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Patel KD, Desai DD, Bhatt JK, Patel DR, Satapara VK. Exploring the Role of Anatomical Imaging Techniques in Preoperative Planning for Orthopaedic Surgeries. Cureus 2023; 15:e46622. [PMID: 37936988 PMCID: PMC10626571 DOI: 10.7759/cureus.46622] [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: 08/19/2023] [Accepted: 10/07/2023] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION The incorporation of a three-dimensional (3D) framework enables the surgeon to strategically plan their surgical intervention through the utilisation of the printed model. This encompasses the process of ascertaining the surgical approach, choosing the suitable reduction technique, finding the required implant dimensions, defining the ideal placement and alignment of the implant, and conducting a simulated practise of the procedure using a 3D printed duplicate of the anatomical structures. Therefore, we designed this study to evaluate the role of two imaging modalities (computed tomography (CT) and magnetic resonance imaging (MRI)) for pre-surgical planning for orthopaedic surgeries. METHODOLOGY The present investigation entailed a prospective analysis of total knee arthroplasties (TKAs) that were performed using patient-specific instrumentation (PSI) from 2019 to 2022. After performing the bone resection operation utilising a customised cutting jig specific to each patient, the exact thickness of the resected bone was evaluated using a vernier calliper. In the MRI group, the researchers directly compared the cutting thickness during surgery with the consistency planned before the operation. In contrast, the CT group added the presumed cartilage thickness (2 mm) to the actual thickness of the bone that was removed from the lateral condyles. RESULTS The planned incision thickness in the distal femoral was 8.5 ± 0.8 in the CT group and 8.9 ± 0.5 in the MRI group, while the actual incision thickness was reported as 9.8 ± 0.54 in CT and 8.3 ± 1.1; however, no significant mean difference was found between both groups. The planned incision thickness was 2.6 ± 1.1 in the CT group and 2.43 ± 1.66 in the MRI group, while the actual thickness was observed as 2.5 ± 0.6 and 2.88 ± 1.12 without significant difference (p = 0.86). CONCLUSION While magnetic resonance imaging (MRI) allows for the visualisation of cartilage, it has been observed that the MRI-based patient-specific instrumentation (PSI) system does not exhibit superior accuracy in projecting bone incision thickness compared to the computed tomography (CT)-based PSI system.
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Affiliation(s)
- Kush D Patel
- Anesthesiology, Nootan Medical College and Research Center, Visnagar, IND
| | - Dushyant D Desai
- Pathology, Nootan Medical College and Research Center, Visnagar, IND
| | - Jaymin K Bhatt
- Pathology and Laboratory Medicine, Nootan Medical College and Research Center, Visnagar, IND
| | - Dinesh R Patel
- Pathology, Nootan Medical College and Research Center, Nootan General Hospital, Visnagar, IND
| | - Vidya K Satapara
- Anatomy, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, IND
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2
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Theeuwen DMJ, Haveman I, Boonen B, van Haaren EH, Hendrickx RPM, Schotanus MGM. No differences in mid-term survival and clinical outcome between CT- and MRI-based patient-specific instrumentation for total knee arthroplasty, a randomized controlled trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03680-1. [PMID: 37573271 DOI: 10.1007/s00590-023-03680-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE The purpose of this prospective randomized controlled trial was to compare the clinical outcome and the survival rate of total knee arthroplasty between CT- and MRI-based patient-specific instrumentation 5 years after initial surgery. METHODS At a mean follow-up of 5.8 years (SD 0.3), 98 patients (64% women, loss to follow-up 28%) were included in this analysis. To assess the differences in clinical outcome, patients fulfilled PROMs preoperatively and at each follow-up moment. At final follow-up, the Forgotten Joint Score was adjusted. RESULTS At final follow-up, no new patients underwent revision surgery in both groups. Regarding the clinical outcome, no statistically significant difference between the groups was found. The Forgotten Joint Score was only performed at final follow-up and showed no significant difference between both groups. CONCLUSION At mid-term follow-up, survival rates between CT- and MRI-based patient-specific instrumentation did not show a significant difference. Regarding clinical outcome, only the EQ-5D-VAS (p < 0.040) showed a statistically significant difference over time, in favor of the MRI-group. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- D M J Theeuwen
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands.
