There are several conditions that can potentially benefit from a TTCA. Fig. 1 illustrates a typical posttraumatic joint years after injury. Despite adequately performed open reduction and internal fixation (ORIF), many of these joints can slowly progress to this degenerative stage. Naturally, there is an even higher necessity for later fusion in the joint that is not repaired. Posttraumatic arthosis is, in the author’s experience, the most common reason necessitating fusion.

Fig. 1 Immediate preoperative anteroposterior (AP) image of a severely degenerated ankle and hindfoot secondary to previous fracture. Note prior hardware removal.

Whether injury to the posterior tibial tendon is acute or chronic, attenuation of the structure allows for progression of the foot into a valgus position. Although sudden onset of a valgus deformity will not immediately alter position of the ankle, chronic valgus will eventually cause attenuation of the medial lagamentous structures and allow progressive subluxation of the talocrural joint. In long-standing, severe pes planus, arthrodesis of this joint may be required.

Numerous conditions can contribute to loss of blood supply to the talus. The avascular necrosis (AVN) form of joint destruction is exceptionally challenging to the foot and ankle surgeon. Loss of bone, poor blood supply, and decreased bone density (and quality) can affect not only the form of fixation used but also dramatically increase the possibility of nonunion. Pagenstert and colleagues⁵ reported an almost 90% rate of nonunion when a similar procedure was performed on patients with a history of talar AVN. Not only does AVN preclude use of an ankle replacement, but the diminished bone quality can increase operating room time and postoperative recovery. In this surgeon’s own practice, any history of AVN often requires a 50% increase in the non–weight-bearing (NWB) and immobilization period compared with patients without a history of AVN.

Rheumatoid arthritis can be severely debilitating when affecting any portion of the lower extremity, but it is much more easily dealt with in the forefoot. Joint destruction of the hindfoot and/or ankle that requires fusion can be challenging given bone quality, treatment medications (ie, prednisone and immunosuppressive therapies), and involvement of other joints that make it difficult to remain NWB. The author has found in his practice that this group of patients seems more prone to progressive loss of postoperative position and has a higher rate of surgical revision or need for continued bracing even after reconstruction.

Although this patient population may not typically present with severe pain, this a is a condition that is at the very least life-altering and at the very worst limb or life-threatening. Given that Charcot is most common in a patient population that is already at high risk, a successful TTCA in the diabetic patient can be achieved but must be coupled with aggressive management of comorbidities. This author has found that a lengthy discussion concerning realistic expectations following a successful surgery and even discussion of amputation are in order before this procedure is performed.

Total ankle replacement (TAR) is slowly becoming an increasingly used treatment for severe ankle degeneration. Unfortunately, in the cases that require salvage, such as infection and subsidence, TTCA is often the only choice. These cases carry higher rates of postoperative complications not only because they are revision cases but also because they usually require significant bone grafting as well. Even autogenous grafting can still be difficult to heal or prone to fixation failure (Fig. 2).

Fig. 2 Lateral view of a failed total ankle. Although the author feels total ankle replacement is a viable option in many patients, the talar component displaced distally and caused progressive pain and loss of implant motion.

Is the patient really ready for this procedure? It is a basic question, but an extremely important one. The patient needs, first, to understand the lengthy healing period and also respect the fact that an estimated 12-week healing period is just that: “estimated.” In a sense, the surgeon’s role after the procedure is not just to manage the patient with regard to pain, infection, and wound and bone healing, but to also act as both a teacher and a supporter. It is best to explain set backs to the patient and provide reasons for the set backs and how they need to be dealt with.

Activity changes will also need to be discussed. Because most patients who reach the stage of requiring a TTCA have usually been limited, this author tries to counsel the patient that although the pain and/or deformity should be reduced following the procedure, there will still be significant limitations in what he or she can do. Bracing may still be needed. Shoe modifications may be needed. In those patients who still have some degree of hindfoot and ankle motion, gait changes following fusion should be discussed. Also, this author, and others,⁶ have found that it is reasonable for most of these patients to require some form of long-term pain management even with a successful outcome.

This topic could be an entire book in and of itself. Any chronic disease that affects healing needs to be optimized. Adequate glucose control, preoperative anemia, obesity, and smoking are just a few of the issues that dramatically affect the perioperative period. It is imperative that the surgeon work closely with the patient’s primary health care provider and/or hospitalist to anticipate and address these issues early. In fact, in the high-risk population, a long period in a rehabilitation facility may be needed to closely monitor not only patient therapy and compliance, but also manage other health conditions.

Complications are difficult to discuss for both the patient and the surgeon. The TTCA is a time-tested procedure, but it carries a high chance of complications.⁷ Granted, the complications can be mild, such as chronic swelling and pain, but they can also be more severe, such as infection and nonunion^5,6,8 or malunion. In many regards to TTCA it is not so much a matter of “if” but “when.” Anecdotally, this author has found in practice more than half of patients with TTCA experience some form of complication.