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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Original clinical research article

Tibio-talo-calcaneal fusion after limb salvage proceduresA

retrospective study
Lukas Zak* , Gerald E. Wozasek*
Department of Traumatology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria

A R T I C L E I N F O A B S T R A C T

Article history: Background: The treatment of limb threatening trauma on the distal tibia or hindfoot often results in
Received 15 November 2016 posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was
Received in revised form 21 March 2017 to present a case series of patients undergoing various techniques of joint fusion after bone
Accepted 28 March 2017
reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons
making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by
Keywords: presenting options and treatment strategies.
Trauma
Patients and methods: Eight patients (4 male, 4 female) after TTC arthrodesis as a denitive procedure
Limb lengthening
Limb salvage
after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this
Tibio-talo-calcaneal arthrodesis retrospective analysis. We included patients treated by external ring xation (1 case), external
xation + wires (1 case), external xation + screws (1 case) and intramedullary nailing (1 ante- and 5
retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations
and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were
treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess
foot deformities in the lateral radiographic view and clinical results were presented.
Results: Independent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In
terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at
the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures
in the lateral radiographs showed values typical for a pes cavus tendency.
Conclusion: Tibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic
arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde
intramedullary nailing does provide acceptable results providing stability, low invasiveness and low
infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring xator may be
necessary when the surgeon is confronted with large bone defects often followed by a nailing after
lengthening procedure. This study shows that limb preservation after limb threatening trauma with
hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice
with reasonable clinical results.
Level of Evidence: IV, Case series
2017 Published by Elsevier Ltd.

Introduction
Limb threatening trauma with open fracture at the distal tibia
or hindfoot, corresponding to a subtotal amputation, is a frequent
nding in polytraumatized patients [1,2]. Preservation of the
affected limb remains challenging. Whether amputation of the
injured extremity is inevitable, widely depends on the extent of
vascular (arteries and veins), nervous, bone and soft tissue
* Corresponding authors.
E-mail addresses: lukas.zak@meduniwien.ac.at (L. Zak),
gerald.wozasek@meduniwien.ac.at (G.E. Wozasek).
(muscles and skin) damage, as well as the warm ischaemic time
[3]. Several treatment options have been described for successful
tibio-talo-calcaneal (TTC) fusion, including the use of plates,
screws, intramedullary nails and external xators [47].
When confronted with injuries involving large bone defects,
other techniques such as stabilization with the Ilizarov ring xator
provide rigid xation and the possibility to combine with bone
reconstruction methods as distraction osteogenesis or segment
transport [8].
After bone reconstruction and wound healing, retrograde
intramedullary nailing may be considered as a salvage procedure9,

http://dx.doi.org/10.1016/j.injury.2017.03.045
0020-1383/ 2017 Published by Elsevier Ltd.

