Opinions about TAR?

[DogSnoot]

Do you like them?
Do they pay well?
Are they a waste of time?
Any input is appreciated.

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[wakaflocka88]

Do you like them?
Do they pay well?
Are they a waste of time?
Any input is appreciated.

Depends. Minimal deformity - sure in the right patient.
No. RVU - eh. Unless done in conjunction with other procedures, a TAR alone is not time well spent. I can knock off a lapi/akin for almost 17 RVU in under 1 hour. You do the math if I have 4 of those lined up a day.
The patients that do the best are the ones with the worst OA pain.
Better question - are you able to handle any potential tragic complications associated with this both intra and post op?

 

[Redsting]

I guess I'll start and then get told I am wrong.

I don't do them. I was not trained nor have I taken any courses on them. Where I am I have seen maybe 4 that would fit the criteria for them. 2 have gone on to get them. That's 2 in the last 5 years. I don't think I would be benefitting anyone. I know someone a couple hours a way that says he does 2 a month. So maybe they are worth while.

However in talking to someone who does several a month in a hospital setting. He says it takes some work like the replacement and gastroc and a couple add on procedures to get to 20 wrvus which depending on the contract is around $1,000. I think its around 3 hours for all of it. To me its not worth the money. If you do just the replacement its 14 wrvus which would be around $700. That's a lot of clinic time to miss and you could do that many wrvus in clinic without the stress or complications afterwards. Maybe if you had a PA seeing all the post ops and/or do several a year otherwise its a no go for me.

 

[Pronation]

There are plenty of ways to milk 20+ RVUs out of a TAR. It's your own fault if you only bill the replacement. It's just like billing a hammertoe surgery, you gotta pop in 6 different CPT codes. Then when you're done with the surgery, just hop in your Ferrari and go home.

 

[Hybrocure]

Assisted in many during residency. I have no desire to do them in practice nor do I feel trained enough to do one despite scrubbing many. In my opinion it’s something that benefits from extra training be it fellowship or TAR type courses/programs post graduation. It is rare that there is a program that actually has a resident do one skin to skin (I’m personally not aware of any).

Even if you did feel prepared to do them, expect a fight at many hospitals and to have your work scrutinized closely for any screw ups especially if you aren’t already part of an ortho group and don’t have that backing.

To get to the point where you do them proficiently enough that it makes the time/RVU worthwhile you’re likely already rich from operating so much anyways. And another problem with TARs is everyone always wants the best surgeon..that’s a hard sell to make to a patient in good faith as a new grad.

 

[Feli]

...Better question - are you able to handle any potential tragic complications associated with this both intra and post op?

I only assisted in a half dozen BKAs in residency, and I don't have privileges for that... so nope.

...I will say this: follow-up is the enemy of 'good surgery.'
You will probably see a lot of stuff in training that is not practical or optimal in practice (Charcot recon, TAR, various hero surgery). Many surgeons want to do whatever is new; some have relative med mal shielding in 'academic' environment or think they need to try aggressive stuff since they teach (when that should truly mean teach what works best). Almost anything seems reasonable in recovery room. Patients will usually - and unfortunately - do almost whatever the doc tells them to do. Heck, even Cartiva or opening base wedge or ex-fix Lapidus or other silly stuff looked cool for a year or more sometimes.

Some of docs go looking for candidates for new stuff (TARs right now) and tend to "find" what they're looking for. Podiatrists are known as "early adopters." It's just like how some "limb salvage" docs do inane stuff to get surgery and RVUs even if it's a clearly lost cause. That may or may not be in the pt's best interest. Most companies require 10 ankle fusions to do the TAR course, and the vast majority of DPMs don't do that in a whole career. That should tell you how relatively rare this path is for most DPMs. Chances are that by the time you go to take a TAR course, that model will be retired anyways (due to crap results) and they're on to a newer one.... tells you a lot of what you need to know right there.

... So, instead of what's cool or hyped or profitable, think what you'd want a family member to have, based on EBM. Long term studies. Comparison studies. TARs have a ton of issues. Cost is high. They break down. Outcomes are not as good if you don't do a ton. Revision is a nightmare and deep infection is often BKA or very serious chance of it. If they need revision and have moved, there are not a ton of skilled high volume TAR revision or TAR-to-fusion-with-block-graft surgeons.