| | - I Haveman
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - B Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - E H van Haaren
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - R P M Hendrickx
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - M G M Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Center, Dr. H Vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
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Tibesku CO, Haas SB, Saunders C, Harwood DA. Comparison of clinical outcomes of VISIONAIRE patient-specific instrumentation with conventional instrumentation in total knee arthroplasty: a systematic literature review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:4379-4393. [PMID: 36449066 PMCID: PMC10293358 DOI: 10.1007/s00402-022-04698-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Malalignment and resulting complications are major challenges in total knee arthroplasty (TKA) which patient-specific instrumentation (PSI) is proposed to alleviate. Previous PSI meta-analyses of TKA outcomes typically do not differentiate between PSI systems and assess relatively few outcomes, so the value of their findings is limited. VISIONAIRE™ cutting guides (Smith + Nephew Inc., Memphis, TN, USA) is a PSI system based on preoperative magnetic resonance and X-ray imaging. A systematic literature review (SLR) and meta-analysis, focussed specifically on VISIONAIRE, were conducted to assess TKA accuracy, intraoperative outcomes, and postoperative outcomes, compared with conventional instrumentation (CI). MATERIALS AND METHODS The SLR was performed using PubMed, Embase, and Google Scholar databases to identify relevant studies published until March 2022. Depending on statistical heterogeneity, meta-analyses were performed for outcome measures with fixed effect (I2 < 50%) or random-effects models (I2 ≥ 50%). Dichotomous outcomes were reported as odds ratios and continuous outcomes were reported as mean differences. Descriptive analyses were performed for outcomes not amenable to meta-analysis. RESULTS Outcomes for VISIONAIRE versus CI were reported in 25 studies. Compared with CI, VISIONAIRE reduced odds of mechanical outliers by 40% (p < 0.0001), with no statistically significant differences in odds of overall coronal, sagittal, or rotational plane component outliers. VISIONAIRE improved surgical efficiency (operating room, turnover, and tourniquet times reduced by 7.3% (p = 0.02), 42% (p = 0.022), and 15.9% (p = 0.01), respectively), lowering the odds of blood transfusion by 53% (p = 0.01) and shortening patients' hospital stays (11.1% reduction; p < 0.0001). There were no significant differences between groups in incidence of postoperative complications and (descriptively analyzed) return-to-function outcomes. CONCLUSION Options for PSI in TKA differ substantially, and it is important to assess the outcomes of individual systems. The current findings suggest that VISIONAIRE guides can lead to improved alignment accuracy and surgical efficiency compared with CI, without compromising postoperative safety and return-to-function outcomes.
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Affiliation(s)
| | - Steven B Haas
- Knee Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
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Hinloopen JH, Puijk R, Nolte PA, Schoones JW, de Ridder R, Pijls BG. The efficacy and safety of patient-specific instrumentation in primary total knee replacement: a systematic review and meta-analysis. Expert Rev Med Devices 2023; 20:245-252. [PMID: 36736371 DOI: 10.1080/17434440.2023.2177152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Patient-specific instrumentation (PSI) for primary total knee arthroplasty (TKA) surgery has been shown to increase accuracy of component positioning. However, it is unclear whether this also translates to actual benefits for patients in terms of better outcomes (efficacy) or less complications such as revisions (safety). We therefore systematically reviewed the literature to determine the efficacy and safety of PSI in primary TKA. METHODS Randomized controlled trials comparing PSI to non-PSI in primary TKA were included. A random effects model was used with meta-regression in case of heterogeneity. RESULTS Forty-three studies were included with a total of 1816 TKA in the PSI group and 1887 TKA in the control group. There were no clinically relevant differences between the PSI-group and non-PSI group regarding all outcomes. There was considerable heterogeneity: meta-regression analyses showed that the year the study was published was an important effect modifier. Early publications tended to show a positive effect for PSI compared to non-PSI TKA, whereas later studies found the opposite. CONCLUSION Based on evidence of moderate certainty, our study suggested that there were no clinically relevant differences in efficacy and safety between patients treated with PSI TKA and patients treated with non-PSI TKA.
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Affiliation(s)
- J H Hinloopen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - R Puijk
- Department of Orthopedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - P A Nolte
- Department of Orthopedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.,Department Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J W Schoones
- Directorate of Research Policy (Formerly: Walaeus Library), Leiden University Medical Centre, Leiden, The Netherlands
| | - R de Ridder
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedics, Reinier Haga Orthopaedic Centre, Zoetermeer, Netherlands
| | - B G Pijls
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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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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Clinical outcomes after using patient specific instrumentation: is it worth the effort? A minimum 5-year retrospective review of 298 PSI knees. Arch Orthop Trauma Surg 2022; 143:3409-3422. [PMID: 36214876 PMCID: PMC9549813 DOI: 10.1007/s00402-022-04593-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 08/10/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Use of patient specific instrumentation (PSI) for performing total knee arthroplasty (TKA) has been shown to improve component positioning but there is dearth of evidence regarding clinical outcomes. The aim of our study was to report patient satisfaction and functional outcome scores of patients who underwent PSI TKAs at minimum 5 year follow up. METHODS This is a retrospective study of a prospectively collected data of patients who underwent PSI TKAs between January 2012 and October 2015 under a single surgeon. Patient Reported Outcome Measures (PROMs), patient satisfaction questionnaires, surgeon directed 3D planning changes and intra-operative changes were collected and analysed. RESULTS The cohort included 298 consecutive PSI TKAs performed on 249 patients at a mean age of 71 years (range: 49-93 years). On an average 4 changes were made for each knee during 3D planning compared to preliminary plan. Intra-operative implant size change was required only in 3% (10 knees). The PROM scores were collected at a mean follow-up period of 6.8 years (range: 5.0-8.6 years) for 224 knees. Oxford Knee Score improved from median pre-operative score of 18 (IQR: 13-24) to median post-operative score of 44 (IQR: 40-47) with a median gain of 23 (IQR: 16-30). The median modified Forgotten Joint Score was 87.5 (IQR: 54.4-98.1). For the Beverland questionnaire, 75% (n = 166) reported being "Very Happy" and only 4% (n = 9/222) were 'Never Happy'. CONCLUSION Excellent patient satisfaction and functional scores at mid-term can be achieve d using PSI technique to perform TKA with careful surgeon directed pre-operative planning.
