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Hofmann S, Tecame A, Victor J, Seitlinger G, Innocenti B. Tibia rotational alignment in total knee arthroplasty: Delphi consensus statements from European Knee Society (EKS). Arch Orthop Trauma Surg 2025; 145:221. [PMID: 40175566 DOI: 10.1007/s00402-025-05826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 03/07/2025] [Indexed: 04/04/2025]
Abstract
Rotational alignment of the tibial component during total knee arthroplasty (TKA) is critical for ensuring optimal tibiofemoral and patellofemoral joint function. Proper alignment minimizes the risk of tibiofemoral mismatch and patellofemoral instability, which can lead to increased joint stress and compromised kinematics. Traditionally, the tibial tubercle axis (TTA) has been the primary landmark for alignment. However, recent insights into knee three-dimensional anatomy reveal significant variability in TTA positioning, challenging its reliability. This study employs a Delphi consensus methodology among European Knee Society (EKS) experts to address key questions regarding tibial rotational alignment in TKA. Through a systematic literature review and expert discussions, a strong consensus was achieved on three main points: (1) optimal alignment should target both the perpendicularity of the anteroposterior tibial axis to the femoral flexion/extension axis and the accurate positioning of the tibial tubercle relative to the femoral trochlea; (2) while the TTA is effective in 70% of cases, its variability in 30% of knees necessitates alternative strategies; (3) current computer-assisted and robotic technologies do not significantly enhance alignment outcomes. These findings emphasize the importance of individualized assessment of rotational deformities and highlight the potential of advanced data analytics to improve future alignment strategies. The consensus underscores the complexity of achieving optimal tibial alignment and the need for continued research to refine surgical techniques and technologies.
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Affiliation(s)
- Siegfried Hofmann
- Orthopedic Department, LKH Murtal-Stolzalpe, Standort Stolzalpe, 8352, Stolzalpe, Stolzalpe 77, Austria
| | - Andrea Tecame
- Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Piazzale Athos Maestri, 5, 43123, Parma, Italy
| | - Jan Victor
- Department Orthopedic Surgery, University Hospital Ghent, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Gerd Seitlinger
- Privatklinik Wehrle-Diakonissen, Standort Aigen, Guggenbichlerstrasse 20, 5026, Salzburg, Austria
| | - Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), École Polytechnique de Bruxelles, Université Libre de Bruxelles, Av. F. Roosevelt, 50 CP165/56, 1050, Brussels, Belgium.
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Stauss R, Savov P, Ettinger M. [New technologies in total knee arthroplasty : Current concepts and personalized treatment strategies]. ORTHOPADIE (HEIDELBERG, GERMANY) 2025; 54:190-198. [PMID: 39961906 DOI: 10.1007/s00132-025-04618-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2025] [Indexed: 02/28/2025]
Abstract
BACKGROUND In total knee arthroplasty (TKA), there is a trend towards personalized concepts. This includes the implementation of new technologies and the increasing popularity of individualized alignment strategies. TARGETS The purpose of personalized TKA is to restore the patient's bony anatomy and constitutional alignment, as well as the physiological soft tissue balance and joint kinematics. Modern technologies facilitate a thorough, three-dimensional analysis of the bony structures and the patient's constitutional alignment. Virtual planning enables a simulation component placement, gap balancing and postoperative alignment. After approval of the surgical plan, the technology-aided execution shows a greater accuracy, precision and reproducibility of implant alignment compared to conventional manual instrumentation. OVERVIEW This article focuses on novel technologies in total knee arthroplasty, including patient-specific instrumentation (PSI), custom implants, navigation and robotics. The purpose of this article is to summarize current evidence, including radiological and functional outcomes, as well as economic aspects. Furthermore, the implementation of novel technologies in the context of personalized alignment strategies will be discussed.
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Affiliation(s)
- Ricarda Stauss
- Universitätsklinik für Orthopädie im Pius Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Deutschland.
| | - Peter Savov
- Universitätsklinik für Orthopädie im Pius Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Deutschland
| | - Max Ettinger
- Universitätsklinik für Orthopädie im Pius Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Deutschland
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Yasuma S, Kato S, Usami T, Hattori Y, Joyo Y, Shiraga H, Nozaki M, Murakami H, Waguri-Nagaya Y. Internal rotational patellar resection and patella alta induced patellar maltracking in total knee arthroplasty: intraoperative measurement of the patellofemoral pressure. Knee Surg Relat Res 2024; 36:25. [PMID: 39175088 PMCID: PMC11342663 DOI: 10.1186/s43019-024-00231-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 08/11/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Anterior knee pain due to patellar maltracking following total knee arthroplasty (TKA) reduces patients' satisfaction. This study aimed to determine the patellofemoral pressure (PFP) in patients with favorable patellar tracking (FT) and impaired patellar tracking (IT) following TKA, the factors causing patellar maltracking, and the effect of lateral retinacular release (LRR) on patients with IT. METHODS Forty-four patients with varus knee osteoarthritis undergoing cruciate-retaining TKA were enrolled. After component implantation, patients with a separation of ≥ 2 mm of the patellar medial facet from the medial femoral trochlea throughout knee range of motion were classified into the IT group; meanwhile, the others were classified into the FT group. PFP was measured intraoperatively in three phases: (1) with the resurfaced patella (RP); (2) with the resurfaced patella and knee (RPK); and (3) when LRR was performed in IT (post-LRR). The PFPs at 0°, 90°, 120°, and 135° knee flexion were compared between FT and IT using the Mann-Whitney U test. Pairwise comparison of the PFP in IT between RPK and post-LRR was performed using the Wilcoxon signed-rank test. Correlations between PFP and pre- and postoperative radiographic parameters, such as hip-knee-ankle angle, lateral distal femoral angle, medial proximal tibial angle, anterior femoral offset, Insall-Salvati ratio (ISR), patellar tilt, and patellar resection angle (PRA), were evaluated using Spearman's rank correlation coefficients. RESULTS High lateral PFP in the knee flexion position led to patellar maltracking. Patients with IT (n = 24) had higher lateral and lower medial PFP than did patients with FT (n = 20) at 90°, 120°, and 135° knee flexion in RP and RPK. LRR in IT reduced the lateral PFP in the knee flexion position. PRA and ISR were correlated with the lateral PFP at no less than 90° in RP and RPK. CONCLUSIONS This study demonstrated that internal rotational patellar resection, which resulted in a thick medial patellar remnant and a thin lateral counterpart, and patella alta were the causative factors of high lateral PFP, which induced patellar maltracking after TKA. Surgeons should avoid internal rotational patellar resection to achieve FT and perform LRR in patients with patellar maltracking.
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Affiliation(s)
- Sanshiro Yasuma
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Sakurako Kato
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Takuya Usami
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Yusuke Hattori
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Yuji Joyo
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Hiroo Shiraga
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan
| | - Masahiro Nozaki
- Department of Orthopaedic Surgery, Nagoya City University, Kawasumi 1, Mizuho-Cho, Mizuho, Nagoya, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University, Kawasumi 1, Mizuho-Cho, Mizuho, Nagoya, Japan
| | - Yuko Waguri-Nagaya
- Department of Orthopaedic Surgery, Nagoya City University East Medical Center, 2-23 Wakamizu 1, Chikusa, Nagoya, Japan.
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Hess S, Husarek J, Müller M, Eberlein SC, Klenke FM, Hecker A. Applications and accuracy of 3D-printed surgical guides in traumatology and orthopaedic surgery: A systematic review and meta-analysis. J Exp Orthop 2024; 11:e12096. [PMID: 39135870 PMCID: PMC11317891 DOI: 10.1002/jeo2.12096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 08/15/2024] Open
Abstract
Background Patient-Specific Surgical Guides (PSSGs) are advocated for reducing radiation exposure, operation time and enhancing precision in surgery. However, existing accuracy assessments are limited to specific surgeries, leaving uncertainties about variations in accuracy across different anatomical sites, three-dimensional (3D) printing technologies and manufacturers (traditional vs. printed at the point of care). This study aimed to evaluate PSSGs accuracy in traumatology and orthopaedic surgery, considering anatomical regions, printing methods and manufacturers. Methods A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were eligible if they (1) assessed the accuracy of PSSGs by comparing preoperative planning and postoperative results in at least two different planes (2) used either computer tomography or magnetic resonance imaging (3) covered the field of orthopaedic surgery or traumatology and (4) were available in English or German language. The 'Quality Assessment Tool for Quantitative Studies' was used for methodological quality assessment. Descriptive statistics, including mean, standard deviation, and ranges, are presented. A random effects meta-analysis was performed to determine the pooled mean absolute deviation between preoperative plan and postoperative result for each anatomic region (shoulder, hip, spine, and knee). Results Of 4212 initially eligible studies, 33 were included in the final analysis (8 for shoulder, 5 for hip, 5 for spine, 14 for knee and 1 for trauma). Pooled mean deviation (95% confidence interval) for total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), total hip arthroplasty (THA) and spine surgery (pedicle screw placement during spondylodesis) were 1.82° (1.48, 2.15), 2.52° (1.9, 3.13), 3.49° (3.04, 3.93) and 2.67° (1.64, 3.69), respectively. Accuracy varied between TKA and THA and between TKA and TSA. Conclusion Accuracy of PSSGs depends on the type of surgery but averages around 2-3° deviation from the plan. The use of PSSGs might be considered for selected complex cases. Level of Evidence Level 3 (meta-analysis including Level 3 studies).
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Affiliation(s)
- Silvan Hess
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Julius Husarek
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- Faculty of MedicineUniversity of BernBernSwitzerland
- Faculty of MedicineMedical University of SofiaSofiaBulgaria
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Sophie C. Eberlein
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Frank M. Klenke
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Andreas Hecker
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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Lei K, Liu LM, Luo JM, Ma C, Feng Q, Yang L, Guo L. Could surgical transepicondylar axis be identified accurately in preoperative 3D planning for total knee arthroplasty? A reproducibility study based on 3D-CT. ARTHROPLASTY 2022; 4:46. [PMID: 36244969 PMCID: PMC9575283 DOI: 10.1186/s42836-022-00147-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical transepicondylar axis (sTEA) is frequently used for positioning of femoral component rotation in total knee arthroplasty (TKA). Previous studies showed that intraoperative identification of sTEA was not reliable. While surgeons or engineers need to identify sTEA with three-dimensional (3D) computer-aid techniques pre- or intraoperatively, the reproducibility of sTEA identification on preoperative 3D images has not been explored yet. This study aimed to investigate the reproducibility of identifying sTEA in preoperative planning based on computed tomography (CT). METHODS Fifty-nine consecutive patients (60 knees involved) who received TKA in our center from April 2019 to June 2019 were included in this study. Six experienced TKA surgeons identified sTEA three times on 3D model established on the basis of knee CT data. The projection angle of each sTEA and the posterior condyle axis on the transverse plane were measured and analyzed. RESULTS The overall intra-observer reproducibility was moderate. The median intra-observer variation was 1.27°, with a maximum being up to 14.07°. The median inter-observer variation was 1.24°, and the maximum was 11.47°. The overall intra-class correlation coefficient (ICC) for inter-observer was 0.528 (95% CI 0.417, 0.643). CONCLUSION The identification of sTEA on a 3D model established on the basis of knee CT data may not be reliable. Combined with the previous cadaveric and surgical studies, caution should be exercised in determining femoral component rotation by referencing sTEA both preoperatively and intraoperatively. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kai Lei
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Li Ming Liu
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Jiang Ming Luo
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Chao Ma
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Qing Feng
- grid.410570.70000 0004 1760 6682Minimally Invasive Gastrointestinal Surgery Center, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Liu Yang
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
| | - Lin Guo
- grid.410570.70000 0004 1760 6682Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038 China
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Xin L, Xingjia M, Shengjie G, Yanwei C, Shuaijie L, Chuan X. Comparison of Tibial Tubercle Landmark Technique and Range of Motion Technique in Primary Total Knee Arthroplasty: A Retrospective Cohort Study. Orthop Surg 2022; 14:3159-3170. [PMID: 36238972 PMCID: PMC9732623 DOI: 10.1111/os.13486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE There is not a standard for rotational alignment of the tibial component in total knee arthroplasty (TKA). For now, the most commonly methods are tibial-tubercle -landmark technique (TTL) and range-of-motion technique (ROM). The study is aimed to compare clinical outcomes and radiographic data of patients who undergone primary TKA with TTL or ROM technique. METHODS This single-surgeon retrospective cohort study includes 60 patients with TTL technique and 60 with ROM technique from December 2017 to January 2019. All patients were evaluated clinically using Hospital for Special Surgery Knee Score (HSS), Feller patellar score, visual analogue scale (VAS) and maximum knee flexion and extension angle before and after surgery at both 6 months and 12 months postoperatively. Radiographic data contain hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), posterior slope angle (PSA) on pre and postoperative X-ray and rotation angle of femoral component (relative to surgical trans-epicondylar axis) and tibial component (relative to surgical trans-epicondylar axis, tibial posterior condylar line and Akagi') on postoperative computed tomography (CT) scan. Clinical outcomes and radiological data were compared between the two groups. RESULTS One hundred twenty patients (120 knees) were enrolled in this study, including 38 males and 82 females, aged from 58 to 78, with an average of 65.7 years. There was no significant difference in demographics and preoperative X-ray data between the two groups (P > 0. 05). Clinical scores of the TTL group were better than those in the ROM group at 6 and 12 months after surgery, when comparing HSS (83.57 ± 5.00 vs 75.90 ± 4.89, F = 59.004, P < 0.001; 90.53 ± 4.31 vs 82.83 ± 4.98, F = 54.509, P < 0.001), Feller patellar score (21.43 ± 2.54 vs 19.10 ± 2.52, F = 14.864, P = 0.001; 26.27 ± 1.98 vs 23.20 ± 2.31, F = 42.204, P < 0.001) and VAS (3.70 ± 0.62 vs 4.38 ± 0.92, F = 14.508, P = 0.001; 2.10 ± 0.90 vs 2.79 ± 0.80, F = 11.554, P = 0.002). But there was no significant difference in the flexion and extension angle between the two groups. In imaging evaluation, no statistical difference was found in pre- and postoperative HKA, mLDFA, mMPTA and PSA. Rotational angles of tibial component only did relative to Akagi' have statistical difference in two groups (2.33 ± 4.3 vs 4.41 ± 3.2, t = 2.143, P < 0.05) (Positive value represented external rotation). CONCLUSION The results of our study showed that both methods were reliable, and TTL technique provided better clinical scores and larger external angle of tibial component, compared to ROM technique.
