Overview: Tibio-talo-calcaneal arthrodesis (TTCA) is a well-established treatment for complex hindfoot pathology, including post-traumatic ankle arthritis, severe deformity, Charcot neuroarthropathy, rigid neurological equinovarus, and failed total ankle arthroplasty. While retrograde intramedullary nails have improved outcomes over traditional fixation, conventional designs can be limited by anatomical constraints—especially in severe deformity or bone loss—making optimal screw placement and reliable compression difficult.

Purpose of the Video: This video presents the TTCA surgical technique using a newly developed retrograde intramedullary nail, highlighting its innovative design, dedicated instrumentation, and technical tips to enhance precision and outcomes. The device enables versatile screw placement, independent compression control, and improved anatomical alignment.

Exposure & Preparation: Anterior joint exposure with precise surface preparation via a LockBox osteotomy to improve stability and correct coronal and sagittal deformity.

Alignment Strategy: Hindfoot alignment is optimized by mediolateral entry-point selection—lateralized for valgus and medialized for varus—using the guidewire as a joystick for fine control.

Implant Features: A distal valgus curve that mirrors physiologic hindfoot alignment, a dynamic talar screw with adjustable positioning for severe bone loss, and independent compression in both talus and calcaneus to avoid undue calcaneal stress.

Patient Series & Outcomes (2022–2024): A consecutive series of nine patients was reviewed: five post-traumatic cases (55.6%), two flatfoot deformities (22.2%), one neurological equinovarus foot (11.1%), and one Charcot foot (11.1%).

Follow-up: 24.8 ± 11.3 months

Fusion: Radiographic fusion achieved consistently at 12–14 weeks

Complications: None reported

Function: AOFAS Ankle-Hindfoot score improved from 38.2 ± 7.5 pre-op to 76.3 ± 8.1 post-op (p < 0.001)

Pain: VAS decreased from 7.8 ± 1.1 to 1.98 ± 0.9 (p < 0.001)

Conclusion: TTCA remains a gold-standard option when joint-preserving procedures or TAA are not feasible. This innovative retrograde nail addresses key limitations of traditional designs by improving alignment control, enabling versatile screw placement—even with severe talar bone loss—and providing independent compression. Early clinical results show reliable fusion, no complications, and significant improvements in function and pain, offering surgeons a dependable solution for complex hindfoot reconstruction.