Point-Counterpoint: Tibiotalocalcaneal Fusions: Intramedullary Nails Or Plates And Screws?

Intramedullary (IM) nails.

While IM nails have a reportedly high complication rate, this author cites the benefits of reduced dissection and sound anatomic alignment, and adds that the use of vascularized bone grafts and proper preparation of the subtalar joint for arthrodesis may help reduce potential complications.

By Thomas S. Roukis, DPM, PhD, FACFAS

The concept and technique of performing tibiotalocalcaneal arthrodesis as a salvage procedure for severe non-reconstructable hindfoot/ankle pathology or failed total ankle replacement are not new. Surgeons can employ a myriad of fixation techniques including: combination screw and plate internal fixation alone; external fixation alone; a combination of internal and external fixation; and retrograde compression intramedullary nail fixation.^1,2

When tibiotalocalcaneal arthrodesis is necessary, a retrograde compression intramedullary nail provides stout, reproducible fixation with external and/or internal compression. When surgeons perform this procedure properly, there is minimal disruption of the vascularity to the involved bone segments.³ However, retrograde compression intramedullary nail fixation has historically had high overall complication rates.

What The Research Reveals About Tibiotalocalcaneal Fusions And IM Nails

Jehan and colleagues, as well as Franceschi and coworkers, conducted systematic reviews of the literature to determine the clinical outcomes, complications and union rates for tibiotalocalcaneal arthrodeses performed with retrograde compression intramedullary nail fixation.^4,5 Jehan and coworkers conducted their systematic review of studies from 1950 to 2010 and included 613 tibiotalocalcaneal arthrodeses fixated with myriad retrograde intramedullary nail fixation devices, most which were not specifically designed for hindfoot/ankle arthrodesis.⁴ Their review determined that the overall complication rate was 55.7 percent, including 16.8 percent hardware removal, 13.3 percent nonunion (with 26 percent of these requiring revision arthrodesis), 8.4 percent infection and 1.5 percent below-knee amputation.

Franceschi and colleagues conducted their systematic review from 1994 to 2014 and included 865 tibiotalocalcaneal arthrodeses fixated with modern, anatomically specific retrograde compression intramedullary nail fixation.⁵ Their review determined that the overall complication rate was 40 percent, including 11.8 percent infection, 8.9 percent hardware removal, 7.5 percent nonunion and 3.2 percent below-knee amputation. Evaluating the systematic review data as a whole, one can conclude that surgeons can achieve satisfactory results with tibiotalocalcaneal arthrodesis using retrograde intramedullary nail fixation. However, surgeons should anticipate a relatively low union rate and high incidence of complications even with utilization of a modern, anatomically specific retrograde compression intramedullary nail.

One reason for the high incidence of complications with this technique may be that surgeons nearly universally resect the fibula. The use of the fibula as a non-vascularized onlay graft for tibiotalocalcaneal arthrodesis originated in 1940 with the Royal Air Force Orthopaedic Service in London.⁶ Although convenient as a source of autogenous corticocancellous structural bone graft, non-vascularized autogenous fibula onlay grafts may be unsuitable in certain situations because their success depends on the viability of the surrounding soft tissues to withstand the operative procedure and revascularize the transplanted bone graft. These challenges are frequently present when performing tibiotalocalcaneal arthrodesis.

In contrast, based on their own non-interrupted arterial supply, vascularized bone grafts have immediate graft viability, show more rapid healing, are more than 50 percent stronger at the time of the index surgery and possess some neovascularization potential into the surrounding soft tissues, allowing for higher consolidation rates in poor recipient bed conditions.^7,8

Evaluation of the vascular supply to the distal fibula reveals that it is quite robust and amenable to vascularized transplantation. Both the anterior and posterior perforating branches provide robust arterial supply to the fibula at the level of the distal tibiofibular syndesmosis. The lateral malleolus itself also has a rich vascular supply via the perimalleolar arterial circulation, including the anterior lateral malleolar artery and fibular metaphyseal artery.^9-11 I have used this “vascularized fibula onlay bone graft” as a “biological washer” successfully in the higher risk patient population with success.^12,13

Another reason for the high incidence of complications with retrograde compression intramedullary nail fixation is the inconsistent documentation and performance of formal subtalar joint preparation for arthrodesis.^14,15 Without question, when performing a tibiotalocalcaneal arthrodesis, one should properly prepare the subtalar joint for formal arthrodesis. There may be a few isolated instances in which the subtalar joint is nearly autofused or extremely rigid, or when preparing the joint would cause too much disruption of the talar vascular supply. However, these are infrequent situations.

