Tibiotalocalcaneal Arthrodesis

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Introduction

This author’s personal patient care experience with tibiotalocalcaneal arthrodesis (TTCA) has been mixed at best. On one hand, a severely deformed, arthritic hindfoot and ankle can improve significantly with this type of arthrodesis. It can dramatically reduce pain, restore a more normal semblance of gait, and markedly improve someone’s life. On the other hand, however, intraoperative or postoperative complications can lead to a worsening of all of the above and extend to loss of both life and limb. This is not to insinuate that this is a poor procedure. Rather, it is a procedure that has found a lesser role in my personal surgical practice. Although it still can afford benefits, bracing, appropriate pain management, ankle replacement, tibial realignment, hindfoot realignment, and isolated ankle or hindfoot fusions seemed to have slowly replaced this end-stage procedure more and more.1, 2, 3, 4

Combined ankle and subtalar arthrodesis is a worthwhile procedure, but excellent patient selection and preparation are paramount to success. In retrospect, some of my own surgical failures were not so much related to inferior surgical technique as they were to inferior patient education with regard to expectations. This article provides only one author’s experience with this surgery and each reader is urged to consider what works best in his or her surgical hands. Naturally, this is a large topic to which this article can only provide a cursory introduction. Many of the articles in this Clinics edition overlap on certain topics and the reader should find numerous, valuable, and diverse opinions throughout. This article is not intended to provide a complete review of the history or outcomes of this particular procedure. It is, rather, intended to give one surgeon’s opinion and experience with the TTCA.

Section snippets

Posttraumatic Arthrosis

There are several conditions that can potentially benefit from a TTCA. Fig. 1 illustrates a typical posttraumatic joint years after injury. Despite adequately performed open reduction and internal fixation (ORIF), many of these joints can slowly progress to this degenerative stage. Naturally, there is an even higher necessity for later fusion in the joint that is not repaired. Posttraumatic arthosis is, in the author’s experience, the most common reason necessitating fusion.

Posterior Tibial Dysfunction

Whether injury to

Preoperative considerations

There are numerous preoperative factors that can affect a surgical outcome. The following is only a selection of the more common ones that can be addressed presurgically. The more factors that are addressed before surgery, the less likely the patient, and the surgeon, will be unhappy with the surgical outcome.

Surgical technique

There are numerous technique modifications that have been advocated for this procedure. Most of them focus on the specific method of internal, external, or combination fixation. This section, in conjunction with the associated surgical photographs, help illustrate one method only.

Compliance

A strict NWB period during recovery is essential. Even minimal disturbance of fixation, no matter how stable the internal or external construct, can cause failure of the union. Factors that should be evaluated when considering options for the patient remaining NWB include size, upper body strength, and overall understanding of NWB importance. Occasionally noncompliance is not so much from a blatant disregard as it is a lack of understanding or a simple inability to do so.

Pain Management

Simply put, this author

Complications

Although minor complications, such as wound dehiscence, are common, other more serious complications can also occur.

Summary

In summary, TTCA is a worthwhile procedure that can provide significant reduction in pain to appropriate patients. However, the postoperative period is not without significant and numerous obstacles that the surgeon must navigate to ensure patient recovery and a successful outcome. Although this surgeon has found the end results to be mixed, in a specific patient population it can provide tremendous benefit to the patient.

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