Highlights From ACFAS 2026: TAR Essentials

Total ankle replacement (TAR) has moved from “niche” to increasingly mainstream, and the standing-room audience at the 2026 ACFAS Annual Scientific Conference underscored that shift. In “TAR Essentials: Indications, Techniques, and Pitfalls,” moderator Ryan T. Scott, DPM, FACFAS guided a practical, four-part review of what matters most right now: appropriate patient selection, implant selection, patient-specific instrumentation (PSI), and deformity correction (including when to stage).

Across presentations, the speakers returned to one core idea: TAR success is rarely about a single implant feature or a single intraoperative “save.” Durable results come from a stable mechanical environment, balanced soft tissues, and fixation that matches the patient’s bone, deformity, and functional demands.

Appropriate Patient Selection: “Suitability is about the whole limb”

Murray J. Penner, MD opened with the “why now” behind TAR’s growth: better outcomes data, improved survivorship of contemporary designs, and more realistic revision pathways. Registries and trial data have helped normalize TAR as an option patients can consider alongside fusion; especially when motion preservation and more “normal” function are meaningful goals.

Penner highlighted that comparative evidence has matured. The UK’s TARVA randomized trial¹ has shown that both TAR and fusion can yield good outcomes, with nuanced differences rather than a single universal winner; longer-term follow-up continues to inform decision-making. In other words, the conversation has evolved from “replacement vs fusion” to “which option best fits this patient’s risks, expectations, deformity, and timeline?”

Clinical pearl: Dr. Penner’s decision-making framework repeatedly emphasized bone quality, soft tissue envelope, limb alignment, and the patient’s likelihood of needing revision(s) over a lifetime. Younger, high-demand patients may still be better served by fusion in select scenarios; primarily because their probability of needing additional surgery over decades is higher. At the other end of the spectrum, older patients with realistic activity goals and manageable deformity may be excellent TAR candidates, if alignment and stability can be achieved.

Choosing the Correct Implant: “Different Names; Same Fundamentals”

Christopher F. Hyer, DPM, MS, FACFAS took on the part of TAR where surgeons may often feel pressure about; selecting an implant in an increasingly crowded landscape. He framed the market reality clearly: sometimes you can’t choose (contracts, committees, hospital standardization), and sometimes you shouldn’t choose lightly. His advice stressed that hands-on experience matters (labs, courses, visiting colleagues), and early-career surgeons should prioritize predictable cases over “hero” deformities while their complication profile is still being written.

Hyer’s most useful distillation was that, regardless of branding, successful implants still require the same “must-haves”:

• Stable platform/fixation
• Balanced ankle and surrounding soft tissues
• Accurate placement/alignment

He also discussed how design philosophy (eg, fixation strategy and surface/bone interface) affects stability under physiologic loading. Emerging work has examined how component design may influence micromotion and early failure modes such as subsidence/loosening—especially in low-profile constructs—reinforcing that fixation choices should reflect bone quality and deformity demands, not marketing.

Clinical pearl: Implant choice is not just “primary vs revision system.” Think forward: What is your revision path if this fails? Systems that allow modular exchange (where appropriate) and have a clear revision strategy can reduce future surgical complexity, especially in younger patients likely to outlive their first implant.

Patient-Specific Instrumentation: “Helpful Tool, Not Autopilot”

Matthew Sorensen, DPM, FACFAS tackled PSI candidly: it can be meaningfully helpful, especially for anatomies where preoperative planning helps clarify complex spatial relationships.

His most practical warning: PSI can create a false sense of security. A guide still has to “seat” correctly, and the surgeon still must verify alignment, balance, and execution. Sorenson urged the audience to actively engage with the planning process: review reports, question assumptions, and request changes rather than “signing off” passively.

The audience discussion sharpened this point further. Several surgeons noted that guides can feel less intuitive on the talar side, and that foot position during PSI use matters—without a traditional jig controlling alignment, it’s easier to drift into plantarflexion and “accept” a cut that subtly propagates error.

Clinical pearl: PSI planning isn’t just a pre-op checkbox. It’s a chance to:

• Confirm limb axis targets (mechanical vs anatomic) and understand how the plan was generated
• Identify bone defects or sclerosis patterns that may alter fixation strategy
• Anticipate technical obstacles (talar translation, tight posterior structures, gutter impingement)

Studies evaluating PSI show benefits may be context-dependent, especially among high-volume TAR surgeons who already have consistent workflows. This reinforced Sorenson’s central message: know yourself and your volume, and use PSI deliberately where it adds value.

Deformity Correction and Staging: “Win the Balance Game”

Steven Haddad, MD delivered the session’s most “systems-thinking” lecture: staging is less about an algorithm and more about orthopaedic risk management. He argued that TAR failure often comes down to a few recurring problems: component loosening, progressive deformity from unrecognized instability, and biologic compromise from extensive soft tissue or bony work.

A key reassurance: preoperative deformity severity is not destiny if the surgeon can reliably correct to a stable, neutral construct intraoperatively. The goal is not a perfect-looking x-ray for social media—it’s a mechanically stable ankle that can tolerate physiologic loads.

Because comparative staging data are limited, Haddad offered a common-sense framework:

• Don’t stage if deformity correction and stability are achievable safely in one setting.
• Stage when the first stage will significantly compromise vascularity/bone biology or when ligament reconstruction needs protected time to mature.
• Stage when midfoot/hindfoot reconstruction requires fixation that cannot tolerate early motion/weightbearing and would put the TAR at risk.

He stressed imaging and planning habits that reduce unpleasant surprises: full-length alignment imaging when indicated, stress views to quantify instability, and CT review that goes beyond “confirm arthritis” to assess sclerosis, defects, and bone quality.

Clinical pearl: Think like a chess player—map your opponent (the deformity) before you start the case. TAR does not “correct” the foot; it requires a corrected foot to succeed.

Reference

1. Goldberg AJ, Chowdhury K, Bordea E, Blackstone J, Brooking D, Deane EL, Hauptmannova I, Cooke P, Cumbers M, Skene SS, Doré CJ. Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT. Health Technol Assess. 2023;27(5):1-80. doi: 10.3310/PTYJ1146. PMID: 37022932; PMCID: PMC10150410.

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