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Liao G, Duoji J, Mu L, Zhang Y, Liu X, Cai D, Zhao C. Efficiency assessment of intelligent patient-specific instrumentation in total knee arthroplasty: a prospective randomized controlled trial. J Orthop Surg Res 2024; 19:593. [PMID: 39342311 PMCID: PMC11437994 DOI: 10.1186/s13018-024-05010-5] [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: 05/19/2024] [Accepted: 08/19/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND In total knee arthroplasty (TKA), the practical use of patient-specific instrumentation (PSI) has been reported previously with both advantage and disadvantage. The application of artificial intelligent (AI) forces overwhelmingly development of medical industries, while the impact of AI on PSI efficiency remains unknown. Thus, this study aimed to assess the efficiency of Intelligent-PSI (i-PSI) in TKA, compared with the conventional instrumentation-TKA (CI). METHODS 102 late-stage OA patients who met inclusive criteria were recruited in this prospective randomized controlled trial and separated into two groups (i-PSI vs. CI). In both groups, an AI preoperative planning engine was applied for surgery decision making. In CI group, conventional instrumentation was applied for bony resection, while resection of i-PSI group was completed with i-PSI. A convolutional neural network was applied to automatically process computer tomography images and thus produced i-PSI. With the help of three-dimension printing, the workflow of production was largely simplified. AI-driven preoperative planning guided resection and alignment decisions. Resection measurement, perioperative radiography and perioperative clinical outcomes were analyzed to verify efficiency of i-PSI. RESULTS In resection outcomes, smaller deviation of lateral and medial distal femoral resection were found in i-PSI group than CI group (P = 0.032 and 0.035), while no difference was found in other resection planes. In radiography outcomes, postoperative coronal alignments of i-PSI group, including postoperative Hip-knee-ankle axis (HKA) (P = 0.025), postoperative HKA outliners (P = 0.042), Femoral coronal alignment (FCA) (P = 0.019) and Joint line convergence angle (JLCA) (P = 0.043) showed closer to neutral position than CI group. Moreover, Femoral sagittal alignment (FSA) of i-PSI group showed closer to neutral position than CI group(P = 0.005). No difference was found in other alignments. In clinical outcomes, i-PSI group seemed to cost more surgical time than CI group (P = 0.027), while others showed no differences between the two groups. CONCLUSION Intelligent Patient-specific Instrumentation in TKA achieved simplified production flow than conventional PSI, while also showed more accurate resection, improved synthesis position and limb alignment than conventional instrumentation. Above all, this study proved that i-PSI being an applicable and promising tool in TKA.
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Affiliation(s)
- Guoqing Liao
- Department of Joint Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Jinmei Duoji
- Department of Orthopedics, Nyingchi People's Hospital, Nyingchi, Xizang, China
| | - Lishuai Mu
- Department of Joint Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Yiling Zhang
- School of Biomedical Engineering, Tsinghua University, Beijing, China
- Longwood Valley Medical Technology Co. Ltd, Beijing, China
| | - Xingyu Liu
- Longwood Valley Medical Technology Co. Ltd, Beijing, China
- School of Life Sciences, Tsinghua University, Beijing, 100084, China
| | - Daozhang Cai
- Department of Joint Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China.
| | - Chang Zhao
- Department of Joint Surgery, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China.
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Hiranaka T. Advantages and limitations of mobile-bearing unicompartmental knee arthroplasty: an overview of the literature. Expert Rev Med Devices 2024; 21:587-600. [PMID: 38873929 DOI: 10.1080/17434440.2024.2367002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Interest in unicompartmental knee arthroplasty (UKA) has recently grown. Mobile bearing UKA, in which the bearing is not fixed but rather perfectly conforms with femoral and tibial components and moves completely passively between the femoral and tibial implant, has now been used for approximately half a century. AREAS COVERED Alongside the recognized advantages of UKA, the mobile-bearing variant benefits from an extremely low rate of polyethylene wear and tolerable minor malalignment. Revision rates for UKA have been reported to exceed those of total knee arthroplasty, but long-term survival rates and outcomes from mobile-bearing UKA have been found to be satisfactory. In addition to the lateral osteoarthritis and loosening, which are main complications of UKA, bearing dislocation is a specific complication of mobile bearing UKA. Fractures and valgus subsidence are more prevalent than in the cementless UKA. While these continue to be features to be addressed, they have been partially solved. EXPERT OPINION Given the manifold benefits of UKA, its application could be extended to a larger patient population. Successful outcomes rely on careful patient selection and the surgeon's extensive familiarity with the procedure. Looking ahead, the incorporation of robotic surgery, already a feature of some fixed-bearing UKAs, might shape the future trajectory of mobile-bearing UKA.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Osaka, Japan
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Theeuwen D, Schoenmakers D, Scholtes M, Kalaai S, Schotanus M, Boonen B. First long-term analysis of survival and clinical outcome in patient-specific instrumentation for total knee arthroplasty: follow-up of a prospective cohort study. Acta Orthop Belg 2024; 90:51-56. [PMID: 38669649 DOI: 10.52628/90.1.11822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Patient-specific instrumentation (PSI) was introduced to improve post-operative alignment, and consequently the revision rate and clinical results after total knee arthroplasty (TKA). Short- to mid-term data are conflicting regarding these theoretical advantages of PSI. The purpose of this retrospective analysis was to evaluate the survival rate and clinical outcome in PSI TKA 8.4 years after initial surgery. To our knowledge, no other study investigated long-term follow-up of TKA procedures using PSI. From a total cohort of 184 consecutive patients (200 TKA) 136 patients (144 TKA, 72%) were prospectively analysed at a mean follow-up of 8.4 years (±0.4). A survival analysis with all-cause revision of TKA as endpoint was performed. Patient-reported outcome measures (PROMs) were obtained preoperatively and after 1-, 2-, 5-, and 8.4-years of follow-up. Differences between these moments of follow-up were analysed. At final follow-up, 4 TKAs (2%) had undergone revision, all between 2-4 years after primary surgery. Reasons for revision were late infection, aseptic loosening, instability and polyethylene insert breakage. The median score of certain PROMs (WOMAC, VAS, EQ-index, EQ-VAS) decreased compared to previous follow-up scores but were significantly higher than preoperative scores. After 8.4 years of follow-up, no additional revision surgery was performed compared to 5-years postoperatively. Certain PROMs at 8.4-year follow-up decreased compared to earlier moments of follow-up, but all PROMs improved compared to preoperative PROMs.
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Pflüger P, Hodel S, Zimmermann SM, Knechtle S, Vlachopoulos L, Fucentese SF. The coronal alignment differs between two-dimensional weight-bearing and three-dimensional nonweight bearing planning in total knee arthroplasty. J Exp Orthop 2024; 11:e12007. [PMID: 38455454 PMCID: PMC10885761 DOI: 10.1002/jeo2.12007] [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: 12/10/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose The goal of this study is (1) to assess differences between two-dimensional (2D) weight-bearing (WB) and three-dimensional (3D) nonweight-bearing (NWB) planning in total knee arthroplasty (TKA) and (2) to identify factors that influence intermodal differences. Methods Retrospective single-centre analysis of patients planned for a TKA with patient-specific instruments (PSI). Preoperative WB long-leg radiographs and NWB computed tomography were analysed and following radiographic parameters included: hip-knee-ankle angle (HKA) (+varus/-valgus), joint line convergence angle (JLCA), femorotibial subluxation and bony defect classified according to Anderson. Preoperative range of motion was also considered as possible covariate. Demographic factors included age, sex, and body mass index. Results A total of 352 knees of 323 patients (66% females) with a mean age of 66 ± 9.7 years were analysed. The HKA differed significantly between 2D and 3D planning modalities; varus knees (n = 231): 9.9° ± 5.1° vs. 6.7° ± 4°, p < 0.001; valgus knees (n = 121): -8.2° ± 6° vs. -5.5° ± 4.4°, p < 0.001. In varus knees, HKA (β = 0.38; p < 0.0001) and JLCA (β = 0.14; p = 0.03) were associated with increasing difference between 2D/3D HKA. For valgus knees, HKA (β = -0.6; p < 0.0001), JLCA (β = -0.3; p = 0.0001) and lateral distal femoral angle (β = -0.28; p = 0.03) showed a significant influence on the mean absolute difference. Conclusion The coronal alignment in preoperative 3D model for PSI-TKA significantly differed from 2D WB state and the difference between modalities correlated with the extent of varus/valgus deformity. In the vast majority of cases, the 3D NWB approach significantly underestimated the preoperative deformity, which needs to be considered to achieve the planned correction when using PSI in TKA. Level of Evidence Level III.
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Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro Hodel
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Stefan M. Zimmermann
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Svenja Knechtle
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
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Marsilio L, Moglia A, Rossi M, Manzotti A, Mainardi L, Cerveri P. Combined Edge Loss UNet for Optimized Segmentation in Total Knee Arthroplasty Preoperative Planning. Bioengineering (Basel) 2023; 10:1433. [PMID: 38136024 PMCID: PMC10740423 DOI: 10.3390/bioengineering10121433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Bone segmentation and 3D reconstruction are crucial for total knee arthroplasty (TKA) surgical planning with Personalized Surgical Instruments (PSIs). Traditional semi-automatic approaches are time-consuming and operator-dependent, although they provide reliable outcomes. Moreover, the recent expansion of artificial intelligence (AI) tools towards various medical domains is transforming modern healthcare. Accordingly, this study introduces an automated AI-based pipeline to replace the current operator-based tibia and femur 3D reconstruction procedure enhancing TKA preoperative planning. Leveraging an 822 CT image dataset, a novel patch-based method and an improved segmentation label generation algorithm were coupled to a Combined Edge Loss UNet (CEL-UNet), a novel CNN architecture featuring an additional decoding branch to boost the bone boundary segmentation. Root Mean Squared Errors and Hausdorff distances compared the predicted surfaces to the reference bones showing median and interquartile values of 0.26 (0.19-0.36) mm and 0.24 (0.18-0.32) mm, and of 1.06 (0.73-2.15) mm and 1.43 (0.82-2.86) mm for the tibia and femur, respectively, outperforming previous results of our group, state-of-the-art, and UNet models. A feasibility analysis for a PSI-based surgical plan revealed sub-millimetric distance errors and sub-angular alignment uncertainties in the PSI contact areas and the two cutting planes. Finally, operational environment testing underscored the pipeline's efficiency. More than half of the processed cases complied with the PSI prototyping requirements, reducing the overall time from 35 min to 13.1 s, while the remaining ones underwent a manual refinement step to achieve such PSI requirements, performing the procedure four to eleven times faster than the manufacturer standards. To conclude, this research advocates the need for real-world applicability and optimization of AI solutions in orthopedic surgical practice.