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Ishibashi S, Mizu-uchi H, Kawahara S, Tsushima H, Akasaki Y, Nakashima Y. Preoperative Virtual Total Knee Arthroplasty Surgery Using a Computed Tomography-based 3-dimensional Model With Variation in Reference Points and Target Alignment to Predict Femoral Component Sizing. Arthroplast Today 2022; 17:27-35. [PMID: 36032795 PMCID: PMC9399891 DOI: 10.1016/j.artd.2022.07.008] [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: 11/10/2021] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background The purpose of this study was to investigate the size differences of 19 different femoral component placements from the standard position in total knee arthroplasty using 3-dimensional virtual surgery. Methods Three-dimensional bone models were reconstructed from the computed tomography data of 101 varus osteoarthritic knees. The distal femoral bone was cut perpendicular to the femoral mechanical axis (MA) in the coronal plane. Twenty different component placements consisting of 5 cutting directions (perpendicular to MA, 3° and 5° extension relative to MA [3°E-MA and 5°E-MA, respectively], and 3° and 5° flexion relative to MA [3°F-MA and 5°F-MA, respectively]) in the sagittal plane, 2 rotational alignments (clinical epicondylar axis [CEA] and surgical epicondylar axis [SEA]), and 2 rotational types of anterior reference guide (central [CR] and medial [MR]) were simulated. Results The mean anteroposterior dimension of femur ranged from 54.3 mm (5°F-MA, SEA, CR) to 62.5 mm (5°E-MA, CEA, MR). The largest and smallest differences of anteroposterior dimension from the standard position (3°F-MA, SEA, and CR) were 7.1 ± 1.3 mm (5°E-MA, CEA, and MR) and −1.2 ± 0.2 mm (5°F-MA, SEA, and CR), respectively. Multiple regression analysis revealed that flexion cutting direction, SEA, and CR were associated with smaller component size. Conclusions The femoral component size can be affected easily by not only cutting direction but also the reference guide type and the target alignment. Our findings could provide surgeons with clinically useful information to fine-tune for unintended loose or tight joint gaps by adjusting the component size.
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Affiliation(s)
- Shojiro Ishibashi
- Department of Orthopedic Surgery, Saiseikai Fukuoka General Hospital, Chuo-ku, Fukuoka, Japan
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Hideki Mizu-uchi
- Department of Orthopedic Surgery, Saiseikai Fukuoka General Hospital, Chuo-ku, Fukuoka, Japan
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
- Corresponding author. Department of Orthopedic Surgery, Saiseikai Fukuoka General Hospital, 1-3-46, Tenjin, Chuo-ku, Fukuoka 810-0001, Japan. Tel. +81 92 771 8151.
| | - Shinya Kawahara
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Hidetoshi Tsushima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Yukio Akasaki
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
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Two-year outcome comparison of custom versus conventional total knee (TKA) implants: a retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Doan GW, Courtis RP, Wyss JG, Green EW, Clary CW. Image-Free Robotic-Assisted Total Knee Arthroplasty Improves Implant Alignment Accuracy: A Cadaveric Study. J Arthroplasty 2022; 37:795-801. [PMID: 34979253 DOI: 10.1016/j.arth.2021.12.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Improving resection accuracy and eliminating outliers in total knee arthroplasty (TKA) is important to improving patient outcomes regardless of alignment philosophy. Robotic-assisted surgical systems improve resection accuracy and reproducibility compared to conventional instrumentation. Some systems require preoperative imaging while others rely on intraoperative anatomic landmarks. We hypothesized that the alignment accuracy of a novel image-free robotic-assisted surgical system would be equivalent or better than conventional instrumentation with fewer outliers. METHODS Forty cadaveric specimens were used in this study. Five orthopedic surgeons performed 8 bilateral TKAs each, using the VELYS Robotic-Assisted System (DePuy Synthes) and conventional instrumentation on contralateral knees. Pre-resection and postresection computed tomography scans, along with optical scans of the implant positions were performed to quantify resection accuracies relative to the alignment targets recorded intraoperatively. RESULTS The robotic-assisted cohort demonstrated smaller resection errors compared to conventional instrumentation in femoral coronal alignment (0.63° ± 0.50° vs 1.39° ± 0.95°, P < .001), femoral sagittal alignment (1.21° ± 0.90° vs 3.27° ± 2.51°, P < .001), and tibial coronal alignment (0.93° ± 0.72° vs 1.65° ± 1.29°, P = .001). All other resection angle accuracies were equivalent. Similar improvements were found in the femoral implant coronal alignment (0.89° ± 0.82° vs 1.42° ± 1.15°, P = .011), femoral implant sagittal alignment (1.51° ± 1.08° vs 2.49° ± 2.10°, P = .006), and tibial implant coronal alignment (1.31° ± 0.84° vs 2.03° ± 1.44°, P = .004). The robotic-assisted cohort had fewer outliers (errors >3°) for all angular resection alignments. CONCLUSION This in vitro study demonstrated that image-free robotic-assisted TKA can improve alignment accuracy compared to conventional instrumentation and reduce the incidence of outliers.