Recognizing The Benefits Of Intramedullary Nails: Less Dissection, Less Vascular Compromise And Better Anatomic Alignment

In comparing modern, anatomically specific retrograde compression intramedullary nail fixation with modern anterior, lateral and/or posterior plate and screw fixation, there are multiple “real world” and “common sense” benefits for using a nail. One obvious benefit is the ability to perform tibiotalocalcaneal arthrodesis through arthroscopic resection of the ankle and subtalar joints with percutaneous delivery of the intramedullary nail.^16,17 Situations ideal for this approach would include a flaccid drop foot deformity.¹⁶

Other clinical situations surgeons may encounter can include an unsalvageable highly comminuted articular injury following a trimalleolar ankle fracture or a geriatric ankle fracture in which one can use a closed retrograde intramedullary nail to achieve stability without significant disruption of vascular supply to the bone or soft tissue envelope.^18-19 Surgeons simply cannot perform these approaches with plate and screw fixation.

The minimum extent of dissection required to properly prepare the ankle and subtalar joints for fusion varies based on the patient’s specific pathology, which one cannot routinely control. However, the additional dissection required to insert an intramedullary nail is limited to small incisions about the plantar heel to deliver the nail, the posterior heel to insert axial screw fixation and the medial and/or lateral lower leg to insert interlocking screws.

In contrast, lateral application of plate and screw fixation mandates much greater surgical dissection to deliver the internal fixation. Surgeons do all of this with direct visualization, which increases exposure of the hardware to room air during the surgery and involves a larger surface area available for bacteria colonization. Rationally, both of these situations increase the risk of deep periprosthetic infection.
Additionally, the extra dissection required would be expected to increase the risk of iatrogenic nerve injury, vascular damage to the soft tissues (leading to enhanced wound healing problems) and vascular compromise to the extra-osseous arterial supply from both the extra dissection and the plate-bone interface necrosis that exists. The potential to damage the plantar neurovascular structures when performing a retrograde intramedullary nail for tibiotalocalcaneal arthrodesis is minimal when one properly performs the technique.²⁰

Inherent to the performance of tibiotalocalcaneal arthrodesis with an intramedullary nail is anatomic alignment to properly deliver the guidewire, reamers and ultimately the intramedullary nail.^20-30 None of the plate and screw systems employ alignment jigs or lead to anatomic alignment. In fact, some of the anterior and posterior plates employed induce anterior translation of the talus by requiring multiple screw placement through the dorsal extension onto the talar neck. Anterior translation of the talus will increase the lever arm of the foot and place extra mechanical stress across the midtarsal joint complex, leading to premature wear over time.^31-33    

Finally, in patients with massive bone loss secondary to failed total ankle replacement, retrograde compression intramedullary nail fixation for tibiotalocalcaneal arthrodesis provides foot and ankle surgeons a viable option for salvage.^34,35 Nevertheless, the world literature is limited with regard to this procedure choice and fixation combination. Further prospective studies should focus on comparing isolated ankle to tibiotalocalcaneal arthrodesis as well as internal fixation constructs employing plate and screw constructs and retrograde compression intramedullary nail fixation.

In Conclusion

Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation has historically been associated with a high incidence of complications including nonunion requiring revision, hardware failure requiring removal and below-knee amputation. Given the elevated risk of these complications, one should consider tibiotalocalcaneal arthrodesis, with or without a bulk structural allograft and fixated with a retrograde compression intramedullary nail, as a salvage procedure that carries a high risk for serious complications unless the procedure is performed by foot and ankle surgeons experienced with this form of fixation.

Newer designs available for clinical use that are cannulated, involve straightforward and a minimal number of steps to insert, and include robust internal compression and stout screw fixation will further increase the use of this form of fixation when surgeons perform tibiotalocalcaneal arthrodesis. The use of bulky plate and screw fixation for tibiotalocalcaneal arthrodesis only fulfills surgeons’ “fixation with fixation” and lacks most, if not all, of the benefits of retrograde intramedullary nail fixation with few, if any, benefits.

Dr. Roukis is an attending foot and ankle surgeon in the Department of Orthopaedics, Podiatry and Sports Medicine with the Gundersen Health System in La Crosse, Wis. He is a Fellow and Past President of the American College of Foot and Ankle Surgeons.

