Review Article
Tibiotalocalcaneal Fusion for
Eva U. Asomugha, MD
Bryan D. Den Hartog, MD
Jeffrey T. Junko, MD
Ian J. Alexander, MD
From the Department of Orthopedic
Surgery, Cleveland Clinic, Cleveland,
OH (Dr. Asomugha), Black Hills
Orthopedic & Spine Center, Rapid
City, SD (Dr. Den Hartog), the
Department of Orthopedics, Summa
Health, Akron, OH (Dr. Junko), and
the Department of Orthopaedic
Surgery, Wexner Medical Center,
Ohio State University, Columbus, OH
(Dr. Alexander).
Dr. Den Hartog or an immediate family
member has received royalties from
OrthoHelix Surgical Designs,
FOOTinnovate, and Tornier; is a
member of a speakers’ bureau or has
made paid presentations on behalf of
OrthoHelix Surgical Designs and
Tornier; serves as a paid consultant to
BioMedical Enterprises, OrthoHelix
Surgical Designs, and Tornier; and
has stock or stock options held in
FOOTinnovate. Dr. Alexander or an
immediate family member serves as a
board member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons
and the American Orthopaedic Foot
and Ankle Society. Neither of the
following authors nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Asomugha and Dr. Junko.
J Am Acad Orthop Surg 2016;24:
125-134
http://dx.doi.org/10.5435/
JAAOS-D-14-00102
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
March 2016, Vol 24, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Severe Deformity and Bone Loss
Abstract
Tibiotalocalcaneal fusion is an effective salvage procedure for
combined end-stage ankle and subtalar arthrosis and for the
management of severe planar deformities of the ankle and hindfoot.
Although the procedure results in a rigid ankle and hindfoot, it is often
the only means of providing patients with a stable and painless foot
and ankle for ambulation. Some patients who require the procedure
have substantial bone loss that can be managed with a variety of
autograft and allograft options. Options for tibiotalocalcaneal fixation
include both internal and external devices, the selection of which
depends on the underlying pathology, amount of bone loss, and type
of bone graft selected. Relatively high complication rates associated
with tibiotalocalcaneal fusion have been reported, with complications
ranging from superficial infection to ultimate amputation; however,
proper patient selection and careful graft and fixation planning
can minimize the postoperative complications of the procedure.
T ibiotalocalcaneal (TTC) fusion is
a salvage procedure for patients
with substantial ankle and subtalar
Indications
General indications for TTC fusion
arthritis or severe malalignment of
include severe, symptomatic hindfoot
the ankle-hindfoot complex. In many
and ankle deformity or combined
cases, this procedure is the only
ankle and hindfoot arthritis for which
option available to provide patients
nonsurgical management has failed.
with a stable, painless, plantigrade
Specific conditions for which such
foot for ambulation. TTC fusion
fusion is commonly indicated include
reduces pain, thereby improving
inflammatory arthropathies; congen-
patients’ activity levels (based on
ital deformity; neuropathic arthri-
functional outcome scores) and al-
tides secondary to diabetes mellitus or
lowing them to return to work. The
inherited polyneuropathies; failed
procedure is associated with a high
total ankle arthroplasty; severe pes
level of patient satisfaction in appro-
planovalgus deformity; fracture mal-
priately counseled patients1 and is
union and nonunion; and bone loss
technically demanding, requiring
and collapse secondary to trauma,
surgical planning that must take
tumor, osteonecrosis, or infection.2-6
into account the patient’s under-
lying diagnosis, comorbidities, and
malalignment. Given the salvage
nature of the procedure, some Preoperative Planning
patients who may be candidates for
TTC fusion present with substantial History
bone loss that must be considered Patient factors that have been shown
preoperatively. to affect outcomes of TTC fusion
125
Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss
include medical comorbidities such
as diabetes mellitus, previous ulcera-
tions, peripheral vascular disease,
renal disease, immunosuppression,
chronic steroid use, rheumatologic
disease, malnutrition, and smoking.
In addition, a history of surgical
intervention, particularly with post-
operative complications (eg, deep
infection, problems with wound
healing), may affect postoperative
outcomes. In several studies of TTC
arthrodesis, 20% to 40% of patients
had a history of diabetes mellitus or
smoking, resulting in poorer than
average outcomes in these
