Tibiotalocalcaneal (TTC) arthrodesis is a salvage operation to treat a difficult problem; normal function is not expected with arthrodesis of these 2 major joints. However, in properly selected patients, TTC arthrodesis using intramedullary nailing is an effective technique to reduce pain and improve function. It allows load sharing, provides anatomic alignment, and has the advantage of being able to simultaneously arthrodese both the joints with 1 device. Its use is not without risks, and care must be taken when choosing the insertion site to reduce the risk of neurovascular insult.