References

1.    Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier P, Friscia DA, Hansen ST, Schaser K, Ljungqvist J, Sands AK. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int. 2013; 34(9):1245–1255
2.    Chou L, Mann RA, Yaszay B, Graves SC, McPeake III WT, Dreeben SM, Horton GA, Katcherian DA, Clanton TO, Miller RA, Van Manen JW. Tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2000; 21(10):804-808.
3.    Mendicino RW, Lamm BM, Catanzariti AR, Statler TK, Paley D. Realignment arthrodesis of the rearfoot and ankle: a comprehensive evaluation. J Am Podiatr Med Assoc. 2005; 95(1):60-71.
4.    Jehan S, Shakeel M, Bing AJF, Hill SO. The success of tibiotalocalcaneal arthrodesis with intramedullary nailing: A systematic review of the literature. Acta Orthop. 2011; 77(5):644-651.
5.    Franceschi F, Franceschetti E, Torre G, Papalia R, Samuelson K, Karlsson J, Denaro V. Tibiotalocalcaneal arthrodesis using an intramedullary nail: A systematic review. Knee Surg Sports Traumatol Arthrosc. 2016; 24(4):1316-1325.
6.    Adams JC. Arthrodesis of the ankle joint: Experiences with the transfibular approach. J Bone Joint Surg Br. 1948; 30(3):506-511.
7.    Goldberg VM, Shaffer JW, Field G, Davy DT. Biology of vascularized bone grafts. Orthop Clin N Am. 1987; 18(2):197-205.
8.    de Boer HH, Wood MB. Bone changes in the vascularized fibular graft. J Bone Joint Surg Br. 1989; 71(3):374-378.
9.    Guo F. Observations of the blood supply to the fibula. Arch Orthop Trauma Surg. 1981; 98(2):147-151.
10.    McKeon KE, Wright RW, Johnson JE, McCormick JJ, Klein SE. Vascular anatomy of the tibiofibular syndesmosis. J Bone Joint Surg Am. 2012; 94(10):931-938.
11.    Giebel GD, Meyer C, Koebke J, Giebel G. The arterial supply of the ankle joint and its importance for the operative fracture treatment. Surg Radiol Anat. 1997; 19(4):231-235.
12.    Liwen D, Futian L, Juan J, Guocheng Z. Transplantation of fibula with vascular pedicle for fusion of ankle in leprotic drop-foot. Indian J Lepr. 2000; 72(4):431-436.
13.    Roukis TS, Kang R. Vascularized pedicled fibula onlay bone graft augmentation for complicated tibio-talo-calcaneal arthrodesis with retrograde intramedullary nail fixation: a case series. J Foot Ankle Surg. 2016; 55(4):857-867.
14.    Mulhern JL, Protzman NM, Levene MJ, Martin SM, Fleming JJ, Clements JR, Brigido JA. Is subtalar joint cartilage resection necessary for tibiotalocalcaneal arthrodesis via intramedullary nail? A multicenter evaluation. J Foot Ankle Surg. 2016; 55(3):572–577.
15.    Dujela M, Hyer C, Berlet G. Rate of subtalar joint arthrodesis after retrograde tibiotalocalcaneal arthrodesis with intramedullary nail fixation: evaluation of the RAIN database. Foot Ankle Spec. 2017; epub Nov. 1.
16.    Mencière ML, Ferraz L, Mertl P, Vernois J, Gabrion A. Arthroscopic tibiotalocalcaneal arthrodesis in neurological pathologies: outcomes after at least one year of follow up. Acta Orthopaedica Belgica. 2016; 82(1):106-111.
17.    Baumbach SF, Braunstein M, Maßen F, et al. [Arthroscopic tibio-talo-calcaneal arthrodesis]. Der Unfallchirurg. 2016; 119(2):86-91.
18.    Pinzur MS. Transarticular stabilization for malunited fracture of the distal tibia in diabetics with loss of protective sensation. Foot Ankle Int. 2001; 22(9):706-710.
19.    Jani MM, Ricci WM, Borrelli J, Barrett SE, Johnson JE. A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility. Foot Ankle Int. 2003; 24(11):838-844.
20.    Roukis TS. Determining the insertion site for retrograde intramedullary nail fixation of tibiotalocalcaneal arthrodesis: A radiographic and intraoperative anatomical landmark analysis. J Foot Ankle Surg. 2006; 45(4):227-234.
21.    Pochatko DJ, Smith JW, Phillips RA, Prince BD, Hedrick MR. Anatomic structures at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod. Foot Ankle Int. 1995; 16(9):542-547.
22.    Moorjani N, Buckingham R, Winston I. Optimal insertion site for intramedullary nails during combined ankle and subtalar arthrodesis. Foot Ankle Surg. 1998; 4(1):21-26.
23.    McGarvey WC, Trevino SG, Baxter DE, Noble PC, Schon LC. Tibiotalocalcaneal arthrodesis: anatomic and technical considerations. Foot Ankle Int. 1998; 9(6):363-369.
24.    Wichman MT, Kelikian AS. Tibiotalocalcaneal arthrodesis nailing with IM rod. J Orthop Tech. 1996; 4(1):1-7.
25.    Stephenson KA, Kile TA, Graves SC. Estimating the insertion site during retrograde intramedullary tibiotalocalcaneal arthrodesis. Foot Ankle Int. 1996; 17(12):781-782.
26.    Flock TJ, Ishikawa S, Hecht PJ, Wapner KL. Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis. Foot Ankle Int. 1997; 18(4):233-235.
27.    Hyer CF, Cheney N. Anatomic aspects of tibiotalocalcaneal nail arthrodesis. J Foot Ankle Surg. 2013; 52(6):724-7.
28.    Dominic MW, Tucker A, McKenna S, Wong-Chung J. Pre-requisites for optimum centering of a tibiotalocalcaneal arthrodesis nail. Foot Ankle Surg. 2014: 20(3):215-20.
29.    Richter M, Evers J, Waehnert D, Deorio JK, Pinzur M, Schulze M, et al. Biomechanical comparison of stability of tibiotalocalcaneal arthrodesis with two different intramedullary retrograde nails. Foot Ankle Surg. 2014: 20(1):14-9.
30.    Knight T, Rosenfeld P, Tudur J, I, Clark C, Savva N. Anatomic structures at risk: curved hindfoot arthrodesis nail-a cadaveric approach. J Foot Ankle Surg. 2014; 53(6):687-91.
31.    Buck P, Morrey BF, Chao EYS. The optimum position of arthrodesis of the ankle: a gait study of the knee and ankle. J Bone Joint Surg. 1987; 69-A(7):1052-1062.
32.    Hintermann B, Nigg BM, Cole GK. Influence of selective arthrodesis on the movement transfer between calcaneus and tibia in vitro. Clin Biomech. 1994; 9(6):356-361.
33.    Wülker N, Stukenborg C, Savory KM, Alfke D. Hindfoot motion after isolated and combined arthrodeses: measurements in anatomic specimens. Foot Ankle Int. 2000; 21(11):921-927.
34.    Thomason K, Eyres KS. A technique of fusion for failed total replacement of the ankle: tibio-allograft-calcaneal fusion with a locked retrograde intramedullary nail. J Bone Joint Surg Br. 2008; 90(7):885-8.
35.    Donnenwerth MP, Roukis TS. Tibio-talo-calcaneal arthrodesis with retrograde compression intramedullary nail fixation for salvage of failed total ankle replacement: a systematic review. Clin Podiatr Med Surg. 2013;30(2):199-206.