patients.2,6,7 DeVries et al6 per-
formed a risk assessment for major
amputation after TTC fusion and
found diabetes mellitus to be the
greatest predictor of amputation,
followed by revision surgery, pre-
operative ulceration, and age. If risk
factors for amputation are present,
care must be taken to mitigate these
compromising factors.
A high index of suspicion for
infection should be maintained
when warranted by the patient’s
history, clinical examination, and
aberrations in the complete blood
count, erythrocyte sedimentation
rate, or C-reactive protein level. A
diagnosis of infection can also be
supported by findings in nuclear
studies, such as tagged white blood
cell scans, a three-phase bone scan,
biopsy, or MRI.
Physical Examination
Examination of the patient should
begin with assessment of the skin
and pedal pulses. If there is any
question about the vascular status of
the limb in which TTC fusion is
being considered, further workup is
warranted and may include vascular
studies or consultation with a vas-
cular surgeon. A neurologic evalua-
tion should include sensation testing
with a 5.07-gauge monofilament
and an evaluation of the muscular
126
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
strength in all planes of the leg that is
to be treated.
Assessment of Alignment
The alignment of the foot and ankle
should be assessed using a systematic
approach. The assessment begins
with an evaluation of the standing
alignment and gait. Special attention
should be paid to the alignment of the
hindfoot and ankle in both the sagit-
tal and coronal planes. An equinus
posture (ie, fixed ankle plantar flex-
ion) is important to detect, along with
any varus or valgus positioning of the
hindfoot. Attention should then be
turned to the forefoot. To assess the
need for forefoot correction, the
hindfoot can be held in the corrected
position while the clinician assesses
the position of the forefoot in the
coronal plane relative to the long axis
of the tibia while the patient is seated.
This may also be done with the
patient in the prone position, partic-
ularly if the hindfoot malalignment is
not manually correctable. If the
coronal plane of the forefoot is per-
pendicular to the coronal axis of the
calcaneus (in a talonavicular neutral
position) with the patient in the prone
position, no forefoot correction will
be needed to establish a plantigrade
foot. If the forefoot is in a rigid varus
or valgus position relative to the
midline of the heel, failure to correct
this at the time of surgery may result
in symptomatic, asymmetric forefoot
loading. In these cases, forefoot
alignment can be addressed with
midfoot or forefoot osteotomies or
fusions. Mild flexible deformities of
the forefoot typically do not require
intervention. In addition, the need for
soft-tissue releases or lengthenings
should be considered preoperatively
in cases with a severe hindfoot and
ankle deformity.
Imaging Studies
Weight-bearing radiographs of the
ankle and foot are mandatory in the
Journal of the American Academy of Orthopaedic Surgeons
evaluation for TTC fusion. Radio-
graphic evidence of arthrosis, bone
loss, shortening, existing implants
from prior surgeries (particularly
broken screws), and deformity
should be noted. A weight-bearing
AP view of both ankles gives an
excellent indication of the degree of
actual or functional shortening
caused by bone loss or malalignment.
A Cobey hindfoot view allows
quantification of hindfoot varus or
valgus.8
In addition to plain radiography,
CT may be indicated in patients with
substantial disruption of the normal
bone architecture of the foot and
ankle and is also useful in revision
arthrodesis for determining the
status of a previous fusion. MRI
may be used in select cases to eval-
uate the extent of osteonecrosis in a
foot and ankle being considered for
TTC fusion.
Surgical Approach
A transfibular or perifibular
approach is most often used for TTC
fusion. Prior surgical incisions or
soft-tissue flaps may dictate varia-
tions in the location of the incision for
such an approach. Occasionally, if
the lateral skin is compromised and a
lateral approach cannot be used, a
posterior approach may be used to
access both the subtalar and ankle
joints.
In TTC fusion, the ankle joint is
prepared first, with articular cartilage
and subchondral bone removed. The
sinus tarsi is then exposed and the
contents are excised. The articular
cartilage and subchondral bone of the
posterior and middle facets are then
resected.
Management of Bone
Defects
After preparation of the ankle joint,
attention is turned to bone grafting