There are many many good F&A surgeons - DPM and ortho - who don't do TAR. Some never did, others tried and quit... same for first MPJ implant nonsense. They do other things well, and they could do TAR if they wanted to. They don't. Instead, they do durable tibiotalar arthrodesis or refer it out to higher volume TAR surgeons if the pt has been sold on and is set on that "motion" option.

Personally, I had decided that arthrodesis was the EBM and pt outcomes and cost effective way to go even before starting residency. I had seen enough TAR disasters just on my clerkships... no joke. The EBM was also increasing sketchy for TAR (similar or worse compared to arthrodesis... despite much easier/healthier TAR pts, studies written mainly by TAR designers and biased TAR promoter surgeons). There is a reason for that. Figure out that reason for yourself (read studies, do some fusions, see some TAR), and then decide if you want to do them and why... and as mentioned, how you will get appreciable volume. I can tell you this... you won't have a ton of end stage ankle OA pts as a podiatrist, some won't be surgical candidates, very few would be TAR candidates... and any TAR candidate is also a fusion candidate (converse is NOT true, lol).

 

[Redsting]

I only assisted in a half dozen BKAs in residency, and I don't have privileges for that... so nope.

It would suck to do all that work, have the complications, then the patient needs a BKA so then you have to call up general surgery or ortho or vascular and ask them do amp a leg cause of some work you did.

I have had a few patients who after failed ankle fusions and failed ankle replacements have a BKA furthering me from wanting to do any TAR.

 

[Feli]

It would suck to do all that work, have the complications, then the patient needs a BKA so then you have to call up general surgery or ortho or vascular and ask them do amp a leg cause of some work you did.

I have had a few patients who after failed ankle fusions and failed ankle replacements have a BKA furthering me from wanting to do any TAR.

Yeah, the day I do "elective" surgery that carries a major risk of limb loss is the day I should quit surgery. Lol.

It's just not clogged carotids or spine cancer... the risk of hugely disastrous morbidity should not be significant at all.

Ankle fusions are no joke and do have their problems, but it's much more of a one-and-done procedure that can be done on many more pts/deformities (the "revision" might just be HWR, not major stuff as with TARs). I think the comparison studies need to remove the 330 lbs IM nail or the pilon/trimall 25 degree valgus ankle fusions as those were never even remotely TAR candidates. On most of the ppl who could have TAR with decent chance of implant longevity (fairly rectus, normal BMI, no neuropathy, etc), you can also do a scope or mini-open ankle desis and do pretty darn well.

 

[dtrack22]

Sure
No
Yes

 

[Retrograde_Nail]

TARs makes sense if you are Schuberth or Jason Nowak. Those guys drop total joints in ankles in 40-45 minutes. I’ve seen both operate. Scrubbed with both. Insane.

 

[heybrother]

A classmate of mine who is awesome, RRA certified, in a good size city, in an orthopedic group, and does full scope told me he'd done 1 since graduating. That means he's done 1 more than I have. He probably should have done a fellowship in TAR to even better prepare himself.

 

[Feli]

TARs makes sense if you are Schuberth or Jason Nowak. Those guys drop total joints in ankles in 40-45 minutes. I’ve seen both operate. Scrubbed with both. Insane.

100%... those are the guys we need to feed volume of TAR candidates to. ^^
I didn't have any DPMs in Mich doing a lot of TAR... not here in NMex either. I'd try to send the few candidates I saw to Detroit F&A ortho or Columbus DPMs when in Mich... now NMex, and TAR qualify pts who don't want fusion get refer to Phoenix or Denver area DPMs. It does us no good to have DPMs who do one every year or two.

It is funny that those guys like Nowak and many others run RRA recon DPM fellowships having never done one themselves, though. Some guys are just good and can get those practice/refer setups. Most of the best surgeons I've ever seen are 3yr trained - or many are 2yr trained if they're old enough. Fellowships in confidence don't seem to be available.

Schuberth retiring is big loss... love or hate his personality, he was a super surgeon. Hopefully some other Kaiser docs can now get high volume to try to semi-salvage all the botched and failed TARs in that NoCal area with new components or graft fusions. There will be more and more of those poor gimpy zombie ankle recons coming out of the woodwork. Fun times.

 

[DYK343]

I did more than my fair share in residency. Trained under a guy who could do them in sub 1hr and did a fair amount of them (Probably 4-5 a month).
I saw some of those go onto BKAs.
I saw a ton of recons of others work because they just wore out in 5 years or they were not done correctly.