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Affiliation(s)
- Gary W Doan
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
| | | | | | | | - Chadd W Clary
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
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Watanabe S, Akagi R, Shiko Y, Ono Y, Kawasaki Y, Ohdera T, Ohtori S, Sasho T. Intra- and inter-observer reliability of implant positioning evaluation on a CT-based three-dimensional postoperative matching system for total knee arthroplasty. BMC Musculoskelet Disord 2021; 22:363. [PMID: 33865360 PMCID: PMC8053298 DOI: 10.1186/s12891-021-04228-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background The evaluation of postoperative total knee arthroplasty (TKA) alignment mainly relies on measurement data obtained from plain radiographs. The aim of this retrospective observational study was to document the intra- and inter-observer reliability in assessment of TKA component positioning after surgery using a three-dimensional (3D) computed tomography (CT) image matching system. Methods Fourteen knees from 14 patients who received primary TKA were included, and images were analyzed by blinded readers not associated with the surgeries. The examiner digitized the reference points according to defined landmarks, and the designated size component was superimposed to the 3D reconstructed CT model for measurement. In addition to the evaluation of implant position against the coronal and sagittal lower limb mechanical axes that were defined based on bony landmarks, implant position against axes connecting implant-based reference points that are easier to indicate was evaluated. Results The overall intra- and inter-observer reliabilities determined by the intraclass correlation coefficients (ICC) of the implant alignment measurement for both femoral and tibial components were good (ICC > 0.60), except in the direction of femoral flexion and extension, for both mechanical and implant-based axes. The difference between implant alignment measurements according to the traditional mechanical axis and the implant-based axis ranged between means of 0.08o and 1.70o and were statistically significantly different. Conclusions The postoperative evaluation of implant position in the coronal and sagittal planes using 3D-CT image matching is reliable and has good reproducibility except for the sagittal alignment assessment of the femoral component. The measured implant position according to the traditional mechanical axis and the implant-based axis were slightly but significantly different.
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Affiliation(s)
- Shotaro Watanabe
- Department of Orthopaedic Surgery, Graduate School of Medicine, Development of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan.,Center for Preventive Medical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Ryuichiro Akagi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Development of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan.
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Yoshimasa Ono
- Department of Orthopaedic Surgery, Graduate School of Medicine, Development of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Toshihiro Ohdera
- Fukuoka Orthopaedic Hospital, 2-10-50 Yanagouchi, Minami-ward, Fukuoka-city, Fukuoka, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Development of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Development of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan.,Center for Preventive Medical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
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Keltz E, Keshet D, Peled E, Zvi Y, Norman D, Keren Y. Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models. World J Orthop 2021; 12:82-93. [PMID: 33614427 PMCID: PMC7866486 DOI: 10.5312/wjo.v12.i2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acetabular fractures pose diagnostic and surgical challenges. They are classified using the Judet-Letournel system, which is based solely on X-ray. However, computed tomography (CT) imaging is now more widely utilized in diagnosing these injuries. The emergence of 3-dimensional (3-D) printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan pre-operatively.
AIM To evaluate the reliability of the Judet-Letournel classification system of acetabular fractures, when using either CT imaging or 3-D printed models.
METHODS Seven patients with acetabular fractures underwent pelvic CT imaging, which was then used to create solid, 3-D printed models. Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach. The same questionnaire was completed using only CT imaging, and two weeks later, using only 3-D printed models. The inter- and intra-observer agreement rates were then analyzed.
RESULTS Inter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification: κ = 0.44, κ = 0.55, respectively (P < 0.001) and fair for preferred surgical approach: κ = 0.34, κ = 0.29, respectively (P < 0.005). Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate: κ = 0.48, κ = 0.41, respectively. No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists.
CONCLUSION The Judet-Letournel classification demonstrated only moderate rates of agreement. The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification, but decreased it with respect to the preferred surgical approach. This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries, thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.
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Affiliation(s)
- Eran Keltz
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
- Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
| | - Doron Keshet
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
- Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
| | - Eli Peled
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
- Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
| | - Yoav Zvi
- Department of Orthopaedic Surgery, Montefiore Medical Center, New York, NY 10461, United States
| | - Doron Norman
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
- Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
| | - Yaniv Keren
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3525408, Israel
- Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 3200003, Israel
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Li Z, Yang Z, Liao W, Wang W, Zou Y, Pan Y, Feng Z. Fewer femoral rotational outliers produced with CT- than with MRI-based patient-specific instrumentation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:2930-2941. [PMID: 31435705 DOI: 10.1007/s00167-019-05678-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/02/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE Previous studies comparing the surgical accuracy between computed tomography (CT)- and magnetic resonance imaging (MRI)-based patient-specific instrumentation (PSI) methods have produced contradictory results. The aim of this study was to determine which is the more reliable imaging method (CT versus MRI) for patient-specific total knee arthroplasty (TKA). CT-based PSI is hypothesised to have an advantage regarding the number of outliers. METHODS A total of 22 randomised controlled trials (RCTs), including 1749 TKA cases, were eligible for the meta-analysis. RCTs, systematic reviews and meta-analyses on this topic published in databases before September 2018 were identified by a literature search. The primary outcome was the number of lower extremities with greater than 3° of difference in alignment angles between the postoperative outcomes and target outcomes. The parameters calculated from the meta-analysis included risk ratios (RRs) and 95% confidence intervals (CIs). Additionally, the publication bias and heterogeneity of the studies were assessed. RESULTS The risk of femoral rotational outliers in the PSI group (RR = 0.48; 95% CI 0.24-0.98) was significantly reduced. Furthermore, subgroup analysis showed that the accuracy in the CT-based PSI group was significantly higher than that in the MRI-based CSI group (RR = 0.31; 95% CI 0.10-0.92). CONCLUSION This meta-analysis shows that when performing TKA with PSI, preoperative CT is beneficial for the production of the PSI, resulting in a significantly lower proportion of outliers in femoral rotational alignment. CT should be the preferred choice for imaging when performing TKA surgery with PSI to obtain better femoral rotational alignment. LEVEL OF EVIDENCE Therapeutic study (systematic review and meta-analysis), Level I.
