Category: Ankle, Hindfoot
Keywords: TTC, Ankle Arthrodesis, Ankle Fusion
Introduction/Purpose: Advanced pathology involving the tibiotalar and the subtalar joint poses a significant treatment challenge to orthopedic surgeons. Tibiotalocalcaneal (TTC) arthrodesis is an orthopedic surgical 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 two different TTC arthrodesis constructs, including intramedullary nail (IMN) and open reduction and internal fixation (ORIF) with a plate/screw construct, in a population of patients with a wide range of deformity and comorbidities.
Methods: A retrospective review was conducted on 76 ankles of 72 consecutive patients who underwent TTC fusion by one fellowship-trained foot and ankle orthopaedic surgeon at a tertiary referral academic center between 2015 and 2025. Diagnoses at presentation, patient characteristics and comorbidities, postoperative outcomes, and operative data were recorded. IMN TTC fusion was performed on 57 ankles (75%) and ORIF TTC fusion on 19 ankles (25%). Mean (SD) age was 59 (15) years, 45 were female (59%), BMI was 35.9 (10.0) kg/m2, 21 were cigarette smokers (28%), 40 were diabetic (53%), 38 were neuropathic (50%), and 18 had cardiovascular disease (24%). At initial presentation, 69 had osteoarthritis (91%), 53 had a subluxation (70%), 34 had Charcot arthropathy (45%), 23 had previous ankle fracture surgeries (30%), 19 had a nonunion (25%), 7 had an osteomyelitis infection (9%), and 4 had avascular necrosis (5%).
Results: Revision TTC fusion was required after 2 of 57 IMN procedures (4%) and 5 of 19 ORIF procedures (26%) (OR, 0.10 [95% CI, 0.02-0.58]). IMN revisions included 2 periprosthetic fractures. ORIF revisions included 1 persistent nonunion, 1 periprosthetic fracture, 3 nonunions. Amputation was performed after 4 IMN procedures (7%) and 1 ORIF procedure (5%) (OR, 1.36 [95% CI, 0.14-12.96]). Complications in 19 patients that presented with nonunion included 2 revision TTC fusions (11%), 1 persistent nonunion (5%), 1 amputation (5%), and 1 broken implant (5%). Complications in 34 patients that presented with Charcot arthropathy included 5 broken implants (15%), 4 amputations (12%), 2 nonunions (6%), 2 periprosthetic fractures (6%), and 2 revision TTC fusions (6%). Hardware was removed after 13 surgeries (17%).
Conclusion: A variety of techniques exist for performing TTC arthrodesis without any current clear indications for a specific fixation method. This study demonstrated an increased rate of revision surgery in the ORIF group versus the IMN group, as well as lower rates of nonunion. Overall, IMN may be a favorable construct compared to ORIF. Further research considerations would focus on increasing sample size to isolate complex comorbidities, including severe deformity, Charcot arthropathy, cigarette smokers, etc., in order to optimize outcomes and decrease complication and revision rates.
AbstractFirst published online January, 2026