Please cite this article in press as: L. Zak, G.E. Wozasek, Tibio-talo-calcaneal fusion after limb salvage proceduresA retrospective study, Injury
(2017), http://dx.doi.org/10.1016/j.injury.2017.03.045
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providing a stable, plantigrade foot and reducing pain as a result of
secondary posttraumatic osteoarthritis [1012].
The aim of this study was to present the results of TTC fusions in
special cases of lower limb trauma with bone defects and
deformity, to compare the methods and to describe the cases in
detail, as they require individual treatment strategies. The study
should help trauma surgeons to make decisions in limb salvage and
deformity correction in complex lower leg and foot injuries.
Patients and methods
Patients
Eight patients (4 female, 4 male, mean age: 40.4 years), treated
with an arthrodesis of the ankle and subtalar joint after limb
threatening trauma of the lower extremity were the subject of this
retrospective analysis. Patients characteristics are illustrated in
Table 1. Institutional review board approval was obtained.
We included patients after open or closed fractures of the
hindfoot with bone defects or axial deviation. The mechanisms of
injury included falls from a height (4 patients, polytrauma
treatment), motor vehicle accidents (2 cases, polytrauma treat-
ment), gun-shot injuries (1 case) and supination trauma leading to
a severe deformity after failed osteosynthesis and failed ankle
arthroplasty (1 case).
All ankle and subtalar joints were primarily xed during
damage control orthopaedic surgery or open fracture treatement
using external xators, xators in combination with wires and
non-operative treatment in a cast. Further surgical treatment
included soft tissue reconstruction, conversion to external ring
xator for distraction osteogenesis or deformity correction or
primary conversion to denite treatment. Segment transport or
callus distraction was performed in 5 cases of large bone defects
with a mean distraction length of 68 mm (2.7 inches).
We excluded patients who underwent hindfoot arthrodesis
after fractures or secondary posttraumatic osteoarthritis without
bone defects, deformity or axial deviation, patients with drop-foot
resulting from isciatic nerve-palsy and cases of non-traumatic
indications (inammatory arthritis, neuropathic arthropathy,
primary osteoarthritis).
Denitive TTC-fusion was achieved with antegrade (1 case) or
retrograde (4 cases, 5 extremities) intramedullary nailing, external
xator + wires (1 case), external ring xator (1 case) or in
combination with screws (1 case). (Table 2) Indications for TTC-
fusion were severe pain, destruction of the articular surface or
posttraumatic arthritis involving both the ankle and subtalar joints
with impaired and painful joint motion. Nailing after lengthening
Table 1
Patients characteristics.
Number of patients 8 visits. Radiographic analysis included evaluation of post traumatic
Gender (male/female) 4/4
Side (right/left) 4/5 (1 bilateral)
Age 40.4 a (range: 2066)
Male 33.3 a
Female 47.5 a
Denitive treatment
Antegrade Nailing 1 talo-calcaneal angle (LTCA) (angle between the mid-talar axis and
Retrograde Nailing 5
External xator + Wires 1
Ext. Ring x. + Screws 1 (angle between the mid-talar axis and the supporting surface) [19]
External ring xator 2 and the Boehler-angle (BA) (angle between the tangent to the
Follow up 34.2 m (SD 23.9; 1390)
a years, m months.
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was necessary to reduce time in external xation, or to correct
either failed non-operative treatment, failed osteosynthesis, or
failed ankle replacement.
Additional surgeries during treatment included re-nailing, soft
tissue reconstruction (VAC, mesh-graft, skin aps), corrective
osteotomy and hardware removal were performed as appropriate
The patients were treated and evaluated for follow-up
examination over years by one surgeon (senior author). All x-
rays were performed under the same conditions.
Taylor Spatial FrameTM (TSF) (Smith & Nephew Inc, Memphis, TN,
USA)
A conventional external xator (DePuy Synthes Compnies,
Zuchwil, Switzerland) was mounted during damage control
procedure in our polytraumaticed patients. Soft tissue-, nerve-
or vessel-reconstruction and temporary skin coverage were
performed as appropriate for each case. An additional arthrode-
sis-wire was necessary to retain the foot in a correct plantigrade
position in selected cases. To address large tibial bone defects, an
Ilizarov frame or a Taylor Spacial Frame (TSF, Smith and Nephew,
London, UK) was used for callus distraction or segment transport,
for alignment correction of the distal lower limb or in cases of
severe deformity of the hindfoot and foot [1315].
For retrograde intramedullary nailing as secondary treatment
after damage control or as a nailing after lengthening procedure
following distraction osteogenesis, a curved ankle arthrodesis nail
(T2 Ankle Arthrodesis Nail, Stryker, Germany) or a tibial nail (T2
Tibial Nail, Stryker, Germany) were used. Antegrade intramedul-
lary nailing was performed using a distal tibial nail (T2 Distal Tibial
Nail, Stryker, Germany) for calcaneal and talar locking. For correct
TTC-fusion the foot was retained at 0 of exion (neutral position)
with 10 15 external rotation, aligning the second metatarsal bone
with the tibial tuberosity. All hindfoot fusions were performed as
minimally invasive arthrodesis without removing the cartilage, as
scars and reduced soft tissue quality after skin grafts and muscle
aps prevented an open procedure.
Post-operative rehabilitation after retrograde intramedullary
nailing and screw-arthrodesis consisted of 2 weeks of cast
immobilization and 6 weeks of non-weight bearing. Physiotherapy
was administered to avoid contractures or impaired joint motion in
all cases, in particular after limb lengthening [16].
Evaluation
Physical examination was performed at regular follow up visits
assessing foot deformity and walking dynamics. In addition,
patients were evaluated if supporting orthopaedic devices such as
canes, crutches or orthopaedic shoes were required for activities of
daily living.
Plain antero-posterior and lateral radiographs as well as long
standing radiographs were routinely obtained during follow-up
deformity (pes equinus or talipes calcaneus), the anterior tibial
foot angle, the calcaneal-inclination angle (CIA) or calcaneal pitch
angle (between the calcaneal inclination axis and the supporting
surface) [17,18], the lateral talar-1st-metatarsal angle (T1MA,
Mearys angle, angle between line drawn from the centers of
longitudinal axes of the talus and the rst metatarsal), the lateral
calcaneal inclination axis) [18], the talar declination angle (TDA)
anterior and posterior aspects of the superior calcaneus).
Furthermore, arthritis of the adjacent joints was recorded using
the classication described by Kellgren and Lawrence. Non-union
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Table 2
Patients list.