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Affiliation(s)
- Liu Xin
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Mao Xingjia
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Guo Shengjie
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Cao Yanwei
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Li Shuaijie
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Xiang Chuan
- Department of Orthopaedic SurgeryThe Second Hospital of Shanxi Medical UniversityTaiyuanChina
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Wen L, Wang Z, Ma D, Qu T. Surgeon Dominated Design Can Improve the Accuracy of Patient-Specific Instruments in Kinematically Aligned TKA. J Pers Med 2022; 12:jpm12081192. [PMID: 35893286 PMCID: PMC9332028 DOI: 10.3390/jpm12081192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/04/2022] [Accepted: 07/16/2022] [Indexed: 11/16/2022] Open
Abstract
Precise bone resection is mandatory for kinematically aligned total knee arthroplasty (KA-TKA). This study is to investigate whether surgeon-dominated design can alter the accuracy of patient-specific instrumentation (PSI) in KA-TKA compared with the engineer design. A total of 24 patients (24 knees) who underwent KA-TKA in our institution were assigned to an engineer design group (10 knees) and surgeon design group (14 knees) chronologically. A novel portable medical-engineer interactive application can greatly enhance the surgeon’s participation in PSI design. The bone resection discrepancies were used to evaluate the accuracy of PSI in bone resection. The overall discrepancy of bone resection was reduced by surgeon-designed PSI compared to engineer-designed PSI by 0.33 mm. Surgeon-designed PSI seems to reduce the outliers in terms of relative discrepancies in bone resection as well, but it does not reach statistical significance. Moreover, surgeon-designed PSI could significantly improve the accuracy of PSI in the restoration of the joint line in terms of medial proximal tibial angle and mechanical lateral distal femoral angle. This study indicates that the dominance of surgeons in both PSI design and subsequent surgical operation should be emphasized in efforts to improve the accuracy of PSI.
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Affiliation(s)
- Liang Wen
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
| | - Zhiwei Wang
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
- Correspondence: ; Tel.: +86-10-85231228
| | - Desi Ma
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
| | - Tiebing Qu
- The Center of Diagnosis and Treatment for Joint Disease, China Rehabilitation Research Center, Beijing 100068, China;
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Mizu-Uchi H, Ma Y, Ishibashi S, Colwell CW, Nakashima Y, D'Lima DD. Tibial sagittal and rotational alignment reduce patellofemoral stresses in posterior stabilized total knee arthroplasty. Sci Rep 2022; 12:12319. [PMID: 35854017 PMCID: PMC9296446 DOI: 10.1038/s41598-022-15759-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Patellofemoral joint complications remain an important issue in total knee arthroplasty. We compared the patellofemoral contact status between cruciate-retaining and posterior-stabilized designs with varying degrees of tibial sagittal and rotational alignment using a computer simulation to ensure proper alignments in total knee arthroplasty. Knee kinematics, patellofemoral contact force and quadriceps force were computed using a musculoskeletal modeling program (LifeMOD/KneeSIM 2010; LifeModeler, Inc., San Clemente, California) during a weight-bearing deep knee bend. Two different posterior tibial slope (PTS)s (3° and 7°) and five different tibial tray rotational alignments (neutral, internal 5° and 10°, and external 5° and 10°) were simulated. Patellofemoral contact area and stresses were next computed using finite element analysis. The patellofemoral contact force for the posterior-stabilized design was substantially lower than the cruciate-retaining design after post-cam contact because of increasing femoral roll-back. Neutral rotational alignment of the tibial component resulted in smaller differences in patellofemoral contact stresses between cruciate-retaining and posterior-stabilized designs for PTSs of 3° or 7°. However, the patellar contact stresses in the cruciate-retaining design were greater than those in posterior-stabilized design at 120° of knee flexion with PTS of 3° combined with internal rotation of the tibial component. Our study provides biomechanical evidence implicating lower PTSs combined with internal malrotation of the tibial component and the resultant increase in patellofemoral stresses as a potential source of anterior knee pain in cruciate-retaining design.
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Affiliation(s)
- Hideki Mizu-Uchi
- Department of Orthopaedic Surgery, Saiseikai Fukuoka General Hospital, 1-3-46, Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan.,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yuan Ma
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shojiro Ishibashi
- Department of Orthopaedic Surgery, Saiseikai Fukuoka General Hospital, 1-3-46, Tenjin, Chuo-ku, Fukuoka, 810-0001, Japan.,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Clifford W Colwell
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, 10666 North Torrey Pines Road, MS126, La Jolla, CA, 92037, USA
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, 10666 North Torrey Pines Road, MS126, La Jolla, CA, 92037, USA.
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9
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Gauci MO. Patient-specific guides in orthopedic surgery. Orthop Traumatol Surg Res 2022; 108:103154. [PMID: 34838754 DOI: 10.1016/j.otsr.2021.103154] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/10/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
The interest of patient-specific guides (PSGs) lies in reliable intraoperative achievement of preoperative planning goals. They are a form of instrumentation optimizing intraoperative precision and thus improving the safety and reproducibility of surgical procedures. Clinical superiority, however, has not been demonstrated. The various steps from design to implementation leave room for error, which needs to be known and controlled by the surgeon who is responsible for final outcome. Instituting large-scale patient-specific surgery requires management systems for guides and innovative implants which cannot be a simple extension of current practices. We shall approach the present state of knowledge regarding PSGs via 5 questions: (1) What is a PSG? Single-use instrumentation produced after preoperative planning, aiming exclusively to optimize procedural exactness. (2) How to use and assess PSGs in orthopedic surgery? Strict rules of use must be adhered to. Any deviation from the predefined objective is, necessarily, an error that must be identified as such. (3) Do PSGs provide greater surgical exactness? The contribution of PSGs varies greatly between procedures. Exactness is enhanced in the spine, in osteotomies around the knee and in bone-tumor surgery. In the shoulder, their contribution is seen only in complex cases. Data are sparse for hip replacement, and controversial for knee replacement. (4) What are the expected benefits of PSGs? As well as improving exactness, PSGs allow a lower radiation dose and shorter operating time. They also enable junior surgeons to train in techniques otherwise reserved to hyperspecialists. (5) How to include PSGs in everyday practice? As well as their potential clinical interest, PSGs involve deep changes in organization, equipment provision and economic model. LEVEL OF EVIDENCE: V; expert opinion.
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Affiliation(s)
- Marc-Olivier Gauci
- Institut Universitaire Locomoteur et du Sport (IULS), CHU de Nice, Unité de Recherche Clinique Côte d'Azur (UCA), Hôpital Pasteur II, 30, voie Romaine, 06000 Nice, France.
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10
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Hu Y, Song D, Liu Y, Zhao Y, Ma W, Yang Y, Yuan Z. Spacer-based gap balancing is useful in total knee arthroplasty: a 3-year follow-up of a retrospective study. J Orthop Surg Res 2021; 16:633. [PMID: 34674736 PMCID: PMC8532342 DOI: 10.1186/s13018-021-02788-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Which technique, gap balancing or measured resection, can obtain better femoral component alignment and soft tissue balance in total knee arthroplasty (TKA) is still controversial. This study aimed to determine whether the gap balancing technique using a modified spacer block in TKA can result in better postoperative clinical outcomes than the measured resection technique. Methods A total of 124 patients who underwent consecutive primary TKA between May 2016 and August 2018 were retrospectively reviewed. The gap balancing technique assisted by a modified spacer block was used in 61 patients, and the measured resection technique was used in 63 patients. The surgical, imaging and knee function outcomes of the two groups were compared. Results The thickness of the posterior medial condyle bone resection using the modified spacer block tool in gap balancing was significantly larger than that of the MR technique (P = 0.001). Compared with the measured resection group, the gap balancing group had a greater external rotation resection angle of the femur (4.06 ± 1.10° vs. 3.19 ± 0.59°, P < 0.001°). Despite these differences, the mean ROM, KSS scores, and WOMAC scores at the 6-week, 1-year, and 2-year follow-ups were not significantly different. Postoperatively, there was no significant difference between the two groups in mechanical axis measurements (P = 0.275), the number of HKA outliers (P = 0.795) or the joint line displacement (P = 0.270). Conclusion The functional outcomes of the gap balancing technique based on the modified spacer are similar to those of measured resection at 3 years. Compared with the MR technique, the GB technique resulted in a greater external rotation resection angle and thicker posterior medial condylar cuts in TKA with knee varus.
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Affiliation(s)
- Yanhui Hu
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China
| | - Da Song
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China
| | - Yi Liu
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China
| | - Yong Zhao
- Department of Orthopaedics, Linqing People's Hospital, Liaocheng, Shandong, China
| | - Wenpu Ma
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China
| | - Yiqun Yang
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China
| | - Zhenfeng Yuan
- Department of Orthopaedics, Liaocheng People's Hospital, 67 Dongchang West Road, Liaocheng, 252000, Shandong, China.
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11
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Tanifuji O, Mochizuki T, Yamagiwa H, Sato T, Watanabe S, Hijikata H, Kawashima H. Comparison of post-operative three-dimensional and two-dimensional evaluation of component position for total knee arthroplasty. Knee Surg Relat Res 2021; 33:21. [PMID: 34256872 PMCID: PMC8278642 DOI: 10.1186/s43019-021-00106-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the post-operative three-dimensional (3D) femoral and tibial component positions in total knee arthroplasty (TKA) by the same co-ordinates' system as for pre-operative planning and to compare it with a two-dimensional (2D) evaluation. MATERIALS AND METHODS Sixty-five primary TKAs due to osteoarthritis were included. A computed tomography (CT) scan of the femur and tibia was obtained and pre-operative 3D planning was performed. Then, 3D and 2D post-operative evaluations of the component positions were performed. KneeCAS (LEXI, Inc., Tokyo, Japan), a lower-extremity alignment assessment system, was used for the 3D post-operative evaluation. Standard short-knee radiographs were used for the 2D post-operative evaluation. Differences between the pre-operative planning and post-operative coronal and sagittal alignment of components were investigated and compared with the results of the 3D and 2D evaluations. RESULTS According to the 3D evaluation, the difference between the pre-operative planning and actual post-operative sagittal alignment of the femoral component and the coronal and sagittal alignments of the tibial component were 2.6° ± 1.8°, 2.2° ± 1.8° and 3.2° ± 2.4°, respectively. Using the 2D evaluation, they were 1.9° ± 1.5°, 1.3° ± 1.2° and 1.8° ± 1.4°, making the difference in 3D evaluation significantly higher (p = 0.013, = 0.003 and < 0.001). For the sagittal alignment of the femoral component and the coronal and sagittal alignment of the tibial component, the outlier (> ± 3°) ratio for the 3D evaluation was also significantly higher than that of the 2D evaluation (p < 0.001, = 0.009 and < 0.001). CONCLUSIONS The difference between the pre-operative planning and post-operative component alignment in the 3D evaluation is significantly higher than that of the 2D, even if the same cases have been evaluated. Two-dimensional evaluation may mask or underestimate the post-operative implant malposition. Three-dimensional evaluation using the same co-ordinates' system as for pre-operative planning is necessary to accurately evaluate the post-operative component position.