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Affiliation(s)
- Luca Marsilio
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy; (A.M.); (M.R.); (L.M.)
| | - Andrea Moglia
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy; (A.M.); (M.R.); (L.M.)
| | - Matteo Rossi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy; (A.M.); (M.R.); (L.M.)
| | | | - Luca Mainardi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy; (A.M.); (M.R.); (L.M.)
| | - Pietro Cerveri
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy; (A.M.); (M.R.); (L.M.)
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Cortina G, Za P, Papalia GF, Gregori P, Condello V, Vasta S, Franceschetti E, Campi S, Madonna V, Papalia R. Restricted kinematic alignment is clinically non-inferior to mechanical alignment in the short and mid-term: A systematic review. Knee 2023; 45:137-146. [PMID: 37925804 DOI: 10.1016/j.knee.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In recent years, kinematic alignment (KA) is becoming a valid alternative to mechanical alignment (MA) in total knee arthroplasty (TKA). However, to avoid early failures, the restricted kinematic alignment (rKA) approach has been developed to restore native knee kinematics without reproducing extreme knee phenotype. This systematic review aims to evaluate clinical and radiological outcomes between rKA and MA for TKA. METHODS A systematic literature search was conducted following PRISMA guidelines on Pubmed, Scopus and Cochrane Library. The following search string was adopted: (((restricted kinematic) AND (mechanical)) AND (alignment)) AND (knee). We included studies that analyzed rKA versus MA in terms of clinical outcomes and complications with a minimum of 6 months of follow up. The following rKA- and MA-related data were evaluated: patient-reported outcome scores (PROMs), radiographic analysis of lower limb alignment, and complications. Criteria from the Methodological Index for Non-Randomized Studies were used to assess the methodological quality of the articles. RESULTS This systematic review included seven clinical studies with a total of 892 knees (471 for MA group and 421 for rKA group, respectively). Overall, post-operative PROMs were similar between rKA and MA. Moreover, rKA reached better results regarding Forgotten Joint Score and post-operative patient satisfaction. Finally, no higher complication rate was observed with the rKA approach. CONCLUSION The rKA aims to restore native knee kinematics, avoiding extreme deformities. Clinical outcomes are not inferior or even better for rKA compared with MA, without increasing the risk of short-middle-term implant failure. However, there is a high heterogeneity regarding the 'restricted' protocols used.
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Affiliation(s)
- Gabriele Cortina
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Pierangelo Za
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | - Pietro Gregori
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vincenzo Condello
- Department of Orthopaedic, Joint Prosthetic, Arthroscopic Surgery and Sports Traumatology, Humanitas Castelli, Bergamo, Italy
| | - Sebastiano Vasta
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Edoardo Franceschetti
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Stefano Campi
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vincenzo Madonna
- Department of Orthopaedic, Joint Prosthetic, Arthroscopic Surgery and Sports Traumatology, Humanitas Castelli, Bergamo, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Pelkowski JN, Young PF, O'Connor MI, Sherman CE, Mcelroy MJ, Ledford CK. Patient specific implants versus conventional implants in primary total knee arthroplasty: No significant difference in patient reported outcomes at 5 years. J Orthop 2023; 46:124-127. [PMID: 37994363 PMCID: PMC10659996 DOI: 10.1016/j.jor.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/29/2023] [Accepted: 10/29/2023] [Indexed: 11/24/2023] Open
Abstract
Background Patient specific implants (PSI) represent a novel innovation aimed to improve patient satisfaction and function after total knee arthroplasty (TKA); however, longitudinal patient reported outcome measures (PROMs) for PSI are not well described. We sought to primarily evaluate PROMs of patients undergoing TKA with either PSI or off-the-shelf (OTS) implants at mid-term follow-up. Methods A retrospective review was performed on a prospectively collected cohort of 43 primary, cruciate-retaining TKAs performed with PSI (n = 23) and OTS implants (n = 20) by a single surgeon. Patient demographics, operative characteristics, range of motion (ROM) return, reoperations, and outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) T-score, Knee Injury and Osteoarthritis outcome score (KOOS), and Knee Society Score-Function (KSS-F)] were compared. Mean follow-up was 5 years. Results TKA performed with either PSI and OTS implants demonstrated no difference in obtaining ROM by 3 months (extension 3° short of full extension vs. 0°, p = 0.16) or flexion (114° vs. 115°, p = 0.99) and final ROM was identical [0° extension to 120° flexion (p = 1)]. Although not significant (p = 0.42), 5 (22%) PSI TKA and 2 (10%) OTS implant patients required manipulation under anesthesia. KSS-F and PROMIS T-scores were higher in the PSI versus OTS TKA patients, respectively (90 vs. 73, p = 0.002; 51.6 vs. 44.5, p = 0.01). However, after multivariable analysis, none of these continuous outcome measures were significantly different (p = 0.28 for KSS and p = 0.45 for PROMIS T-score) between the groups. Conclusion In a series of TKAs performed with PSI, no difference existed in postoperative ROM, reoperations, or patient-reported outcomes compared to OTS implants at 5 years. Surgeons may utilize the equivocal midterm results during TKA preoperative patient discussion of implant technologies.
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Affiliation(s)
- Jessica N. Pelkowski
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Porter F. Young
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Mary I. O'Connor
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Courtney E. Sherman
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Mark J. Mcelroy
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Cameron K. Ledford
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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Keskinis A, Paraskevopoulos K, Diamantidis DE, Ververidis A, Fiska A, Tilkeridis K. The Role of 3D-Printed Patient-Specific Instrumentation in Total Knee Arthroplasty: A Literature Review. Cureus 2023; 15:e43321. [PMID: 37700954 PMCID: PMC10493459 DOI: 10.7759/cureus.43321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Total knee arthroplasty (TKA) is currently one of the most common orthopedic surgeries due to the ever-increasing average life expectancy. The constant need for effective and accurate techniques was contributed to the development of three-dimensional (3D) printing in that field, especially for patient-specific instrumentation (PSI) and custom-made implants fabrication. PSI may offer numerous benefits, such as resection accuracy, mechanical axis alignment, cost-effectiveness, and time economy. Nonetheless, the results of existing studies are controversial. For this purpose, a review article of the published articles was conducted to summarize the role of 3D-printed PSI in TKA.
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Affiliation(s)
- Anthimos Keskinis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantinos Paraskevopoulos
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | | | - Athanasios Ververidis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
| | - Aliki Fiska
- Anatomy Laboratory, Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantinos Tilkeridis
- Orthopedic Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GRC
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Trends in Computer-Assisted Surgery for Total Knee Arthroplasty in Germany: An Analysis Based on the Operative Procedure Classification System between 2010 to 2021. J Clin Med 2023; 12:jcm12020549. [PMID: 36675478 PMCID: PMC9863460 DOI: 10.3390/jcm12020549] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Alignment strategies for primary total knee arthroplasty (TKA) have changed significantly over time with a shift towards a more individualized alignment goal. At the same time, computer-assisted surgery (CAS) has gained interest for intraoperative control and accuracy in implant positioning and limb alignment. Despite the often discussed benefits and drawbacks of robotics and navigation for TKA, the routine use of these new devices on a day-to-day basis remains obscure. Therefore, nationwide hospital billing data based on the Operation Procedure Classification System (OPS) were retrieved from the Federal Statistical Office of Germany for the period from 2010 to 2021. OPS codes for primary total knee arthroplasty (OPS code: 5-822*) were further analyzed regarding the usage of computer navigation (additional OPS code: 5-988) or robotic devices (additional OPS code: 5-987). Gender and age at the time of surgery were also assessed. The results show a total of 2,226,559 primary TKAs were implanted between 2010 and 2021, of which 2,044,914 were performed conventionally (91.84% of all TKAs). A total of 170,276 TKAs were performed using navigation technique (7.65% of all TKAs) and another 11,369 TKAs were performed using robotics (0.51% of all TKAs). For the period from 2018 to 2021, a substantial increase in robot-assisted TKA (R-TKA) was observed, with an average increase rate of 84.74% per year, while the number of navigated TKAs declined (-3.67% per year). Computer-assisted surgery, and particularly robotics for TKA, are seeing growing popularity and stepwise translation into routine clinical use in Germany, with a steep increase rate of more than 80% per year since 2018. Nevertheless, the majority of TKAs are still performed using manual instrumentation, rendering conventional TKA the currently unchanged gold standard.
