Sagittal Position of Nail in Talus Affects Tibiotalocalcaneal Arthrodesis Outcomes

Background: Tibiotalocalcaneal (TTC) nails are commonly used implants for hindfoot arthrodesis. This study evaluated the relationship between the sagittal placement of the nail—specifically, more anterior versus more posterior positioning within the talus—and patient outcomes following surgery. Methods: We conducted a retrospective, single-center study involving patients aged 18 years and older who underwent hindfoot nail fusion. Variables analyzed included smoking status, body mass index (BMI), diabetes mellitus (DM) status, age, cause of surgery, surgical complications including nonunion, and need for revision surgery. Postoperative X-rays were assessed to calculate the talar-to-nail ratio (tnR), defined as the distance between the anterior margin of the talus and the center of the hindfoot nail (nL) relative to the total length of the talus (tL), expressed as tnR = nL/tL. Results: The study included 53 patients (24 male, 29 female) aged 18-92 years. The mean tnR was 54.635% (SD = 9.925), with a range from 23.89% to 76.71%. Bivariate analysis showed no significant relationship between the analyzed variables and nonunion or revision surgery, with the exception of tnR, which was significantly positively associated with revision surgery (59.130 ± 8.253 vs 51.912 ± 9.967, P = .009). In multivariable logistic regression, while DM and age were not significantly associated with revision surgery (P > .05), tnR demonstrated a significant association, with an odds ratio of 1.093 (95% CI: 1.017-1.193) and a P-value of .026. Conclusion: More posterior nail placement, as indicated by a higher tnR, is significantly associated with an increased likelihood of revision surgery, potentially due to an increased foot lever arm. These findings suggest that more anterior nail placement may lead to improved surgical outcomes in TTC arthrodesis.