Outcomes of Tibiotalocalcaneal Arthrodesis Using a Nail-Plate Construct

Research Type: Level 4 – Case series Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a surgical treatment option for pathologies of the ankle and hindfoot. Among its indications are a variety of arthropathies, deformity correction, and limb salvage.3,5,8 A number of fixation methods in TTC arthrodesis have been described, including retrograde intramedullary nailing (IMN), multiplanar external fixation, and plate-screw constructs.3,8,45 Recent orthopaedic trauma literature has highlighted advantages of hybrid nail-plate constructs in treating complex distal femur fractures.22,25,35,50 With these studies in mind, we present a novel technique of TTC arthrodesis using a hybrid IM nail-plate construct. We hypothesize that this technique will lead to high rates of limb salvage and low rates of hardware failure. Methods: Thirty-nine patients (forty-one limbs) with TTC arthrodesis treated at our institution by five fellowship-trained foot and ankle surgeons between September 2020 and May 2024 met inclusion criteria and were included in our cohort. A retrospective chart review was performed to obtain pre-operative demographic data, previous treatment data, time to intervention, operative approach and construct, number of re-operations, and clinical outcomes after operative management using a plate-nail construct for TTC arthrodesis. Results: The mean age was 58 (range, 26-74) years and mean BMI was 34.8. 39% (16/41) were diabetic. 63% (26/41) had peripheral neuropathy, and 41% (17/41) had a diagnosis of Charcot arthropathy. Mean clinical follow-up was 10.7 (range, 2.5-33.9) months. Preoperatively 32% (13/41) limbs had a history of infection. Post operatively, 39% (16/41 limbs) had wound complications. 27% (11/41) were diagnosed with deep or superficial infections. Seven limbs had an ulcer present at time of surgery of which 86% (6/7) healed during the post operative period. Thirty four percent (14/41) had a history of ulceration with 6/41 feet incurred a new ulceration post operatively. 27% (11/41) required subsequent procedures, including nine debridements, six transtibial amputations, and four partial hardware removals. There were no revision procedures. Conclusion: TTC arthrodesis is often employed as a limb salvage technique in cases of complex hindfoot pathology and deformity. These patients often present unique challenges such as neuropathy, deformity, history of prior operations or infections, and suboptimal bone quality. IMN or plate fixation alone may result in suboptimal outcomes. We report an 85% limb salvage rate, and hardware failure rate of 7% (3/41). Major complications were limited to patients with severe, poorly controlled medical comorbidities. Hybrid fixation using a hindfoot arthrodesis nail combined with a tibiotalocalcaneal locking plate presents an attractive fixation option with acceptable success rates even in challenging cases.