Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail and Augmented Allograft after Failed Total Ankle Replacement: An Exploratory Retrospective Matched Cohort Study

Introduction The high 10-year extraction rate of failed second- and third-generation total ankle replacements (TARs) has led to an increasing prevalence of revision procedures with substantial bone defect. In this context, revision technique utilizing tibiotalocalcaneal arthrodesis (TTCA) with massive bone allograft and autograft is a salvage procedure, providing variable outcomes that need to be compared to those after primary TTCA. This study compared fusion rates, reoperations, and clinical outcomes of two cohorts of TTCA. Material and methods A retrospective single-center cohort of patients was initially identified, finally including 10 patients who underwent revision TTCA (R-TTCA) with augmented allograft after failed TAR, and compared to a control group of 10 patients who underwent primary TTCA (P-TTCA), matched at a 1 :1 ratio for age, sex, side and body mass index. Tibiotalar and subtalar fusion rates, reoperations, and AOFAS scores were collected retrospectively. The mean follow-up was 3 years (range 1 – 7 years). Results Tibiotalar and subtalar fusion rates after R-TTCA were 100% and 70%, respectively, similar to those after primary TTCA (100% and 70%, p > 0.999, respectively). Reoperations after R-TTCA occurred in 2 cases, showing a similar reoperation risk (20% versus 30%, p > 0.999). Mean postoperative AOFAS scores were similar in both groups (63 versus 48, p = 0.083, respectively), with residual pain being lower in the R-TTCA group (p = 0.013). Conclusions Tibiotalocalcaneal arthrodesis utilizing a retrograde nail with femoral head structural allograft and autograft could be a valuable salvage procedure after failed TAR. While subtalar nonunion was the main complication, radiographic and functional outcomes appear to be comparable to those of primary tibiotalocalcaneal arthrodesis. These results should be considered in relation to the small number of cases in our series; larger-scale studies need to be carried out to confirm them. Level of evidence III; retrospective matched cohort study