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Rudran B, Magill H, Ponugoti N, Williams A, Ball S. Functional outcomes in patient specific instrumentation vs. conventional instrumentation for total knee arthroplasty; a systematic review and meta-analysis of prospective studies. BMC Musculoskelet Disord 2022; 23:702. [PMID: 35870913 PMCID: PMC9308296 DOI: 10.1186/s12891-022-05620-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Total Knee Arthroplasty (TKA) is an established surgical option for knee osteoarthritis (OA). There are varying perceptions of the most suitable surgical technique for making bone cuts in TKA. Conventional Instrumentation (CI) uses generic cutting guides (extra- and intra-medullary) for TKA; however, patient specific instrumentation (PSI) has become a popular alternative amongst surgeons. Methods A literature search of electronic databases Embase, Medline and registry platform portals was conducted on the 16th May 2021. The search was performed using a predesigned search strategy. Eligible studies were critically appraised for methodological quality. The primary outcome measure was Knee Society Function Score. Functional scores were also collected for the secondary outcome measures: Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale (VAS) for pain. Review Manager 5.3 was used for all data synthesis and analysis. Results There is no conclusive evidence in the literature to suggest that PSI or CI instrumentation is better for functional outcomes. 23 studies were identified for inclusion in this study. Twenty-two studies (18 randomised controlled trials and 4 prospective studies) were included in the meta analysis, with a total of 2277 total knee arthroplasties. There were 1154 PSI TKA and 1123 CI TKA. The majority of outcomes at 3-months, 6-months and 12 show no statistical difference. There was statistical significance at 24 months in favour of PSI group for KSS function (mean difference 4.36, 95% confidence interval 1.83–6.89). The mean difference did not exceed the MCID of 6.4. KSS knee scores demonstrated statistical significance at 24 months (mean difference 2.37, 95% confidence interval (CI) 0.42—4.31), with a MCID of 5.9. WOMAC scores were found to be statistically significant favouring PSI group at 12 months (mean difference -3.47, 95% confidence interval (CI) -6.57- -0.36) and 24 months (mean difference -0.65, 95% confidence interval (CI) -1.28—-0.03), with high level of bias noted in the studies and a MCID of 10. Conclusions This meta-analysis of level 1 and level 2 evidence shows there is no clinical difference when comparing PSI and CI KSS function scores for TKA at definitive post operative time points (3 months, 6 months, 12 months and 24 months). Within the secondary outcomes for this study, there was no clinical difference between PSI and CI for TKA. Although there was no clinical difference between PSI and CI for TKA, there was statistical significance noted at 24 months in favour of PSI compared to CI for TKA when considering KSS function, KSS knee scores and WOMAC scores. Studies included in this meta-analysis were of limited cohort size and prospective studies were prone to methodological bias. The current literature is limited and insufficiently robust to make explicit conclusions and therefore further high-powered robust RCTs are required at specific time points.
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Minimum 5-Year Outcomes of a Multicenter, Prospective, Randomized Control Trial Assessing Clinical and Radiological Outcomes of Patient-Specific Instrumentation in Total Knee Arthroplasty. J Arthroplasty 2022; 37:1579-1585. [PMID: 35077818 DOI: 10.1016/j.arth.2022.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patient-specific instrumentation (PSI) was developed to produce more accurate alignment of components and consequently improve clinical outcomes when used in total knee arthroplasty. We compare radiological accuracy and clinical outcomes at a minimum of 5-year follow-up between patients randomized to undergo total knee arthroplasty performed using PSI or traditional cutting block techniques. METHODS This multicenter, randomized control trial included patients blinded to the technique 1used. Outcome measures were coronal alignment measured radiologically, Euroqol-5D, Oxford knee score, and International Knee Society Score measured at 1- and 5-year follow-up. RESULTS At a minimum 5-year follow-up, there were 38 knees in the PSI group and 39 in the conventional instrumentation group for analysis. Baseline demographics and clinical outcome scores were matched between groups. Overall, there was no significant difference in the coronal femoral angle (P = .59), coronal tibial angle (P = .37), tibiofemoral angle (P = .99), sagittal femoral angle (P = .34), or the posterior tibia slope (P = .12) between knees implanted using PSI and those implanted with traditional cutting blocks. On the measurement of coronal alignment, intraobserver reliability tests demonstrated substantial agreement (k = 0.64). Clinical outcomes at both 1-year and 5-year follow-up demonstrated statistically significant and clinically relevant improvement in scores from baseline in both groups, but no difference could be detected between the Euroqol-5D (P = .78), Oxford knee score (P = .24), or International Knee Society Score (P = .86) between the 2 groups. CONCLUSION This study has shown no additional benefit to PSI in terms of improved alignment or functional outcomes at minimum 5-year follow-up over traditional techniques.
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Yamamura K, Inori F, Konishi S. Prosthetic Accuracy Depends on the Design of Patient-Specific Instrumentation: Results of a Retrospective Study Using Three-Dimensional Imaging. J Knee Surg 2022; 35:978-982. [PMID: 33241546 DOI: 10.1055/s-0040-1721127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To determine accuracy of patient-specific instrumentation (PSI), the preoperative three-dimensional (3D) plan should be superimposed on the postoperative 3D image to compare prosthetic alignment. We aimed to compare prosthetic alignment on a preoperative 3D computed tomography (CT) plan and postoperative 3D-CT image, and evaluate the accuracy of PSI during total knee arthroplasty (TKA). Thirty consecutive knees (30 patients) who underwent TKA using PSI were retrospectively evaluated. The preoperative plan was prepared using 3D CT acquisitions of the hip, knee, and ankle joints. The postoperative 3D CT image obtained 1 week after surgery was superimposed onto the preoperative 3D plan using computer software. Differences in prosthetic alignment between the preoperative and postoperative images were measured using six parameters: coronal, sagittal, and axial alignments of femoral and tibial prostheses. Differences in prosthetic alignment greater than 3 degrees were considered outliers. Two observers performed all measurements. All parameters were repeatedly measured over a 4-week interval. This measurement method's intraobserver and interobserver reliabilities were more than 0.81 (very good). For the femoral and tibial prostheses, absolute differences between the preoperative and postoperative 3D CT images were significantly larger in the sagittal than in the coronal and axial planes (p < 0.001). The outlier rate for the sagittal alignment of femoral and tibial prostheses was significantly higher than that for the alignment of coronal and axial planes (p < 0.001). However, there were no significant differences in the range of motion (ROM) before and after TKA when comparing cases with and without outliers in the sagittal plane. Even though the present study did not reveal any issues with the ROM that depended on the presence of an outlier, accurate verification of prosthetic alignment for individual PSI models may be necessary because the designs, referenced images, and accuracy are different in each model.
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Affiliation(s)
- Kazumasa Yamamura
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
| | - Fumiaki Inori
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
| | - Sadahiko Konishi
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
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Schroeder L, Dunaway A, Dunaway D. A Comparison of Clinical Outcomes and Implant Preference of Patients with Bilateral TKA: One Knee with a Patient-Specific and One Knee with an Off-the-Shelf Implant. JBJS Rev 2022; 10:01874474-202202000-00003. [PMID: 35120075 DOI: 10.2106/jbjs.rvw.20.00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The purpose of this retrospective study was to compare clinical outcome results, perceived function, and overall preference among patients who had undergone staged bilateral total knee arthroplasty (TKA) with a cruciate-retaining, customized implant (customized TKA, or C-TKA) in 1 knee and an off-the-shelf (OTS) implant in the contralateral knee. METHODS Forty-seven patients (94 knees) from a single study center who underwent C-TKA in 1 knee and had previously undergone TKA with an OTS implant in the contralateral knee were included in this study. As the primary outcome measures, the Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) and the Forgotten Joint Score (FJS) were self-administered by the study subjects at a single follow-up time point. Additionally, a follow-up questionnaire to compare patients' perceived joint stability, knee mobility, perceived feeling of the replaced joint, pain levels, and overall preference between their knees was administered. RESULTS The average follow-up was 2.3 years (range, 0.7 to 3.8 years) for C-TKA and 6.7 years (range, 1.6 to 11.1 years) for the OTS TKA. Significantly higher KOOS, JR (82 versus 77; p = 0.03) and FJS (68 versus 58; p = 0.04) results were found with C-TKA. The evaluation of the follow-up questionnaire showed that more patients reported having "a little" or "a lot" less pain (49% versus 15%), better perceived mobility (45% versus 12%) and stability (36% versus 13%), and a more "normal" feeling of their knee (60% versus 10%) with the C-TKA implant compared with their OTS counterpart. When patients were asked to directly compare their knees, we found that 72.3% of the patients preferred the knee that received C-TKA over the contralateral OTS knee replacement, with 21.3% seeing no difference and 6.4% preferring the OTS knee replacement. CONCLUSIONS We believe that this is the first study to examine patient-reported outcomes of customized and OTS TKA implant designs in the same patient. We conclude that patients in this study cohort who underwent staged bilateral TKA with a C-TKA implant in 1 knee and an OTS prosthesis in the other knee reported better for their patient-specific knee replacement, with higher FJS and KOOS, JR values, and overall, preferred the C-TKA knee more often compared with the OTS knee replacement. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lennart Schroeder
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital, LMU Munich, Munich, Germany
| | | | - Daniel Dunaway
- Department of Orthopedic Surgery, Far Oaks Orthopedists, Kettering, Ohio
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Comparative Cost Analysis of Four Different Computer-Assisted Technologies to Implant a Total Knee Arthroplasty over Conventional Instrumentation. J Pers Med 2022; 12:jpm12020184. [PMID: 35207672 PMCID: PMC8880057 DOI: 10.3390/jpm12020184] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/16/2022] Open
Abstract
Several computer-assisted technologies, such as navigation and robotics, have been introduced to Total Knee Arthroplasty (TKA) in order to increase surgical precision and reduce complications. However, these technologies are often criticized due to the increased costs and effort associated with them; however, comparative data are missing. The aim of the present study was to evaluate differences in intraoperative workflows and the related perioperative cost-profiles of four current computer-assisted technologies, used to implant a TKA, in order to gain a comparison to conventional instrumentation. For the cost analysis, additional preoperative imaging and instruments, increased operating room (OR) and planning-time, and expenditures for technical support of the equipment and disposals were calculated, in comparison to conventional TKA, for (1) standard computer-navigation, (2) patient specific instruments (PSI), (3) image-based robotic assistance, and (4) imageless robotic assistance. Workflows at four expert centers which use these technologies were reviewed by an independent observer. The total cost calculation was based on a 125 TKA per year unit in Switzerland. Computer-navigation resulted in 14 min (+23%) increased surgery time and, overall, USD 650 in additional costs. PSI technology saved 5 min (8%) OR time but it created USD 1520 in expenditures for imaging and disposals. The image-based robotic system was the most expensive technology; it created overall additional costs of USD 2600, which predominately resulted from technical support, disposals, the CT-Scan, and 14 min of increased OR time. The imageless robotic assistance resulted in the largest increase in OR-time, as it resulted in an additional 25 min (+42%) on average. Overall, additional costs of USD 1530 were calculated. Every one of the assistive technologies in this study increased the total cost of TKA when compared to a conventional technique, and the most important variables, related to cost, were technical support and additional disposables. The longer surgical times and additional surgical trays required for the techniques had a marginal effect on overall costs. This comparative cost analysis gives valuable information for future efforts to calculate the real costs of these technologies and the subsequent return on investment of each technique.
