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Tibiotalocalcaneal Arthrodesis – Hindfoot Fusion

Tibiotalocalcaneal arthrodesis is a surgical procedure in which the ankle joint and subtalar joint are fused together to relieve chronic pain and restore stability to the hindfoot.

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Things worth knowing about "Tibiotalocalcaneal Arthrodesis"

Tibiotalocalcaneal arthrodesis is a surgical procedure in which the ankle joint and subtalar joint are fused together to relieve chronic pain and restore stability to the hindfoot.

What is Tibiotalocalcaneal Arthrodesis?

Tibiotalocalcaneal arthrodesis (TTC arthrodesis) is an orthopaedic surgical procedure in which two joints of the hindfoot are permanently fused: the ankle joint (between the tibia and the talus) and the subtalar joint (between the talus and the calcaneus). The goal is to eliminate pain caused by severely damaged joint surfaces, correct deformity, and provide a stable, weight-bearing foot.

The name of the procedure is derived from the three bones involved: the tibia (shin bone), the talus (ankle bone), and the calcaneus (heel bone). Arthrodesis refers to the surgical stiffening or fusion of a joint.

Indications – When Is This Surgery Performed?

TTC arthrodesis is indicated when conservative treatments have failed to provide adequate relief and the patient's quality of life is significantly impaired. Common indications include:

Advanced ankle osteoarthritis affecting multiple joint levels
Rheumatoid arthritis with severe involvement of the ankle and subtalar joints
Post-traumatic arthritis following fractures or dislocations around the ankle
Avascular necrosis of the talus
Severe hindfoot deformity such as adult-acquired flatfoot
Neuropathic arthropathy (e.g., Charcot foot in diabetes mellitus)
Revision surgery following failed total ankle replacement

Surgical Technique and Procedure

The surgery is typically performed under general or spinal anaesthesia and lasts approximately two to four hours. The main steps include:

Surgical approach to the hindfoot (most commonly retrograde or lateral)
Removal of remaining cartilage from the articular surfaces of the tibia, talus, and calcaneus
Alignment of the bones in a functionally optimal position (neutral ankle angle, slight external rotation)
Fixation of the bones – most commonly using a retrograde intramedullary nail inserted through the heel bone upward through the talus and into the tibia
Additional fixation with screws or plates as required by the individual anatomy
Optional use of bone graft (autologous or allograft) to promote bone healing

In selected cases, an external fixator or plate osteosynthesis may be used as an alternative.

Postoperative Care and Rehabilitation

Careful rehabilitation is essential for a successful outcome:

Immobilisation: The foot is immobilised in a below-knee cast or orthosis in the early postoperative period.
Non-weight-bearing: The operated limb is typically kept non-weight-bearing for 6 to 12 weeks.
Physiotherapy: Targeted exercises to strengthen surrounding muscles and to retrain gait patterns.
Bone consolidation: Full bony fusion usually takes 3 to 6 months, and may take longer in some patients.
Radiographic follow-up: Regular X-rays are taken to monitor the progress of bone healing.

Outcomes and Prognosis

When TTC arthrodesis is performed successfully, patients typically experience significant pain relief and improved ability to bear weight and walk. Because both the ankle and subtalar joints are fused, motion in these joints is permanently lost. Adjacent joints such as the Chopart and Lisfranc joints partially compensate for this loss of movement.

Published studies report fusion rates of 80 to 95 percent. Patient satisfaction is generally good to very good when the procedure is performed for the right indication and followed by appropriate postoperative care.

Possible Risks and Complications

As with any surgical procedure, TTC arthrodesis carries certain risks:

Non-union (pseudarthrosis): Failure of bony fusion (occurs in approximately 5 to 15 percent of cases)
Wound healing problems and infection
Hardware failure or loosening of implants
Nerve injury (e.g., sural nerve damage)
Thromboembolic events (deep vein thrombosis, pulmonary embolism)
Secondary osteoarthritis in adjacent joints due to altered load distribution
Malunion if fusion occurs in an unfavourable position

Risk factors for complications include diabetes mellitus, smoking, osteoporosis, and peripheral vascular disease.

References

Chaparro-Rico BDM, Sebastiani E, Murgia A et al.: Tibiotalocalcaneal Arthrodesis with Retrograde Intramedullary Nail: A Systematic Review. Foot and Ankle Surgery, 2022. PubMed PMID: 34556406.
Budnar VM, Hyer CF: Tibiotalocalcaneal Arthrodesis. In: Foot and Ankle Clinics of North America. Elsevier, 2011; 16(1): 103–114.
Coughlin MJ, Saltzman CL, Anderson RB (eds.): Mann's Surgery of the Foot and Ankle. 9th ed. Elsevier Saunders, Philadelphia, 2014.

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