Plates and screws.

Noting the limitations of employing IM nails in the calcaneus and emphasizing preservation of medullary bone, these authors maintain that the combination of plate and screws provides optimal fixation for tibiotalocalcaneal fusions.

By Lawrence A. DiDomenico, DPM, FACFAS, Ashley Mychak, DPM, and Justin Rivera, DPM

Tibiotalocalcaneal arthrodesis is frequently indicated as a salvage procedure for hindfoot malalignments that are often complex extensions of systemic disease, such as neuromuscular disease, post-traumatic arthritis, talar osteonecrosis, inflammatory arthritis or diabetic Charcot arthropathy. It is generally the end-stage procedure when other conservative treatment modalities have failed.

In addition, surgeons often utilize tibiotalocalcaneal arthrodesis after failed total ankle arthroplasty, significant trauma resulting in infection, avascular necrosis or severe arthritis. The ultimate goal of tibiotalocalcaneal arthrodesis is to provide a pain-free, stable, plantigrade foot that is well aligned anatomically and has provided for an environment where the foot, ankle and leg can be free of ulcerations. It involves a well planned approach by an experienced surgeon.

Shearman and colleagues described the principles of fixation, and stated that the following four points are necessary for adequate fixation.¹
1. Adequate correction of the deformity is essential to achieve adequate biomechanical alignment. Malalignment is associated with persistent symptoms and mobility problems.
2. Achieve maximum bony contact to ensure stability of the fusion and fixation with grafting of bone gaps to aid bony fusion.
3. Minimize soft tissue and vascular disruption, which can compromise bony union and wound healing.
4. Use a stable fixation construct to allow for successful fusion.