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CT-based patient-specific instrumentation for total knee arthroplasty in over 700 cases: single-use instruments are as accurate as standard instruments. Knee Surg Sports Traumatol Arthrosc 2022; 30:447-455. [PMID: 32676744 PMCID: PMC8866287 DOI: 10.1007/s00167-020-06150-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Efforts in total knee arthroplasty are made to improve accuracy for a correct leg axis and reduce component malpositioning using patient-specific instruments. It was hypothesized that use of patient-specific instruments (vs. computer-navigated and conventional techniques) will reduce the number of outliers. Our second hypothesis was that single-use instrumentation will lead to the same accuracy compared to patient-specific instruments made of metal. METHODS 708 primary total knee arthroplasties between 2014 and 2018 using computer tomography (CT)-based patient-specific cutting block technique and a preoperative planning protocol were retrospectively reviewed. Preoperative data [hip-knee-angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), tibial slope, femoral component flexion] was compared to postoperative performed standard radiological follow-up X-rays. Differences of > 3° between measurements were defined as outliers. RESULTS Overall 500 prostheses using standard instrumentation and 208 prostheses using single-use instruments were implanted. Preoperative HKA axes (- 1.2°; p < 0.001), femoral component flexion (Δ 0.8°, p < 0.001), LDFA (Δ - 1.5°, p < 0.001), MPTA (Δ - 0.5°, p < 0.001) and tibial posterior slopes (Δ 0.5°, p < 0.001), respectively, were different from postoperative axes. More outliers occurred using standard (vs. single-use) instruments (p < 0.001) regarding postoperative HKA (ranges of standard- vs. single-use: instruments: HKA 178.0°-180.5° vs. 178.0°-180.5°, femoral component flexion 0.0°-6.0° vs. 0.0°-4.5°, LDFA 90.0°-91.0° vs. 90.0°-90.0°, MPTA 90.0°-90.0° vs. 90.0°-90.0°, tibial posterior slope - 10° to 10° vs. - 1° to 10°). No differences were seen for other angles measured. Comparing both systems, total number of outliers was higher using standard (8%) vs. single-use instruments (4.3%). CONCLUSION This study shows a high accuracy of CT-based patient-specific instrumentation concerning postoperative achieved knee angles and mechanical leg axes. Single-use instruments showed a similar accuracy. LEVEL OF EVIDENCE III.
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Claassen L, Luedtke P, Nebel D, Yao D, Ettinger S, Daniilidis K, Stukenborg-Colsman C, Plaass C. Establishing a New Patient-Specific Implantation Technique for Total Ankle Replacement: An In Vitro Study. Foot Ankle Spec 2021:19386400211029741. [PMID: 34253082 DOI: 10.1177/19386400211029741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Revision rates after total ankle replacements (TARs) are higher compared with other total joint replacements. The present study aimed to establish a new patient-specific implantation (PSI) technique for TAR. MATERIAL AND METHODS A total of 10 complete Caucasian cadaver legs had whole leg computed tomography scans. The individual geometrical ankle joint axis was determined, and based on this axis, the position of the prosthesis was planned. We assessed prosthesis placement, guiding block position, and preoperative and postoperative ankle rotational axes. RESULTS The guiding block position interobserver reliability was 0.37 mm 0.45 (mean ± SD) for the tibial guiding block. The value for the first talar guiding block was 1.72 ± 1.3 mm and for the second talar guiding block, 0.61 ± 0.39 mm. The tibial slope as well as the frontal angles of the anatomical tibial axis compared to the tibial and talar articular surfaces showed no statistically relevant differences with numbers available. The deviation of the assessed preoperative joint axis to the postoperative joint axis was 14.6° ± 7.8. CONCLUSION The present study describes the results of an establishing process of a new PSI technique for TAR. The reliability of guiding block positioning and, thereby, prosthesis placement is sufficient. LEVEL OF EVIDENCE Biomechanical study.
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Affiliation(s)
- Leif Claassen
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Philipp Luedtke
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Dennis Nebel
- Laboratory for Biomechanics and Biomaterials of the Hannover Medical School
| | - Daiwei Yao
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Sarah Ettinger
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | | | | | - Christian Plaass
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
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Moorthy V, Chen JY, Liow MHL, Chin PL, Chia SL, Lo NN, Yeo SJ. Mid-term functional outcomes of patient-specific versus conventional instrumentation total knee arthroplasty: a prospective study. Arch Orthop Trauma Surg 2021; 141:669-674. [PMID: 33386974 DOI: 10.1007/s00402-020-03729-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Patient-specific instrumentation (PSI) utilizes three-dimensional imaging to produce total knee arthroplasty cutting jigs which matches patient's native anatomy. However, there are limited mid- to long-term studies examining its clinical efficacy. The aim of this study was to compare functional outcomes of PSI surgery versus conventional TKA surgery at 5-year follow-up. MATERIALS AND METHODS Sixty patients were prospectively recruited into either the MRI-based PSI or conventional TKA group. Functional outcomes were assessed using the Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS) and Oxford Knee Score (OKS), while quality of life was evaluated with the Physical Component Score (PCS) and Mental Component Score (MCS) of Short-Form 36 and compared between the two groups at 5-year follow-up. RESULTS Although the PCS was 7 ± 3 points better in the PSI group preoperatively (p = 0.017), it became 5 ± 2 points worse than the conventional group at 5-year follow-up (p = 0.025). As compared to the PSI group, the conventional group showed a significantly greater improvement in PCS at 5 years as compared to before surgery (p = 0.003). There were no significant differences in KSFS, KSKS, OKS or MCS between the two groups. CONCLUSIONS PSI TKA did not result in improved functional outcomes or better quality of life when compared to conventional TKA. The additional costs and waiting time associated with PSI are not justifiable and therefore not recommended as an alternative to conventional TKA. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
| | - Jerry Yongqiang Chen
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Pak Lin Chin
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Block 6 Level 7, Outram Road, Singapore, 169608, Singapore
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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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Wang B, Guo H, Geng T, Sun K, Zhang L, Lu Z, Jin Q. The effect of strontium ranelate on titanium particle-induced periprosthetic osteolysis regulated by WNT/β-catenin signaling in vivo and in vitro. Biosci Rep 2021; 41:BSR20203003. [PMID: 33443286 PMCID: PMC7846966 DOI: 10.1042/bsr20203003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022] Open
Abstract
Aseptic loosening following periprosthetic osteolysis is the primary complication that limits the lifetime of total joint arthroplasty (TJA). The wear particles trigger a chronic inflammation response in the periprosthetic tissue and turn over the bone balance to bone resorption. The present study aimed to investigate the possible effect and mechanism of strontium ranelate (SR), a clinically safe drug for osteoporosis, on particle-induced periprosthetic osteolysis. Thirty-six female C57BL/6j mice underwent tibial Ti-nail implantation to establish an animal model of aseptic loosening. After 12 weeks, micro-CT results showed that strontium ranelate could inhibit periprosthetic bone resorption. In vitro, Ti particles were used to stimulate RAW264.7 cell line to collect conditioned medium, and co-culture MC3T3-E1 cell line with conditioned medium to establish a cell model of aseptic loosening. The results of alkaline phosphatase (ALP) detection, immunofluorescence, and flow cytometry demonstrated that strontium ranelate could regulate the expression of OPG/RANKL, promote differentiation and mineralization, and inhibit apoptosis in osteoblasts. Moreover, we revealed that SR's exerted its therapeutic effect by down-regulating sclerostin, thereby activating the Wnt/β-catenin signal pathway. Therefore, this research suggests that strontium ranelate could be a potential drug for the prevention and treatment of particle-induced aseptic loosening post-TJA.
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Affiliation(s)
- Bolun Wang
- Department of Orthopedic Surgery, Ningxia Medical University, 1160 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Haohui Guo
- Department of Orthopedics, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Tianxiang Geng
- Department of Orthopedic Surgery, Ningxia Medical University, 1160 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Kening Sun
- Department of Orthopedics, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Liang Zhang
- Department of Orthopedics, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Zhidong Lu
- Department of Orthopedics, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
| | - Qunhua Jin
- Department of Orthopedics, General Hospital of Ningxia Medical University, 804 Shengli Street, Xingqing Area, Yinchuan, Ningxia, P.R. China 750004
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Fucentese SF, Koch PP. A novel augmented reality-based surgical guidance system for total knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:2227-2233. [PMID: 34698930 PMCID: PMC8595230 DOI: 10.1007/s00402-021-04204-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/29/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Many of the functional complications that arise after total knee arthroplasty (TKA) are caused by a non-optimal balance of the knee after surgery. Over the past 20 years, technology has been used in the Operating Room (OR) to help improve precision and balance. The results of Computer-Assisted Surgery (CAS) and robotic systems show improved accuracy regarding implant positioning but a relatively small improvement in patient-reported outcomes and implant survival compared to conventional TKA. Recently, Augmented Reality (AR) has been proposed as a technology that could improve accuracy in orthopaedic surgery, providing a more efficient and cost-effective solution. MATERIALS AND METHODS This article describes a novel AR-based surgical guidance system that measures intra-operatively the effect of prosthesis alignment and positioning on soft tissue balance. The system is integrated in a pair of smart glasses and two small sensors and displays surgical targets directly in the field of view of the surgeon. RESULTS The system has been used in a limited number of cases. While the preliminary experience has been positive, clinical research is ongoing to confirm to confirm the performance of the system and the impact on clinical outcomes. CONCLUSION Augmented Reality can be a valuable tool to improve accuracy in TKA. The use of smart glasses and integrated sensors improves the efficiency of the procedure, particularly when coupled with single-use instrumentation. A novel protocol for soft tissue assessment allows for a 3-dimensional evaluation of the ligaments and a better measurement of the effect of tibial rotation.