and the management of bone defects.
For most fusions in which the talus is
intact, little if any additional bone
grafting is necessary. For larger
defects, the surgeon must decide
whether to maintain a shortened limb
or repair the defect by bone grafting.
Larger defects can be classified as
either medullary or segmental. Med-
ullary defects that have a shell of
viable cortical bone can be filled with
graft. Examples include a primary
defect resulting from partial loss of
the talar body or removal of a total
ankle implant. In many of these cases,
the intact medial malleolus serves as a
cortical bridge, and the residual
medullary defect can be filled with
cancellous graft.
Segmental defects have substantial
loss of cortical and cancellous bone
and cannot contain nonstructural
graft material. These defects are a
challenging problem because the
surgeon must decide whether to
shorten the defective limb or restore
the limb to a more anatomic length.
An advantage of the former is that it
limits fusion to only a single bone
interface. If limb-length restoration is
chosen, structural bone grafts should
be used. A relative disadvantage of
such structural grafting is that bone
fusion must occur at two interfaces:
the proximal and distal ends of the
graft. Kleiber et al9 investigated the
use of tricortical iliac crest graft and
femoral head allograft in both soli-
tary ankle fusion (n = 16) and ankle
fusion as a component of TTC fusion
(n = 3). The average maximum graft
width was 9.5 mm. Fixation was
achieved with either an anterolateral
plate with cannulated screws or a
blade plate. Nearly 90% of patients
treated with either type of graft ob-
tained fusion at an average of 14.9
weeks after grafting, with an overall
improvement in preoperative coro-
nal and sagittal alignment.
In all settings in which TTC fusion
is done, proper soft-tissue tension-
ing and wound closure must be
March 2016, Vol 24, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ensured. A previously shortened or
angularly deformed limb may have
substantial soft-tissue contractures
that may require lengthenings or
releases. Relevant soft-tissue struc-
tures that may need to be addressed
under such circumstances include
the Achilles tendon, the gastrocne-
mius muscle, and the tibialis poste-
rior or peroneal tendons.
Autograft Techniques
Autogenous sources of graft for TTC
fusion include the iliac crest for can-
cellous and corticocancellous bone,
the tibia or femur for cancellous bone
harvested with a reamer-irrigator-
aspirator (RIA) device, and the fibula
for interpositional struts.
Tricortical Iliac Crest
Interposition
A tricortical iliac crest strut graft is
useful for repairing small (#2 cm)
segmental defects in the talus or
tibiotalar region. Several case series
have demonstrated good union rates
and restoration of height with the
use of these grafts in subtalar
arthrodesis, primarily in cases in
which calcaneal height has been lost
because of a previous fracture.10,11
Tricortical iliac crest grafts have also
been used in ankle arthrodesis in
cases of failed short-stem implants
used in total ankle arthroplasty.12 In
general, a large bone block is ob-
tained from the iliac crest and
divided into two. The resulting bone
blocks are then interposed side by
side within the defect. Any remaining
deep space can be filled with can-
cellous graft, which may be obtained
from the iliac crest or from the
excised distal fibula. Potential
drawbacks of iliac crest autograft are
donor-site morbidity (eg, pain, sur-
gical site infection, abdominal her-
niation) and the limited volume of
graft that can be obtained.
Eva U. Asomugha, MD, et al
Reamer-Irrigator-Aspirator
A RIA device can be used to ream the
intramedullary (IM) canal and col-
lect a large volume of cancellous
bone for autografts. Studies have
shown that up to 50 mL of bone
graft can be collected from the tibia
with this device.13,14 Bone from the
tibia should be harvested only when
TTC IM nailing is planned. Alter-
natively, bone harvested from the
femur may be harvested if a larger
amount of cancellous autograft
bone is desired or if an IM nail will
not be used for fixation. In general,
graft bone collected by reaming
with the RIA system is useful for
repairing large medullary defects;
however, good results also have
been achieved with fusion when
segmental defects are present14
(Figure 1).
Fibular Strut Interposition
Interposition of a fibular strut is
particularly useful for spanning tibial
medullary defects and short seg-
mental defects (,3 cm) at the ankle.
If a transfibular approach is used,
the fibular osteotomy is performed
in a transverse manner. The medial
and distal aspect of the fibula is
decorticated. A window that
matches the width of the fibular
strut is then made in the lateral wall
of the tibia, which is often very thin,
to gain access to the medullary
defect. Fibrous tissue and necrotic
bone are removed. The strut is in-
serted into the medullary canal of
the tibia and any excess bone is re-
sected. The decorticated surfaces
should appose the tibial canal and
the talus or, in the absence of the
talus, the decorticated superior sur-
face of the calcaneus. Because the
fibular strut will not fill the entire
defect, another source of cancellous
graft must be used to fill the re-
maining space. The defect may be
spanned from the tibial diaphysis to
the calcaneus with a locking plate. If
127
Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss

