Hexapod-assisted limb salvage after talectomy: outcomes of tibiocalcaneal arthrodesis using the TL-hex system

BACKGROUND: Severe talar destruction due to infection, trauma, avascular necrosis, or neuroarthropathy represents a major reconstructive challenge. Talectomy followed by tibiocalcaneal arthrodesis (TCA) is a limb-salvage option in selected high-risk patients, although optimal fixation remains controversial. Modern hexapod external fixators offer computer-assisted multiplanar control that may improve alignment and fusion after talectomy. The aim of this study was to evaluate the clinical and radiographic outcomes of talectomy followed by TCA using the TL-HEX system in a series of high-risk patients. METHODS: A retrospective observational study was conducted between January 2020 and January 2024 including all patients who underwent total talectomy followed by TCA using a TL-HEX circular external fixator. Indications included talar destruction secondary to infection, avascular necrosis, post-traumatic collapse, Charcot neuroarthropathy, and aseptic loosening of total ankle arthroplasty. Primary outcomes were radiographic fusion and hindfoot alignment. Secondary outcomes included time to union, functional scores (AOFAS, EFAS), pain (VAS), complications, and patient satisfaction. Preoperative and final follow-up outcomes were compared using paired statistical tests, with significance set at p < 0.05. RESULTS: Thirteen patients (mean age 57 years) were included with a mean follow-up of 24 months. Radiographic fusion was achieved in 11 of 13 patients (84.6%) using the TL-HEX alone, with a mean time to union of 22.1 ± 3.1 weeks. Two patients required conversion to intramedullary fixation, both achieving final consolidation. Mean AOFAS score improved from 39.2 ± 10.8 to 74.1 ± 9.7 (p < 0.001), VAS pain score from 5.1 ± 1.2 to 1.4 ± 1.1 (p < 0.001), EFAS score from 3.2 ± 1.8 to 14.3 ± 3.8 (p < 0.001), and SF-36 PCS from 23.4 ± 2.6 to 38.6 ± 3.5 (p < 0.001). Mean final hindfoot alignment was 6.5° of valgus, and all fused patients obtained a stable, plantigrade foot without bracing. No postoperative strut adjustments were required in any patient. Patient satisfaction was high (84.6% satisfied, 15.4% partially satisfied, none dissatisfied). No deep infections, amputations, or neurovascular complications occurred. CONCLUSION: Tibiocalcaneal arthrodesis using a TL-HEX hexapod fixator appears to be a feasible limb-salvage strategy after talectomy in selected high-risk patients, achieving satisfactory fusion, alignment, and functional improvement in our cohort. LEVEL OF CLINICAL EVIDENCE: IV.