Failed TAR Michael Brage, MD Seattle, WA mbrage@bespamed.com - PowerPoint PPT Presentation

Failed TAR Michael Brage, MD Seattle, WA mbrage@bespamed.com

Disclosure • Consultant speaker: • Wright Medical, INC/Stryker • Bespa Global • Paragon 28 • Kinos • Integra

How long do primary TARs last? • A systematic review and meta ‐ analysis • Included 58 papers (7942 TARs) with an inter ‐ observer reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98 • The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval 0.7 to 1.6) Zaidi R et al: J Bone Joint Surg, 2013, 95 ‐ B, 1500 ‐ 7 We don’t yet know the longevity of modern total ankles

Indications for revision  Impingement  Malposition of components  Loosening of components  Pain  Infection  Ligamentous instability

Problems encountered  Component subsidence  Bone defects  Coexisting adjacent joint arthritis  Hindfoot, midfoot deformities

Removal of custom talar stem

A simple algorithm

Revised algorithm… Surgeon’s Prosthesis Prosthesis choice salvageable unsalvageable

A case: prosthesis salvageable • STAR in since 2014 • Only recently painful • 10/10 pain

CT scans CT scans always show more

Revision Curettage cyst Outlining the depth

Salvaged: calcium phosphate cement, new poly A revision gastroc recession was performed

At 6 months

2 year follow-up

Motion at 2 years Only a few degrees of plantar flexion Dorsiflexion Plantar flexion

Prosthesis unsalvageable options: The options in the United States: •Wright Medical InBone 2 •Wright Medical Invision •Salto Talaris XT 2 Ankle Not options in my hands: •STAR •Salto Talaris Anatomic Ankle •Depuy Agility •Zimmer Trabecular Metal Ankle •Exactech Vantage •Paragon Ankle

Surgical Technique: Revision TAR General Assessment once prosthesis is removed assess talar insufficiency determine bone deficit assess the subtalar joint evaluate for fractures

Surgical Technique: Revision TAR Malleolar Fracture avoid malleolar fracture as much as possible fix malleolar fx with K-wires or screw

Surgical Technique: Revision TAR Place talar trial to assess residual talus Use lamina spreader Adjust talus cut freehand

Surgical Technique: Revision TA R Tibial Preparation leg placed and secured in “the” foot holder proper alignment obtained with AP and Lateral alignment rods under C-arm tibia is drilled

Surgical Technique: Revision TAR Tibial Preparation • cutting block is lined up to the drill, then tibial cuts completed • tibia is reamed • tibial stems inserted until tibial tower construct is complete

Surgical Technique: Revision TAR Talus Preparation when there’s lots of talus • leg removed from foot holder • talar trial and trial PE liner inserted • trial components removed and talar stem is reamed • talar component is positioned • properly sized PE liner inserted

When there’s talar insufficiency

Fuse the subtalar joint

Use autograft from tibial cut

At one year

At 7 years

Motion at 7 years Dorsiflexion Plantar flexion

When there is even less talus..

Even less talus…

Level off residual talus until it lines up

At 6 months At 2 years

ROM at 6 months ROM at 2 years Dorsiflexion Dorsiflexion

ROM at 6 months ROM at 2 years Plantar flexion Plantar flexion

When there’s no viable talus  69 F hx of RA 6 years s/p R STAR TAA

CT shows very little viable talus left

Planning of the total talus replacement is based on a CAT scan of the opposite normal ankle. digital data then used to mirror it to fit the bad ankle

The prosthesis is then manufactured using a 3D printer to match the abnormal ankle

Talus made with InBone 2 dome

Final prosthesis

Intraoperative

2 years postop

Invision Revision System

INVISION Total Ankle Revision System The Next Step in Total Ankle Revision Arthroplasty Bone Loss & Tibial Coverage  Standard and Long Tibial Tray Fixation & Stability lengths to allow optimum  Modular Tibial stems cortical coverage for robust stability  Multiple thicknesses to address  Plasma spray and Tibial defects smooth options Talar Coverage  Broad anatomic footprint to Poly Options provide cortical rim coverage  Thickness options  2 sagittal sizing options to ranging from 6mm to 20mm maximize Talar neck coverage Joint Height Restoration  Talar Plate with two Fixation & Stability thickness options to help  Talar pegs positioned for restore natural joint height anterior bone purchase

Ballooning osteolysis

Invision System

Invision System

Failed STAR to Salto XT • 51 year old female • STAR implanted 2 years previous • Never helpful, always painful Courtesy Bruce Sangeorzan, MD

Failed STAR

Mechanical axis alignment

Sizing, cutting block placement

Talar trial placement

Final OR images

2 years….

Motion at 2 years….

50 F hx 2 years s/p Zimmer TAA from arthrodesis conversion

Intraoperatively

1year post-operatively

Thank you