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Affiliation(s)
- Osamu Tanifuji
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori Chuo-ku, Niigata City, Niigata, 951-8510, Japan.
| | - Tomoharu Mochizuki
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Hiroshi Yamagiwa
- Department of Orthopedic Surgery, Saiseikai Niigata Hospital, Niigata, Japan
| | - Takashi Sato
- Department of Orthopedic Surgery, Niigata Medical Center, Niigata, Japan
| | - Satoshi Watanabe
- Department of Orthopedic Surgery, Niigata Medical Center, Niigata, Japan
| | - Hiroki Hijikata
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori Chuo-ku, Niigata City, Niigata, 951-8510, Japan
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12
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Patientenspezifische Instrumentierung und Totalendoprothesen am Knie. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Zusammenfassung
Hintergrund
Die patientenspezifische Instrumentierung (PSI) ist eine vielversprechende neue Technologie in der orthopädischen Chirurgie, die das Ziel verfolgt, die Implantationstechnik der Knietotalendoprothese (Knie-TEP) im Vergleich zur konventionellen Instrumentierung zu vereinfachen und präziser zu machen. Ziel dieses Artikels ist es, Vorteile und Grenzen der PSI für die primäre Knie-TEP zu beschreiben.
Material und Methoden
Es erfolgte eine umfassende Literaturrecherche zum Thema PSI in der Knieprothetik hinsichtlich Evidenz für Planung, Präzision, klinische Ergebnisse, intraoperative Parameter sowie Kosten und Effizienz.
Ergebnisse
Die dreidimensionale Computertomographie (CT) weist in der präoperativen Planung der Knie-TEP eine höhere Genauigkeit auf als 2‑D-Röntgenaufnahmen. Die meisten Arbeiten postulierten keine signifikanten Effekte zugunsten der Genauigkeit der PSI gegenüber der Standard-Knie-TEP. Aber sie berichteten auch nicht, dass die Genauigkeit mit PSI schlechter sei. Hinsichtlich des klinischen Outcomes gibt es genügend Konsens unter den veröffentlichten Studien, um festzuhalten, dass es kurz- und mittelfristig keinen Unterschied zwischen Patienten gibt, die mit PSI oder konventioneller Technik operiert wurden. Eine große Metaanalyse konnte weder eine kürzere Operationszeit noch eine geringere Komplikationsrate für die PSI-Knie-TEP feststellen. Lediglich der intraoperative Blutverlust erwies sich als niedriger im Vergleich zur Standardtechnik, jedoch mit unveränderter Transfusionsrate. Kosteneffektivitätsanalysen lassen schlussfolgern, dass die PSI aktuell (noch) nicht kosteneffektiv ist.
Diskussion
Obwohl die aktuell vorliegenden Studienergebnisse die PSI-Technologie hinsichtlich vieler messbaren Kriterien nicht eindeutig von der Standardtechnik abheben, zeigt die PSI viele theoretische und praktische Vorteile.
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Sezer HB, Bohu Y, Hardy A, Lefevre N. Knee Prosthesis in the Computer Era. Orthop Surg 2021; 13:395-401. [PMID: 33506615 PMCID: PMC7957434 DOI: 10.1111/os.12762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/11/2022] Open
Abstract
Over the past two decades, computer assistance has revolutionalized surgery and has enabled enormous advancements in knee prosthesis surgery. Total knee arthroplasty (TKA) is a hot topic of orthopaedic research. Reflecting population dynamics, its use continues to increase, especially in high demand populations. Therefore, efforts to achieve the best fit and precise alignment in TKA continue. Computer assistance is valuable for knee prosthesis surgeons in this regard. This manuscript investigated the use of computer assistance in knee prosthesis surgery. The effects of computer use on important facets of knee prosthesis surgery, such as precision, clinical aspects, and costs, were examined. Moreover, an overall review of the recent literature on the navigation and personalized cutting guides was conducted.
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Affiliation(s)
| | - Yoann Bohu
- Clinique du Sport Paris VParisFrance
- Institut de L'Appareil Locomoteur NolletParisFrance
| | - Alexandre Hardy
- Clinique du Sport Paris VParisFrance
- Institut de L'Appareil Locomoteur NolletParisFrance
| | - Nicolas Lefevre
- Clinique du Sport Paris VParisFrance
- Institut de L'Appareil Locomoteur NolletParisFrance
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14
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León-Muñoz VJ, Parrinello A, Manca S, Galloni G, López-López M, Martínez-Martínez F, Santonja-Medina F. Patient-Specific Instrumentation Accuracy Evaluated with 3D Virtual Models. J Clin Med 2021; 10:jcm10071439. [PMID: 33916110 PMCID: PMC8036812 DOI: 10.3390/jcm10071439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022] Open
Abstract
There have been remarkable advances in knee replacement surgery over the last few decades. One of the concerns continues to be the accuracy in achieving the desired alignment. Patient-specific instrumentation (PSI) was developed to increase component placement accuracy, but the available evidence is not conclusive. Our study aimed to determine a PSI system’s three-dimensional accuracy on 3D virtual models obtained by post-operative computed tomography. We compared the angular placement values of 35 total knee arthroplasties (TKAs) operated within a year obtained with the planned ones, and we analyzed the possible relationships between alignment and patient-reported outcomes. The mean (SD) discrepancies measured by two experienced engineers to the planned values observed were 1.64° (1.3°) for the hip–knee–ankle angle, 1.45° (1.06°) for the supplementary angle of the femoral lateral distal angle, 1.44° (0.97°) for the proximal medial tibial angle, 2.28° (1.78°) for tibial slope, 0.64° (1.09°) for femoral sagittal flexion, and 1.42° (1.06°) for femoral rotation. Neither variables related to post-operative alignment nor the proportion of change between pre-and post-operative alignment influenced the patient-reported outcomes. The evaluated PSI system’s three-dimensional alignment analysis showed a statistically significant difference between the angular values planned and those obtained. However, we did not find a relevant effect size, and this slight discrepancy did not impact the clinical outcome.
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Affiliation(s)
- Vicente J. León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Correspondence:
| | - Andrea Parrinello
- Product Management Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland;
| | - Silvio Manca
- Patient Matched Technology Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland; (S.M.); (G.G.)
| | - Gianluca Galloni
- Patient Matched Technology Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland; (S.M.); (G.G.)
| | - Mirian López-López
- Subdirección General de Tecnologías de la Información, Servicio Murciano de Salud, Avenida Central, 7, Edificio Habitamia, Espinardo, 30100 Murcia, Spain;
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
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15
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Distal femoral valgus cut angles unreliable in total knee arthroplasty. J Orthop 2021; 24:29-33. [PMID: 33679025 DOI: 10.1016/j.jor.2021.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/07/2021] [Indexed: 11/20/2022] Open
Abstract
We hypothesized that valgus distal femoral cut angle made using a conventional cutting guide would be reproducible in a Sawbone model, regardless of training level. 3°, 5°, or 7° valgus cuts were made on lower extremity Sawbone specimens and were measured with radiographic imaging. 66 patient radiographs were also analyzed to compare pre and post-operative femoral cut angles, and VR12 measurements from each patient were collected. All femoral cuts deviated significantly from target cuts. Also, pre-TKA valgus angles showed no correlation with the angles post-TKA, and final cut angle did not correlate with functional outcomes at 1 year post-surgery.
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Ferràs-Tarragó J, Sabalza-Baztán O, Sahuquillo-Arce JM, Angulo-Sánchez MÁ, Amaya-Valero J, De-La-Calva Ceinos C, Baixauli-García F. Security of 3D-printed polylactide acid piece sterilization in the operating room: a sterility test. Eur J Trauma Emerg Surg 2021; 48:3895-3900. [PMID: 33452547 DOI: 10.1007/s00068-020-01564-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION 3D-printing technology has become very popular the last 10 years, and their advantages have been widely proved. However, its safety in the operating room after sterilization has not been evaluated. Thus, the use of 3D printing is still questioned. The aim of this work is to evaluate the security of polylactic acid (PLA) to print surgical models after its sterilization. MATERIALS AND METHODS One hundred and eighty-six PLA plates and 6 negative controls without microorganisms were seeded. After 10 days of culture, the PLA plates were randomized into three groups: A, B, and C. Group A underwent a sterilization process using an autoclave program at 134 °C. Group B was seeded in different culture media and group C was used to make crystal violet stains on the biofilms formed on the PLA. Mechanical properties of PLA after autoclave sterilization including, the breaking load, deformation and breaking load per surface were calculated. RESULTS Hundred percent of the group B showed monomicrobial growth. Stains performed on group C PLA showed biofilms in all PLA pieces. After sterilization, no pathogen growth was observed in group A during the culture observation period showing 100% sterilization effectiveness. A filling percentage of 5% obtained a breaking load of 6.36 MPa, and its elastic limit occurred after an elongation of 167.4%. A 10% infill was mechanically safe. CONCLUSIONS Autoclave sterilization of PLA-printed pieces is safe for the patient and mechanically strong for the surgeon. This is the first 3D-printing protocol described and evaluated to implement 3D-printing technology safely in the operating room. SIGNIFICANCE AND IMPACT OF STUDY This is the first 3D-printing protocol described to print and sterilize 3D biomodels using an autoclave showing its biological safety and its mechanical resistance.
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Affiliation(s)
- Joan Ferràs-Tarragó
- Orthopaedic Surgery and Traumatology. Hospital La Fe, Av Fernando Abril Martorell 106, Valencia, Spain.
| | | | | | | | - Jose Amaya-Valero
- Orthopaedic Surgery and Traumatology. Hospital La Fe, Av Fernando Abril Martorell 106, Valencia, Spain
| | | | - Francisco Baixauli-García
- Orthopaedic Surgery and Traumatology. Hospital La Fe, Av Fernando Abril Martorell 106, Valencia, Spain
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Lei K, Liu LM, Xiang Y, Chen X, Fan HQ, Peng Y, Luo JM, Guo L. Clinical value of CT-based patient-specific 3D preoperative design combined with conventional instruments in primary total knee arthroplasty: a propensity score-matched analysis. J Orthop Surg Res 2020; 15:591. [PMID: 33298106 PMCID: PMC7724895 DOI: 10.1186/s13018-020-02123-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/25/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To evaluate the operation and early clinical effect in primary total knee arthroplasty (TKA) about the novel combination of CT-based patient-specific three-dimensional (3D) preoperative design and conventional osteotomy instruments, compared with the conventional method. Methods After a 1:1 propensity score-matching (PSM), patients were matched to the novel technique group and the conventional group, 109 cases in each group. The conventional group adopted a preoperative design based on a full-length radiograph (FLX) and received TKA with conventional osteotomy instruments. The novel technique group used a CT-based patient-specific 3D preoperative design combined with conventional osteotomy instruments; during the surgery, the femoral entry point, femoral valgus osteotomy angle, the fix point of tibial plateau extramedullary guide pin, and the position of tibial extramedullary positioning rod were accurately selected according to the preoperative 3D design to ensure accurate intraoperative implementation. The lower limb alignment, component position, operation time, tourniquet time, hospital stay, blood loss volume, incidence of postoperative complications, visual analog scale (Vas) score, and New Knee Society Score System (NEW-KSS) at 1 day before operation and 1, 6, and 12 months after operation were recorded and compared. Results The novel technique group was significantly better than the conventional group in controlling lateral tibial component angle (LTC) (P < 0.001), and the novel technique group had lower percentages of hip-knee-ankle angle (HKA) outliers (P < 0.001) and overcorrection (P = 0.003). The operation time, tourniquet time, and hospital stay of the novel technique group was shorter (P < 0.05). In 1 month after the operation, the novel technique group achieved a significantly better VAS score (P < 0.05), but a similar NEW-KSS score (P > 0.05) when compared with the conventional group. But in 6 and 12 months after surgery, no statistical differences were seen in the above two scores (P > 0.05). Conclusion The novel technique of CT-based patient-specific 3D preoperative design combined with conventional instruments can improve the accuracy of osteotomy in primary total knee arthroplasty, with benefits of significantly reducing pain and rapid recovery during the early postoperative period, but having no obvious effect on outcome after a 1-year follow-up.