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Affiliation(s)
- Zhihao Li
- Guangzhou University of Traditional Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510403, Guangdong, People's Republic of China
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Zhidong Yang
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Wencui Liao
- The Liuzhou Hospital of Traditional Chinese Medicine, No. 32, Jiefang North Road, Chengzhong District, Liuzhou, 545000, Guangxi, People's Republic of China
| | - Weigang Wang
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Yonggen Zou
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Yaocheng Pan
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China
| | - Zongquan Feng
- Guangzhou University of Traditional Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510403, Guangdong, People's Republic of China.
- The Foshan Hospital of Traditional Chinese Medicine, No. 6, Qinren Road, Chancheng District, Foshan, 528000, Guangdong, People's Republic of China.
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Ballard DH, Mills P, Duszak R, Weisman JA, Rybicki FJ, Woodard PK. Medical 3D Printing Cost-Savings in Orthopedic and Maxillofacial Surgery: Cost Analysis of Operating Room Time Saved with 3D Printed Anatomic Models and Surgical Guides. Acad Radiol 2020; 27:1103-1113. [PMID: 31542197 DOI: 10.1016/j.acra.2019.08.011] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 12/16/2022]
Abstract
RATIONALE AND OBJECTIVE Three-dimensional (3D) printed anatomic models and surgical guides have been shown to reduce operative time. The purpose of this study was to generate an economic analysis of the cost-saving potential of 3D printed anatomic models and surgical guides in orthopedic and maxillofacial surgical applications. MATERIALS AND METHODS A targeted literature search identified operating room cost-per-minute and studies that quantified time saved using 3D printed constructs. Studies that reported operative time differences due to 3D printed anatomic models or surgical guides were reviewed and cataloged. A mean of $62 per operating room minute (range of $22-$133 per minute) was used as the reference standard for operating room time cost. Different financial scenarios were modeled with the provided cost-per-minute of operating room time (using high, mean, and low values) and mean time saved using 3D printed constructs. RESULTS Seven studies using 3D printed anatomic models in surgical care demonstrated a mean 62 minutes ($3720/case saved from reduced time) of time saved, and 25 studies of 3D printed surgical guides demonstrated a mean 23 minutes time saved ($1488/case saved from reduced time). An estimated 63 models or guides per year (or 1.2/week) were predicted to be the minimum number to breakeven and account for annual fixed costs. CONCLUSION Based on the literature-based financial analyses, medical 3D printing appears to reduce operating room costs secondary to shortening procedure times. While resource-intensive, 3D printed constructs used in patients' operative care provides considerable downstream value to health systems.
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Affiliation(s)
- David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110.
| | | | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffery A Weisman
- University of Illinois at Chicago Occupational Medicine, Chicago, Illinois
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110
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Petterson SC, Blood TD, Plancher KD. Role of alignment in successful clinical outcomes following medial unicompartmental knee arthroplasty: current concepts. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Thijs E, Theeuwen D, Boonen B, van Haaren E, Hendrickx R, Vos R, Borghans R, Kort N, Schotanus MGM. Comparable clinical outcome and implant longevity after CT- or MRI-based patient-specific instruments for total knee arthroplasty: a 2-year follow-up of a RCT. Knee Surg Sports Traumatol Arthrosc 2020; 28:1821-1826. [PMID: 31270591 DOI: 10.1007/s00167-019-05616-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Patient-specific instruments (PSI) are already widespread used in total knee arthroplasty (TKA). Either computed tomography (CT) scans or magnetic resonance imaging (MRI) scans are used pre-operatively to create jigs to guide resection during surgery. This study is a sequel of previous work that showed significantly more radiological outliers for posterior slope when CT-based guides were used. The aim of this study was to assess differences in revision rate and clinical outcome between the two groups at 2-year follow-up. METHODS At the 2-year follow-up, 124 patients were analysed in this prospective, randomised single-blind study. A survival analysis with revision of the TKA as endpoint was performed. Patients fulfilled four patient-reported outcome measurements (PROMs). Scores on the questionnaires were compared between both groups at the different follow-up visits. RESULTS At final follow-up, there was no significant difference in the survival rates of the CT- and MRI-based PSI surgery. Postoperatively, the PROMs significantly improved within each group compared with the pre-operative values. There were no significant differences for the PROMs between both groups at the 2-years follow-up. CONCLUSIONS Although previous results showed more outliers regarding posterior slope for CT-based PSIs, no difference in revision rate or the outcome of PROMs was found at 2-year follow-up. Further research to determine what the influence is of radiological outliers on implant survival and clinical outcomes is necessary. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Elke Thijs
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Dieuwertje Theeuwen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Bert Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Emil van Haaren
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Roel Hendrickx
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob Borghans
- Department of Radiology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | | | - Martijn G M Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Centre, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands.