DiDomenico and coworkers stated that the ideal fusion should provide stability through secure fixation, reduce excessive forces through good alignment and preserve the soft tissue envelope in order to have a high fusion rate.² Good fixation and a solid construct are going to dictate the outcomes of these patients undergoing tibiotalocalcaneal arthrodesis.

It is our opinion that the way to optimize fixation is with the use of screws and a plate construct. The senior author has used an inverted femoral condylar locking plate with a lateral transfibular approach and independent large cancellous screws or a posterior approach with independent large cancellous screws and a humeral locking plate. Both approaches provide the surgeon the ability to visualize the anatomy involved in a tibiotalocalcaneal arthrodesis, prepare the joints for fusion, and reduce and properly align the extremity.

Salient Step-By-Step Pearls

Following reduction of the deformity, insert two or more of the temporary guidewires for stabilization. Insert the guidewires from the inferior cortex of the calcaneus to the distal, anterior tibial cortex. Measure and insert the large cannulated cancellous positional screws, being sure to capture two cortices (bicortical purchase). After determining an appropriate plate to use, utilize temporary fixation to measure and be certain there are multiple points of fixation on the lateral aspect of the calcaneus, and the proximal portion of the plate is aligned along with the tibia. Insert the central hole of the plate in the calcaneal portion of the plate into the far cortex in order to lag the plate to the lateral wall of the calcaneus. Another option of securing the plate to the calcaneus is to use a large Weber clamp to secure the plate to the lateral aspect of the calcaneus.

Place the femoral plate in an inverted position to fit the plate contour, which suitably matches the natural alignment of the anatomy of the surgical site.² With the lateral approach and the use of a femoral locking plate, resect the fibula and prepare it for a bone graft in order to fill any voids that may remain after fixation. The bicortical purchase of the independent large cancellous screws and the bicortical purchase of the lag and logging screws through the plate to the medial wall of the calcaneus provide excellent stability and maintain the arthrodesis site in proper anatomic position and length.

After lagging the plate to the calcaneus, there are multiple screw holes for either additional lag screws or locking screws to aid in stabilization of the plate to the calcaneus. This technique allows for multiple points of fixation, bicortical fixation with the calcaneus (the weakest bone in the construct) and non-locking or locking screws. When one compares this construct to a nail construct, the nail construct typically offers one point of fixation in the calcaneus and, based on the goal of the surgery, possibly one point of fixation in the talus (if present) and proximal screws through the nail. With the plating fixation and the strong bicortical fixation of the independent large cancellous screws, one obtains bicortical screw purchase in the calcaneus, talus (if present) and tibia. The lag screws in the proximal plate assist in reduction and alignment as the plate reduces with the tibia. This helps to reduce the ankle and subtalar joints into anatomic alignment. If there is a large varus or valgus deformity, the plating system makes attaining the desired axial alignment relatively easy.

One can then use a mix of locking and non-locking screws in the proximal portion of the plate into the tibia. We recommend using locking screws in the distal tibia (closer to the fusion site) in order to prevent the construct being too stiff and causing stress to the mid-distal shaft of the tibia.

If there are issues with compromised soft tissues that make the lateral approach unsafe, we recommend an alternative: approaching the tibiotalocalcaneal arthrodesis posteriorly. DiDomenico and colleagues describe a posterior approach via an incision over the Achilles tendon.³ The approach is possible due to a robust, well vascularized soft tissue envelope provided by the posterior structures, including the low lying muscle belly of the flexor hallucis longus. Maintaining good vascular supply to the bone and surrounding soft tissue is important in this patient population.

Avoiding Reaming And Preserving The Medullary Bone

Utilizing independent large cancellous screws and a lateral or posterior locking plating system maintains the medullary bone. When utilizing an intramedullary nail, reaming of the medullary bone is necessary for the preparation and inser-tion of the intramedullary nail. While reaming out the medullary canal in preparation for insertion of the nail, it results in disruption of healthy cancellous bone, endosteum and the marrow contained within. When reaming the bone, the bone may become compromised for healing by harming the medullary canal. McKibbin stated that normally, the cortex is supplied largely through the medullary system.⁴ By disrupting that system, we are putting the bone at risk. An advantage to a plate and screw construct, specifically a locking plate and locking screw construct, is that the plate and screw salvage vascularization to the bone.¹ This is due to decreased contact pressure between the plate and bone, and reduced periosteal devascularization. The plate and screw construct also maintain the medullary system.