Nr Sex Age Side Arthrodesis ATFA CIA T1MA LTCA TDA BA

1r w 56 right retrograde nail 89.5 0 4 3 8 33 1
1l w 56 left retrograde nail 80 11.9 0 2 18 4.4
2 w 43 left ext. x. + wires 87.1 23.1 5 41 18 19.1
3 m 33 right retrograde nail 112.7 38.9 26.2 43 6 31.1
4 m 54 left retrograde nail 105 29.9 20.3 0,5 1 36
5 w 25 left antegrade nail 83.5 31 20.5 44 12 35.6
6 w 66 left ring xator 92.3 24.1 8.8 30.5 6.4 10.3
7 m 20 right retrograde nail 98.7 13.4 1.9 31 17.3 38
8 m 26 right ring x. + screw 105 20.6 n.a. n.a. n.a. n.a.

of the ankle- and subtalar joint were evaluated according to the
classication described by Weber and Cech.
Statistical analysis
Statistical analysis was performed using SPSS 21 (IBM SPSS
Statistics for Windows, Version 21.0, IBM Corp, Armonk, NY,USA).
Results are presented as medians with range or means with
standard deviation. The MannWhitney U test was used to
compare means of non-normally distributed data and the
Students t-test for normally distributed data. A p-value < 0.05
was considered statistically signicant.
Results
The mean follow up was 34 month (SD  24; range: 1390). The
mean time from injury to the denitive arthrodesis was 53.8
months (range: 0200). Tibio-talo-calcaneal arthrodesis was
performed 37 month (SD  18, range: 1266) after the initial
trauma. Independent, pain-free mobilisation with full weight
bearing was achieved in all 8 cases. In terms of subjective outcome,
all patients reported a highly satisfying result. Physical examina-
tion revealed a stable arthrodesis in all cases. A broad-based gait
was described in 2 cases. Seven patients required orthopaedic
shoes to improve gait. In three cases crutches or a walking stick
were used for longer walking distances. Two patients were able to
regularly participate in recreational sports, although return to
previously attended sports was not possible. The number of
necessary conversions from primary to denitive treatment was 2
(range 03) and were performed 54 month between accident and
denite treatment.
Radiologic evaluation
Radiographic analysis revealed incomplete union (vascular
normotrophic according the classication of Weber and Cech) at
the central portion of the subtalar and ankle joint after nail-
removal in one case. Complete consolidation was recorded in 8
out of 9 treated feet. Adjacent talonavicular joint degeneration
was observed in all cases. The average Kellgren and Lawrence
grading was 3.
Gross destruction of the articular cartilage or severe periartic-
ular rarefaction on radiographs were only seen in one case in
another, the complete hind- and mid-foot was fused into a bony
structure.
Evaluation of measured angles is illustrated in Table 3.
The radiological evaluation of the foot angles in the lateral view
showed for the foot position a mean value of 95 (SD  11 ;range:
80 113 ), a mean calcaneal inclination angle (CIA) of 19
(SD:  16 ; range: 12 to 39 ), a lateral talar-1st metatarsal angle
(T1MA, Mearys angle) of 10 (SD  11 ; range: 4 to 26 ) a lateral
talocalcaneal angle of 24 (LTCA, SD  19 ; range:, 1 44 ), a talar
declination angle of 11 (TDA, SD  7 ; range: 122 ) and a Boehler-
angle of 26 (BA, SD  13 ; range:, 4 38 ).
A statistically signicant difference to the mean of the normal
range was observed for Meary angle (T1MA) and the TDA as well as
the LTCA respectively. The angles indicate a tendency towards
drop-foot (foot position) and concave foot deformities (Meary/
T1MA, LTCA).
Nail removal was performed after consolidation because of
delayed deep wound infection in 3 cases or on request of the
patient in 1 case. Other complications included delayed union of
the arthrodesis (2), non-unions of the fractured tibia (1) and
supercial wound infection or delayed wound healing (3).
Discussion
There are few studies in literature combining bone reconstruc-
tion and distraction osteogenesis with arthrodesis. TTC-fusion is a
salvage procedure for patients with diseases including Charcot
arthropathy, post-traumatic degenerative joint disease, avascular
necrosis of the talus, osteoporotic fractures of the hindfoot and
failed total ankle arthroplasty [11,20,21] and is associated with
good functional outcomes and high patient satisfaction [11,20]. In
all of our cases the aim of independent, pain free mobilisation was
achieved.

