Staged Tibiotalocalcaneal Arthrodesis for Infected Nonunion of the Hindfoot

Research Type: Level 4 – Case series Introduction/Purpose: The management of post-traumatic osteomyelitis and nonunion of the distal tibia and hindfoot involves eradication of infection, deformity correction, and bony stabilization in the setting of bone loss, poor bone quality, and instability. In recent decades, advancements in surgical techniques and hindfoot implants have enabled the delivery of localized intramedullary antibiotics. When combined with staged tibiotalocalcaneal (TTC) arthrodesis, this approach has yielded promising results, helping to achieve successful arthrodesis, infection eradication, and bone healing. This retrospective case series describes the clinical outcomes of twenty-nine patients who underwent staged TTC arthrodesis in the setting of prior infection. Methods: Between September 1, 2017, and September 1, 2024, a single surgeon operating at two Midwest institutions identified twenty-nine patients with infected nonunion of the distal tibia or hindfoot. All infections were confirmed by intraoperative cultures. Initial treatment involved placement of an antibiotic-embedded polymethylmethacrylate (PMMA) coated intramedullary rod with or without provisional external fixation, followed by exchange of the rod for a definitive hindfoot nail at an interval stage. Patient demographic data, comorbidities, surgical details, and follow-up outcomes were collected retrospectively. Descriptive statistics were used to assess fusion rates, infection rates, functional outcomes, and patient-reported outcomes. Results: 65.5% of patients analyzed were male, and the average age at time of TTC fusion was 54.5 ± 13.9 years. Fusion across the site of nonunion was achieved in twenty-two patients (75.9%), while four (13.8%) had stable fibrous union. Three patients (10.3%) lacked three months of follow up data at the time of analysis. Methicillin-sensitive Staphylococcus aureus was the most common causative organism, observed in nine patients (31.0%). Twenty-six patients (89.7%) achieved clinical resolution of their infection, and four patients (13.8%) continued chronic suppressive antibiotic therapy. Fourteen patients (48.3%) required shoe modifications, and seven (24.1%) used assistive devices at last follow-up. Of these seven, two died of unrelated causes before full recovery. In total, three patients died of unrelated causes, and no patients required amputation. Conclusion: Staged TTC arthrodesis can be an effective method for managing distal tibia and hindfoot nonunion, with high rates of fusion and infection remission. Functional outcomes remain an area for continued study.