I dont have the volume in my last or current job to support TAR
Even if I did I wouldnt do it because the headache for about 1k isnt worth it.

I pretty much seek out the easiest most straight forward cases now.
I will still do a charcot recon with multilevel fusion. But why do that when I can do 1-2 bunions, an exostectomy, and a 5th toe arthroplasty in a surgical block and move on with my day? My easy day is much less stressful and much easier post op. I only offer the big stuff anymore when I know its a slam dunk. If its going to be an obvious pain to do or manage after I refer to surgeons in the area who want this type of work.

This is kind of a new philosophy starting my new job. In my last job I was the surgeon everyone referred all the stuff to that they didnt want to tackle. Learned a lot... including when not to cut.

Im looking for early retirement. Doing TARs wont likely get me there. That said a lot of the surgeons who do high volume TARs are also fairly well known/published and often have BIG industry consult or royalty fees paid yearly. This is ultra rare but I keep trying to come up with something I can convince my fellow DPMs is a good idea so I can retire. As long as its flashy it shouldnt be too difficult.

 

[Pronation]

I do a few a year. Good outcomes but am very selective. Takes me about 2 hours. Probably gonna stop doing these for all the above reasons.

 

[Retrograde_Nail]

I do a few a year. Good outcomes but am very selective. Takes me about 2 hours. Probably gonna stop doing these for all the above reasons.

What implants do you use?

 

[Pronation]

What implants do you use?

Ultimately we decided on 400cc implants. Initially I had wanted to go straight to 850cc implants but this got a lot of pushback from her.

 

[Retrograde_Nail]

Ultimately we decided on 400cc implants. Initially I had wanted to go straight to 850cc implants but this got a lot of pushback from her.

Good talk see you out there

 

[Adam Smasher]

I don't do TAR, was interested in them for about a minute during residency, and have zero regrets that they are not part of my repertoire. So I didn't feel like I had much to contribute to the discussion when this was originally posted. However, some thoughts randomly popped into my head, so here's just an epidemiological perspective on it (purely anecdotal).

EVERY DAY, I treat patients who happen to have had their knees replaced.
EVERY DAY, I treat patients who happen to have had their hips replaced.
A few times each year, I'll see a patient who happened to have had their SHOULDER replaced.

TWICE in my career since residency (6 years now) have I treated patients who happened to have had their ankle replaced. I've had a few more who had their ankles fused. I've actually treated a total of 1 patient with end stage ankle arthritis for whom I ordered an Arizona brace (probably made just as much off it, lol).

There are rare conditions I have seen more frequently than ankle arthritis. I have seen more patients with psoriatic arthritis. I have seen more patients with syndactyly of their digits.

Moral of the story, I suspect I see a good cross-section of the general population, and ankle arthritis is really uncommon. Obviously someone's going to treat it, and I have all the respect in the world for those surgeons. But you can have a perfectly busy workday without needing to place a single TAR

 

[Retrograde_Nail]

I don't do TAR, was interested in them for about a minute during residency, and have zero regrets that they are not part of my repertoire. So I didn't feel like I had much to contribute to the discussion when this was originally posted. However, some thoughts randomly popped into my head, so here's just an epidemiological perspective on it (purely anecdotal).

EVERY DAY, I treat patients who happen to have had their knees replaced.
EVERY DAY, I treat patients who happen to have had their hips replaced.
A few times each year, I'll see a patient who happened to have had their SHOULDER replaced.

TWICE in my career since residency (6 years now) have I treated patients who happened to have had their ankle replaced. I've had a few more who had their ankles fused. I've actually treated a total of 1 patient with end stage ankle arthritis for whom I ordered an Arizona brace (probably made just as much off it, lol).

There are rare conditions I have seen more frequently than ankle arthritis. I have seen more patients with psoriatic arthritis. I have seen more patients with syndactyly of their digits.

Moral of the story, I suspect I see a good cross-section of the general population, and ankle arthritis is really uncommon. Obviously someone's going to treat it, and I have all the respect in the world for those surgeons. But you can have a perfectly busy workday without needing to place a single TAR

I agree with your opinion in spirit. But if you are PP podiatry you are not going to see a high volume of MSK ankle patients. Do you do a lot of MSK ankle cases like fractures or recon? If not then why would you see this kind of deformity? Not being malicious.

If you are DPM apart of a hospital or ortho group then you will see more candidates.