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Affiliation(s)
- Kai Lei
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Li Ming Liu
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Yi Xiang
- Department of Orthopaedics, Logistic Support Forces of the Chinese PLA 985 Hospital, No. 30 Qiaodong Street, Taiyuan, 030001, Shanxi, China
| | - Xin Chen
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Hua Quan Fan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Yang Peng
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Jiang Ming Luo
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Lin Guo
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China.
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刘 欣, 郭 升, 李 帅, 曹 晏, 向 川. [Progress in the method of tibial prosthesis rotation alignment in total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1200-1204. [PMID: 32929917 PMCID: PMC8171723 DOI: 10.7507/1002-1892.201911058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/27/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To summarize the methods of tibial prosthesis rotation alignment in total knee arthroplasty, and provide reference for clinicians to select and further study the methods of tibial prosthesis rotation alignment. METHODS The advantages and disadvantages of various tibial prosthesis rotation alignment methods were analyzed and summarized by referring to the relevant literature at home and abroad in recent years. RESULTS There are many methods for tibial prosthesis rotation alignment, including reference to relevant anatomical landmarks, range of motion (ROM) technique, computer-assisted navigation, and personalized osteotomy. The inner one-third of the tibial tuberosity is a more accurate reference anatomical landmark, but the obesity, severe knee deformity and dysplasia have impacts on the precise placement of the tibial prosthesis. ROM technique do not need to refer to the anatomical landmark of the tibia, and aren't affected by landmark variation. It can be used for severe knee valgus deformity and the landmarks that are difficult to identify. However, it may cause internal rotation of tibial prosthesis. Computer- assisted navigation and personalized osteotomy can achieve more accurate alignment in sagittal, coronal, and rotational alignment of femoral prosthesis. However, due to the lack of reliable anatomical landmarkers related to tibia fixation, it is still controversial whether it can help the alignment of tibial prosthesis rotation. CONCLUSION The surgeon should master the methods of rotation and alignment of tibial prosthesis, make preoperative plans, select appropriate alignment methods for different patients, and achieve individualization. Meanwhile, several anatomical landmarkers should be referred to properly during the operation, which can be used to detect the correct placement of tibial prosthesis and avoid large rotation error.
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Affiliation(s)
- 欣 刘
- 山西医科大学第二医院骨科（太原 030001）Department of Orthopedics, the Second Affiliated Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - 升杰 郭
- 山西医科大学第二医院骨科（太原 030001）Department of Orthopedics, the Second Affiliated Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - 帅杰 李
- 山西医科大学第二医院骨科（太原 030001）Department of Orthopedics, the Second Affiliated Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - 晏维 曹
- 山西医科大学第二医院骨科（太原 030001）Department of Orthopedics, the Second Affiliated Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
| | - 川 向
- 山西医科大学第二医院骨科（太原 030001）Department of Orthopedics, the Second Affiliated Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P.R.China
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Are There Differences in Accuracy or Outcomes Scores Among Navigated, Robotic, Patient-specific Instruments or Standard Cutting Guides in TKA? A Network Meta-analysis. Clin Orthop Relat Res 2020; 478:2105-2116. [PMID: 32530896 PMCID: PMC7431275 DOI: 10.1097/corr.0000000000001324] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several kinds of cutting guides, including patient-specific instrumentation, navigation, standard cutting guides, accelerometer-based navigation, and robotic guidance, are available to restore a planned alignment during TKA. No previous study has simultaneously compared all of these devices; a network meta-analysis is an especially appealing method because it allows comparisons across approaches that were not compared head-to-head in individual randomized controlled trials. QUESTIONS/PURPOSES We performed a network meta-analysis to determine whether novel approaches to achieving implant alignment, such as patient-specific instrumentation, navigation, accelerometer-based navigation, and robotic guidance, provide any advantage over standard cutting guides in terms of: (1) hip-knee-ankle (HKA) alignment outliers greater than ± 3°, (2) outcome scores (1989 - Knee Society Score and WOMAC score) measured 6 months after surgery, or (3) femoral and tibial implant malalignment (greater than ± 3°), taken separately, in the frontal and sagittal plane, as well as other secondary outcomes including validated outcome scores 1 and 2 years after surgery. METHODS In our network meta-analysis, we included randomized controlled trials comparing the different cutting guides by using at least one of the previously specified criteria, without limitation on language or date of publication. We searched electronic databases, major orthopaedic journals, proceedings of major orthopaedic meetings, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform until October 1, 2018. This led to the inclusion of 90 randomized controlled trials involving 9389 patients (mean age 68.8 years) with 10,336 TKAs. Two reviewers independently selected trials and extracted data. The primary outcomes were the proportion patients with malalignment of the HKA angle (defined as HKA > 3° from neutral) and the Knee Society Score and WOMAC scores at 6 months postoperatively. We combined direct and indirect comparisons using a Bayesian network meta-analysis framework to assess and compare the effect of different cutting guides on outcomes. Bayesian estimates are based on the posterior distribution of an endpoint and are called credible intervals. Usually the 95% credible interval, corresponding to a posterior probability of 0.95 that the endpoint lies in the interval, is computed. Unlike the frequentist approach, the Bayesian approach does not allow the calculation of the p value. RESULTS The proportion of HKA outliers was lower with navigation than with patient-specific instrumentation (risk ratio 0.46 [95% credible interval (CI) 0.34 to 0.63]) and standard cutting guides (risk ratio 0.45 [95% CI 0.37 to 0.53]); however, this corresponded to an actual difference of only 12% of patients for navigation versus 21% of patients for patient-specific instrumentation, and 12% of patients for navigation versus 25% for standard cutting guides. We found no differences for other comparisons between different cutting guides, including robotics and the accelerometer. We found no differences in the Knee Society Score or WOMAC score between the different cutting guides at 6 months. Regarding secondary outcomes, navigation reduced the risk of frontal and sagittal malalignments for femoral and tibial components compared with the standard cutting guides, but none of the other cutting guides showed superiority for the other secondary outcomes. CONCLUSIONS Navigation resulted in approximately 10% fewer patients having HKA outliers of more than 3°, without any corresponding improvement in validated outcomes scores. It is unknown whether this incremental reduction in the proportion of patients who have alignment outside a window that itself has been called into question will justify the increased costs and surgical time associated with the approach. We believe that until or unless these new approaches either (1) convincingly demonstrate superior survivorship, or (2) convincingly demonstrate superior outcomes, surgeons and hospitals should not use these approaches since they add cost, have a learning curve (during which some patients may be harmed), and have the risks associated with uncertainty of novel surgical approaches. LEVEL OF EVIDENCE Level I, therapeutic study.
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Li Z, Yang Z, Liao W, Wang W, Zou Y, Pan Y, Feng Z. Fewer femoral rotational outliers produced with CT- than with MRI-based patient-specific instrumentation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:2930-2941. [PMID: 31435705 DOI: 10.1007/s00167-019-05678-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/02/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE Previous studies comparing the surgical accuracy between computed tomography (CT)- and magnetic resonance imaging (MRI)-based patient-specific instrumentation (PSI) methods have produced contradictory results. The aim of this study was to determine which is the more reliable imaging method (CT versus MRI) for patient-specific total knee arthroplasty (TKA). CT-based PSI is hypothesised to have an advantage regarding the number of outliers. METHODS A total of 22 randomised controlled trials (RCTs), including 1749 TKA cases, were eligible for the meta-analysis. RCTs, systematic reviews and meta-analyses on this topic published in databases before September 2018 were identified by a literature search. The primary outcome was the number of lower extremities with greater than 3° of difference in alignment angles between the postoperative outcomes and target outcomes. The parameters calculated from the meta-analysis included risk ratios (RRs) and 95% confidence intervals (CIs). Additionally, the publication bias and heterogeneity of the studies were assessed. RESULTS The risk of femoral rotational outliers in the PSI group (RR = 0.48; 95% CI 0.24-0.98) was significantly reduced. Furthermore, subgroup analysis showed that the accuracy in the CT-based PSI group was significantly higher than that in the MRI-based CSI group (RR = 0.31; 95% CI 0.10-0.92). CONCLUSION This meta-analysis shows that when performing TKA with PSI, preoperative CT is beneficial for the production of the PSI, resulting in a significantly lower proportion of outliers in femoral rotational alignment. CT should be the preferred choice for imaging when performing TKA surgery with PSI to obtain better femoral rotational alignment. LEVEL OF EVIDENCE Therapeutic study (systematic review and meta-analysis), Level I.
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Affiliation(s)
- Zhihao Li
- Guangzhou University of Traditional Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510403, Guangdong, People's Republic of China
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Zhidong Yang
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Wencui Liao
- The Liuzhou Hospital of Traditional Chinese Medicine, No. 32, Jiefang North Road, Chengzhong District, Liuzhou, 545000, Guangxi, People's Republic of China
| | - Weigang Wang
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Yonggen Zou
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Yaocheng Pan
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Zongquan Feng
- Guangzhou University of Traditional Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510403, Guangdong, People's Republic of China.
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China.
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D'Lima DP, Huang P, Suryanarayan P, Rosen A, D'Lima DD. Tibial tray rotation and posterior slope increase risk for outliers in coronal alignment. Bone Joint J 2020; 102-B:43-48. [PMID: 32475266 DOI: 10.1302/0301-620x.102b6.bjj-2019-1533.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The extensive variation in axial rotation of tibial components can lead to coronal plane malalignment. We analyzed the change in coronal alignment induced by tray malrotation. METHODS We constructed a computer model of knee arthroplasty and used a virtual cutting guide to cut the tibia at 90° to the coronal plane. The virtual guide was rotated axially (15° medial to 15° lateral) and with posterior slopes (0° to 7°). To assess the effect of axial malrotation, we measured the coronal plane alignment of a tibial tray that was axially rotated (25° internal to 15° external), as viewed on a standard anteroposterior (AP) radiograph. RESULTS Axial rotation of the cutting guide induced a varus-valgus malalignment up to 1.8° (for 15° of axial rotation combined with 7° of posterior slope). Axial malrotation of tibial tray induced a substantially higher risk of coronal plane malalignment ranging from 1.9° valgus with 15° external rotation, to over 3° varus with 25° of internal rotation. Coronal alignment of the tibial cut changed by 0.07° per degree of axial rotation and 0.22° per degree of posterior slope (linear regression, R2 > 0.99). CONCLUSION While the effect of axial malalignment has been studied, the impact on coronal alignment is not known. Our results indicate that the direction of the cutting guide and malalignment in axial rotation alter coronal plane alignment and can increase the incidence of outliers. Cite this article: Bone Joint J 2020;102-B(6 Supple A):43-48.
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Affiliation(s)
- Dominique P D'Lima
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA
| | - Philip Huang
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA
| | | | - Adam Rosen
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA
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Thijs E, Theeuwen D, Boonen B, van Haaren E, Hendrickx R, Vos R, Borghans R, Kort N, Schotanus MGM. Comparable clinical outcome and implant longevity after CT- or MRI-based patient-specific instruments for total knee arthroplasty: a 2-year follow-up of a RCT. Knee Surg Sports Traumatol Arthrosc 2020; 28:1821-1826. [PMID: 31270591 DOI: 10.1007/s00167-019-05616-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Patient-specific instruments (PSI) are already widespread used in total knee arthroplasty (TKA). Either computed tomography (CT) scans or magnetic resonance imaging (MRI) scans are used pre-operatively to create jigs to guide resection during surgery. This study is a sequel of previous work that showed significantly more radiological outliers for posterior slope when CT-based guides were used. The aim of this study was to assess differences in revision rate and clinical outcome between the two groups at 2-year follow-up. METHODS At the 2-year follow-up, 124 patients were analysed in this prospective, randomised single-blind study. A survival analysis with revision of the TKA as endpoint was performed. Patients fulfilled four patient-reported outcome measurements (PROMs). Scores on the questionnaires were compared between both groups at the different follow-up visits. RESULTS At final follow-up, there was no significant difference in the survival rates of the CT- and MRI-based PSI surgery. Postoperatively, the PROMs significantly improved within each group compared with the pre-operative values. There were no significant differences for the PROMs between both groups at the 2-years follow-up. CONCLUSIONS Although previous results showed more outliers regarding posterior slope for CT-based PSIs, no difference in revision rate or the outcome of PROMs was found at 2-year follow-up. Further research to determine what the influence is of radiological outliers on implant survival and clinical outcomes is necessary. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Elke Thijs
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Dieuwertje Theeuwen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Bert Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Emil van Haaren
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Roel Hendrickx
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob Borghans
- Department of Radiology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | | | - Martijn G M Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands.
