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J Bone Joint Surg Am. 2014 Apr 2;96(7):574-80. doi: 10.2106/JBJS.M.00010.

Addressing hindfoot arthritis with concomitant tibial malunion or nonunion with retrograde tibiotalocalcaneal nailing: a novel treatment approach.

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Department of Orthopedics, Thomas Jefferson University Hospital, Curtis Building #801, 1015 Walnut Street, Philadelphia, PA 19107.
Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address:



Tibial malunions and nonunions are associated with degenerative changes about the ankle. A comprehensive literature review revealed no articles discussing treatment options for patients with tibial shaft malunion and ipsilateral ankle arthritis. The aim of our study was to evaluate a series of patients in whom tibial osteotomy and retrograde tibiotalocalcaneal nailing were used to treat both tibial deformity and ankle osteoarthritis.


Twenty-five patients underwent retrograde tibiotalocalcaneal nailing with concomitant realignment tibial osteotomy with takedown of the nonunion or malunion in a single procedure. All surgical procedures were performed by a single surgeon at a single institution. Baseline patient characteristics (age, sex, body mass index [BMI], preoperative diagnosis, and prior surgical procedures) were recorded. Data including visual analog scale (VAS) pain scores (0 to 10, with 0 indicating no pain and 10 indicating worst pain) and American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores were prospectively collected at the preoperative evaluation and the time of final follow-up, and patients were asked about their final satisfaction. Preoperative VAS scores averaged 8.3 (range, 7 to 10) of 10, which improved to an average of 2.8 (range, 0 to 6) at the time of final follow-up (p < 0.01). The preoperative AOFAS-AH scores averaged 43 (range, 18 to 62) of 100 and improved to 76 (range, 57 to 84) at the time of follow-up (p = 0.022). Twenty-one patients (84%) stated that they were extremely satisfied with the result of the procedure, three patients (12%) were satisfied, and one patient (4%) with a poor result was unsatisfied.


Tibial malunion or nonunion with concomitant hindfoot arthritis can be addressed with a single-stage procedure consisting of tibial osteotomy and retrograde intramedullary nailing for correction of the angular deformity and hindfoot fusion. This procedure provides a viable alternative to multiplanar external fixation or a staged procedure addressing the nonunion or angular deformity and the hindfoot arthritis separately.

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