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

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

Apr 22, 2023 227 likes •856 views

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

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Failed TAR

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

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Disclosure

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

How long do primary TARs last?

Zaidi R et al: J Bone Joint Surg, 2013, 95‐B, 1500‐7

We don’t yet know the longevity of modern total ankles

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Indications for revision

 Impingement  Malposition of components  Loosening of components  Pain  Infection  Ligamentous instability

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Problems encountered

 Component subsidence  Bone defects  Coexisting adjacent joint

arthritis

 Hindfoot, midfoot

deformities

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Removal of custom talar stem

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A simple algorithm

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Revised algorithm…

Prosthesis salvageable Prosthesis unsalvageable Surgeon’s choice

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A case: prosthesis salvageable

  • STAR in since

2014

  • Only recently

painful

  • 10/10 pain
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CT scans

CT scans always show more

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Revision

Curettage cyst Outlining the depth

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Salvaged: calcium phosphate cement, new poly

A revision gastroc recession was performed

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At 6 months

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2 year follow-up

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Motion at 2 years

Only a few degrees of plantar flexion

Dorsiflexion Plantar flexion

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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
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Surgical Technique: Revision TAR General Assessment once prosthesis is removed

determine bone deficit evaluate for fractures assess talar insufficiency assess the subtalar joint

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Surgical Technique: Revision TAR Malleolar Fracture

avoid malleolar fracture as much as possible fix malleolar fx with K-wires or screw

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Surgical Technique: Revision TAR

Place talar trial to assess residual talus Use lamina spreader Adjust talus cut freehand

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Surgical Technique: Revision TAR 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

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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

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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
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When there’s talar insufficiency

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Fuse the subtalar joint

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Use autograft from tibial cut

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At one year

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At 7 years

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Motion at 7 years

Dorsiflexion Plantar flexion

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When there is even less talus..

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Even less talus…

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Level off residual talus until it lines up

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At 6 months At 2 years

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ROM at 6 months ROM at 2 years

Dorsiflexion Dorsiflexion

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ROM at 6 months ROM at 2 years

Plantar flexion Plantar flexion

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69 F hx of RA 6 years s/p R STAR TAA

When there’s no viable talus

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CT shows very little viable talus left

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Planning of the total talus replacement is based on a CAT scan

  • f the opposite normal ankle.

digital data then used to mirror it to fit the bad ankle

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

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Talus made with InBone 2 dome

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Final prosthesis

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Intraoperative

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2 years postop

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Invision Revision System

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INVISION Total Ankle Revision System

The Next Step in Total Ankle Revision Arthroplasty

Poly Options

  • Thickness options

ranging from 6mm to 20mm

Fixation & Stability

  • Modular Tibial stems

for robust stability

  • Plasma spray and

smooth options

Joint Height Restoration

  • Talar Plate with two

thickness options to help restore natural joint height

Bone Loss & Tibial Coverage

  • Standard and Long Tibial Tray

lengths to allow optimum cortical coverage

  • Multiple thicknesses to address

Tibial defects

Talar Coverage

  • Broad anatomic footprint to

provide cortical rim coverage

  • 2 sagittal sizing options to

maximize Talar neck coverage

Fixation & Stability

  • Talar pegs positioned for

anterior bone purchase

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Ballooning osteolysis

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Invision System

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Invision System

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Failed STAR to Salto XT

  • 51 year old female
  • STAR implanted 2 years previous
  • Never helpful, always painful

Courtesy Bruce Sangeorzan, MD

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Failed STAR

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Mechanical axis alignment

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Sizing, cutting block placement

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Talar trial placement

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Final OR images

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2 years….

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Motion at 2 years….

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

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Intraoperatively

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1year post-operatively

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Thank you