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Design improvement in patient-specific instrumentation for total knee arthroplasty improved the accuracy of the tibial prosthetic alignment in the coronal and axial planes. Knee Surg Sports Traumatol Arthrosc 2020; 28:1560-1567. [PMID: 31240377 DOI: 10.1007/s00167-019-05571-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 06/17/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE The accuracy of patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) is still controversial, especially in the tibial prosthesis. It was hypothesized that the design modification of PSI improved the tibial prosthetic alignment and reduced the associated complications. The aim of this study was to compare the accuracy of a conventional PSI with that of a newly designed PSI for total knee arthroplasty (TKA) using a new three-dimensional (3D) measurement method. METHODS Thirty TKAs each using the conventional and newly designed PSIs were studied. The postoperative 3D-computed tomography (3D CT) image was superimposed on the preoperative 3D CT plan. The absolute differences in the tibial prosthetic alignment between the preoperative and postoperative 3D CT images were directly measured in the coronal, sagittal, and axial planes. Knees in which the difference in the prosthetic alignment was > 3° were considered deviations. RESULTS The new PSI showed less mean absolute differences and lower rate of deviations than the conventional PSI in the coronal and axial planes (p = 0.045 and p = 0.004, respectively). The deviations (> 3°) of the tibial prosthesis using the conventional PSI were 27, 30, and 63% and of those using the new PSI were 0, 20, and 20% in the coronal, sagittal, and axial planes, respectively. CONCLUSIONS This is the first report to evaluate the effect of improvement in PSI design on the postoperative alignment using 3D method, and it clearly showed that the modification significantly improved the accuracy of alignment and reduced the deviations. LEVEL OF EVIDENCE Therapeutic study, case-control study, Level III.
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Patient-Specific or Conventional Instrumentations: A Meta-analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2164371. [PMID: 32258107 PMCID: PMC7085852 DOI: 10.1155/2020/2164371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 02/13/2020] [Indexed: 02/05/2023]
Abstract
Objective To conduct a meta-analysis of randomized controlled trials (RCTs) to compare knee arthroplasty with patient-specific instrumentation (PSI) with the conventional instrumentation (CI). Methods RCTs were selected in PubMed and Embase from 2012 to 2018. Key data extracted included malalignment of mechanical axis, blood loss, surgical time, Oxford Knee Score (OKS), Knee Society Score (KSS), length of stay, and complications. Subgroup analysis was also performed regarding different PSI systems and different image processing methods. Results 29 RCTs with 2487 knees were eligible for the meta-analysis. Results showed that PSI did not improve the alignment of the mechanical axis compared with CI, but MRI-based PSI and Visionaire-specific PSI decrease the risk of malalignment significantly (P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and Conclusion PSI reduced the blood loss and improved KSS. MRI-based PSI reduced operative time and risk of malalignment of mechanical axis compared with CT-based PSI. Moreover, Visionaire-specific PSI achieves better alignment result of the mechanical axis than other systems.
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Affiliation(s)
- Louis Dagneaux
- Department of Orthopaedic Surgery, Lower Limb Surgery Unit, Lapeyronie University Hospital, Montpellier, France
| | - François Canovas
- Department of Orthopaedic Surgery, Lower Limb Surgery Unit, Lapeyronie University Hospital, Montpellier, France
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Randelli PS, Menon A, Pasqualotto S, Zanini B, Compagnoni R, Cucchi D. Patient-Specific Instrumentation Does Not Affect Rotational Alignment of the Femoral Component and Perioperative Blood Loss in Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. J Arthroplasty 2019; 34:1374-1381.e1. [PMID: 30979672 DOI: 10.1016/j.arth.2019.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/17/2019] [Accepted: 03/06/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Proposed aims of patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) are to improve accuracy of component alignment, while reducing blood loss and surgical time. The primary goal of this prospective, randomized, controlled, clinical trial is to verify whether PSI improves the rotational alignment of the femoral component in comparison to conventionally implanted TKA. METHODS One-hundred thirty-three consecutive patients were assessed for eligibility. Block randomization was performed to allocated patients in the treatment (PSI) or control group. During hospital stay, surgical times were recorded, and total blood volume loss and estimated red blood cell were calculated. Two months after surgery, a computed tomography of the knee was obtained to measure femoral component rotation to the transepicondylar axis and tibial component slope. RESULTS Sixty-nine patients were enrolled. PSI did neither result in a significant improvement in femoral component rotation nor result in a reduction of outliers, as compared with conventional instrumentation. No significant improvement in terms of tibial slope, blood loss, total surgical time, and ischemia time could be identified. The number of tibial recuts required in the PSI group was significantly higher than in the control group (P = .0003). CONCLUSION PSI does not improve the accuracy of femoral component rotation in TKA in comparison to conventional instrumentation. Moreover, PSI did not appear to influence any of the other variables investigated as secondary goals by this study. The results of this study do not support its routine use during standard TKA. LEVEL OF EVIDENCE Level I, randomized, controlled trial.
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Affiliation(s)
- Pietro S Randelli
- Department of Biomedical Sciences for Health, Laboratory of Applied Biomechanics, Università degli Studi di Milano, Milan, Italy; 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Alessandra Menon
- Department of Biomedical Sciences for Health, Laboratory of Applied Biomechanics, Università degli Studi di Milano, Milan, Italy; 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Stefano Pasqualotto
- Divisione di Ortopedia e Traumatologia, IRCCS Ospedale Classificato Equiparato Sacro Cuore - Don Calabria, Negrar, Italy
| | - Beatrice Zanini
- Dipartimento di Scienze della Salute, Università del Piemonte Orientale A. Avogadro, Novara, Italy
| | - Riccardo Compagnoni
- 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy
| | - Davide Cucchi
- Department of Biomedical Sciences for Health, Laboratory of Applied Biomechanics, Università degli Studi di Milano, Milan, Italy; Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Bonn, Germany
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León-Muñoz VJ, Martínez-Martínez F, López-López M, Santonja-Medina F. Patient-specific instrumentation in total knee arthroplasty. Expert Rev Med Devices 2019; 16:555-567. [PMID: 31154870 DOI: 10.1080/17434440.2019.1627197] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic procedures. During the past decade, patient-specific instrumentation (PSI) has been commercially introduced in order to simplify and make TKA surgery more effective, precise and efficient than conventional mechanical instrumentation (CI) and computer-assisted surgery (CAS). Nevertheless, there are critical arguments against PSI for routine use. The aim of the current manuscript is to describe advantages and limitations of PSI for primary TKA. AREAS COVERED By means of a description of the available literature different aspects are discussed (accuracy, clinical and functional outcomes, operative time, blood loss, efficiency and costs). EXPERT OPINION Most publications do not claim a significant increase in PSI accuracy over CI, but they also do not postulate PSIs accuracy is worse either. Regarding clinical aspects, PSI did not appear to give any advantage over standard techniques although, equally, it did not appear to show any disadvantages. PSI seems to reduce operative time, could reduce perioperative blood loss and provides logistical benefits in the operation room. Further studies will be required to more thoroughly assess all the advantages and disadvantages of this promising technology as an alternative to CI and CAS.
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Affiliation(s)
- Vicente J León-Muñoz
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain
| | - Francisco Martínez-Martínez
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain.,b Faculty of Medicine , University of Murcia , Murcia , Spain
| | - Mirian López-López
- c Subdirección General de Tecnologías de la Información. Servicio Murciano de Salud , Murcia , Spain
| | - Fernando Santonja-Medina
- a Orthopaedic Surgery and Traumatology Department , Hospital Clínico Universitario Virgen de la Arrixaca , Murcia , Spain.,b Faculty of Medicine , University of Murcia , Murcia , Spain
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The original Akagi line is the most reliable: a systematic review of landmarks for rotational alignment of the tibial component in TKA. Knee Surg Sports Traumatol Arthrosc 2019; 27:1018-1027. [PMID: 30203197 DOI: 10.1007/s00167-018-5131-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE There is no present consensus on the most reliable anatomical landmarks or axes for tibial rotational alignment in total knee arthroplasty (TKA). The goal was therefore to review the literature and compare accuracy and repeatability of different axes for tibial baseplate rotation in TKA. METHODS Medline and Embase were searched for articles that reported accuracy in terms of error or discrepancy from the trans-epicondylar axes (TEA), and/or repeatability in terms of intraclass correlation coefficient, of one or more axes used for tibial baseplate rotation in TKA. Twenty-one articles met criteria, and their data were extracted and tabulated. RESULTS The selected articles evaluated 15 different axes, 13 for reliability, 12 for repeatability. The lowest errors or discrepancies from the projected TEA were reported for the original 'Akagi line' (posterior cruciate ligament posteriorly to medial border of tibial tuberosity), its variant using the sulcus of the tibial spines as anterior landmark, as well as the anterior tibial border and the curve-on-curve technique. The best inter-observer repeatabilities were reported for 'Akagi line' variants that use the geometric centre of the tibial plateau posteriorly and the medial border of the tibial tuberosity, or the medial sixth of the patellar tendon anteriorly. Considering accuracy and repeatability simultaneously, only two axes were found to satisfy both criteria consistently: the original 'Akagi line' and the anterior tibial border. CONCLUSIONS Because of the small number of studies found, the collected evidence remains insufficient to recommend reference axes for intra-operative rotational alignment of the tibial baseplate in TKA. A combination of two or more anatomical landmarks or projected axes could be used to ensure adequate tibial baseplate rotation, while considering individual patient morphology and implant design to optimize knee kinematics and prevent prosthetic overhang. LEVEL OF EVIDENCE Level IV, systematic review of level III and IV studies.
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Hanada M, Furuhashi H, Matsuyama Y. Investigation of the control of rotational alignment in the tibial component during total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1313-1317. [PMID: 30929083 DOI: 10.1007/s00590-019-02427-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/26/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND In this study, rotational errors that occur in relation to the tibial component of total knee arthroplasty (TKA) were investigated intraoperatively using a CT-free navigation system and postoperative CT images to confirm the correctness of the rotation. METHODS Forty patients who underwent TKA using the navigation system were examined. These patients were split evenly into two groups, those whose rotational position was confirmed using a mark made manually on the tibia, and those whose rotation was confirmed using the navigation. All patients underwent postoperative CT scanning and were evaluated using the Knee Society Score. RESULTS With navigation, a significant difference was found between the rotational positions for which we made a keel hole and those for which the tibial component was inserted unguided. After cementing, the rotational position in the group for which a manual mark was used to confirm the rotation differed significantly from the position for the group for which navigation during cementing was used. Although there were four outliers that had rotational errors over 3° after cementing in the manual mark group, there were no outliers in the navigation group. While there was significant difference in the rotational errors of the tibial component on postoperative CT between two groups, the Knee Society Score did not differ between two groups. CONCLUSION The exact rotation of a tibial component cannot be maintained by simply creating a keel hole. The use of a manual mark resulted in rotational errors of the tibial component and the creation of the outliers. Therefore, it is suggested that the use of a navigation system can reduce the occurrence of such errors.
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Affiliation(s)
- Mitsuru Hanada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Hiroki Furuhashi
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Chanalithichai N, Tammachote N, Jitapunkul C, Kanitnate S. Rotational component alignment in patient-specific total knee arthroplasty compared with conventional cutting instrument. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1297-1304. [PMID: 30923964 DOI: 10.1007/s00590-019-02423-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/22/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Although many studies investigated the accuracy of customized cutting block (CCB), the data on rotational alignment are still lacking. The study aimed to assess whether CCB improved the component rotational position compared with conventional cutting instrument (CCI) using computed tomography scanning. METHODS Eighty-six of 102 total knee arthroplasties from the previous randomized study were analyzed. The outcomes were rotational position of the femoral and tibial components, frequency of outliers and intra-class correlation coefficient. RESULTS The mean femoral component rotation was not different between CCB versus CCI: 0.9° ± 0.8° versus 1.1° ± 1.1° (P = 0.29). Both groups had similar outlier frequencies: 2% (CCB) versus 2% (CCI) (P = 0.74). CCB had nearly 1° less mean tibial component deviation compared with CCI (P < 0.001): (1) dorsal tangent reference (DTR): 0.7° ± 0.8° versus 1.5° ± 1.0°, and (2) tibial trans-epicondylar reference (TTR): 0.5° ± 0.9° versus 1.4° ± 1.1°. Outlier frequencies were similar: (1) DTR: 0% CCB versus 5% CCI (P = 0.24), and (2) TTR: 5% in CCB versus 12% CCI (P = 0.20). Measurements based on tibial tubercle showed that CCB had ~ 1.4° less mean tibial component deviation compared with CCI: 0.3° ± 1.4° versus 1.7° ± 1.6° (P < 0.001) with a corresponding, less frequency of outliers: 0% versus 19% (P = 0.002). However, there was poor intra-observer reproducibility (0.61). CONCLUSIONS CCB did not improve femoral component rotational alignment compared with CCI nor affect outlier frequency, but it marginally improved the accuracy of tibial rotational alignment. The tibial tubercle reference point had poor intra-observer reproducibility.