I do think the technology has drastically improved but there are still a lot of patients who get TAR with great surgeons nationally that continue to have problems such as gutter impingement, poly wear, cyst formation, or talar AVN or simply the implant just hurts. Just check the TAR Facebook group. Every day there are patients on there griping about they’re implants and the majority of them go to Duke or Harborview or Kaiser.

I’ve got DPM colleagues that do a lot of TARs and they are great surgeons and they still have issues. Joint replacement issues are a greater scale of complications than from a basic foot and ankle surgery. Doing a TAR and having a complication is an instant ortho secondary referral…guaranteed. That ortho will serve you on a platter to medi-mal lawyer. So think long and hard if you want to do this.

 

[Feli]

...Moral of the story, I suspect I see a good cross-section of the general population, and ankle arthritis is really uncommon. ...

I don't think ankle OA is uncommon at all... tons of fx, bad sprains, or just wear and tear ankle OA. It's mainly just that rigid brace or ankle fusion works pretty well (not so at all for knee or hip fusion, obviously).

TARs have a lot of problems; nobody who does them will say they do not.
The ankle's not a hinge joint and it's not a ball and socket either. Sure, it's a hinge technically or for test purposes, but the transverse plane tib-fib torsion on walking is significant.

 

[BubbaWub]

I don't do TAR, was interested in them for about a minute during residency, and have zero regrets that they are not part of my repertoire. So I didn't feel like I had much to contribute to the discussion when this was originally posted. However, some thoughts randomly popped into my head, so here's just an epidemiological perspective on it (purely anecdotal).

EVERY DAY, I treat patients who happen to have had their knees replaced.
EVERY DAY, I treat patients who happen to have had their hips replaced.
A few times each year, I'll see a patient who happened to have had their SHOULDER replaced.

TWICE in my career since residency (6 years now) have I treated patients who happened to have had their ankle replaced. I've had a few more who had their ankles fused. I've actually treated a total of 1 patient with end stage ankle arthritis for whom I ordered an Arizona brace (probably made just as much off it, lol).

There are rare conditions I have seen more frequently than ankle arthritis. I have seen more patients with psoriatic arthritis. I have seen more patients with syndactyly of their digits.

Moral of the story, I suspect I see a good cross-section of the general population, and ankle arthritis is really uncommon. Obviously someone's going to treat it, and I have all the respect in the world for those surgeons. But you can have a perfectly busy workday without needing to place a single TAR

I agree. It is quite a rare deformity/condition. My practice is one of the busiest in the nation, and I rarely see ankle arthritis.

Thank you

 

[HardRoadPaved]

I agree. It is quite a rare deformity/condition. My practice is one of the busiest in the nation, and I rarely see ankle arthritis.

Thank you

I think its hard to see with all that nail dust flying around

 

[BubbaWub]

I think its hard to see with all that nail dust flying around

I wear special protective goggles that help keep my vision clear during these procedures. I can see quite clearly.

Thank you

 

[HardRoadPaved]

I wear special protective goggles that help keep my vision clear during these procedures. I can see quite clearly.

Thank you

Yea hope that fits well with the masking too; N95 is better for that plume over standard masks.

Also if you're truly seeing 80% at risk foot care, I dont think TAR candidates are strolling in on the regular.

 

[Adam Smasher]

I agree with your opinion in spirit. But if you are PP podiatry you are not going to see a high volume of MSK ankle patients. Do you do a lot of MSK ankle cases like fractures or recon? If not then why would you see this kind of deformity? Not being malicious.

In theory, I would see ankle arthritis for the same reason I see patients with cataracts and patients with COPD and patients with coronary artery disease. I'm not treating any of it, but people with those problems come to me for their onychomycosis and other lobster problems. TAR patients don't get onychomycosis? Again, I'm taking a purely cross-sectional view of the general population, which problems are common, which things aren't. Ankle arthritis is the second kind of thing. I've seen more patients with heart valve replacements than ankle replacements.

I don't think ankle OA is uncommon at all... tons of fx, bad sprains, or just wear and tear ankle OA.

Obviously if you can market yourself and be a magnet for this sort of problem then more power to you. In a heavy ankle rearfoot practice, you're going to attract those patients just like any other specialist who treats rare disease.

I don't have a firm opinion on TAR because I'm not doing them. I do however have opinions on business and marketing, i.e. be good at doing things that affect a large number of people, be able to earn money that way, and then, if you really want to, learn to do TARs