TAR: Better Motion, Higher Satisfaction Gregory C Berlet MD, - - PowerPoint PPT Presentation

TAR: Better Motion, Higher Satisfaction

Gregory C Berlet MD, FRCS(C), FAOA Orthopedic Foot and Ankle Center Columbus Ohio

Disclosures

• Consultant/Speaker Bureau/Royalties/

Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio

Advanced Arthritis Options: 2017

Goals:

• Pain improvement
• Functional

improvement

• Patient perception
• f wellness

(PROMIS)

Times Are Changing

Why Evolve To Arthroplasty ?

• Partly because the alternative has

significant challenges –Surrounding joint arthritis

• Partly because of negative patient

perception of ankle fusion

• Partly because patients want more than

just pain relief – they want function, and I believe that this will be reflected in PROMIS scores

Patients Read Research Too !

• 3-dimensional gait analysis 1 yr postop
• 14 fusions vs 14 TAR vs 14 controls
• Conclusion:

– Pts w/ TAR had:

• Greater increases in walking velocity
• Greater stride length
• Greater cadence

Flavin, Brodsky et al. FAI. 34(10) 2013

Motion after TAR (historic)

Pyevich et al.

– 36 at an average f/u of 4.8 years – Minimum of 10°

Knecht et al.

– 18 at an average f/u of 9 years – Minimum of 2°

Pyevich MT et al. JBJS Am 80: 1998 Knecht SI et al JBJS Am 86 2004

Motion after TAR Maintained

• Initial ROM achieved by

TAR is maintained

• Average motion of 23°

(6.3% less than 10°)

– No change at 3, 6, 12 months, then yearly – 1-5 year f/u

Lagaay PM et al. JFAS 49:2010

Motion after TAR ( contemporary)

Hsu and Haddad:

– 59 10 TAR with INBONE – Mean total ankle motion improved from 290 to 380

Hofmann et al

– 81 Salto Talaris – Avg post op motion was 39.50

Hsu AR, Haddad SL. JBJS Am 97(3), 2015 Hofmann et al JBJS 98(24), 2016

TAR Can Improve Motion

Wood et al. –Improvement of >10 of DF

• 19% BPs, 18% STARs

–Improvement of >10 of PF

• 8% BPs, 17% STARS

Wood PL et al. JBJS Br 91-B(1):2000

Motion Sparing vs Producing

Brodsky et al (2017):

• 76 TAR with > 1 year

follow up

• Pre and post operative

gait analysis to evaluate sagittal range

• f motion

Brodsky et al FAI 38(10), 2017

TAR is Motion Producing

Findings:

• Pre-operative motion predictive of

better post-operative range of motion

• Patients with stiff ankles pre-op had

greater improvement in function as measured by multiple parameters

Brodsky et al FAI 38(10), 2017

Ankle Fusion or Arthroplasty ?

Jordan RW et al (2014):

• Systematic review comparing

management of ESAA

• 4 studies selected:

– Three were level III retrospective comparison – One was a level II prospective comparison study

Jordan et al Adv Orthopedics 2014

Ankle Fusion or Arthroplasty ?

4 qualifying studies:

• 2 studies showed significant functional

improvements in TAR

• 2 studies showed no difference
• Conclusion: Insufficient evidence to

support a decision between TAR and Fusion

Jordan et al Adv Orthopedics 2014

COFAS Ankle Arthritis Staging

Stage I: Isolated ESAA Stage II: ESAA with ankle valgus or varus <100, instability or equinus Stage III: ESAA with tibial, hindfoot or midfoot deformity Stage IV: ESAA with subtalar, talonavicular

• r CC arthritis

TAR vs Ankle Fusion

4 yr follow up:

• TAR/AF result in significant outcome

improvement for all types of arthritis

• Complex (Types 3&4) Fusions have somewhat

worse outcomes than Non-Complex (Types 1&2) Fusions

• In types 3 and 4 ESAA TAR outcomes are

significantly better than ankle fusion

COFAS Annual Meeting January 2017

Surrounding Joint Disease

COFAS Stage IV ESAA:

• Evolving evidence

suggests that patients with surrounding joint disease ( COFAS type IV) do better with TAR than fusion

COFAS Annual Meeting January 2017

Comparison of Treatment Outcomes of Arthrodesis and Two Generations of Total Ankle Replacement (2017)

• Prospective cohort comparing
• utcomes in 273 consecutive patients

treated for ankle arthritis with either arthrodesis or TAR between ‘05 –’11

Benich et al JBJS 99(21), 2017

Prospective: TAR vs AF

Benich et al (2017):

• Level II data
• Sig improvement of most measured

parameters in both fusion and TAR

• Most improvement occurred over the

first 6 months

Benich et al JBJS 99(21), 2017

Scores Better in TAR

Benich et al (2017):

• Average improvement in MFA and SF36

was better for TAR than arthrodesis

• Younger patients had more

improvement than older

• Newer generation TAR had better

improvement than older generation

Benich et al JBJS 99(21), 2017

TAR and Ankle Motion Wins

• Average motion in TAR with 3rd generation

implants is around 400

• Patients want more than just pain relief

they want function

• Benich et al (2017) showed in a

prospective level II study that TAR has better function and clinical scores

SUMMARY

Ankle Motion and TAR

• Ankle motion is not magic

–You have to plan and work for it ! –What you have on the table is the best it is going to be

• I quote normal ROM after TAR is 300,

modern generation implants closer to 400

SUMMARY

THANK YOU