Minimally Invasive Tibiotalocalcaneal Arthrodesis with a Retrograde Intramedullary Locking Nail: A Narrative Review

Abstract

Background: Tibiotalocalcaneal arthrodesis is an important limb-salvage procedure for painful, unstable, or deformed ankles when disease involves both the ankle and subtalar joints. Retrograde intramedullary locking nails provide axial load sharing, compression, and multiplanar fixation while limiting soft-tissue disruption. Objective: This narrative review summarizes the indications, preoperative assessment, implant design, operative principles, role of bone grafting, clinical outcomes, complications, and technical measures associated with retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis. Main body: Appropriate patient selection and accurate correction of deformity are central to successful fusion. The intended position is neutral ankle flexion, slight hindfoot valgus, and slight external rotation. Modern nails have evolved from simple straight constructs with limited distal control to curved or valgus-designed implants with independent calcaneal and talar locking, dynamic compression, and longer tibial segments. Meticulous preparation of the ankle and subtalar joint surfaces, exact guidewire placement, controlled reaming, stable distal and proximal locking, and compression across the fusion sites are essential. Bone graft is not routinely required in uncomplicated primary fusion but is useful when union is threatened by osteonecrosis, bone defects, infection, or previous nonunion. Diabetes, Charcot neuroarthropathy, smoking, severe deformity, compromised soft tissues, and previous infection increase the risk of wound complications, deep infection, delayed union, nonunion, and implant-related failure. Conclusion: Retrograde intramedullary locking nailing is a versatile option for tibiotalocalcaneal arthrodesis, particularly in complex deformity and poor bone quality. Outcomes depend less on the implant alone than on sound indication, accurate alignment, complete joint preparation, stable compression, and careful management of host risk factors.