Purpose of Review

The function of retrograde hindfoot smash in the treatment of acute orthopedic injury is explored .

Recent Findings

Tibio-talar calcaneal ( TTC ) smash is an acceptable discussion alternative for the low-demand geriatric patient with peri-articular ankle trauma permitting immediate weight-bearing with low rates of complication and return to functionality. Hindfoot complete can be used for limb salvage in the younger active patient ; however, joint-preserving reconstruction is preferred when feasible .


Retrograde TTC nail is a reliable option for hindfoot/distal tibia stabilization particularly in the aged frail population. Hindfoot nail is reserved for a choose subset of active patients when austereness of bone, joint, and soft tissue injury are not amenable to more conventional reconstruction.


Geriatric ankle fracture, Hindfoot nail, Tibio-talar calcaneal nail, Primary ankle fusion, Limb salvage


Retrograde tibio-talar calcaneal smash has a definitive function in the treatment armamentarium for acuate injury involving the distal tibia and hindfoot. Although rigorous indications for this technique continue to evolve, tibio-talar calcaneal ( TTC ) nails have been shown to effectively treat a range of hosts and pathologies from low-energy geriatric injuries to severe high-energy injury. Yet, hindfoot nail has traditionally been utilized as a secondary procedure for post-traumatic reconstruction/arthrodesis, and is frequently perform months to years after the lookout injury [ 1 ]. A smash is ideally suited for the authentic immobilization of the hindfoot/distal third base tibia via insertion through a biologically advantageous surgical photograph. Depending on the indications for the routine and the functional goals of the surgery, TTC nails can be for acute trauma stabilization with or without captive for roast fusion. Outcomes have been largely optimistic in the discussion of mentally ill geriatric peri-articular ankle trauma [ 2, 3 •, 4 •, 5 •, 6 •, 7 •, 8 •• ], and hindfoot nail of austere high-octane injuries in a younger, active population is a useful limb salvage proficiency [ 9 – 14 ]. TTC nails have besides been used in concurrence with other reconstructive techniques to far improve the likelihood of a successful arthrodesis .

Indications for Acute TTC Nailing

Hindfoot nails are a feasible option for arthrodesis of the ankle and/or subtalar joint after dangerous lower extremity injury. basal arthrodesis in the acute accent management of hard foot and ankle injury continues to gain in popularity, particularly for patients with injury patterns associated with profound irreversible cartilage injury [ 15, 16 ]. specific examples include AO type 43-C pilon fractures, talus fracture/dislocations, and calcaneal fractures. Purported benefits of TTC nails in this setting include the requirement of merely a single reconstructive operation to promote optimum long-run outcomes. A hindfoot fusion nail efficaciously renders the hindfoot stiff, mechanically inhibiting motion at both the ankle and subtalar joints. however, acute arthrodesis with a hindfoot smash can be potentially advantageous over more conventional fusion constructs in patients with particular host and injury factors. For exemplify, the polytrauma patient with a devastating tibial plafond and/or hindfoot injury may benefit from the placement of a TTC breeze through as a load sharing device, which may permit early mobilization [ 6 •, 7 •, 12 ]. Hosts with co-morbid aesculapian conditions, such as diabetes and peripheral vascular disease, are candidates for this less incursive stabilization technique, thereby limiting the risk of infectious complications from impaired wound healing. Injury patterns with austere attendant closed or open soft weave disturbance are ideally suited for an intra-osseous device [ 17 ]. Fractures with excessive comminution or bone loss profit from a bridging pinpoint arrested development. last, complex fracture patterns that render both the ankle and subtalar joints vulnerable to early post-traumatic arthrosis deserve retainer for retrograde hindfoot collar. In contrast, TTC collar is an take option treatment scheme for the low-demand geriatric patient after peri-articular fragility ankle trauma. Nailing is a mighty technique for faithfully stabilizing the hindfoot/distal tibia of this patient age group, which besides commonly presents with co-morbidities including diabetes or vasculopathies in addition to their intrinsic poor people bone quality. Nailing in these hosts may be performed with or without courtly formulation of the articulation for fusion. Nails are typically chosen when more traditional inner or external obsession techniques are deemed undependable [ 18 ], and if early mobilization is a treatment goal. Selected injury patterns amenable to hindfoot breeze through in the geriatric host include fluid ankle fracture-dislocations, tibial pilon fractures, and distal quarter tibia fractures [ 2, 3 • ]. Further, open peri-articular ankle injuries are suitable for TTC nailing following debridement through the traumatic hurt. inflexible stabilization of the bony human body not only promotes bone curative, but besides creates an optimum heal environment for the compromise soft weave envelope .

