Small Incision, Big Impact: Minimally Invasive TTC Nailing in Complex Foot and Ankle Fusion

At the American Society of Podiatric Surgeons (ASPS) Annual Conference, researchers from Barry University and HCA Florida Mercy Hospital presented a poster describing a minimally invasive approach to tibiotalocalcaneal (TTC) fusion.

Led by Justin Martinez, MBS; Asia Denning, BSc; Adam Reece, DPM; and Enrique Rosario Aloma, DPM, the poster highlighted the performance of TTC nailing without formal subtalar joint preparation in a patient with severe ankle and subtalar arthritis unresponsive to conservative therapy. A 3-cm anterior incision provided access for limited dissection and insertion of a hindfoot fusion nail under fluoroscopic guidance. Locking screws were placed across the tibia, talus, and calcaneus to ensure alignment and stability. Postoperatively, the patient progressed from non–weight-bearing to ambulation in a CAM boot between weeks 8 and 12, transitioning to regular footwear by week 16. At 12 months, the patient remained pain-free with no wound complications, infection, or implant failure, and reported unrestricted mobility.

The authors cited previous literature in their poster that indicated a 74% subtalar joint union rate in cases without joint preparation. They propose that compressive forces from the intramedullary nail may promote bone bridging and functional arthrodesis while minimizing wound morbidity—a crucial advantage for patients with diabetes, vascular compromise, or high infection risk.

For podiatric surgeons, the authors share that minimally invasive TTC nailing may represent a safe and efficient option for complex hindfoot pathology, especially in medically fragile patients. By limiting incision size and tissue trauma, this approach can potentially reduce postoperative complications such as dehiscence, delayed healing, and infection. The biomechanical compression generated by the nail may encourage osteoarthritic-like remodeling that leads to stable arthrodesis without extensive cartilage removal. This could translate to shorter recovery times and faster return to ambulation, with reduced perioperative risk.

The authors emphasized the importance of precise intraoperative alignment and compression, noting that while the initial outcomes are favorable, broader validation is needed. Future multicenter studies could refine patient selection criteria and define long-term success rates compared to traditional open TTC fusion.