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Affiliation(s)
- Sandro F. Fucentese
- grid.7400.30000 0004 1937 0650University Hospital Balgrist, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Peter P. Koch
- grid.452288.10000 0001 0697 1703Department of Orthopaedic Surgery and Traumatology, Kantonsspital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
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Nedopil AJ, Howell SM, Hull ML. Deviations in femoral joint lines using calipered kinematically aligned TKA from virtually planned joint lines are small and do not affect clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2020; 28:3118-3127. [PMID: 31768572 DOI: 10.1007/s00167-019-05776-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Kinematically aligned total knee arthroplasty (KA TKA) strives to restore the native distal and posterior joint lines of the femur. Because the joint lines of a virtually planned femoral component on the native femur can serve as surrogates of those of the native femur, the present study determined position and orientation deviations of the femoral joint lines following calipered KA TKA from virtually planned joint lines and whether these alignment deviations affect clinical outcomes. Our hypotheses were that the alignment deviations for most knees would be less than 2 mm and/or 2° and that larger alignment deviations would not be associated with lower clinical outcome scores. METHODS A review of lower extremity CT scanograms and CT scans of the knee identified 36 patients treated with calipered KA TKA in one limb and no other skeletal deformities in either limb. 3D models of the operated femur with the implanted femoral component and the native femur were created. The articular surfaces of a 3D model of the implanted femoral component in the TKA knee were shape-matched to the condyles of the native femur to create a virtual plan. The shape-matched femoral component served as a reference from which to determine alignment deviations of the femoral component implanted in the ipsilateral femur. The Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) were obtained at an average of 20 months. RESULTS For proximal-distal and anterior-posterior positions and varus-valgus and internal-external orientations of the femoral component, the root mean square deviations from the planned joint lines ranged from 1.4 to 1.5 (mm or degrees). The mean differences ranged from - 0.1 to 0.2 (mm or degrees) indicating an absence of systematic alignment deviations. The proportion of knees with joint lines within ± 2 mm and ± 2° of the joint lines of virtually planned knees ranged from 83 to 92%. For the FJS and OKS, the median values were 79 (out of 100) and 45 (out of 48), respectively, and there were no significant correlations between deviations in the positions and orientations and either the FJS or the OKS. CONCLUSION Alignment deviations were bounded by 2 mm and 2° for most knees, which previous biomechanical studies have shown reduce the risks of stiffness, loss of extension, loss of flexion, and tibial compartment forces higher than those of the native knee. Moreover, because median FJS and OKS were relatively high, and because larger alignment deviations did not correlate with lower outcome scores, deviations did not affect clinical outcomes. These results validate calipered KA TKA as a surgical technique which closely restores the distal and posterior femoral joint lines to those planned and achieves concomitant high patient-reported outcome scores. Thus, surgeons can use the calipered KA TKA technique with confidence that the surgical alignment goal will be satisfied with sufficient accuracy that high patient-reported outcomes are achieved. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA
| | - Maury L Hull
- Department of Biomedical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA.
- Department of Mechanical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA.
- Department of Orthopaedic Surgery, Ambulatory Care Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA.
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22
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Olaiya OR, Nadeem I, Horner NS, Bedi A, Leroux T, Alolabi B, Khan M. Templating in shoulder arthroplasty - A comparison of 2D CT to 3D CT planning software: A systematic review. Shoulder Elbow 2020; 12:303-314. [PMID: 33123220 PMCID: PMC7545523 DOI: 10.1177/1758573219888780] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Computed tomography (CT) utilizing computer software technology to generate three-dimensional (3D) rendering of the glenoid has become the preferred method for preoperative planning. It remains largely unknown what benefits this software may have to the intraoperative placement of the components and patient outcomes. PURPOSE The purpose of this systematic review is to compare 2D CT to 3D CT planning in total shoulder arthroplasty. STUDY DESIGN Systematic review. METHODS A systematic database search was conducted for relevant studies evaluating the role of 3D CT planning in total shoulder arthroplasty. The primary outcome was component placement variability, and the secondary outcomes were intra- and inter-observer reliability in the context of preoperative planning. RESULTS Following title-abstract and full-text screening, six eligible studies were included in the review (n = 237). The variability in glenoid measurements between 3D CT and 2D CT planning ranged from no significant difference to a 5° difference in version and 1.7° difference in inclination (p<0.05). Posterior bone loss was underestimated in 52% of the 2D measured patients relative to 3D CT groups. Irrespective of 2D and 3D planning (39% and 43% of cases respectively), surgeons elected to implant larger components than those templated. There was no literature identified comparing differences in time, cost, functional outcomes, complications, or patient satisfaction. CONCLUSION The paucity of evidence exploring clinical parameters makes it difficult to comment on clinical outcomes using different methods of templating. More studies are required to identify how improved radiographic outcomes translate into improvements that are clinically meaningful to patients.
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Affiliation(s)
- Oluwatobi R Olaiya
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Ibrahim Nadeem
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Asheesh Bedi
- MedSport, University of Michigan, Ann Arbor, MI, USA
| | - Timothy Leroux
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Canada
| | - Bashar Alolabi
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada,Moin Khan, 50 Charlton Ave E., Hamilton, Ontario L8N 4A6, Canada.
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23
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Abstract
BACKGROUND Compared with the current gold standard of knee endoprosthetics, the concept of kinematic alignment is more responsive to the individual anatomy of the patient as it enables the three-dimensional restoration of individual axes, joint lines and capsule tension. One point of criticism is the lack of intraoperative control over individual bone resections with conventional instrumentation. However, with the help of CT-based individual 3D-printed cutting blocks, a precise preoperative plan can be transferred to the operating room. The aim of this article is to explain the operative technique of patient-specific instrumentation (PSI)-protected kinematic alignment. METHODS The procedure is based on a preoperative 3D model of the bony anatomy of the patient, with the aid of which the planning of the operation, with the positioning and size of the implant, as well as the necessary bone resections, are carried out. With this information about anatomy and resection levels the individual cutting blocks are produced, aided by a 3D printer. Intraoperative control is achieved by measuring the resection by means of a gage and comparison with the digital 3D design. DISCUSSION With the aid of the 3D-printed PSI cutting blocks the preoperative plan of kinematic alignment can be implemented in a precise manner. It is a simple tool and does not require any great expense. Compared with the conventional instrumentation, the operating time is shortened. However, because of the purely CT-based design, no information about the state of the soft tissue is obtained.
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24
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Turgeon TR, Cameron B, Burnell CD, Hedden DR, Bohm ER. A double-blind randomized controlled trial of total knee replacement using patient-specific cutting block instrumentation versus standard instrumentation. Can J Surg 2020; 62:460-467. [PMID: 31782643 DOI: 10.1503/cjs.018318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Patient-specific cutting blocks in total knee arthroplasty have been promoted to improve mechanical alignment, reduce alignment outliers and improve patient outcomes. The aim of this study was to compare the efficacy of patient-specific instrumentation (PSI) and conventional instrumentation (CI) in achieving neutral alignment and accurate component positioning in total knee arthroplasty. Methods We conducted a double-blinded randomized controlled trial in which patients were randomly assigned to treatment with either PSI or CI. Results Fifty-four patients were included in the study. No relevant improvement in coronal alignment was found between the PSI and CI groups with post-hoc power of 0.91. Tibial slope was found to be more accurately reproduced to the preoperative target of 3° with PSI than with CI (3.8°± 3.1° v. 7.7°± 3.6°, respectively, p < 0.001). There were no differences found in patient-reported outcome measures, surgical time or length of hospital stay. Conclusion Given the added cost of the PSI technique, its use is difficult to justify given the small improvement in only a single alignment parameter. Clinical trial registration Clinicaltrials.gov, no. NCT03416946
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Affiliation(s)
- Thomas R. Turgeon
- From the Department of Surgery, Section of Orthopaedics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); the Concordia Joint Replacement Group, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); and the Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Cameron)
| | - Brett Cameron
- From the Department of Surgery, Section of Orthopaedics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); the Concordia Joint Replacement Group, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); and the Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Cameron)
| | - Colin D. Burnell
- From the Department of Surgery, Section of Orthopaedics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); the Concordia Joint Replacement Group, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); and the Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Cameron)
| | - David R. Hedden
- From the Department of Surgery, Section of Orthopaedics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); the Concordia Joint Replacement Group, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); and the Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Cameron)
| | - Eric R. Bohm
- From the Department of Surgery, Section of Orthopaedics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); the Concordia Joint Replacement Group, Winnipeg, Man. (Turgeon, Burnell, Hedden, Bohm); and the Max Rady College of Medicine, University of Manitoba, Winnipeg, Man. (Cameron)
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25
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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: 2.0] [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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26
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Dong Y, Zhang Z, Dong W, Hu G, Wang B, Mou Z. An optimization method for implantation parameters of individualized TKA tibial prosthesis based on finite element analysis and orthogonal experimental design. BMC Musculoskelet Disord 2020; 21:165. [PMID: 32164625 PMCID: PMC7068904 DOI: 10.1186/s12891-020-3189-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/04/2020] [Indexed: 11/22/2022] Open
Abstract
Background Individualized and accurate implantation of a tibial prosthesis during total knee arthroplasty (TKA) can assist in uniformly distributing the load and reducing the polyethylene wear to obtain a long-term prosthetic survival rate, but individualized and accurate implantation of a tibial prosthesis during TKA remains challenging. The purpose of this study was to optimize and individualize the positioning parameters of a tibial prosthesis to improve its accurate implantation using a new method of finite element analysis in combination with orthogonal experimental design. Methods Ten finite element models of TKA knee joint were developed to optimize the implantation parameters (varus angle, posterior slope angle, and external rotation angle) of tibial prosthesis to reduce the peak value of the contact pressure on the polyethylene liner according to the method of finite element analysis in combination with orthogonal experimental design. The influence of implantation parameters on the peak value of the contact pressure on the polyethylene liner was evaluated based on a range analysis in orthogonal experimental design. Results The optimal implantation parameters for tibial prosthesis included 0° varus, 1° posterior slope, and 4° external rotation. Under these conditions, the peak value of the contact pressure on the polyethylene liner remained the smallest (16.37 MPa). Among the three parameters that affect the peak value of the contact pressure, the varus angle had the greatest effect (range = 6.70), followed by the posterior slope angle (range = 2.36), and the external rotation angle (range = 2.15). Conclusions The optimization method based on finite element analysis and orthogonal experimental design can guide the accurate implantation of the tibial prosthesis, reducing the peak value of the contact pressure on the polyethylene liner. This method provides new insights into the TKA preoperative plan and biomechanical decision-making for accurately implanting TKA prosthesis.