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Affiliation(s)
- Nuttawut Chanalithichai
- Department of Orthopaedics, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand
| | - Nattapol Tammachote
- Department of Orthopaedics, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand.
| | - Chane Jitapunkul
- Department of Orthopaedics, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand
| | - Supakit Kanitnate
- Department of Orthopaedics, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand
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Gong S, Xu W, Wang R, Wang Z, Wang B, Han L, Chen G. Patient-specific instrumentation improved axial alignment of the femoral component, operative time and perioperative blood loss after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1083-1095. [PMID: 30377714 PMCID: PMC6435625 DOI: 10.1007/s00167-018-5256-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/19/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of the present study was to compare patient-specific instrumentation (PSI) with standard instrumentation (SI) in patients undergoing total knee arthroplasty (TKA). PSI is hypothesized to have advantages with respect to component alignment; number of outliers (defined as alignment > 3° from the target alignment); operative time; perioperative blood loss; and length of hospital stay. This new surgical technique is expected to exhibit superior performance. METHODS A total of 23 randomized controlled trials (RCTs) involving 2058 knees that compared the clinical outcomes of TKA between PSI and SI were included in the present analysis; these RCTs were identified via a literature search of the PubMed, Embase, and Cochrane Library databases through March 1, 2018. The outcomes of interest included coronal, sagittal and axial component alignment (presented as the angle of deviation from the transcondylar line); number of outliers; operative time; perioperative blood loss; and length of hospital stay. RESULTS There was a significant difference in postoperative femoral axial alignment between PSI and SI patients (95% CI - 0.71 to - 0.21, p = 0.0004, I2 = 48%). PSI resulted in approximately 0.4° less deviation from the transcondylar line than SI. Based on our results, PSI reduced operative time by a mean of 7 min compared with SI (95% CI - 10.95 to - 3.75, p < 0.0001, I2 = 78%). According to the included literature, PSI reduced perioperative blood loss by approximately 90 ml compared with SI (95% CI - 146.65 to - 20.18, p = 0.01, I2 = 74%). We did not find any differences between PSI and SI with respect to any other parameters. CONCLUSIONS PSI has advantages in axial alignment of the femoral component, operative time, and perioperative blood loss relative to SI. No significant differences were found between PSI and SI with respect to alignment of the remaining components, number of outliers, or length of hospital stay. LEVEL OF EVIDENCE Therapeutic study (systematic review and meta-analysis), Level I.
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Affiliation(s)
- Song Gong
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Weihua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Ruoyu Wang
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Zijian Wang
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Bo Wang
- 0000 0004 0368 7223grid.33199.31Department of Rehabilitation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Lizhi Han
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Guo Chen
- 0000 0004 0368 7223grid.33199.31Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
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Computer navigation for total knee arthroplasty achieves better postoperative alignment compared to conventional and patient-specific instrumentation in a low-volume setting. Orthop Traumatol Surg Res 2018; 104:971-975. [PMID: 29704634 DOI: 10.1016/j.otsr.2018.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Procedure volume is an important determinant of total knee arthroplasty (TKA) outcomes. We aimed to determine whether computer navigation or patient-specific instrumentation (PSI) would improve postoperative alignment in a low-volume setting. HYPOTHESIS PSI for TKA achieves better limb and implant alignment compared to conventional TKA and to computer navigated TKA. MATERIALS AND METHODS This is a retrospective cohort study of 385 primary TKAs (Women=59%. Mean age=67years. Mean BMI=30.1kg/m2), which were performed using conventional instrumentation (n=117; 30%), computer navigation (n=209; 54%), or patient-specific instrumentation (n=59; 15%) in a low-volume center (<50 TKAs/year). The risk of postoperative leg and implant mechanical alignment outliers in the coronal plane (>3° from neutral), average alignment and operation time were assessed. RESULTS The risk of postoperative mechanical alignment outliers (>3°) was reduced by 89% in the navigated group (4% outliers) compared to the conventional group (35%) (RR=0.11; p<0.0001). No significant improvement was observed in the PSI group (27%) (RR=0.91; p=0.772). The risk of postoperative femoral component coronal alignment outliers was reduced by 63% in the navigated group (11%) compared to the conventional group (31%) (RR=0.37; p=0.018). No significant reduction in outliers was observed in the PSI group (32%) (RR=1.08; p=0.816). There was a reduction in the risk of tibial component coronal malalignment of 66% in the navigated group (5%) compared to the conventional group (13%) (RR=0.33; p=0.070). There was a two-fold increase in the risk of tibial component alignment outliers in the PSI group (29%) (RR=1.94; p=0.110). DISCUSSION Computer navigation improved postoperative alignment in TKA. No evidence of improved alignment was seen with patient-specific instrumentation. The routine use of patient-specific instrumentation in low-volume centers is not supported by the currently available data. TYPE OF STUDY Retrospective cohort study. Level IV.
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No improvement in reducing outliers in coronal axis alignment with patient-specific instrumentation. Knee Surg Sports Traumatol Arthrosc 2018; 26:2788-2796. [PMID: 29071356 DOI: 10.1007/s00167-017-4741-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 10/02/2017] [Indexed: 01/28/2023]
Abstract
PURPOSE AND HYPOTHESIS Patient-specific instrumentation (PSI) uses 3D preoperative imaging to produce individualized cutting blocks specific to patients' anatomy and according to the preoperative plan with the aim to reduce the number of mechanical leg alignment (MLA) outliers, to improve implant positioning and to decrease surgery time. The primary purpose of this study was to investigate the efficacy of a specific PSI in comparison with standard instrumentation (SI) in reducing the number of MLA outliers. It was hypothesized that the number of MLA outliers would be significantly lower in the PSI group. METHODS A multicenter randomized controlled trial was implemented. There were 59 patients in the PSI group and 66 in the SI group. The absolute number of outliers outside the ± 3° target neutral MLA was compared between the groups with a Chi-square test. As secondary outcomes, the Knee Society Score (KSS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were compared between the groups preoperatively and at 90-day follow-up. RESULTS There were 15 (26.3%) MLA outliers in the PSI group and 8 (12.3%) in the SI group. The number of outliers was not independent from the group ( X2 (1) = 3.8, p = 0.04; Relative risk = 1.5). Preoperatively, there were no significant differences between the groups when comparing their KSS and KOOS sub-scores. At 90 days postoperatively, the patients in the SI group showed better KOOS-Quality of Life (KOSS-QOL) in comparison with the PSI group (p < 0.0001). CONCLUSION The use of PSI did not significantly reduce the number of MLA outliers in comparison with SI. There were no differences when comparing the achieved mean MLA of both groups. LEVEL OF EVIDENCE Level I, prospective randomized controlled trial.
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Schotanus MGM, Thijs E, Heijmans M, Vos R, Kort NP. Favourable alignment outcomes with MRI-based patient-specific instruments in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:2659-2668. [PMID: 28698929 DOI: 10.1007/s00167-017-4637-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/06/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE Patient-specific instruments (PSIs) are already in relatively common use, and their post-operative radiographic results are equal to those for total knee arthroplasty (TKA) with conventional instrumentation. PSI use requires a preoperative MRI scan, CT scan, or a combination of MRI and a long-leg standing radiograph. However, there is no consensus as to which of these modalities, MRI or CT, is the preferred imaging modality when performing TKA with PSIs. METHODS This systematic literature review and meta-analysis studied the differences in alignment outliers between CT- and MRI-based PSI for TKA. A search of the Cochrane Database of Systematic Reviews, MEDLINE/PubMed and Embase was conducted, without restriction on date of publication. Only level I evidence studies written in English that included TKA with the use of MRI- and CT-based PSI were selected. A meta-analysis was then performed of the rate of outliers in the biomechanical axis and individual femoral and tibial component alignment. Where considerable heterogeneity among studies was present or the data did not provide sufficient information for performing the meta-analysis, a qualitative synthesis was undertaken. RESULTS Twelve randomized controlled trials, studying 841 knees, were eligible for data extraction and meta-analysis. MRI-based PSI resulted in a significantly lower proportion of coronal plane outliers with regard to the lateral femoral component (OR 0.52, 95% CI 0.30-0.89, P = 0.02), without significant heterogeneity (n.s.). There were no significant differences regarding the biomechanical axis or frontal femoral and individual tibial component alignment. CONCLUSION This systematic review and meta-analysis demonstrate that alignment with MRI-based PSI is at least as good as, if not better than, that with CT-based PSI. To prevent for malalignment, MRI should be the imaging modality of choice when performing TKA surgery with PSI. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Martijn G M Schotanus
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands.
| | - Elke Thijs
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - Marion Heijmans
- Zuyderland Academy, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nanne P Kort
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
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Bizzozero P, Bulaid Y, Flecher X, Ollivier M, Parratte S, Argenson JN. Morphometric Tibial Implant Decreases Posterior Overhang Rate and Improves Clinical Outcomes: Results of a Prospective, Matched Controlled Study. J Arthroplasty 2018; 33:2804-2809. [PMID: 29748070 DOI: 10.1016/j.arth.2018.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/04/2018] [Accepted: 04/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tibial implant's positioning in total knee arthroplasty (TKA) requires a compromise between implant's rotation and bone coverage. We hypothesized that morphometric tibial trays (MTTs) would improve implant positioning and clinical outcomes as compared with symmetrical tibial trays. METHODS Thirty-three patients were included prospectively according to the following criteria: age from 18 to 85 years, body mass index <35 kg/m2, and posterostabilized cemented TKA performed for primary arthritis. Patients were matched for age, gender, body mass index, and preoperative international knee society (IKS) scoring system and Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, in a 1:1 fashion with patients from a prospectively collected database receiving a symmetrical tibial tray TKA. Tibial implant's rotation, bone coverage, and the percentage of patients with a posterior overhang (PO) >3 mm were assessed using computerized tomography. The IKS and the KOOS were compared at 3-year follow-up. RESULTS Bone coverage (90% vs 88%, P = .07) and rotation (mean difference 0.7 ± 3°; P = .69) were not different between the 2 groups. The percentage of patient with a PO was lower in the morphologic group (2/33 vs 14/33, P = .01, odds ratio = 10.3 [2.12-50.24]). Functional scores were superior in the morphometric group: IKS (mean difference 20 ± 21 points; P = .0005), mainly due to a difference in the IKS pain subscore (mean difference 11 ± 15 points; P = .0002). According to the multivariate analysis, an MTT had a positive, independent effect on IKS pain (P = .006) and KOOS pain subscores (P = .03) at the last follow-up. CONCLUSION The use of an MTT in TKA did not modify the tibial implant position in the axial plane; however, it decreased implant's posterior overhang and improved functional scores. The clinical improvement was mainly found on pain scores.
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Affiliation(s)
- Paul Bizzozero
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Yassine Bulaid
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Xavier Flecher
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Matthieu Ollivier
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Sébastien Parratte
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Jean-Noel Argenson
- Department of Orthopaedic Surgery, APHM, Institut du mouvement et de l'appareil locomoteur, Sainte-Marguerite Hospital, Marseille, France; Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
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Abane L, Zaoui A, Anract P, Lefevre N, Herman S, Hamadouche M. Can a Single-Use and Patient-Specific Instrumentation Be Reliably Used in Primary Total Knee Arthroplasty? A Multicenter Controlled Study. J Arthroplasty 2018; 33:2111-2118. [PMID: 29576488 DOI: 10.1016/j.arth.2018.02.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/25/2018] [Accepted: 02/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this controlled multicenter study is to evaluate the clinical and radiologic outcomes of primary total knee arthroplasty (TKA) using single-use fully disposable and patient-specific cutting guides (SU) and compare the results to those obtained with traditional patient-specific cutting guides (PSI) vs conventional instrumentation (CI). METHODS Seventy consecutive patients had their TKA performed using SU. They were compared to 140 historical patients requiring TKA that were randomized to have the procedure performed using PSI vs CI. The primary measure outcome was mechanical axis as measured on a standing long-leg radiograph using the hip-knee-ankle angle. Secondary outcome measures were Knee Society and Oxford knee scores, operative time, need for postoperative transfusion, and length of hospital stay. RESULTS The mean hip-knee-ankle value was 179.8° (standard deviation [SD] 3.1°), 179.2° (SD 2.9°), and 178.3° (SD 2.5°) in the CI, PSI and SU groups, respectively (P = .0082). Outliers were identified in 16 of 65 (24.6%), 15 of 67 (22.4%), and 14 of 70 (20.0%) knees in the CI, PSI, and SU group, respectively (P = .81). There was no significant difference in the clinical results (P = .29 and .19, respectively). Operative time, number of unit transfusion, and length of hospital stay were not significantly different between the 3 groups (P = .45, .31, and 0.98, respectively). CONCLUSION The use of an SU in TKA provided similar clinical and radiologic results to those obtained with traditional PSI and CI. The potential economic advantages of single-use instrumentation in primary TKA require further investigation.
