Use of a modified retrograde femoral rod as a custom length tibiotalocalcaneal nail

There has been increasing interest in the use of hindfoot tibiotalocalcaneal (TTC) nails to treat ankle and distal tibia fractures in select patient populations who are at increased risk for soft tissue complications after open reduction and internal fixation with traditional plate and screw constructs. We describe a technique which uses a retrograde femoral nail as a custom length TTC nail. By using a simple modification of the insertion jig, we are able to achieve safe screw trajectories that allow for robust distal interlocking fixation. Review of implantation in multiple cadaveric specimens demonstrates safe placement of distal screw fixation in the calcaneus without risking injury to important neurovascular structures. Because of the 2-cm incremental length options of this particular device, we are able to achieve supraisthmal fixation in the tibia which may lessen the risk for fracture that may be more likely to occur at the tip of a short TTC nail option. Furthermore, a custom length TTC nail is more costly and also requires advanced notice to acquire for the case; retrograde femoral nails are readily stocked and accessible at our level 1 trauma center. This TTC technique offers anatomic restoration while also offering convenience, instrument familiarity, cost savings, and increased patient safety.