# Revision of Tibiotalar Arthrodesis Nonunion Using Intramedullary Fibular Autograft Combined with Cancellous Iliac Graft and Bone Marrow Aspirate Concentrate: A Case Report and Literature Narrative Review

## TL;DR

A new surgical technique using intramedullary fibular autograft combined with bone marrow aspirate concentrate successfully treated a failed ankle fusion.

## Contribution

This is the first reported use of intramedullary fibular autograft in revision tibiotalar arthrodesis nonunion.

## Key findings

- The patient achieved pain-free weight-bearing and radiographic evidence of fusion within 3 months.
- Combining intramedullary fibular autograft with cancellous graft and BMAC provided mechanical and biological benefits.
- CT-based assessment is recommended to confirm successful fusion outcomes.

## Abstract

Background/Objectives: Nonunion after tibiotalocalcaneal (TTC) arthrodesis remains challenging, especially in revision settings where union rates are substantially lower than in primary procedures. Biological adjuncts are commonly used to enhance healing, yet most described methods employ fibular onlay struts and cancellous autograft. To our knowledge, intramedullary placement of a fibular autograft for ankle fusion has not previously been reported. This study presents a revision of TTC arthrodesis nonunion treated with this technique and summarizes existing evidence on revision ankle arthrodesis, fibular grafting, and bone marrow aspirate concentrate (BMAC). Methods: We report a revision TTC arthrodesis nonunion managed with a decorticated intramedullary fibular autograft spanning the tibiotalar canal, supplemented with cancellous iliac crest autograft and BMAC. A review of PubMed, Scopus, and Google Scholar (search date: 1 September 2025) was performed to identify studies addressing revision ankle fusion, fibular grafting techniques, and BMAC use in foot and ankle arthrodesis. Primary outcomes included union and complications, with CT-based assessment prioritized when available. Results: At 3 months, radiographs and CT demonstrated progressive osseous bridging consistent with fusion; the patient achieved pain-free weight-bearing without complications. Conclusions: Intramedullary fibular autograft in revision TTC arthrodesis is a novel biological-mechanical strategy that leverages endosteal contact and axial stability while augmenting osteogenesis with cancellous autograft and BMAC. The review supports the biological plausibility and safety of this approach and underscores the importance of CT-based assessment.