One of the most challenging scenarios is the patient with a complex hindfoot deformity involving both the ankle and the subtalar joint. “Hindfoot deformities involve complex anatomy, and may be caused by trauma, arthritis, congenital disease or may be related to Charcot neuropathy,” explains Paul J. Juliano, M.D., chief, foot and ankle orthopaedics, Bone and Joint Institute. Tibiotalocalcaneal (TTC) arthrodesis, often paired with osteotomy, is a salvage procedure typically performed in patients with severe tibiotalar and subtalar arthropathy with a significant pre-operative deformity. Over the past 10 to 15 years, treatment has shifted away from external fixation to internal fusion achieved with an intra-medullary nail.1,2
Dr. Juliano, who has performed approximately 200 TTC fusions using an intra-medullary nail, further notes, “An intra-medullary nail for TTC fusion presents a few advantages, including that it’s a load-sharing device, which removes some stress from involved joints. In contrast to external devices, nails don’t interfere with clothing or bathing, and more easily provide compression, which is key for achieving union. They’re also skin-sparing and pose less risk of infection, which is ideal for patients with a poor quality soft tissue envelope, such as those with severe diabetes.” Case in point: A 57-year-old male patient presented with a severe pain and varus deformity of the ankle secondary to Charcot-Marie-Tooth disease. He was walking on the lateral border of his foot, had to purchase custom footwear and utilized a cane. The deformity was corrected with this single-stage operation. The patient has reported relief of pain and a lifestyle improvement. He does not require the use of a cane to walk, and is wearing “off the shelf” shoes. (See figures.)
According to one meta-analysis, successful union rate is high (approximately 87 percent), with large reductions in pain and deformity.² In cases of non-union, the surgeon may dynamize the nail device, which is fairly simple. Dr. Juliano, explains, “With a delayed-union, the surgeon can perform a secondary surgery to remove the proximal screw. This allows additional compression of the arthrodesis site, and increases the likelihood of union.”
Common complications with intra-medullary nail for TTC fusion are infection and device-related adverse events.¹ Dr. Juliano notes, “In very rare instances, in elderly patients with severe osteopenia, a stress fracture above the nail can occur, since the bone is of poor quality. I’ve found that the fracture will heal with immobilization and without the need for nail removal. The procedure should be avoided in patients with avascular necrosis of the talus, since the underlying bone quality is compromised.”
In general, this procedure is not appropriate for patients with any form of severe infection or in pediatric patients. Rarely, TTC fusion with an intra-medullary nail could be used to stabilize an acute fracture, either due to trauma, or fracture secondary to hemodialysis-related bone disease.
Paul J. Juliano, M.D.
Chief, Foot and Ankle Orthopaedics
Vice-Chair and Residency Program Director, Orthopaedics and Rehabilitation
Professor, Orthopaedics and Rehabilitation
FELLOWSHIPS: Orthopaedic surgery, Union Memorial Hospital, Baltimore, Md.; University of Maryland Medical System, Baltimore, Md.
RESIDENCY: Orthopaedic surgery, National Naval Medical Center, Bethesda, Md.
MEDICAL SCHOOL: Georgetown University School of Medicine, Washington, DC
- Jehan S, Shakeel M, Bing AJ, Hill SO. 2011. The success of tibiotalocalcaneal arthrodesis with intramedullary nailing: A systematic review of the literature. Acta Orthop Belg. 77(5):644-51.
- Hatic SO, Berlet, GC. 2011. Intramedullary Nail Options for Tibiotalocalcaneal Fusion. Orthopaedic Knowledge Online Journal. 9(9):1-4.