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Affiliation(s)
- Yuefu Dong
- Department of Orthopedics, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, Lianyungang, China
| | - Zhen Zhang
- School of Materials Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Wanpeng Dong
- School of Materials Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Guanghong Hu
- Institute of Plasticity Forming Technology & Equipment, Shanghai Jiao Tong University, Shanghai, China
| | - Bing Wang
- Department of Orthopedics, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, Lianyungang, China
| | - Zhifang Mou
- Department of Critical Care Medicine, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, No.8 Lingzhou East Road, Haizhou District, Lianyungang, 222000, China.
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27
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Zahn RK, Graef F, Conrad JL, Renner L, Perka C, Hommel H. Accuracy of tibial positioning in the frontal plane: a prospective study comparing conventional and innovative techniques in total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:793-800. [PMID: 32124032 PMCID: PMC7244465 DOI: 10.1007/s00402-020-03389-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 12/05/2022]
Abstract
BACKGROUND Coronal alignment of the tibial component determines functional outcome and survival in total knee arthroplasty (TKA). Innovative techniques for tibial instrumentation have been developed to improve accuracy and reduce the rate of outliers. METHODS In a prospective study, 300 patients were allocated to four different groups using a randomization process (two innovative and two conventional) techniques of tibial instrumentation (conventional: extramedullary, intramedullary; innovative: navigation and patient-specific instrumentation (PSI); n = 75 for each group). The aims were to reconstruct the medial proximal tibial angle (MPTA) to 90° and the mechanical tibio-femoral axis (mTFA) to 0°. Both angles were evaluated and compared between all groups three months after the surgery. Patients who presented with a postoperative mTFA > 3° were classified as outliers. RESULTS The navigation and intramedullary technique both demonstrated that they were significantly more precise in reconstructing a neutral mTFA and MPTA compared to the other two techniques. The odd's ratio (OR) for producing outliers was highest for the PSI method (PSI OR = 5.5, p < 0.05; extramedullary positioning OR = 3.7, p > 0.05; intramedullary positioning OR = 1.7, p > 0.05; navigation OR = 0.04, p < 0.05). We could only observe significant differences between pre- and postoperative MPTA in the navigation and intramedullary group. The MPTA showed a significant negative correlation with the mTFA in all groups preoperatively and in the extramedullary, intramedullary and PSI postoperatively. CONCLUSION The navigation and intramedullary instrumentation provided the precise positioning of the tibial component. Outliers were most common within the PSI and extramedullary technique. Optimal alignment is dependent on the technique of tibial instrumentation and tibial component positioning determines the accuracy in TKA since mTFA correlated with MPTA pre- and postoperatively.
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Affiliation(s)
- R. K. Zahn
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - F. Graef
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
| | - J. L. Conrad
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - L. Renner
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - C. Perka
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - H. Hommel
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
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28
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Pauzenberger L, Munz M, Brandl G, Frank JK, Heuberer PR, Laky B, Schwameis E, Anderl W. Patient-specific instrumentation improved three-dimensional accuracy in total knee arthroplasty: a comparative radiographic analysis of 1257 total knee arthroplasties. J Orthop Surg Res 2019; 14:437. [PMID: 31831022 PMCID: PMC6909617 DOI: 10.1186/s13018-019-1465-6] [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: 09/30/2019] [Accepted: 11/08/2019] [Indexed: 01/19/2023] Open
Abstract
Background The purpose of this study was to compare restoration of mechanical limb alignment and three-dimensional component-positioning between conventional and patient-specific instrumentation in total knee arthroplasty. Methods Radiographic data of patients undergoing mobile-bearing total knee arthroplasty (n = 1257), using either conventional (n = 442) or patient-specific instrumentation (n = 812), were analyzed. To evaluate accuracy of axis restoration and 3D-component-positioning between conventional and patient-specific instrumentation, absolute deviations from the targeted neutral mechanical limb alignment and planned implant positions were determined. Measurements were performed on standardized coronal long-leg and sagittal knee radiographs. CT-scans were evaluated for accuracy of axial femoral implant rotation. Outliers were defined as deviations from the targeted neutral mechanical axis of > ± 3° or from the intraoperative component-positioning goals of > ± 2°. Deviations greater than ± 5° from set targets were considered to be severe outliers. Results Deviations from a neutral mechanical axis (conventional instrumentation: 2.3°± 1.7° vs. patient-specific instrumentation: 1.7°± 1.2°; p < 0.001) and numbers of outliers (conventional instrumentation: 25.8% vs. patient-specific instrumentation: 10.1%; p < 0.001) were significantly lower in the patient-specific instrumentation group. Significantly lower mean deviations and less outliers were detected regarding 3D-component-positioning in the patient-specific instrumentation compared to the conventional instrumentation group (all p < 0.05). Conclusions Patient-specific instrumentation prevented from severe limb malalignment and component-positioning outliers (> ± 5° deviation). Use of patient-specific instrumentation proved to be superior to conventional instrumentation in achieving more accurate limb alignment and 3D-component positioning, particularly regarding femoral component rotation. Furthermore, the use of patient-specific instrumentation successfully prevented severe (> 5° deviation) outliers.
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Affiliation(s)
- Leo Pauzenberger
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Sports Surgery Clinic, Dublin, Ireland
| | - Martin Munz
- Medical University of Vienna, Vienna, Austria
| | - Georg Brandl
- Vienna Shoulder & Sports Clinic, Vienna, Austria
| | | | - Philipp R Heuberer
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria.,Health Pi, Vienna, Austria
| | - Brenda Laky
- Vienna Shoulder & Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria.,MedSciCare, Vienna, Austria
| | | | - Werner Anderl
- Vienna Shoulder & Sports Clinic, Vienna, Austria. .,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria. .,Shoulder & Sports Center, Mödling, Austria.
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29
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Kizaki K, Shanmugaraj A, Yamashita F, Simunovic N, Duong A, Khanna V, Ayeni OR. Total knee arthroplasty using patient-specific instrumentation for osteoarthritis of the knee: a meta-analysis. BMC Musculoskelet Disord 2019; 20:561. [PMID: 31759392 PMCID: PMC6875166 DOI: 10.1186/s12891-019-2940-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Total knee arthroplasty using patient-specific instrumentation (TKA-PSI), which are disposable cutting block guides generated to fit each patient's 3-dimensional knee anatomy, has been developed to treat patients with end-stage osteoarthritis of the knee. Surrogate markers such as radiographic malalignment have been well investigated, however, patient-important outcomes are not well examined to elucidate the efficacy of TKA-PSI. The aim of this review is to determine if TKA-PSI improves patient-reported outcome measures (PROM), surgery time, blood loss, transfusion and complications (e.g. surgical site infection, deep venous thrombosis, and revision TKA). METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ongoing clinical trials. For PROMs, surgery time, blood loss, and transfusion rate, we included randomized controlled trials (RCT) comparing TKA-PSI and standard TKA to treat osteoarthritis of the knee. For complications, we also included non-randomized comparative studies (non-RCT). RESULTS This review includes 38 studies, 24 of which were RCT and 14 of which were non-RCT. These included a total of 3487 patients. The predominant population in the included studies highly reflected the general population, with 62% being female, aged over 60 and having end-stage osteoarthritis of the knee. TKA-PSI did not improve PROMs as compared to standard TKA for less than 1-year (mean difference 0.48, 95% confidence interval (CI) -1.92-0.97 in the Oxford knee score, mean 3-month follow-up) and for 1-year or more (mean difference 0.25, 95%CI - 4.39-4.89 in the WOMAC score, mean 29-month follow-up). TKA-PSI did not reduce surgery time (mean difference - 3.09 min, 95%CI -6.73-0.55). TKA-PSI decreased blood loss with a small effect size corresponding to a 0.4 g/dl hemoglobin decrease (95%CI 0.18-0.88), but did not decrease transfusion rate (risk difference - 0.04, 95%CI -0.09-0.01). TKA-PSI did not reduce complication rates (risk difference 0.00, 95%CI - 0.01-0.01 in the composite outcome). CONCLUSIONS TKA-PSI does not improve patient-reported outcome measures, surgery time, and complication rates as compared to standard TKA. TKA-PSI decreases blood loss with a small effect, which is not enough to reduce transfusion rate.
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Affiliation(s)
- Kazuha Kizaki
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada.,Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada
| | - Ajaykumar Shanmugaraj
- Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada
| | - Fumiharu Yamashita
- Department of Orthopaedic surgery and rheumatology, Kyoto Shimogamo Hospital, 17 Shimogamo, Kyoto, 606-0866, Japan
| | - Nicole Simunovic
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada.,Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada
| | - Vickas Khanna
- Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada
| | - Olufemi R Ayeni
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada. .,Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Hamilton, Ontario, L8N 3Z5, Canada.
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30
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León-Muñoz V, Lisón-Almagro A, López-López M. Influence of instrumentation on the surgical time to implant a total knee prosthesis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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31
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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: 1.8] [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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Comparison of custom cutting guides based on three-dimensional computerized CT-scan planning and a conventional ancillary system based on two-dimensional planning in total knee arthroplasty: a randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2019; 43:2529-2538. [PMID: 31227853 DOI: 10.1007/s00264-019-04357-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Incorrect positioning of components during total knee arthroplasty (TKA) increases the risk of pain, instability, and early revision. The purpose of this study was to compare 3D planning-assisted and a conventional system for TKA positioning. We hypothesized that the use of three-dimensional CT-scan planning and custom cutting guides would increase the accuracy of component positioning. METHODS A randomized, controlled, prospective study of two groups was performed. In one group, patient-specific custom cutting guides (PSCG) were used for component positioning based on 3D CT-scan planning. In the control group, TKA was performed with a conventional ancillary system. The components' positioning angles were measured on 3D reconstructions. The main evaluation criterion was the percentage of outliers outside of a target zone of ± 3° for the coronal positioning of the femoral component. RESULTS Eighty patients were included. The percentage of outliers for the femoral component was significantly lower in the 3D-guided group (1 patient) compared to the control group (7 patients p = 0.02). The coronal femoral angle was restored with greater accuracy in the 3D-assisted group (- 0.1° ± 1.4°) compared to the control group (1.6° ± 2.5°). Surgery was significantly shorter in the 3D group. The clinical outcomes were better in the 3D group at the two year follow-up with fewer failures and a lower standard deviation in IKS scores. CONCLUSION The use of a 3D planning and custom guides can improve TKA component positioning by increasing the accuracy of implants alignment and reducing the percentage of outliers. The same benefit was not demonstrated for the global knee alignment and the clinical scores with no indisputable clinical advantage for the PSCG.