Figure 1

A, Preoperative AP radiograph of the right distal tibia and talus in a 30-year-old man who presented with chronic osteomyelitis.
The patient underwent staged irrigation and débridement with placement of an antibiotic spacer. B, Postoperative AP radiograph
demonstrating the distal tibia and talus after the resultant bone defect was filled entirely with cancellous autograft bone obtained
from the femur via the reamer-irrigation-aspiration system, and the fusion site was secured with a lateral locking plate.
C, Immediate postoperative AP radiograph of the ankle after graft placement. Postoperative AP (D) and lateral (E) radiographs of
the ankle demonstrating complete incorporation of the bone graft at the final follow-up visit.

a conventional TTC fusion plate is
not sufficiently long to allow fixa-
tion proximal to the defect, other
periarticular locking plates may be
used. Colman and Pomeroy15 re-
ported good results with a similar
technique of fibular onlay strut
grafting with cannulated screw fix-
ation for ankle fusion.
Allograft Techniques
Options for allograft used in TTC
fusion include cancellous chips, bulk
allograft obtained from the femoral
head, and struts of corticocancellous
bone from the iliac crest or fibula.
These options may be augmented with
a variety of orthobiologic agents. For
well-contained defects, chips of can-
cellous allograft bone may be used;

128 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Figure 2
A, Intraoperative photograph of the ankle demonstrating the placement of a bulk femoral head allograft to manage talar bone
loss. Postoperative AP (B) and lateral (C) radiographs demonstrating fixation of the ankle with a laterally placed
tibiotalocalcaneal fusion plate. D, Coronal CT scan demonstrating the fusion site.
bulk allografts and strut grafts are
useful for repair of larger defects.
Femoral head allograft may be used
for salvage of a large segmental defect
when TTC fusion is required4,16
(Figure 2). A relative contraindication
to TTC fusion with allograft is severe
hindfoot valgus (.25°) because
realignment may lead to excessive
tension on the lateral soft tissues
and possibly to wound necrosis. In
such cases, TTC fusion with short-
ening should be considered.
In the setting of substantial bone loss
in the talar body, the collapsed talar
body is excised through the lateral
incision, and the tibial plafond, talar
head and neck, and posterior facet of
the subtalar joint are prepared. An
acetabular reamer of the appropriate
size (based on the size of the talar
defect) is selected, and the defect is
reamed with the ankle and subtalar
joints held in neutral position. The
thawed femoral head allograft is de-
corticated with the corresponding
female reamer and placed in the defect.
The fusion may be fixed with a lateral
plate and augmented with cannulated
screws placed through the graft.16
March 2016, Vol 24, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
In a retrospective case series of 32
patients who underwent TTC fusion
with bulk femoral head allografts,
radiographic union was achieved in 16
patients (50%). Seven patients had
asymptomatic nonunion, resulting in a
71% overall rate of functional limb
salvage.4 Diabetes mellitus was the
only predictive factor for nonunion;
all of the patients with diabetes mel-
litus had radiographic nonunion.
Although the overall functional limb
salvage rate was good for this patient
population, the authors emphasized
that TTC fusion with a bulk femoral
head allograft is technically challeng-
ing and has a high complication rate.
Nearly one fourth of patients experi-
enced at least one complication, with
nonunion being the most common.4
Ultimately, nearly 20% of all patients
required a below-knee amputation.
Orthobiologics
In patients at high risk of complica-
tions after TTC fusion, augmentation
with bone-marrow aspirate, platelet-
rich plasma, or an orthobiologic
material may be used. The use of
Eva U. Asomugha, MD, et al
orthobiologics for elective foot and
ankle procedures may be off label, and
the proposed use of such a material
should be discussed with the patient
before surgery. DeVries et al6 retro-
spectively investigated fusion rates