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Patient-Specific or Conventional Instrumentations: A Meta-analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2164371. [PMID: 32258107 PMCID: PMC7085852 DOI: 10.1155/2020/2164371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 02/13/2020] [Indexed: 02/05/2023]
Abstract
Objective To conduct a meta-analysis of randomized controlled trials (RCTs) to compare knee arthroplasty with patient-specific instrumentation (PSI) with the conventional instrumentation (CI). Methods RCTs were selected in PubMed and Embase from 2012 to 2018. Key data extracted included malalignment of mechanical axis, blood loss, surgical time, Oxford Knee Score (OKS), Knee Society Score (KSS), length of stay, and complications. Subgroup analysis was also performed regarding different PSI systems and different image processing methods. Results 29 RCTs with 2487 knees were eligible for the meta-analysis. Results showed that PSI did not improve the alignment of the mechanical axis compared with CI, but MRI-based PSI and Visionaire-specific PSI decrease the risk of malalignment significantly (P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and Conclusion PSI reduced the blood loss and improved KSS. MRI-based PSI reduced operative time and risk of malalignment of mechanical axis compared with CT-based PSI. Moreover, Visionaire-specific PSI achieves better alignment result of the mechanical axis than other systems.
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17
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Kang DG, Kim KI, Bae JK. MRI-based or CT-based patient-specific instrumentation in Total knee Arthroplasty: How do the two systems compare? ARTHROPLASTY 2020; 2:1. [PMID: 35236432 PMCID: PMC8796460 DOI: 10.1186/s42836-019-0020-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/12/2019] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patient-specific instrumentation (PSI) has been introduced into total knee arthroplasty (TKA) to improve accuracy in restoration of alignment. PSI in TKA refers to custom-made cutting jigs manufactured according to anatomic configuration of the patient’s bone based on preoperative magnetic resonance imaging (MRI) or computed tomography (CT) scans. The purpose of this study was to compare the MRI- or CT-based PSI to see if they could reproduce accurate bone resection and postoperative outcomes.
Methods
Seventy-one patients who received elective TKA using a PSI system for primary osteoarthritis with varus deformity were prospectively enrolled for this study. We randomly allocated those patients to MRI-based PSI group (36 patients) and CT-based PSI group (35 patients). The actual resection thickness and planned resection thickness by preoperative PSI electronic program were compared between the two groups. Radiographic findings of the postoperative limb alignment, three-dimensional position of the implants, and related complications were also evaluated. Clinical evaluation was also performed before and 2 years after the surgery.
Results
There were no significant differences in the resection thickness in femur and tibia between actual resection and planned resection in both groups. Furthermore, there were no significant differences between two groups in terms of coronal, sagittal and rotational alignment of the components. All clinical assessments revealed no differences between two groups 2 years after the operation. No specific complication related to PSI was observed.
Conclusions
Although MRI allows for visualization of cartilage, MRI-based PSI system did not show better accuracy in predicting the thickness of bone resection than CT-based PSI. Moreover, there were no differences in radiographic and clinical outcomes between the two groups.
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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: 42] [Impact Index Per Article: 8.4] [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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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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Attard A, Tawy GF, Simons M, Riches P, Rowe P, Biant LC. Health costs and efficiencies of patient-specific and single-use instrumentation in total knee arthroplasty: a randomised controlled trial. BMJ Open Qual 2019; 8:e000493. [PMID: 31206056 PMCID: PMC6542447 DOI: 10.1136/bmjoq-2018-000493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 01/17/2023] Open
Abstract
Aim To investigate whether patient-specific instrumentation (PSI) and single-use instrumentation (SUI) improve operating room efficiency in terms of time and cost to the healthcare provider over conventional/reusable instrumentation (CVR) when performing total knee arthroplasty (TKA). Patients and methods Patients requiring TKA were randomised into one of four surgical groups: CVR, CVS (conventional/SUI), PSR (PSI/reusable) and PSS (PSI/SUI). All surgical procedures were video recorded to determine specific surgical time intervals. Other variables reported included the number of instrument trays used, missing equipment, direct instrument costs and the weight of the instruments the staff had to handle. Oxford Knee Score (OKS), estimated blood loss and lengths of hospital stay were also recorded as markers of patient experience. Results PSR was significantly quicker in all the recorded time intervals, used less trays, experienced less missing equipment and resulted in lower blood loss and shorter hospital stays. SUI reported significantly slower operating room times and resulted in higher blood loss, but SUI was 88% lighter and 20% cheaper on average when compared with their reusable counterparts. Despite the economic advantages of PSI and SUI, the patients who reported greatest improvements in OKS were those allocated to the CVR group, but no clinically meaningful difference in OKS was found at any time point. Conclusions PSI and SUI for TKA have the potential of reducing operating room times over conventional, reusable sets. This reduction will benefit theatre personnel ergonomically, while presenting the healthcare provider with potential cost-saving benefits in terms of reduced sterilisation costs and surgical times.
