Complications of tibio-talo-calcaneal fusion using hindfoot nails

P. Fenton, N. Bali, R. Matheshwari, B. Youssef, K. Meda

Introduction: There are many methods of achieving fusion in the hindfoot utilising internal or external fixation. Hindfoot nails have been increasingly used particularly in patients with significant deformity or compromised soft tissues. Good results in terms of union and clinical outcomes have been reported. However significant complications can occur. The purpose of this study was to assess the rate and type of complications following use of hindfoot nails at our institution.

Methods: We identified patients from a prospective database. All underwent hindfoot nailing under the care of the senior author using a standard technique. Casenotes, operation notes and radiographs were reviewed for all patients. Union at the fusion site was assessed together with the final hindfoot alignment. Details of complications were recorded.

Results: We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18-69). Eleven had a neuropathic cause of hindfoot deformity, 17 idiopathic arthritis, 12 previous fracture. Nineteen required additional procedures. Forty patients achieved ankle fusion and 36 subtalar joint fusion. The commonest complication was prominent metalwork with 13 patients requiring metalwork removal. In addition 5 patients developed CRPS and 1 sustained a peri-prosthetic fracture at the tip of the nail. Nine patients developed a deep infection. In six patients limb salvage was achieved by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. One patient required a period of stabilisation in a monolateral external fixator. Three of the infected cases underwent below knee amputation.

Conclusion: Hindfoot fusion with tibio-talo-calcaneal nails can achieve good clinical and radiological results. However significant complications can occur resulting, in a small minority, in amputation although limb preservation was possible in most cases of deep infection. We believe hindfoot nailing should be used as salvage procedure in selected cases.