and times to fusion in revision TTC
fusions with a retrograde nail in
patients who received (n = 7) or did
not receive (n = 16) recombinant
human bone morphogenetic protein
(rhBMP)-2 at the time of revision
surgery. There was no significant
difference in the time to radiographic
union, the rate of complications, or
the rate of fusion in the two groups;
the group that did not receive rhBMP-
2 had a fusion rate of 68.8% versus
71.4% in the rhBMP-2 group.17
Given the lack of large, comparative
studies on the effects of rhBMP-2 on
TTC fusion, its use should be con-
sidered only in patients who may have
a particularly high risk of nonunion
or delayed union.
Fixation
Options for fixation in TTC fusion
include spanning external fixation,
129
Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss

Figure 3

A, Preoperative lateral radiograph of the ankle in a patient with traumatic extrusion of the talar body that resulted in .3 cm of
limb shortening. The patient underwent staged proximal distraction osteogenesis with a Taylor spatial frame (TSF). A
cancellous autograft obtained from the femur via a reamer-irrigator-aspirator device was inserted at the tibiotalocalcaneal
(TTC) fusion site. B, Immediate postoperative lateral radiograph of the ankle demonstrating proximal osteotomy for bone
lengthening with application of the TSF. C, Final postoperative lateral radiograph of the ankle demonstrating successful TTC
fusion nearly 1 year after the index procedure.

cannulated screws, IM nailing, and
lateral plating. Before fixation is
done, the graft of choice is put into
place, with care taken to achieve
good bone apposition. Regardless of
the type of fixation chosen, com-
pression should be achieved at the
fusion site, if possible. The ankle is
fixed in a position of neutral dorsi-
flexion, with the hindfoot in 0° to 5°
of valgus relative to the tibia.
Spanning External Fixation
and Bone Transport
External fixation has many advan-
tages, particularly in the setting of
chronic osteomyelitis and when
lengthening is needed. Selection of an
external fixator is dictated by the
goals of fixation. The Ilizarov appa-
ratus has been shown to be an
effective option for limb salvage in
high-risk patients, many of whom
may otherwise have undergone
amputation. Four methods for
the use of the Ilizarov apparatus
have been described: compression,
distraction, bifocal compression-
distraction, and bone transport. For
both bifocal compression-distraction
and bone transport, compression is
achieved at the site of TTC fusion and
a proximal metaphyseal corticotomy
is done, followed by gradual distrac-
tion at a rate of 1 mm/d after the first
week (Figure 3). This technique can
be used in cases in which residual
shortening would lead to a limb-
length discrepancy of .3 cm. Suc-
cessful tibiocalcaneal fusion has been
reported in up to 85% of patients
treated with the Ilizarov apparatus,
with eradication of infection in up to
100% of patients with osteomyeli-
tis.5,18 Disadvantages of spanning
fixation include the prolonged
course of treatment, patient dis-
comfort and pain, the potential for
pin-tract infection, and the risk of
proximal nonunion or malunion
when distraction or bone transport is
done. In general, the use of internal
fixation is favored unless there is
concern related to prior infection or
when bone transport is being used to
restore limb length.
Fixation With Cannulated
Screws
In neurologically intact patients
without bone loss, fixation in TTC
fusion can be achieved with three
long, cannulated screws (Figure 4).
Multiple configurations of screw
placement have been described,
including the use of two screws
placed parallel and extending from
the plantar lateral calcaneus through
the talus and into the tibia, with one
screw perforating the anteromedial
cortex and the other penetrating the
posteromedial cortex of the distal
tibia. An additional cannulated
screw that extends across the tibio-
talar joint can be inserted from the
distal lateral tibia and directed to the
medial talus.
Small case series have demon-
strated successful fusion, improved
patient-reported outcome scores, and
few complications associated with