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Affiliation(s)
- Andre Attard
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Gwenllian Fflur Tawy
- Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, UK
| | - Michiel Simons
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Philip Riches
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Philip Rowe
- Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Leela C Biant
- Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, UK
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Becker R, Bäker K, Hommel H, Bernard M, Kopf S. No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1456-1462. [PMID: 29767270 DOI: 10.1007/s00167-018-4981-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 05/04/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE It was hypothesized that malrotation of femoral component in total knee arthroplasty (TKA) will significantly impact clinical outcome. METHODS Eighty-eight consecutive patients with primary osteoarthritis of the knee were prospectively evaluated. They received a cemented posterior stabilized TKA (NexGen, Zimmer/Biomet® Inc., Warsaw, IN, USA). The femoral component was placed in 3° of external rotation referenced to the posterior condylar line. Postoperatively, a CT scan was performed to evaluate rotation of femoral component in the transverse plane. SF-36, KSS, and WOMAC, as well as their range of motion was assessed prior to surgery, after 6 and 24 months. Data are presented as mean and standard deviation (SD), as well as range if applicable. Correlation analysis was performed between the placement of the femoral component in the transverse plane and the clinical outcome. RESULTS Femoral component placement was on average 0.1° [SD 2.5°, range - 6.5° to + 6.5°] referenced to the surgical transepicondylar line showing a wide range between the two landmarks after surgery. After 6 months, WOMAC category 'physical function' correlated significantly with femoral component rotation (r = - 0.28, p = 0.007). After 24 months, WOMAC categories 'physical function' and 'pain' correlated significantly with femoral rotation (r = - 0.41, p < 0.001; and r = - 0.33, p = 0.001). No significant correlations were found between femoral component rotation and range of motion (r = 0.04), WOMAC category "stiffness", KSS, as well as SF-36 questionnaires. These reported formally significant correlations were without any clinical relevance. DISCUSSION The study showed that there is a significant patients specific femoral component placement in the transverse plane. Internal or external malrotation of the femoral component does not correlate automatically with poor knee function. The lack of correlation between femoral component position and clinical as well as functional outcome underlines complexity and significant individuality of each patient. The surgeon should be aware of the finding and attention should be paid during surgery when significant divergency is seen between the two landmarks. Soft tissue balancing might be very crucial in these specific patients, which needs to be studied in depth in the future. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Roland Becker
- Department of Orthopaedics and Traumatology, Brandenburg Medical Scholl Theodor Fontane, Hochstrasse 26, 14770, Brandenburg, Germany.
| | - Katharina Bäker
- Department of Traumatolgy, Helios Hospital, August-Bebel-Straße 55A, 39288, Burg bei Magdeburg, Germany
| | - Hagen Hommel
- Department of Orthopaedics, Hospital-MOL GmBH, Sonnenburger Weg 3, 16269, Wriezen, Germany
| | - Manfred Bernard
- Hospital Sanssouci Potsdam, Helene-Lange-Straße 13, 14469, Potsdam, Germany
| | - Sebastian Kopf
- Department of Orthopaedics and Traumatology, Brandenburg Medical Scholl Theodor Fontane, Hochstrasse 26, 14770, Brandenburg, Germany
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Zahn RK, Renner L, Perka C, Hommel H. Weight-bearing radiography depends on limb loading. Knee Surg Sports Traumatol Arthrosc 2019; 27:1470-1476. [PMID: 29992465 DOI: 10.1007/s00167-018-5056-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/06/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE The mechanical axis of the lower limb has shown to vary between different weight-bearing conditions and change after total knee arthroplasty (TKA). The purpose of this study was to investigate the correlation between mechanical axis alignment in standing long-leg radiographs and limb loading after TKA. METHODS Mechanical axis of the lower limb and limb loading have been prospectively evaluated in 115 patients 10 days and 3 months after TKA. By the moment of standing long-leg radiography for analysis of the mechanical leg axis, two digital scales separately captured the load of each limb. RESULTS Mechanical axis changed from an initial - 1° ± 2° valgus alignment to a varus axis of + 1° ± 2° (p < 0.01). This change in alignment was associated with an increase of limb loading from 89.9 ± 10.7 to 93.0 ± 7.0% (p < 0.01). The mechanical axis strongly correlated with relative limb loading at the first and second measurements (r = 0.804, p < 0.001, respectively, r = 0.562, p < 0.001). A significant change in the rate of outliers was registered within the observation period. These alterations and distinctions were much more pronounced in patients with postoperative incomplete extension (n = 15). CONCLUSIONS The postoperative mechanical axis correlates with limb loading. A clinical relevant change in frontal alignment of the lower limb is associated with increased limb loading after TKA. The actual mechanical axis can only be assessed at physiological limb loading in long-leg radiographs with complete extension at full weight bearing. LEVEL OF EVIDENCE Diagnostic study, Level II.