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Affiliation(s)
- Laurent Abane
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | - Amine Zaoui
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | - Philippe Anract
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | | | | | - Moussa Hamadouche
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
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Tammachote N, Panichkul P, Kanitnate S. Comparison of Customized Cutting Block and Conventional Cutting Instrument in Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2018; 33:746-751.e3. [PMID: 29108794 DOI: 10.1016/j.arth.2017.09.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Customized cutting block (CCB) was designed to ensure the accurate alignment of knee prostheses during total knee arthroplasty. Given the paucity of CCB efficacy data, we compare CCB with conventional cutting guide using a randomized controlled trial. METHODS One hundred eight osteoarthritic knee patients underwent total knee arthroplasty by one experienced surgeon were randomized to receive CCB (n = 54) or conventional cutting instrument (CCI) surgery (n = 54). The primary outcomes were limb alignment, prostheses position, and operative time. The secondary outcomes were hemodynamic alteration after surgery, functional outcomes (modified Western Ontario and McMaster University Osteoarthritis Index) and range of motion at 2 years after surgery. RESULTS Mean hip-knee-ankle angle in the CCB group was 179.4° ± 1.8° vs 179.1° ± 2.4° in the CCI group, Δ = 0 (95% confidence interval [CI] -0.6 to 1.1, P = .55). Mean operative time was faster in the CCB arm: 93 ± 12 vs 104 ± 12 minutes, Δ = 11 (95% CI -16.7 to -7.2, P < .0001). There were no differences in hemodynamic parameters, mean blood loss (446 [CCB] vs 514 mL [CCI], Δ = -68 [95% CI -138 to 31 mL, P = .21]), postoperative hemoglobin changes, incidence of hypotension (systolic <90 mm Hg), oliguria, and rates of blood transfusion. Functional outcomes and range of motion were also similar. CONCLUSION There was no improvement in alignment, hemodynamic changes, blood loss, and knee functional outcomes. CCB reduced surgical time by 11 minutes in our population. CCB cost-effectiveness should be further investigated.
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Affiliation(s)
- Nattapol Tammachote
- Department of Orthopaedics, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Phonthakorn Panichkul
- Department of Orthopaedics, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Supakit Kanitnate
- Department of Orthopaedics, Thammasat University, Khlong Luang, Pathum Thani, Thailand
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Van Leeuwen JAMJ, Snorrason F, Röhrl SM. No radiological and clinical advantages with patient-specific positioning guides in total knee replacement. Acta Orthop 2018; 89:89-94. [PMID: 29161930 PMCID: PMC5810839 DOI: 10.1080/17453674.2017.1393732] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Although the use of patient-specific positioning guides (PSPGs) in total knee replacement (TKR) in theory is promising, the technique has not yet proven its superior- ity compared with the conventional method. We compared radio- logical alignment and clinical outcome between TKR performed with the use of PSPGs and the conventional operation method. Patients and methods - 3 hospitals participated in a prospec- tive trial. 109 patients were randomized to either the conventional method or to the use of PSPGs. Postoperatively a full-length standing anteroposterior radiograph and a postoperative CT scan were taken. On the CT scan the alignments were measured for both the femoral and tibial components in the frontal, sagit- tal, and axial plane. The Knee injury and Osteoarthritis Outcome Score (KOOS), the Eurocol-5D-3L (Eq5D) descriptive system and visual analogue scale (VAS), a pain score (NRS), and range of motion (ROM) were recorded preoperatively, and at 3 months, 1, and 2 years. The operation time and length of hospital stay were recorded. Results - 90 patients were available for postoperative CT mea- surements. A statistically significant difference was found between the conventional TKR instrumentation and the use of PSPGs for the frontal femoral (mean (SD) 0.6° (1.7) vs. -0.3° (2.2), CI 0.08 to 1.69) and tibial (-0.3° (1.5) vs. 0.9° (2.1), CI -1.98 to -0.44) compo- nent angles and for the tibial alignment in the sagittal plane (-3.8° (3.0) vs. -2.2° (2.5), CI -2.72; -0.42). The proportions of outliers were similar between the groups as well as the hip-knee-ankle angle, the KOOS sub scores, the Eq5D, pain (NRS), ROM, opera- tion time, and length of hospital stay. Interpretation - The use of PSPGs requires a preoperative CT scan or MRI and the guides have an additional cost. As this study was not able to prove any extra benefit of the use of PSPGs we recommend the conventional operation method for TKR.
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Affiliation(s)
- Justin A M J Van Leeuwen
- Department of Orthopaedic Surgery, Betanien Hospital, Skien, Norway,Faculty of Medicine, University of Oslo, Oslo, Norway,Correspondence:
| | - Finnur Snorrason
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Stephan M Röhrl
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Aunan E, Østergaard D, Meland A, Dalheim K, Sandvik L. A simple method for accurate rotational positioning of the femoral component in total knee arthroplasty. Acta Orthop 2017; 88:657-663. [PMID: 28799446 PMCID: PMC5694811 DOI: 10.1080/17453674.2017.1362733] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - There are many techniques for placing the femoral component in correct rotational alignment in total knee arthroplasty (TKA), but only a few have been tested against the supposed gold standard, rotation determined by postoperative computed tomography (CT). We evaluated the accuracy and variability of a new method, the clinical rotational axis (CRA) method, and assessed the association between the CRA and knee function. Patients and methods - The CRA is a line derived from clinical judgement of information from the surgical transepicondylar axis, the anteroposterior axis, and the posterior condylar line. The CRA was used to guide the rotational positioning of the femoral component in 80 knees (46 female). At 3 years follow-up, the rotation of the femoral component was compared with the CT-derived surgical transepicondylar axis (CTsTEA) by 3 observers. Functional outcome was assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS) and patient satisfaction (VAS). Results - The mean (95% CI) rotational deviation of the femoral component from the CTsTEA was 0.2° (-0.15°-0.55°). The standard deviation (95% CI) was 1.58° (1.36°-1.85°) and the range was from 3.7° internal rotation to 3.7° external rotation. No statistically significant association was found between femoral component rotation and KOOS, OKS, or VAS. Interpretation - The CRA method was found to be accurate with a low grade of variability.
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Affiliation(s)
- Eirik Aunan
- Department of Orthopaedic Surgery,Correspondence:
| | - Daniel Østergaard
- Department of Radiology, Sykehuset Innlandet Hospital Trust, Lillehammer
| | | | | | - Leiv Sandvik
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
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Rivière C, Iranpour F, Auvinet E, Aframian A, Asare K, Harris S, Cobb J, Parratte S. Mechanical alignment technique for TKA: Are there intrinsic technical limitations? Orthop Traumatol Surg Res 2017; 103:1057-1067. [PMID: 28888523 DOI: 10.1016/j.otsr.2017.06.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/15/2017] [Accepted: 06/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mechanically aligned (MA) total knee arthroplasty (TKA) is affected by disappointing functional outcomes in spite of the recent improvements in surgical precision and implant designs. This might suggest the existence of intrinsic technical limitations. Our study aims to compare the prosthetic and native trochlear articular surfaces and to estimate the extent of collateral ligament imbalance, which is technically uncorrectable by collateral ligament release when TKA implants are mechanically aligned. STUDY HYPOTHESIS Conventional MA technique generates a high rate of prosthetic overstuffing of the distal groove, distal lateral trochlear facet and distal lateral femoral condyle (Hypothesis 1), and technically uncorrectable collateral ligament imbalance (hypothesis 2)? Disregarding the distal femoral joint line obliquity (DFJLO) when performing femoral cuts explains distal lateral femoral prosthetic stuffing and uncorrectable imbalance (hypothesis 3)? METHODS Twenty patients underwent a conventional MA TKA. Pre-operative MRI-based 3D knee models were generated and MA TKA was simulated. Native and prosthetic trochlear articular surfaces were compared using in-house analysis software. Following the automatic determination by the planning software of the size of the extension and flexion gaps, an algorithm was applied to balance the gaps and the frequency and amplitude of technically uncorrectable knee imbalance were estimated. RESULTS The conventional MA technique generates a significant slight distal lateral femoral prosthetic overstuffing (mean 0.6mm, 0.8mm, 1.25mm for the most distal lateral facet point, groove, and at the most distal point of lateral femoral condyle, respectively) and a high rate of type 1 and 2 uncorrectable knee imbalance (30% and 40%, respectively). The incidence of distal lateral prosthetic overstuffing (trochlea and condyle) and uncorrectable knee imbalance were strongly to very strongly correlated with the DFJLO (r=0.53 to 0.89). CONCLUSION Conventional MA technique for TKA generates frequent lateral distal femoral prosthetic overstuffing and technically uncorrectable knee imbalance secondary to disregarding the DFJLO when adjusting the femoral component frontal and axial rotations, respectively. LEVEL OF EVIDENCE level 4.
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MESH Headings
- Aged
- Aged, 80 and over
- Algorithms
- Arthroplasty, Replacement, Knee/instrumentation
- Arthroplasty, Replacement, Knee/methods
- Female
- Humans
- Imaging, Three-Dimensional
- Knee Joint/diagnostic imaging
- Knee Joint/surgery
- Knee Prosthesis
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Models, Anatomic
- Osteoarthritis, Knee/diagnostic imaging
- Osteoarthritis, Knee/surgery
- Software
- Surgery, Computer-Assisted/instrumentation
- Surgery, Computer-Assisted/methods
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Affiliation(s)
- C Rivière
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom.
| | - F Iranpour
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - E Auvinet
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - A Aframian
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - K Asare
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - S Harris
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - J Cobb
- The MSK Lab, Charing Cross Camus, Imperial College London, Laboratory Block, W6 8RP London, United Kingdom
| | - S Parratte
- Service de chirurgieorthopédique, hôpital Sainte-Marguerite, université Aix-Marseille, 20, avenue Viton, 13009 Marseille, France
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Zambianchi F, Colombelli A, Digennaro V, Marcovigi A, Mugnai R, Fiacchi F, Sandoni D, Belluati A, Catani F. Assessment of patient-specific instrumentation precision through bone resection measurements. Knee Surg Sports Traumatol Arthrosc 2017; 25:2841-2848. [PMID: 26704807 DOI: 10.1007/s00167-015-3949-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 12/15/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE In the present study, the precision of two patient-specific instrumentation (PSI) systems for total knee arthroplasty (TKA) was evaluated by comparing bony resection thicknesses of the pre-operative PSI planning and intra-operative measurements by a vernier calliper. It was hypothesized that the data provided by pre-operative planning were accurate within ±2 mm of the bone resection thickness measured intra-operatively. METHODS Forty-one patient-specific TKAs were examined: 25 performed with Visionaire® technology and 16 with OtisMed® system. PSI accuracy was analysed comparing the resected bone thicknesses in the femoral and tibial cuts with pre-operatively planned resections. To determine pre-operative planning precision, the thickness values reported by the PSI planning were subtracted from the values reported intra-operatively by the calliper. RESULTS The mean absolute differences between pre-operatively planned resections and corresponding intra-operative thickness measurements ranged from a minimum of 2.6 mm (SD 0.8) to a maximum of 3.6 mm (SD 1.3) in all three anatomical planes in both groups. In every plane, the mean absolute discrepancies between planned resections and measured cuts differed significantly from zero (p < 0.0001). The proportion of differences within ±2 mm between intra-operative measured resections and planned PSI cuts occurred in more than 90 % of the cohort for femoral distal resections. Less precision was reported for the femoral posterior medial cuts (70.7 % within ±2 mm) and the tibial cuts (70.7 % on the medial, 75.6 % on the lateral side). Prosthetic component alignment on the coronal and transverse planes resulted in considerable deviations from the pre-operative planning. CONCLUSION The two examined PSI technologies were accurate in femoral distal cuts, determining acceptable femoral component placement on the coronal plane. Posterior femoral and tibial cuts were less precise. Deviations from the pre-operative resection planning were reported in every plane. Inaccuracy was explained by ambiguous custom-made jigs placement on the bony surface. LEVEL OF EVIDENCE III.