130 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

cannulated screw fixation for TTC
fusion.19,20 Biomechanical studies
comparing the use of IM nails with
interlocking screws versus fixation
with two or three crossed cannulated
screws have shown that IM nails are
biomechanically superior with re-
gard to bending and torsional forces,
making proper patient selection
critical for minimizing the risk of
construct failure in TTC fusion.21,22
Tibiotalocalcaneal Fusion
Nailing
For patients with neurologic compro-
mise or a severe angular deformity of
the hindfoot without substantial bone
loss, such as those with Charcot-
Marie-Tooth disease or diabetic neu-
ropathy, a retrograde TTC fusion
with an IM nail can be done (Figure
5). The fusion nail is a rigid, load-
sharing device that allows consider-
able compression across the ankle
and talocalcaneal joints. One advan-
tage of fusion nailing in this high-risk
patient population is the ability to
insert the nail through a limited
surgical exposure. However, the
utility of fusion nailing is limited in
patients with substantial deformities
of the distal tibia. The design of
nails used for TTC arthrodesis has
evolved substantially over the past
three decades to improve the overall
performance of the ankle and hind-
foot. Nails of modern design offer
the options of a straight alignment or
a distal valgus bend, various inter-
locking screw configurations, and
various options for nail length.
The surgeon should first decide
whether to use a straight or valgus
nail for TTC fusion. When a straight
nail is used, the entry point should be
selected such that the nail is aligned
within the central aspect of the
tibial canal. Given the lateral offset of
the calcaneus, calcaneal purchase of
the nail may be compromised. A val-
gus nail can be positioned in the
central calcaneus rather than in the
March 2016, Vol 24, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
sustenaculum tali, which increases
the purchase of the nail in the calca-
neus. Mückley et al23 reported on
their experience using a valgus-
curved TTC fusion nail in a pro-
spective study of 27 patients and 28
retrospectively reviewed charts.
Bone union was achieved in 96% of
patients, with an overall improve-
ment in American Orthopaedic Foot
and Ankle Society and Medical
Outcomes Study 36-Item Short Form
scores. Twenty-five percent of
patients experienced a complication,
with four complications related
directly to instrumentation (one in-
traoperative fracture and three cases
of soft-tissue irritation by a nail).
Radiographically, the ankles had a
mean 0° of valgus with a mean ta-
localcaneal angle of 26° (normal, 25°
to 30°). The authors concluded that
a valgus-curved TTC fusion nail is a
good salvage option for achieving
bone union in patients at high risk
for failure or complications.
Recent nail designs also offer
various configurations for locking
screws. Augmentation screws can be
placed proximally or distally, in the
coronal or sagittal planes, and locked
in a dynamic or static position. In a
cadaver study, Fleming et al21 dem-
onstrated that retrograde nails with
proximal and distal locking screws
had greater stiffness than did nails
without locking screws. This finding
was supported by O’Neill et al,24
who reported increased initial and
final stiffness and a greater load to
failure with IM nail fixation aug-
mented with interlocking screws.
Means et al25 compared distal
locking screws inserted into the
calcaneus in a posterior-to-anterior
direction versus a lateral-to-medial
direction. Eight matched cadaver
legs underwent dorsiflexion fatigue
testing. Interlocking screws inserted
in a posterior-to-anterior direction
demonstrated greater initial and
final stiffness and load to failure and
less plastic deformation than did
Eva U. Asomugha, MD, et al
Figure 4
Lateral radiograph of the ankle
demonstrating cannulated screw
fixation in a patient with good bone
stock and no neurologic
compromise.
screws inserted in a lateral-to-medial
direction.
Selection of appropriate nail length
is important for TTC fusion nailing.
Longer nails end in the proximal
tibia. In one study, longer nails had a
lower risk of inducing a cortical stress
reaction at the proximal end of the
nail than did shorter nails.26
Fusion rates of up to nearly 90%
have been reported with the use of
retrograde IM nails, with complica-
tion rates ranging from 20% to
50%.2,27-29 A systematic review of
33 studies, including 641 procedures
in 631 patients, revealed a fusion
rate of 86.7%, with an average time
to union of 4.5 months. The reported
complication rate was .55% and
was largely related to implants
(16.7%), including broken devices,
ulcers secondary to prominent
devices, and stress reactions or
fractures. Revision surgery was
required in 22% of cases, and revi-
sion fusion was required in 3%.2
Good results have been reported
with the use of nails for TTC
arthrodesis in patients with moderate
to severe angular deformities. In a
study of 30 TTC fusions with com-
pression nailing and interlocking
131
Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss

