Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population

Objective: To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. Intervention: Tibiotalocalcaneal hindfoot fusion nail. Main Outcome Measurements: Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. Results: Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%–91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%–67%). Conclusions: Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.