When utilizing the lock plating technique, the senior author advises using two or more long, large, fully threaded screws. Typically, one would insert the screws from the inferior calcaneus to the distal anterior tibia or from the tarsal bones to the distal posterior tibia. These screws are positional screws for bone grafting. The bicortical fixation is superior to unicortical fixation and the combined size of two or more large cancellous screws (6.5, 7.0, 7.3, 8.0, etc. based on the system being used) is larger than the largest intramedullary nail of 12 mm.

Recognizing The Challenges With The Calcaneus And IM Nails

In normal alignment of the foot and ankle, the calcaneus lies slightly lateral to the long axis of the tibia. When using a straight intramedullary nail, the surgeon will have to medialize the calcaneus in order to insert a straight nail from the calcaneus into the tibia, therefore navigating away from normal anatomic alignment. If a surgeon chooses to use an intramedullary nail with a lateral bend, the insertion can cause harm to the cortex of the distal tibia as the surgeon inserts up the tibia.

The calcaneus is the weakest component of a tibiotalocalcaneal fusion. The calcaneus has a very thin outer cortex filled with cancellous bone. The stronger portion of the calcaneus is the sustentaculum tali, which is medial and superior, and really has no direct contact with an intramedullary nail. Due to this, the holding ability of an intramedullary nail within the calcaneus is relatively weak.

Insertion within the calcaneus can be challenging in patients with Charcot neuroarthropathy. Patients with Charcot neuroarthropathy are typically heavier and have bone destruction and/or compromised bone. Most of the larger intramedullary nails are 12 mm in diameter. It is very difficult to perfectly insert a 12 mm nail in the central portion of the calcaneus repeatedly. Although the intramedullary nail may appear to be well inserted with fluoroscopic evaluation, the surgeon must realize that with the complex three-dimensional shape of the calcaneus, it can be challenging to perfectly and repeatedly place the nail within the bone that exhibits a thin cortex and cancellous bone. In complex patients, this is often the site of failure of an intramedullary nail. Frequently, the lateral radiograph projections will look satisfactory. However, the insertion into the calcaneus is challenging due to the complexity of the anatomy of the calcaneus.

Fixation of the calcaneus with an intramedullary nail is limited to a posterior to anterior screw or a lateral to medial screw. With the fixation of a locked plating system into the calcaneus, there are multiple holes for fixation. The inserted screws can be bicortical, which is superior to unicortical, and there are options of non-locking and locking screws that surgeons can utilize in the calcaneus.

Relative to the lateral approach and plating, after one has fixated the plate to the lateral wall of the calcaneus, the plate will automatically reduce the deformity and align the hindfoot and ankle.

In Conclusion

Although the intramedullary nail works well and provides adequate stiffness to the construct, it has been our experience that coupling of large independent screw fixation with a locked plating system is much more predictable and reproducible. The screw and locking plate technique is technically easier to reproduce, and it maintains the bone’s medullary canal. Newer locked plating designs allow for screws in multiple planes that can provide more stability. With a more reproducible technique and the possibility of achieving a stronger, more stable construct along with maintaining more vasculature to the bone, the combination of screws and a locking plate is the senior author’s primary choice of a construct when performing a tibiotalocalcaneal arthrodesis.

Dr. DiDomenico is in private practice at Ankle and Foot Care Centers in Youngstown, Ohio. He is the Section Chief of the Department of Podiatry at St. Elizabeth Hospital in Youngstown, Ohio. Dr. DiDomenico is also the Director of Fellowship Training of the Reconstructive Rearfoot and Ankle Surgical Fellowship and Residency Training at Northside Hospital in Youngstown, Ohio. Dr. DiDomenico is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Mychak is a Fellow at Ankle and Foot Care Centers in Youngstown, Ohio.

Dr. Rivera is a second-year resident at Northside Hospital in Youngstown, Ohio.

References
1.    Shearman A, Eleftheriou K, Patel A, Pradhan R, Rosenfeld P. Use of a proximal humeral locking plate for complex ankle and hindfoot fusion. J Foot Ankle Surg. 2016; 55(3):612-618.
2.    Didomenico L, Wargo-Dorsey M. Tibiotalocalcaneal arthrodesis using a femoral locking plate. J Foot Ankle Surg. 2012; 51(1):128-132.
3.    Didomenico L, Sann P. Posterior approach using anterior ankle arthrodesis locking plate for tibiotalocalcaneal arthrodesis. J Foot Ankle Surg. 2011; 50(5):626-629.
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