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León-Muñoz VJ, Lisón-Almagro AJ, López-López M. Influence of instrumentation on the surgical time to implant a total knee prosthesis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:321-326. [PMID: 31182387 DOI: 10.1016/j.recot.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/26/2019] [Accepted: 04/07/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To demonstrate if there is a difference in the time that the surgery is prolonged to implant a knee prosthesis according to the instrumentation system used. MATERIAL AND METHODS Retrospective analysis of the duration of 243 interventions (skin-to-skin time and ischemia time) performed by the same surgeon. Seventy-two cases operated with conventional instruments (IC), 68 by means of computer assisted surgery (CAS) and 103 with personalized instrumentation system (PSI). RESULTS IC skin-to-skin time 87,85 min (SD 11,86). IC ischemia time 94,44 min (SD 11,49). Computer assisted surgery skin-to-skin time 123,46 min (SD 11,27). Computer assisted surgery ischemia time 129,63 min (SD 11,37). PSI skin-to-skin time 78,69 min (SD 13,06). PSI ischemia time 84,63 min (SD 12,06). There is a significant difference between PSI and the other instrumentation systems (p 0,000). CONCLUSIONS In our study, the time consumption for the implantation of a knee prosthesis has been significantly lower when cutting blocks have been used, than when we have used other systems.
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Affiliation(s)
- V J León-Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - A J Lisón-Almagro
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de la Vega Lorenzo Guirao, Cieza, Murcia, España
| | - M López-López
- Subdirección General de Tecnologías de la Información, Servicio Murciano de Salud, Murcia, España
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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: 4.2] [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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Cucchi D, Menon A, Aliprandi A, Soncini G, Zanini B, Ragone V, Compagnoni R, Ferrua P, Fossati C, Randelli P. Patient-specific Instrumentation Affects Rotational Alignment of the Femoral Component in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Orthop Surg 2019; 11:75-81. [PMID: 30834703 PMCID: PMC6430487 DOI: 10.1111/os.12420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 12/04/2022] Open
Affiliation(s)
- Davide Cucchi
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, University of Milan, Monza, Italy
| | - Alessandra Menon
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, University of Milan, Monza, Italy.,1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Monza, Italy
| | | | | | - Beatrice Zanini
- IRCCS Policlinico San Donato, San Donato, Italy.,Department of Health Sciences, "Amedeo Avogadro" University of Eastern Piedmont, Novara, Italy
| | - Vincenza Ragone
- IRCCS Policlinico San Donato, San Donato, Italy.,Department of Health Sciences, "Amedeo Avogadro" University of Eastern Piedmont, Novara, Italy
| | - Riccardo Compagnoni
- 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Monza, Italy
| | - Paolo Ferrua
- Department of Knee Surgery, Azienda Socio Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan
| | - Chiara Fossati
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, University of Milan, Monza, Italy.,1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Monza, Italy
| | - Pietro Randelli
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, University of Milan, Monza, Italy.,1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Monza, Italy
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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: 8.6] [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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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: 3.8] [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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Buller LT, Menken L, Rodriguez JA. The custom total knee replacement: A bespoke solution. ACTA ACUST UNITED AC 2018. [DOI: 10.1053/j.sart.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mou Z, Dong W, Zhang Z, Wang A, Hu G, Wang B, Dong Y. Optimization of parameters for femoral component implantation during TKA using finite element analysis and orthogonal array testing. J Orthop Surg Res 2018; 13:179. [PMID: 30029670 PMCID: PMC6053797 DOI: 10.1186/s13018-018-0891-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/12/2018] [Indexed: 12/02/2022] Open
Abstract
Background Individualized and accurate implantation of a femoral component during total knee arthroplasty (TKA) is essential in achieving equal distribution of intra-articular stress and long-term survival of the prosthesis. However, individualized component implantation remains challenging. This study aimed to optimize and individualize the positioning parameters of a femoral component in order to facilitate its accurate implantation. Methods Using computer-simulated TKA, the positioning parameters of a femoral component were optimized individually by finite element analysis in combination with orthogonal array testing. Flexion angle, valgus angle, and external rotation angle were optimized in order to reduce the peak value of the pressure on the polyethylene liner of the prosthesis. Results The optimal implantation parameters of the femoral component were as follows: 1° flexion, 5° valgus angle, and 4° external rotation. Under these conditions, the peak value of the pressure on the polyethylene liner surface was minimized to 16.46 MPa. Among the three parameters, the external rotation angle had the greatest effect on the pressure, followed by the valgus angle and the flexion angle. Conclusion Finite element analysis in combination with orthogonal array testing can optimize the implantation parameters of a femoral component for TKA. This approach would possibly reduce the wear of the polyethylene liner and prolong the survival of the TKA prosthesis, due to its capacity to minimize stress. This technique represents a new method for preoperative optimization of the implantation parameters that can achieve the best possible TKA outcome.
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Affiliation(s)
- Zhifang Mou
- Department of Critical Care Medicine, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, Lianyungang, China
| | - Wanpeng Dong
- School of Materials Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Zhen Zhang
- School of Materials Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Aohan Wang
- School of Materials Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Guanghong Hu
- Institute of Plasticity Forming Technology & Equipment, Shanghai Jiao Tong University, Shanghai, China
| | - Bing Wang
- Department of Orthopedics, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, Lianyungang, China
| | - Yuefu Dong
- Department of Orthopedics, The Affiliated Lianyungang Hospital of Xuzhou Medical University/the First People's Hospital of Lianyungang, Lianyungang, China.
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Klasan A, Dworschak P, Heyse TJ, Lahner M, Malcherczyk D, Efe T, El-Zayat BF. Patient-specific instruments’ routine use over conventional total knee arthroplasty remains inconclusive: Analysis of 961 cases. Technol Health Care 2018; 26:523-528. [DOI: 10.3233/thc-171167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Antonio Klasan
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
| | - Philipp Dworschak
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
| | - Thomas J. Heyse
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
| | - Matthias Lahner
- Joint Center Hilden, Ruhr-University Bochum, Bochum, Germany
| | - Dominik Malcherczyk
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
| | - Turgay Efe
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
| | - Bilal Farouk El-Zayat
- Center for Orthopaedics and Traumatology, University Clinic Marburg, Marburg, Germany
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Slevin O, Hirschmann A, Schiapparelli FF, Amsler F, Huegli RW, Hirschmann MT. Neutral alignment leads to higher knee society scores after total knee arthroplasty in preoperatively non-varus patients: a prospective clinical study using 3D-CT. Knee Surg Sports Traumatol Arthrosc 2018; 26:1602-1609. [PMID: 29026941 DOI: 10.1007/s00167-017-4744-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/02/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The optimal coronal alignment is still under debate. However, in most of the studies, alignment was only assessed using radiographs, which are not accurate enough for assessment of tibial and femoral TKA position. The primary purpose of this study was to assess the relationship between coronal TKA alignment using 3D-reconstructed CTs and clinical outcome in patients with preoperative varus in comparison with patients with natural or valgus deformity. It was the hypothesis that neutral limb alignment shows a better outcome after TKA. METHODS Prospectively collected data of 38 patients were included. The clinical and radiological follow-up was 24 months. The patients were grouped into two groups with regard to their preoperative limb alignment. Group A (varus) consisted of 21 patients with preoperative varus of 3° or more, while group B (non-varus) consisted of 17 patients with neutral (- 3 < 0 > + 3) or valgus alignment (> + 3). For assessment of TKA component position and orientation, 3D-reconstructed CT was used. The measurements of the deviation from the whole limb mechanical axis (HKA angle) and the joint line alignment in the femoral (mLDFA) and the tibial side (MPTA) were assessed in the preoperative leg as well as during follow-up after TKA. For clinical outcome assessment, the Knee Society Score (KSS) was used at 1 and 2 years postoperatively. Correlation between KSS score and each variable was done using a linear and quadratic regression model (p < 0.05). RESULTS The mean postoperative HKA angle was - 1.3 (varus) in the varus group and + 1.4 (valgus) in the non-varus group. Overall, significant correlations between the preoperative and postoperative alignments were found. In the preoperatively non-varus group, a highly significant correlation was found between neutral limb alignment (HKA = 0° ± 3°) and higher KSS (r 2 = 0.74, p = 0.00). In the varus group, no correlation was found between the postoperative whole limb alignment and the components' position in the coronal plane to KSS score. CONCLUSION A significant correlation was found between neutral limb alignment and higher KSS only in patients with preoperative non-varus alignment. The concept of constitutional varus alignment is still under debate. Moreover, it appears that one should aim for a more individualized, alignment target based on the individual knee morphotype. LEVEL OF EVIDENCE Diagnostic study, Level II.
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Affiliation(s)
- Omer Slevin
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Liestal, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Laufen, Switzerland
| | - Anna Hirschmann
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Filippo F Schiapparelli
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Liestal, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Laufen, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Rolf W Huegli
- University of Basel, Basel, Switzerland.,Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, 4101, Bruderholz, Switzerland. .,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Liestal, Switzerland. .,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Laufen, Switzerland. .,University of Basel, Basel, Switzerland.