Table 3
Patients list.

Nr Correction DO length Kellgren Gait,

1r DC 2 broad-based, short step length
1l DC + ST (NAL) 80 mm 1
2 4 limping (slightly), 2 cruches (occasional)
3 DC + ST (NAL) 10 mm 2 limping (slightly)
4 ST (NAL) 80 mm 2 limping (slightly), stick
5 ST (NAL) 40 mm 2 limping (slightly), 1 cruch (occasional)
6 DC 5 broad-based
7 1 limping (slightly)
8 DC + CD 130 mm 5 limping (slightly)

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The high union rate in our case series is comparable with
previously published literature despite it is performed as a
minimally invasive procedure. The incomplete union in the
subtalar joint in one case might be explained by remaining
cartilage in the subtalar joint during nail implantation as bad soft
tissue situation didnt allow open arthrotomy to remove the joint.
However, clinically, fusion was achieved in all cases and patients
were subjectively satised with the result.
Union rate of retrograde nailing in TTC arthrodesis is described
with 86% for the tibiotalar and 74% for the subtalar joint [22] and
85.7% [11] to 96% for both joints respectively. In a multicenter-
study Rammelt et al. [23] reported a fusion rate of 84%, a supercial
wound infection rate of 5.3%, and no deep infection or osteomye-
litis. In a study by Goebel et al. [24] bony consolidation after
retrograde or antegrade intramedullary TTC-fusion was achieved
in 8589% of cases.
However, complications such as supercial or deep wound
infections are frequent [9], especially in cases after severe bone-
and soft tissue damage and may require removal of the nail. This
was necessary in 3 out of 7 cases in our study.
Further, accomplishing the ideal foot position is difcult in
particular in joints with large areas of destruction or bone defects.
In our study an angle of 94.9 between the tibial axis and the foot
conforms to a slight tendency of drop foot, potentially inuenced
by the fact of non-weight bearing radiographs. This appears to be a
limitation of the study and is stated as one. However, other
measured angles are less or not inuenced due to the fact that the
ankle joint has been xed.
In the majority of cases our radiological results showed a pes
cavus or neutral angles of the foot. The combination of a
descending lateral talar-1st metatarsal-angle (T1MA, Mearys
angle) and an increased pointed talar declination angle (TDA)
(<21 ) both typically for a pes cavus appears to be a good
compensation and neutralisation for the total foot-shape.
Contrarily, Shibuya et al. described values for the talar
declination angle as a mean of 31.04 (9.07), evaluated in the
atfoot-group of his study (against 26.97  6.09 in the control
group) [25] and indicated a threshold of >23 for atfoot
deformity [19]. In contrast, a mean TDA of 10.8 as shown in
our cases, is typically for a pes cavus deformity. However, few data
are available in current literature considering talar angles in pes
cavus. In our study, the calcaneal inclination or pitch angle was at
the lower border of the normal range:, using values described by
Koulouris et al. [18], with a high range: between 12 after
comminuted calcaneal fracture and 39 after gunshot fracture
with destroyed hindfoot and drop-foot correction. However,
Thomas et al. evaluated ranges for the calcaneal pitch angle
between 13.2 and 26.2 in the normal position [17].
DeVries [26] reported for the talar-1st metatarsal angle 8.6  7
after double hindfoot arthrodesis and 9.1 7 after triple-arthrodesis
(both sparing the ankle joint) for hindfoot-arthrits treatment,
comparable to our results with a mean of 9.8  11.1. Values of
47.1 10.9 and 44.1 10.4 respectively for the lateral talo-
calcaneal angle (24.4  19.3 ), and 23.8  5.5 and 23.2  4.1
for the talar declination angle were also stated as post-operative
results [26]. There are similar values reported by Sammarco et al. [27]
after subtalar and talonavicular arthrodesis with a postoperative
T1MA of 4.4 (range:, 1 11 ) and a TCA of 42.1 (range:, 25 75 ).
Adjacent joint arthritis increased in 32% in the population [27].
However, no values could be found for the tibio-talo-calcaneal
