Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series

Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation is associated with a high incidence of complications. This is especially true when performed with a bulk structural allograft and poor soft tissue quality. In select high-risk limb salvage cases, we have augmented tibiotalocalcaneal arthrodesis procedures stabilized using retrograde intramedullary nail fixation with a vascularized pedicled fibular onlay bone graft. We present the data from 10 such procedures with a mean follow-up period of 10.9 ± 5.4 (range 6 to 20) months involving 10 patients (9 males and 1 female). The etiology was avascular osteonecrosis of the talus and/or distal tibia and a resultant large volume cavitary bone defect (8 ankles), severe equinocavovarus contracture (1 ankle), and failed total ankle replacement (1 ankle). A frozen femoral head bulk allograft was used twice, a whole frozen talus allograft once, and a freeze-dried calcaneal allograft once. The fibula was mobilized with intact musculoperiosteal perforating branches of the peroneal artery as a vascularized pedicle onlay bone graft fixated with a screw and washer construct. The mean fibular graft length was 10.2 ± 2.3 cm. The mean interval to radiographic fusion was 2.6 ± 0.6 months and to weightbearing was 3.1 ± 1.4 months. Two stable bulk allograft–host bone and fibular graft–host bone nonunions occurred after intramedullary nail hardware failure. Tibiotalocalcaneal arthrodesis augmented by vascularized pedicled fibular graft stabilized with retrograde compression intramedullary nail fixation offers a reliable option for complex salvage situations when few other options exist.