Biomechanics of Tibio-talar Calcaneal Nailing

anterior to the commercial handiness of hindfoot nails, the utility of retrograde TTC stabilization using an intramedullary nail down to bridge the subtalar and tibio-talar joints after selected high- and low-energy trauma was apparent to orthopedic injury surgeons. Curved humeral [ 4 • ] and tibial nails [ 2 ] were used “ off-label ” for fracture stabilization and/or joint arthrodesis, inserted retral through the front tooth action of the heelbone ( Fig. ). The geometry of the chosen nails accounted for the lateral pass outgrowth of the heelbone in relative to the tibial shaft in the wreath plane. Longer nails were initially preferred due to the early belief that failure to bypass the isthmus of the tibia with the chosen stabilization technique would increase the risk of periprosthetic fracture [ 7 • ] .An external file that holds a picture, illustration, etc.
Object name is 12178_2018_9507_Fig1_HTML.jpgOpen in a separate window fortunately, nails specific for hindfoot stabilization have been developed and are in widespread use. modern nail designs permit their intra-osseous passage through the heelbone and talus into the tibia. Further, crisscross interlock options exist for the heelbone, talus, and tibia to control both rotation and distance. Intra-operative or dynamic compression can be applied when advantageous. Hindfoot smash has evolved as a feasible treatment strategy because of its numerous biomechanical advantages. TTC nails are durable inner splints for supporting fracture marriage and/or hindfoot arthrodesis. They are mechanically superior to extra-medullary implants in this application [ 19 ]. TTC nails exert maximal leverage in the short distal segment, ensuring a more rigid, dependable fixation. TTC nails are besides load sharing constructs, which makes the fracture site more amenable to earlier weight-bearing after injury. Beyond mechanics, hindfoot nails preserve fracture biology. The minimally encroaching application of TTC nails limits the likely for iatrogenic wind complications. Co-morbid hosts and/or hard injuries associated with cushy tissue compromise benefit from the limit surgical exposure required for breeze through insertion. Furthermore, reaming a path for the nail generates cancellate autograft, which is beneficial for fracture and/or arthrodesis union .

Hindfoot Nailing Without an Intent to Fuse

When using a tibio-talar calcaneal nail down in the treatment of fractures and/or dislocations of the hindfoot or distal tibia, a decision needs to be made as to whether a courtly fusion of the cross joints is necessary. A fusion is typically required for young and/or active patients, to avoid hardware failure. Further, successful coalition will promote best outcomes in these higher demand patients. In geriatric and/or low-demand patients, a dinner dress joint training may be unnecessary for acceptable results [ 6 • ]. Hindfoot nailing without a joint formulation has been performed with a gamey success and return to officiate pace in these hosts following malleolar and distal tibial fragility injuries. Hardware failure has not been found to be a significant complication in this minimally ambulant affected role population [ 7 • ] .

Arthrodesis Using a Tibio-talar Calcaneal Nail

Joint-preserving reconstruction using inner and/or external fixation is the preferable operative worry design for younger patients with fractures and/or dislocations that involve the ankle and/or subtalar joints [ 20 ]. A primary coil arthrodesis, however, does have a significant character in the surgeon ’ second discussion armamentarium, particularly in the set of austere profound irreversible cartilage injury. These cases will quickly progress to arthrosis following conventional management. An acuate coalition therefore merits consideration. The degree of joint price is typically a marker for the severity of accompaniment gentle tissue compromise. In an feat to limit surgical dissection while silent promoting alignment and immobilization, a hindfoot nail can be used as a chief fusion modality. joint readiness is recommended in addition to nail interpolation. In line to the low-demand geriatric patient, a young, active patient will typically have pain and dysfunction if the ankle joint does not fuse. Further, this population will likely go on to hardware failure in the absence of a successful arthrodesis due to cyclic load on the retained implant ( Fig. ).

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Adjunctive Techniques Used with a TTC Fusion Strategy

Diverse injury patterns and host characteristics mandate an personalize secret agent design for patients who present with a severe injury to the distal tibia and hindfoot. The goals of hindfoot nail-mediated reconstruction include the avoidance of disfigurement and the universe of a union across the fracture site and selected joint surfaces. When performing a primary arthrodesis with a hindfoot nail, adjunctive techniques are much utilitarian to supplement the biomechanical milieu. limited ORIF in junction with the passing of a hindfoot nail down after severe tibial pilon fractures is intended to grossly align/compress the major fracture fragments of the distal tibia and/or hindfoot, thereby restoring the affected role ’ s native osseous human body and encouraging coupling. minimally invasive approaches are typically used for fracture decrease and instrumentation. Lag screws with or without low-profile plates are typically employed for this application. For exercise, major fragments, including the Chaput, Volkmann, and medial tibial plafond segments, can be grossly aligned and instrumented with a limited shape of home arrested development, followed by the removal of the remaining cartilage prior to hindfoot nail passage in an feat to encourage optimum alignment, primary coil arthrodesis, and fracture healing. supplementary internal arrested development should besides be considered across fix joint surfaces to encourage an uneventful coalition. large fragment, partially threaded cannulated screws are much used to compress the joint surface. Screws are strategically placed to avoid the path of the hindfoot pinpoint. Trans-articular low-profile plates can besides be used to impart rigidity and bone/joint curative across the coalition aggregate [ 21 ]. Biologic supplementation may besides be used as part of the patient ’ mho individualized care plan. autogenous cancellate bone graft should be considered in the plant of fractures and/or roast surfaces with bone defects. Structural autograft may besides be utilized to this end [ 22 ], which may involve the decortication and transfer of the distal fibula to the lateral distal tibia/talus ( Fig. ) [ 23 ]. This biological plate will besides impart early on constancy to the fusion concept as it incorporates into the fusion bulk .An external file that holds a picture, illustration, etc.
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Outcomes Using the TTC Nail for Acute Trauma