Figure 5

A, Preoperative AP standing radiograph of the ankles in a patient with a severe cavovarus deformity of the left ankle with
chronic instability, Charcot-Marie-Tooth disease, and good bone stock. Tibiotalocalcaneal fusion nailing was performed in
the right ankle. An intramedullary nail was chosen over cannulated screw fixation because of the neuropathy. Postoperative
lateral (B) and PA (C) radiographs of the left ankle demonstrating augmentation of ankle fixation with an anteromedial plate.

screws inserted in a posterior-to-
anterior direction, Brodsky et al30
reported that 13 limbs (43.3%)
had severe varus or valgus angular
deformities of .15°. Postoperatively,
76% of treated limbs had coronal
deformities of ,5°. Functional out-
come and pain scores improved
considerably. The authors reported
one nonunion and complications in
23.3% of patients.
Plate Fixation
Plate fixation may also be used for
TTC fusion. Locking plates provide
fixed-angle fixation for fusion and
deformity correction. The potential
for improved purchase provided by
plate fixation is particularly impor-
tant in the calcaneus, which consists
primarily of cancellous bone and is
often deformed. Indications for plate
fixation with TTC fusion include the
presence of large medullary defects,
segmental defects in which a tricor-
tical bone graft from the iliac crest
or a fibular strut graft is used, distal
tibial deformity, a retained IM
implant, osteoporotic bone, and
substantial loss of bone from the talar
body because fixation with a nail and
nonstructural graft may prove tenu-
ous. Plates may also be used to aug-
ment fixation with IM nails. A
disadvantage of plate fixation is that
it requires a fibulectomy and addi-
tional exposure, including exposure
of the lateral wall of the calcaneus
and distal tibia, which may introduce
a higher risk of wound complication
and nerve injury.
A variety of locking plates, includ-
ing plates specifically designed for the
ankle and hindfoot, can be used for
TTC fusion. If these tailored plates
are not available, other periarticular
fixed-angle plates may be used.
Ahmad et al31 described the use of a
3.5-mm proximal humeral locking
plate for TTC fusion in 17 patients.
Fusion was achieved at a mean of
20.6 weeks in nearly 95% of the
patients. Periarticular distal femoral
locking plates have also been used
for TTC fusion.32 Typically, four or
five screws are inserted into the cal-
caneus, with at least four bicortical
screws inserted into the tibial shaft
proximal to the defect. Additional
screws can be placed outside the
plate to augment the construct, but
this is usually not necessary (Figure
6). Blade plates have also been used
for TTC fusion, but they have been
largely replaced with fixed-angle
locking plates.
Biomechanical studies have re-
ported equivocal results with the use
of locked plating or IM nail fixation
for TTC fusion. In six matched
cadaver specimens, O’Neill et al33
found that a locking-plate construct
had greater final rigidity than did a
distally interlocked retrograde IM
nail. No difference between the two
types of construct was found in any
of the other parameters that the
authors tested. Ohlson et al34 com-
pared the biomechanical properties
of a periarticular humeral locking
plate and an interlocked IM nail for
fixation in TTC fusion and found no
difference in stiffness, load to failure,
or plastic deformation with these
two devices. A review of the recent
literature indicates that either IM
nailing or locking-plate fixation may
be used in patients with good TTC
bone stock. However, in patients