fusion. These angles emphasize the importance of the position of the
small foot-joints and the general foot position.
In an acute situation with destroyed bones, joints and soft
tissue, the decision whether to amputate or salvage a limb or even
a foot should not impair the patients overall health. An
experienced surgeon is therefore needed. Signicant progress
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has been made in the orthopaedic, plastic, and vascular surgical
elds, to make the salvage procedures of even severely mutilated
limbs possible [28].
The main aim of limb salvage with TTC arthrodesis is to obtain a
painless, brace-free, plantigrade foot and a good union which
maintains alignment. The majority of patients need orthopaedic
shoes and some of them intermediate use of walking sticks or
crutches. Slight limping was apparent in all patients, but they were
satised with the result. Persistent alterations in gait will remain
due to fusion procedure [29]. Retrospectively seen, amputation
was no option, despite their long way of rehabilitation.
A disadvantage of joint fusion seems to be the development of
osteoarthritis in the adjacent joints on the ipsilateral extremity
[30]. Nevertheless, osteoarthritis on the ipsilateral knee or
metatarsophalangeal is not more common after ankle arthrodesis
compared to the contralateral side [30].
In intramedullary nail xation, high stability, low invasivity
and low morbidity are recognized as advantages [24]. The nails
currently in use, with foot and ankle specic locking options,
show sufcient stability in comparison to adapted retrograde
femoral nails especially in osteoporotic bone [20,31]. Advan-
tages for both nail types (esp. retrograde) include: insertion threw
small incisions, biomechanical properties apparently superior to
those of plate and/or screw constructs, offering greater bending
stiffness, dynamic compression capability, and more rotational
stability [4].
In the literature, deformity is a seldom indication for TTC
arthrodesis nails [12]. Our study includes limitations as the small
heterogeneous patient population treated through various
methods and implants. Furthermore, no subjective patient
evaluations were recorded, and lateral x-rays were non-weight
bearing foot radiographs, which could potentially inuence
angles such as the tibia-foot angle or Mearys angle. The number
of radiological parameters used in this study should compensate
this disadvantage and improves the validity of the results. Some
of our statements are limited, based on the fact of missing
comparison groups regarding reconstruction vs. amputation, TTC
fusion vs. other limb preventive methods or early vs. late fusion.
However, these kind of cases are very rare, even in a level one
trauma centre and amputation was even more seldom in the same
time period.
Conclusion
Intramedullary nailing for TTC arthrodesis provides rm
stability, low invasiveness, low infection rates and even good
results despite bad bone quality. It can be combined with nailing
after lengthening to prevent bowing and refracture of the
regenerate after distraction osteogenesis and enables patients to
return early to their activities of daily living. Nevertheless this
technique has its limitations in complex malalignment of the
hindfoot and bone loss. To our opinion the external (ring) xator
seems to be an adequate option, especially in cases of large bone
defects combining arthrodesis with callus distraction or segment
transport, but also in cases of severe deformity. The decision
depends on the condition of soft tissue, bone and deformity of the
foot and ankle. The study shows that limb reconstruction after
severe traumata of the lower limb appears to have good clinical
results with patients satisfaction being able to full weight bearing.
Despite the long way of treatment and rehabilitation, amputation
can be avoided even in complex cases.
Conict of interest
The authors declare no conict of interest.
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Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.
injury.2017.03.045.
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