of severe hindfoot varus deformity from
neurogenic etiology (Spinal Cord Injury). Two-week postoperative AP ankle (C) and lateral ankle (D) radiograph of tibiotalocalcaneal
arthrodesis with a hindfoot arthrodesis nail in a below knee plaster of Paris back slab.

preoperative state and 93% (27/29) would repeat the surgery,
indicating a high level of satisfaction. Of the 2 patients that
would not repeat their surgery, the FFI-R scores were 95 and
118. There is limited ability to interpret a single postoperative
FFI-R in a cohort of patients, but we have provided this
information as an insight into the current functional status of
those patients that have had a hindfoot fusion.
The success demonstrated in our study and operative
technique is at least equivalent and has favorable fusion rates
with comparable studies.10,11 Our systematic use of resected

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Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015
fibular for bone grafting, combined with meticulous cartilage
denudation and drilling of subchondral surfaces is thought to
assist fusion in a patient cohort with prohibitive biological
states. Mückley et al10 agreed with the importance of bone
graft. Taylor et al11 did not specify the use of intraoperative
autograft and achieved a lower fusion rate, and required 14.5%
revision with femoral head allograft.
The complexity and heterogeneity of deformity and
symptoms in our patient series is wide ranging (Table 2). We
have performed concomitant procedures on 60% of our
patients. These range from tibial, hindfoot, midfoot, and
forefoot corrections, removal of metal ware and soft tissue
debridement and transfer. In 15.8% of our series, talectomy
was performed to achieve satisfactory alignment (Table 3).
Mückley et al10 commented on the need for tenotomies,
pedicled sural flap and plating of the talonavicular joint in 2
patients, although the rate of talectomy is unknown. There is
little information regarding concomitant procedures in other
TTCA case series. We propose that assessing and correcting all
deformities of the foot and ankle and respecting the soft tissue
envelope, has led to our 100% salvage rate (Fig. 6). Longer
term complications, such as adjacent joint arthritis and tibial
diaphyseal pain, are potentially not captured.
The risks of a single (slightly longer) anesthetic can be
viewed as having at least an equivalent if not lesser risk of
repeated anesthetics. This effect is even more clinically sig-
nificant in those patients aged above 70, a difficult intubation
or with cardiovascular instability.28
The use of a hindfoot arthrodesis nail is a reliable, safe,
and effective device and technique to achieve arthrodesis and
limb salvage in the treatment of ankle and hindfoot arthritis
and deformity correction. We suggest that addressing con-
comitant ankle and foot deformities need to be corrected when
present. We believe of focus on achieving a plantigrade foot
and ankle, even in cases of nonunion, salvage of the foot has
been achieved. We present the largest consecutive series in the
use of this device and an operative technique that can be
replicated independent of etiology and preoperative deformity.
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Jorgensen and Lutz Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015

CME QUESTIONS

1. Name the most common aitelogy requiring Tibiotalocalcaneal Arthrodesis (TTCA).

a. Combined Ankle/Subtalar Osteoarthritis
b. Failed Ankle Joint Fusions
c. Charcot Arthropathy
d. Failed Total Ankle Replacement (TAR)
2. Positioning of the foot relative to the tibia requires careful attention during reaming. The ideal position is:
a. 51 valgus, plantigrade, 101 Externally Rotated
b. 01 valgus, plantigrade, 101 Externally Rotated
c. 51 valgus, plantigrade, 01 Externally Rotated
d. 01 valgus, 51 dorsiflexed, 01 Externally Rotated
3. Alignment of the foot and respect of the soft tissue envelope is essential for best outcomes. What is the most common intra-
operative procedure to be considered?
a. Tendon transfer
b. Femoral Head Allograft
c. Talectomy
d. Achilles Tendon Tenotomy
4. TTCA is NOT indicated in:
a. Talar Osteonecrosis
b. Severe Subtalar Arthritis
c. Failed Total Ankle Replacement (TAR)
d. Disabling Fixed Deformities
5. The most common reason for failure of TTCA is?
a. Age
b. Diabetes
c. Preoperative Ulceration
d. Revision Surgery

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Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015 Hindfoot Fusion With Concomitant Corrections

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Jorgensen and Lutz Techniques in Foot & Ankle Surgery  Volume 14, Number 3, September 2015

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