132 Journal of the American Academy of Orthopaedic Surgeons

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 Eva U. Asomugha, MD, et al

with destabilizing bone defects, we Figure 6

prefer to use locking-plate fixation.

Correction of Forefoot
Alignment
The importance of accurate intra-
operative assessment and correction
of forefoot alignment in TTC fusion
cannot be overemphasized. Failure to
address malalignment may result in
patient dissatisfaction with the out-
come of fusion. After fusion is com-
plete, the two thumb test can be
performed by evenly loading the
plantar aspect of the first and fifth
metatarsal heads with the surgeon’s
thumbs. The coronal position of the
forefoot is assessed and compared
with the position of the long axis of
the tibia or the leg. Because forefoot
valgus (ie, greater plantar flexion of
the first ray relative to the fifth ray) is
better tolerated than varus and is
more easily accommodated with a A, Preoperative AP radiograph of the ankle demonstrating extensive bone loss
and a subtalar dislocation in a patient with diabetes mellitus and Charcot
foot orthosis, it is preferable to arthropathy. B, Postoperative AP radiograph of the ankle demonstrating fixation
position the forefoot in slight valgus with a distal femoral locking plate.
rather than in varus.
Malposition of the forefoot can be
advanced age, neuroarthropathy, effectively managed with allografting,
corrected through either a dorsal
diabetes mellitus, and smoking.6,35 autografting, or bone transport. The
opening wedge osteotomy of the
In addition, wound sloughing has choice of fixation is dictated by the
medial cuneiform bone for varus
been reported with the correction of type of deformity, the method of
forefoot positioning or a dorsal clos-
substantial deformities in the coronal managing bone deficiency, the
ing wedge osteotomy of the base of
plane and restoration of height.16 underlying neurologic status, and the
the first metatarsal bone for excessive
Neurovascular structures at risk of underlying risk factors and co-
forefoot valgus. Alternatively, if
injury with IM nailing include the morbidities. Certain risk factors, such
arthrosis is present in the first tarso-
lateral plantar nerve and artery and as diabetes mellitus, immunosup-
metatarsal joint, it can be corrected
the flexor hallucis longus tendon. pression, and smoking, considerably
through realignment and fusion of
The formation of a painful neuroma increase the risk of complications,
the joint.
can be minimized with careful and patients with these risk factors
planning of the incision for TTC should be forewarned of the risk of
Complications fusion and meticulous dissection and amputation as a potential outcome of
retraction. the procedure.
Complication rates as high as 60%
have been reported with TTC fusion;
the most common complications Summary References
include nonunion, malunion, infec-
tion, and implant-related prob- TTC fusion is a viable salvage pro- Evidence-based Medicine: Levels of
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after TTC fusion is reported to be deformity or end-stage combined contents. In this article, reference 6 is
as high as 20%.4 Risk factors for ankle and subtalar arthritis. Major a level II study. References 1, 2, 7,
higher rates of complication include bone defects in the ankle can be and 13 are level III studies.

March 2016, Vol 24, No 3 133

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss
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