Tibiotalocalcaneal Arthrodesis: Deformity Correction in Medically Comorbid Patients

Background: Tibiotalocalcaneal (TTC) arthrodesis is a common orthopaedic procedure used to manage end-stage pathologies of the ankle and hindfoot. A variety of surgical techniques exist to accomplish TTC arthrodesis. We retrospectively reviewed and compared postoperative outcomes of 2 different TTC arthrodesis constructs, including intramedullary nail (IMN) and open plating (OP) with a plate/screw construct, in high-risk patients with a wide range of deformity and comorbidities. Methods: A retrospective review was conducted on 73 ankles of 69 consecutive patients who underwent TTC arthrodesis by a fellowship-trained foot and ankle orthopaedic surgeon at a tertiary referral academic center between 2014 and 2025. Diagnoses, patient characteristics and comorbidities, postoperative outcomes, and operative data were recorded and evaluated. Results: Postoperative complications occurred in 23 of 73 ankles overall (32%), including 16 of 55 IMN fusions (29%) and 7 of 18 OP fusions (39%) (OR 0.64, 95% CI 0.21-1.96; P = .56). Revision TTC arthrodesis was required after 2 of 55 IMN TTC fusions (4%) and 5 of 18 OP TTC fusions (28%) (OR 0.10, 95% CI 0.02-0.56; P = .008). IMN revisions were for 2 periprosthetic fractures. OP revisions were for 4 nonunions and 1 periprosthetic fracture. Amputation was performed after 4 IMN fusions (7%) and 1 OP fusion (6%)(OR 1.33, 95% CI 0.14-12.76; P = .99). In 19 ankles that presented with nonunion, the salvage TTC arthrodesis was associated with 2 revision TTC fusions (11%), 1 persistent nonunion (5%), and 1 amputation (5%). In 34 ankles that presented with Charcot arthropathy, the salvage TTC arthrodesis was associated with 4 amputations (12%), 2 nonunions (6%), 2 periprosthetic fractures (6%), and 2 revision TTC fusions (6%). Hardware removal was necessary after 13 surgeries (18%). Conclusion: This study suggested a lower rate of union and an increased rate of revision surgery after open plating arthrodesis compared with intramedullary nail arthrodesis. Overall, intramedullary nailing may be a more reliable construct compared with open plating in high-risk patients with diabetes and severe deformities. Level of Evidence: Level III, retrospective cohort study.