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Kosse NM, Heesterbeek PJC, Schimmel JJP, van Hellemondt GG, Wymenga AB, Defoort KC. Stability and alignment do not improve by using patient-specific instrumentation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2018; 26:1792-1799. [PMID: 29181560 DOI: 10.1007/s00167-017-4792-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/06/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE The primary aim of the study was to examine stability and alignment after total knee arthroplasty (TKA) using patient-specific instrumentation (PSI) and conventional instrumentation (CI). The hypothesis was that stability and alignment would be better using PSI than CI, 12 months postoperatively. The secondary aim included the evaluation of clinical outcomes after TKA. METHODS In this prospective randomized controlled trial, 42 patients with knee osteoarthritis received a Genesis II PS prosthesis with either PSI or CI. Patients visited the hospital preoperatively and postoperatively after 6 weeks and 3 and 12 months. To evaluate stability, varus-valgus laxity was determined in extension and flexion using stress radiographs 12 months postoperatively. Three months postoperatively, a long-leg radiograph and CT scan were obtained to measure hip-knee-ankle (HKA) alignment and component rotation. Furthermore, frontal and sagittal alignment of the components, the Knee Society Score, VAS Pain, VAS Satisfaction, Knee injury and Osteoarthritis Outcome score, Patella score (Kujala), University of California Los Angeles activity score, anterior-posterior laxity, (serious) adverse device-related events, and intraoperative complications were reported. The clinical outcomes were compared using independent t tests or non-parametric alternatives, and repeated measurements ANOVA with a significance level of p < 0.05. RESULTS No significant differences were found between the two groups regarding stability, HKA angle, and rotational alignment. In four patients, the PSI did not fit correctly on the tibia and/or femur requiring intraoperative modifications. Both groups improved significantly over time on all clinical outcomes, with no significant differences between the groups 12 months postoperatively. The PSI group showed less tibial slope than the patients in the CI group [PSI 2.6° versus CI 4.8° (p = 0.02)]. Finally, the PSI group more frequently received a thinner insert size than the CI group (p = 0.03). CONCLUSIONS Patients operated with PSI did not differ from CI in terms of stability and alignment. However, in the PSI group ligament releases were more often required intraoperatively. Furthermore, the two methods did not show different clinical results. It seems that the preoperative planning for the PSI facilitates more conservative bone cuts than CI, but whether this is clinically relevant should be investigated. Since PSI is more expensive and time consuming than CI, and does not outperform CI with regard to clinical results, we recommend to use CI. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Nienke M Kosse
- Sint Maartenskliniek Research, Sint Maartenskliniek, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands.
| | - Petra J C Heesterbeek
- Sint Maartenskliniek Research, Sint Maartenskliniek, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Janneke J P Schimmel
- Sint Maartenskliniek Research, Sint Maartenskliniek, P.O. Box 9011, 6500 GM, Nijmegen, The Netherlands
| | | | - Ate B Wymenga
- Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Koen C Defoort
- Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, The Netherlands
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Ninomiya JT. Does Assessment with a Single Postoperative Radiograph Predict Long-Term Success of Total Knee Arthroplasty?: Commentary on an article by Matthew P. Abdel, MD, et al.: "Effect of Postoperative Mechanical Axis Alignment on Survival and Functional Outcomes of Modern Total Knee Arthroplasties with Cement. A Concise Follow-up at 20 Years. J Bone Joint Surg Am 2018; 100:e38. [PMID: 29557874 DOI: 10.2106/jbjs.17.01361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James Toshio Ninomiya
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kawaguchi K, Michishita K, Manabe T, Akasaka Y, Higuchi J. Comparison of an Accelerometer-Based Portable Navigation System, Patient-Specific Instrumentation, and Conventional Instrumentation for Femoral Alignment in Total Knee Arthroplasty. Knee Surg Relat Res 2017; 29:269-275. [PMID: 29172387 PMCID: PMC5718798 DOI: 10.5792/ksrr.17.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/18/2017] [Accepted: 07/24/2017] [Indexed: 10/26/2022] Open
Abstract
Purpose The KneeAlign2 (KA2, OrthoAlign Inc.) accelerometer-based portable navigation system and patient-specific instrumentation (PSI; Signature, ZimmerBiomet) are widely used for ideal femoral component alignment in total knee arthroplasty (TKA). However, there has been no comparative study of the KA2 system, PSI, and conventional intramedullary instrumentation (CON). The purpose of this study was to compare the accuracy in achieving proper femoral component alignment and clinical features by using the KA2 navigation system, PSI, and CON. Materials and Methods We retrospectively compared the accuracy of femoral component alignment of 34 TKAs performed with the KA2 system for implantation of the femoral component, 32 TKAs with PSI, and 33 TKAs with CON. Results In the coronal plane, use of the KA2 system was more likely to result in optimal femoral component alignment than the CON and PSI (p<0.01). In the sagittal plane, use of the KA2 system was more likely to result in optimal component alignment than PSI, but the difference between the KA2 and CON was insignificant. Conclusions The portable accelerometer-based KA2 navigation system enabled ideal femoral implantation in the coronal and sagittal planes, as compared to the PSI or CON.
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Affiliation(s)
- Kohei Kawaguchi
- Department of Orthopaedic, Japan Community Healthcare Organization, Yugawara Hospital, Kanagawa, Japan
| | - Kazuhiko Michishita
- Department of Orthopaedic, Japan Community Healthcare Organization, Yugawara Hospital, Kanagawa, Japan
| | - Takeshi Manabe
- Department of Orthopaedic, Japan Community Healthcare Organization, Yugawara Hospital, Kanagawa, Japan
| | - Yoshiyuki Akasaka
- Department of Orthopaedic, Japan Community Healthcare Organization, Yugawara Hospital, Kanagawa, Japan
| | - Junya Higuchi
- Department of Orthopaedic, Japan Community Healthcare Organization, Yugawara Hospital, Kanagawa, Japan
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Slevin O, Amsler F, Hirschmann MT. No correlation between coronal alignment of total knee arthroplasty and clinical outcomes: a prospective clinical study using 3D-CT. Knee Surg Sports Traumatol Arthrosc 2017; 25:3892-3900. [PMID: 28005142 DOI: 10.1007/s00167-016-4400-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was to evaluate femoral and tibial as well as whole leg coronal TKA alignment using 3D-reconstructed CTs and to assess the relationship of coronal TKA alignment and clinical outcome in a large prospective series of patients. It was hypothesized that a coronal deviation of TKA position and leg alignment from the mechanical axis is correlated with poorer patients' outcome after TKA. METHODS A total of 81 consecutive patients who underwent primary TKA were prospectively included. The patient's demographics such as age, gender and time from primary TKA were noted. All patients underwent clinical and radiological examination including standardized radiographs (anteroposterior and lateral weight-bearing, patellar skyline view) and CT as part of their postoperative follow-up. For assessment of TKA component position and orientation 3D-reconstructed CT was used. For clinical outcome scoring the Knee Society Score (KSS) was used at 1 and 2 years postoperatively. Linear and quadratic regression models were used to test for correlations between alignment variables and KSS (p < .05). RESULTS The mean Knee Society Score was 181 ± 28 (range 52-200) 2 years postoperatively, while 78% of the patients were completely pain free and 22% had some persisting pain interfering with their daily activities. The mean mechanical whole limb alignment (HKA angle), femoral component alignment and tibial component alignment were 0°, 0.1° and -0.7°, respectively. The component position parameters, as well as the whole limb alignment measurements, did not show any statistically significant correlation with the KSS, after 1 and 2 years postoperatively. CONCLUSION In this prospective study, using 3D-CT to measure the component position, the postoperative outcome was not influenced by coronal TKA component position as well as the whole leg alignment. The findings challenge the current target of neutral coronal alignment and point towards a more individualized mechanical alignment target. LEVEL OF EVIDENCE Prognostic study, Level I.
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Affiliation(s)
- Omer Slevin
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland
| | | | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.
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The Effect of Patient-Specific Instrumentation Incorporating an Extramedullary Tibial Guide on Operative Efficiency for Total Knee Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2034782. [PMID: 28840124 PMCID: PMC5559926 DOI: 10.1155/2017/2034782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/19/2017] [Accepted: 05/16/2017] [Indexed: 11/17/2022]
Abstract
This retrospective study was to determine if patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) leads to shortened surgical time through increased operating room efficiency according to different tibial PSI designs. 166 patients underwent primary TKA and were categorized into three groups as follows: PSI without extramedullary (EM) tibial guide (group 1, n = 48), PSI with EM tibial guide (group 2, n = 68), and conventional instrumentation (CI) group (group 3, n = 50). Four factors were compared between groups, namely, operative room time, thickness of bone resection, tibial slope, and rotation of the component. The mean surgical time was significantly shorter in the PSI with EM tibial guide group (group 2, 63.9 ± 13.6 min) compared to the CI group (group 3, 82.8 ± 24.9 min) (P < 0.001). However, there was no significant difference in the PSI without EM tibial guide group (group 1, 75.3 ± 18.8 min). This study suggests that PSI incorporating an EM tibial guide may lead to high operative efficiency in TKA compared to CI. This trial is registered with KCT0002384.
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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: 2.9] [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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Postoperative alignment of TKA in patients with severe preoperative varus or valgus deformity: is there a difference between surgical techniques? BMC Musculoskelet Disord 2017. [PMID: 28637433 PMCID: PMC5480120 DOI: 10.1186/s12891-017-1628-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There have been conflicting studies published regarding the ability of various total knee arthroplasty (TKA) techniques to correct preoperative deformity. The purpose of this study was to compare the postoperative radiographic alignment in patients with severe preoperative coronal deformity (≥10° varus/valgus) who underwent three different TKA techniques; manual instrumentation (MAN), computer navigated instrumentation (NAV) and patient specific instrumentation (PSI). METHODS Patients, who received a TKA with a preoperative coronal deformity of ≥10° with available radiographs were included in this retrospective study. The groups were: MAN; n = 54, NAV; n = 52 and PSI; n = 53. The mechanical axis (varus / valgus) and the posterior tibial slope were measured and analysed using standing long leg- and lateral radiographs. RESULTS The overall mean postoperative varus / valgus deformity was 2.8° (range, 0 to 9.9; SD 2.3) and 2.5° (range, 0 to 14.7; SD 2.3), respectively. The overall outliers (>3°) represented 30.2% (48 /159) of cases and were distributed as followed: MAN group: 31.5%, NAV group: 34.6%, PSI group: 24.4%. No significant statistical differences were found between these groups. The distribution of the severe outliers (>5°) was 14.8% in the MAN group, 23% in the NAV group and 5.6% in the PSI group. The PSI group had significantly (p = 0.0108) fewer severe outliers compared to the NAV group while all other pairs were not statistically significant. CONCLUSIONS In severe varus / valgus deformity the three surgical techniques demonstrated similar postoperative radiographic alignment. However, in reducing severe outliers (> 5°) and in achieving the planned posterior tibial slope the PSI technique for TKA may be superior to computer navigation and the conventional technique. Further prospective studies are needed to determine which technique is the best regarding reducing outliers in patients with severe preoperative coronal deformity.
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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: 80] [Impact Index Per Article: 11.4] [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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