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Affiliation(s)
- F Zambianchi
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy.
| | - A Colombelli
- Department of Orthopaedic Surgery, Ospedale Santa Maria delle Croci, Azienda USL di Ravenna, Ravenna, Italy
| | - V Digennaro
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - A Marcovigi
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - R Mugnai
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - F Fiacchi
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - D Sandoni
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - A Belluati
- Department of Orthopaedic Surgery, Ospedale Santa Maria delle Croci, Azienda USL di Ravenna, Ravenna, Italy
| | - F Catani
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, via del Pozzo 71, 41124, Modena, Italy
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42
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Biau DJ, Boulezaz S, Casabianca L, Hamadouche M, Anract P, Chevret S. Using Bayesian statistics to estimate the likelihood a new trial will demonstrate the efficacy of a new treatment. BMC Med Res Methodol 2017; 17:128. [PMID: 28830464 PMCID: PMC5568256 DOI: 10.1186/s12874-017-0401-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/02/2017] [Indexed: 12/29/2022] Open
Abstract
Background The common frequentist approach is limited in providing investigators with appropriate measures for conducting a new trial. To answer such important questions and one has to look at Bayesian statistics. Methods As a worked example, we conducted a Bayesian cumulative meta-analysis to summarize the benefit of patient-specific instrumentation on the alignment of total knee replacement from previously published evidence. Data were sourced from Medline, Embase, and Cochrane databases. All randomised controlled comparisons of the effect of patient-specific instrumentation on the coronal alignment of total knee replacement were included. The main outcome was the risk difference measured by the proportion of failures in the control group minus the proportion of failures in the experimental group. Through Bayesian statistics, we estimated cumulatively over publication time of the trial results: the posterior probabilities that the risk difference was more than 5 and 10%; the posterior probabilities that given the results of all previous published trials an additional fictive trial would achieve a risk difference of at least 5%; and the predictive probabilities that observed failure rate differ from 5% across arms. Results Thirteen trials were identified including 1092 patients, 554 in the experimental group and 538 in the control group. The cumulative mean risk difference was 0.5% (95% CrI: −5.7%; +4.5%). The posterior probabilities that the risk difference be superior to 5 and 10% was less than 5% after trial #4 and trial #2 respectively. The predictive probability that the difference in failure rates was at least 5% dropped from 45% after the first trial down to 11% after the 13th. Last, only unrealistic trial design parameters could change the overall evidence accumulated to date. Conclusions Bayesian probabilities are readily understandable when discussing the relevance of performing a new trial. It provides investigators the current probability that an experimental treatment be superior to a reference treatment. In case a trial is designed, it also provides the predictive probability that this new trial will reach the targeted risk difference in failure rates. Trial registration CRD42015024176. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0401-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David J Biau
- INSERM U1153, Paris, France. .,Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France. .,Université Paris-Descartes, Paris 5, Paris, France.
| | - Samuel Boulezaz
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Laurent Casabianca
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Moussa Hamadouche
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Anract
- INSERM U1153, Paris, France.,Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Sylvie Chevret
- INSERM U1153, Paris, France.,Université Paris-Diderot, Paris 7, Paris, France
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43
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Zhu M, Chen JY, Chong HC, Yew AKS, Foo LSS, Chia SL, Lo NN, Yeo SJ. Outcomes following total knee arthroplasty with CT-based patient-specific instrumentation. Knee Surg Sports Traumatol Arthrosc 2017; 25:2567-2572. [PMID: 26410097 DOI: 10.1007/s00167-015-3803-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 09/16/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE A 24-month prospective follow-up study was carried out to compare perioperative clinical outcomes, radiographic limb alignment, component positioning, as well as functional outcomes following total knee arthroplasty (TKA) between patient-specific instrumentation (PSI) and conventional instrumentation (CI). METHODS Ninety consecutive patients, satisfying the inclusion and exclusion criteria, were scheduled to undergo TKA with either PSI or CI. A CT-based PSI was used in this study, and a senior surgeon performed all surgeries. Patients were clinically and functionally assessed preoperatively, 6 and 24 months post-operatively. Perioperative outcomes were also analysed, including operating time, haemoglobin loss, the need for blood transfusion, length of hospitalisation, and radiographic features. RESULTS At 24-month follow-up, clinical and functional outcomes were comparable between the two groups. PSI performed no better than CI in restoring lower limb mechanical alignment or improving component positioning. There were no differences in operating time, haemoglobin loss, transfusion rate, or length of hospitalisation between PSI and CI. CONCLUSION No significant clinical benefit could be demonstrated in using PSI over CI after 24 months, and routine use of PSI is not recommended in non-complicated TKA. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Meng Zhu
- Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Jerry Yongqiang Chen
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Hwei Chi Chong
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Andy Khye Soon Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Leon Siang Shen Foo
- Island Orthopaedic Consultants, Mount Elizabeth Medical Centre, 3 Mount Elizabeth, Singapore, 228510, Singapore
| | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
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44
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Value of the cumulative sum test for the assessment of a learning curve: Application to the introduction of patient-specific instrumentation for total knee arthroplasty in an academic department. Knee 2017; 24:615-621. [PMID: 28396050 DOI: 10.1016/j.knee.2017.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/08/2017] [Accepted: 03/16/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of the study was to use the cumulative summation (CUSUM) test to assess the learning curve during the introduction of a new surgical technique (patient-specific instrumentation) in total knee arthroplasty (TKA) in an academic department. METHODS The first 50TKAs operated on at an academic department using patient-specific templates (PSTs) were scheduled to enter the study. All patients had a preoperative computed tomography scan evaluation to plan bone resections. The PSTs were positioned intraoperatively according to the best-fit technique and their three-dimensional orientation was recorded by a navigation system. The position of the femur and tibia PST was compared to the planned position for four items for each component: coronal and sagittal orientation, medial and lateral height of resection. Items were summarized to obtain knee, femur and tibia PST scores, respectively. These scores were plotted according to chronological order and included in a CUSUM analysis. The tested hypothesis was that the PST process for TKA was immediately under control after its introduction. RESULTS CUSUM test showed that positioning of the PST significantly differed from the target throughout the study. There was a significant difference between all scores and the maximal score. No case obtained the maximal score of eight points. The study was interrupted after 20 cases because of this negative evaluation. CONCLUSION The CUSUM test is effective in monitoring the learning curve when introducing a new surgical procedure. Introducing PST for TKA in an academic department may be associated with a long-lasting learning curve. The study was registered on the clinical.gov website (Identifier NCT02429245).
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45
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Alcelik I, Blomfield M, Öztürk C, Soni A, Charity R, Acornley A. A comparison of short term radiological alignment outcomes of the patient specific and standard instrumentation for primary total knee arthroplasty: A systematic review and meta-analysis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:215-222. [PMID: 28502570 PMCID: PMC6197451 DOI: 10.1016/j.aott.2017.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 11/19/2016] [Accepted: 12/03/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to review the radiological alignment outcomes of patient Specific (PS) cutting blocks and Standard Instrumentation in Primary Total Knee Arthroplasty. METHODS We hypothesized that the use of PS techniques would significantly improve sagittal, coronal and rotational alignment of the prosthesis on short term. We performed a systematic review and a meta-analysis including all the randomised controlled trials (RCT) using PS and standard (ST) total knee arthroplasty to date. RESULTS A total of 538 PS TKA and 549 ST TKA were included in the study. Statistical analysis of the outliers for femoral component sagittal, coronal and rotational positioning, tibial component sagittal and coronal positioning and the overall mechanical axis were assessed. We found that there was no significant benefit from using PS instrumentation in primary knee arthroplasty to aid in the positioning of either the tibial or femoral components. Furthermore sagittal plane tibial component positioning was worse in the PS than the traditional ST group. CONCLUSION Our results suggest that at present PS instrumentation is not superior to ST instrumentation in primary total knee arthroplasty. LEVEL OF EVIDENCE Level 1, Systematic review of therapeutic studies.
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Affiliation(s)
| | | | | | - Ashish Soni
- Airedale Hospital, Orthopaedics Department, UK
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46
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Kazarian GS, Chen AF. Patients experience mixed results with respect to sexual quality and frequency after total knee arthroplasty: a systematic review. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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48
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Thienpont E, Schwab PE, Fennema P. Efficacy of Patient-Specific Instruments in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2017; 99:521-530. [PMID: 28291186 DOI: 10.2106/jbjs.16.00496] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patient-specific instrumentation (PSI) was introduced with the aim of making the procedure of total knee arthroplasty more accurate and efficient. The purpose of this study was to compare PSI and standard instrumentation in total knee arthroplasty with regard to radiographic and clinical outcomes as well as operative time and blood loss. METHODS A meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched from 2011 through 2015. We included randomized controlled trials and cohort studies that reported the effect of PSI on the aforementioned outcomes. The primary end point was deviation from the mechanical axis by >3°. Random and fixed-effect models were used for analysis. RESULTS A total of 44 studies, which included 2,866 knees that underwent surgery with PSI and 2,956 knees that underwent surgery with standard instrumentation, were evaluated. The risk of mechanical axis malalignment was significantly lower for PSI, with a pooled relative risk of 0.79 (p = 0.013). The risk of tibial sagittal-plane malalignment was higher for PSI than for standard instrumentation (relative risk = 1.32, p = 0.001), whereas the risk of femoral coronal-plane malalignment was significantly lower (relative risk = 0.74, p = 0.043). The risk of tibial coronal-plane malalignment was significantly higher for PSI only when employing fixed-effect meta-analysis (relative risk = 1.33, p = 0.042). Minor reductions in total operative time (-4.4 minutes, p = 0.002) and blood loss (-37.9 mL, p = 0.015) were noted for PSI. CONCLUSIONS PSI improves the accuracy of femoral component alignment and global mechanical alignment, but at the cost of an increased risk of outliers for the tibial component alignment. The impact of the increased probability of tibial component malalignment on implant longevity remains to be determined. Meta-analyses indicated significant differences with regard to operative time and blood loss in favor of PSI. However, these differences were minimal and, by themselves, not a substantial justification for routine use of the technology. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emmanuel Thienpont
- 1University Hospital Saint Luc, Brussels, Belgium 2AMR Advanced Medical Research, Männedorf, Switzerland
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49
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Abstract
Recent studies have challenged the long-held notion that neutral mechanical alignment after total knee arthroplasty leads to optimal function and survivorship. The ideal alignment for function and survivorship may actually be different. Kinematic alignment, where components are implanted to re-create the natural flexion/extension axis of the knee, may lead to improved functional results. Residual varus alignment may not adversely impact survivorship provided the tibial component is implanted in neutral alignment. Cite this article: Lording T, Lustig S, Neyret P. Coronal alignment after total knee arthroplasty. EFORT Open Rev 2016;1:12-17. doi: 10.1302/2058-5241.1.000002.
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Affiliation(s)
- Timothy Lording
- Melbourne Orthopaedic Group and The Alfred Hospital, Australia
| | - Sébastien Lustig
- Albert Trillat Center, Groupement Hospitalier Nord, Université Lyon 1, France
| | - Philippe Neyret
- Albert Trillat Center, Groupement Hospitalier Nord, Université Lyon 1, France
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50
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MacDessi S, Marimuthu K, Kumar VS, Chen D, Harris IA. Patient-specific cutting guides for total knee arthroplasty. Hippokratia 2017. [DOI: 10.1002/14651858.cd012589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Samuel MacDessi
- Sydney Knee Specialists; Orthopaedic Surgery; Suite 8, 19 Kensington Street Kogarah NSW Australia 2217
| | - Kanniraj Marimuthu
- All India Institute of Medical Sciences; Department of Orthopaedics; Aurobindo Marg Ansari Nagar New Delhi Delhi India 110029
| | - Venkatesan S Kumar
- Wrightington Hospital; Lower Limb Department; Hall Lane, Appley Bridge Wigan Lancashire UK WN6 9EP
| | - Darren Chen
- Sydney Knee Specialists; Orthopaedic Surgery; Suite 8, 19 Kensington Street Kogarah NSW Australia 2217
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW Australia; Ingham Institute for Applied Medical Research; Elizabeth Street Liverpool New South Wales Australia 2170
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