Hindfoot nail down is an satisfactory discussion alternative for the decrepit, low-demand geriatric patient with precarious periarticular ankle fracture/dislocations. TTC collar may besides be chosen when conventional methods of inner and/or external fixation are deemed unreliable. multiple result studies have validated the condom and efficacy of acute TTC nail of fragility fractures in low-demand hosts .

  • Jonas et alabama. [ 6 • ] selectively treated 31 chiefly geriatric unstable ankle fractures with a hindfoot collar and early on mobilization. encourage results were reported, as 94 % of patients returned to their pre-injury flush of function. however, complications included three periprosthetic fractures and two break nails, prompting others to hypothesize that longer nails that bypassed the isthmus of the tibia were necessary to prevent periprosthetic complications [ 4 •, 7 • ] .
  • Al-Nammari [ 7 • ] described a case series of 48 decrepit aged patients with a mean age of 82 treated for unstable ankle fractures with a long talocalcaneal nail applied through the heelbone, bridging the subtalar and ankle joints without ball joint planning. early weight-bearing was encouraged. Ninety percentage of patients returned to their pre-injury functionality. No nail breakages or periprosthetic fractures were reported, which the authors attributed to the function of a long TTC nail .
  • Georgiannos et aluminum. [ 8 •• ] performed a prospective randomized study comparing TTC collar and traditional clear reduction internal fixation ( ORIF ) in the management of malleolar, unstable ankle injury in geriatric patients. postoperative complications were quadruple higher in the ORIF group. While the functional outcomes of both groups were equivalent, as measured by the Olerud Molander Ankle Score .

TTC nail down must be used more cautiously in the new, active agent affected role, as a joint-preserving reconstruction is more advantageous in these hosts. Hindfoot smash, however, has been successfully employed after the most dangerous bone, joint, and soft tissue injuries and in the sickest hosts to promote limb salvage ( Fig. ). unfortunately, the body of literature that supports using TTC nails in the treatment high-octane injury is more limited, consisting of a small case series and case reports, highlighting the identical selective nature of this proficiency in the active affected role population [ 10 – 14 ] .An external file that holds a picture, illustration, etc.
Object name is 12178_2018_9507_Fig4_HTML.jpgOpen in a separate window Al-Ashhab [ 10 ] reported on hindfoot nailing with formal joint training for 20 back-to-back severe high-octane tibial pilon fractures deemed unreconstructable by the author in a relatively young affected role cohort, with an average senesce of 33. The generator in all cases performed a distal fibulectomy, which was used as autograft to facilitate joint cooking and serve as an adjunct for fusion. Unions were observed in all cases, with 90 % of fractures deemed to be in an acceptable alignment. good consequence scores ( average 85 ) according to the AOFAS were reported despite unnecessary immobilization of the subtalar roast. extra reports describe the successful salvage of high-octane traumatic injuries using a retrograde hindfoot nail [ 11 – 14 ]. Co-morbid hosts can achieve a viable arm reconstruction using this method acting, as conventional strategies can be fraught with unacceptable iatrogenic complications. Patients with talus fracture/dislocations or frank extrusions are besides potential candidates for TTC nail reconstruction ( Fig. ). Mangled extremities with injuries to the tibial plafond, anklebone, and/or calcaneous can besides be considered for this method acting. last, fracture/dislocations associated with a severe soft tissue injury may benefit from rigid hindfoot stabilization to stop the cycle of injury, permitting soft weave recovery in the set of a accompaniment reconstruction .An external file that holds a picture, illustration, etc.
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Tibio-talar calcaneal complete is a minimally encroaching scheme for efficaciously stabilizing the hindfoot and distal tibia. It should be utilized in selected patients based on clinical judgment, which should include the consideration of both horde and wound practice. Hindfoot breeze through is optimally indicated for the minimal demand, aged patient with mentally ill peri-articular ankle injury, as it permits early weight-bearing in these patients. Indications for this proficiency in the unseasoned, active patient population should be made on a individual basis, and should be reserved as a salvage cock for alone the most complex injuries .


Conflict of Interest

Both authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with homo or animal subjects performed by any of the authors .


This article is part of the Topical Collection on Foot and Ankle Trauma

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Category : Nail Technique

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