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Affiliation(s)
- Robert Karl Zahn
- Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Lisa Renner
- Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Hagen Hommel
- Clinic for Orthopaedics, Sports Medicine, and Rehabilitation, KH-MOL GmBH, Sonnenburger Weg 3, 16269, Wriezen, Germany.,Academic Teaching Hospital of the Medical School of Brandenburg Theodor Fontane, Fehrbelliner Strase 38, 16816, Neuruppin, Germany
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Scherer TP, Hoechel S, Müller-Gerbl M, Nowakowski AM. Comparison of knee joint orientation in clinically versus biomechanically aligned computed tomography coordinate system. J Orthop Translat 2019; 16:78-84. [PMID: 30723684 PMCID: PMC6350020 DOI: 10.1016/j.jot.2018.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/23/2018] [Accepted: 07/18/2018] [Indexed: 12/01/2022] Open
Abstract
Background Preoperative planning of total knee arthroplasty is usually performed using knee-centred computed tomography (CT) data sets. The disadvantage of these data sets is having no account of the biomechanical axis of the lower extremity, known as Mikulicz line. It aligns the femoral head to the middle of the talocrural joint. For optimal prosthesis arrangement, the knee CT data set must therefore be brought in congruency with this line of loading to achieve the best results and eliminate rotational malalignments. This study aims to establish a relation between the knee-centred clinical coordinate system (CCS) and a biomechanical coordinate system (BCS) based on the Mikulicz line. Methods CT data sets of 45 lower extremities were evaluated. Using VG Studio Max, a visualisation and measurement software program; each CT data set was aligned according to the CCS and BCS. After superimposing both the aligned data sets, the deviations of both coordinate systems in all three planes were measured with the centre of the knee defined as the origin. Results For the coronal plane, the CCS was demonstrated to be 2.54° in adduction compared to the BCS [standard deviation (SD) = 1.8°]. In sagittal view, the CCS was demonstrated to be 0.3° retroversed (SD = 3.27°). Finally, the deviation in the axial plane showed an outward rotation of 3.39° (SD = 1.99°). The alignment as well as the measurements demonstrated high intraobserver and interobserver reproducibility. Conclusion Both coordinate systems can be established in knee-centred CT data sets in a reproducible manner. Clearly, the CCS differs significantly from the BCS describing the biomechanical axis, but mathematical-based adaptations and corrections can be performed. The translational potential of this article The findings of this study allow a mathematical conversion of a knee CT to the biomechanical axis of the leg.
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Affiliation(s)
- Thomas P Scherer
- Department of Biomedicine, Musculoskeletal Research, University of Basel, Pestalozzistrasse 20, CH-4056 Basel, Switzerland
| | - Sebastian Hoechel
- Department of Biomedicine, Musculoskeletal Research, University of Basel, Pestalozzistrasse 20, CH-4056 Basel, Switzerland
| | - Magdalena Müller-Gerbl
- Department of Biomedicine, Musculoskeletal Research, University of Basel, Pestalozzistrasse 20, CH-4056 Basel, Switzerland
| | - Andrej M Nowakowski
- Department of Biomedicine, Musculoskeletal Research, University of Basel, Pestalozzistrasse 20, CH-4056 Basel, Switzerland.,Orthopaedic Department, Spital Uster, Brunnenstrasse 42, CH-8610 Uster, Switzerland
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24
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Bi-planar intra-articular deformity following malunion of a Schatzker V tibial plateau fracture: Correction with intra-articular osteotomy using patient-specific guides and arthroscopic resection of the tibial spine bone block. Knee 2018; 25:959-965. [PMID: 29891210 DOI: 10.1016/j.knee.2018.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/19/2018] [Accepted: 05/24/2018] [Indexed: 02/02/2023]
Abstract
Malunited tibial plateau fractures are a surgical challenge. We report a case of a malunion following a Schatzker V tibial plateau fracture with a biplanar deformity of the medial hemi-plateau. This was treated with an intra-articular osteotomy and biplanar restoration of the medial hemi-plateau using patient-specific guides and 3-dimensional planning based on computed tomography (CT) images. The mechanical axis was paradoxically preserved and the lateral compartment showed evidence of overload and degeneration secondary to a malunited tibial spine bone block providing varus/valgus constraint. This was arthroscopically resected at the same sitting. The tibial plateau was restored to the desirable height with a vast improvement in function and pain levels.
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25
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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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26
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Schotanus MGM, Thijs E, Heijmans M, Vos R, Kort NP. Favourable alignment outcomes with MRI-based patient-specific instruments in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:2659-2668. [PMID: 28698929 DOI: 10.1007/s00167-017-4637-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/06/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE Patient-specific instruments (PSIs) are already in relatively common use, and their post-operative radiographic results are equal to those for total knee arthroplasty (TKA) with conventional instrumentation. PSI use requires a preoperative MRI scan, CT scan, or a combination of MRI and a long-leg standing radiograph. However, there is no consensus as to which of these modalities, MRI or CT, is the preferred imaging modality when performing TKA with PSIs. METHODS This systematic literature review and meta-analysis studied the differences in alignment outliers between CT- and MRI-based PSI for TKA. A search of the Cochrane Database of Systematic Reviews, MEDLINE/PubMed and Embase was conducted, without restriction on date of publication. Only level I evidence studies written in English that included TKA with the use of MRI- and CT-based PSI were selected. A meta-analysis was then performed of the rate of outliers in the biomechanical axis and individual femoral and tibial component alignment. Where considerable heterogeneity among studies was present or the data did not provide sufficient information for performing the meta-analysis, a qualitative synthesis was undertaken. RESULTS Twelve randomized controlled trials, studying 841 knees, were eligible for data extraction and meta-analysis. MRI-based PSI resulted in a significantly lower proportion of coronal plane outliers with regard to the lateral femoral component (OR 0.52, 95% CI 0.30-0.89, P = 0.02), without significant heterogeneity (n.s.). There were no significant differences regarding the biomechanical axis or frontal femoral and individual tibial component alignment. CONCLUSION This systematic review and meta-analysis demonstrate that alignment with MRI-based PSI is at least as good as, if not better than, that with CT-based PSI. To prevent for malalignment, MRI should be the imaging modality of choice when performing TKA surgery with PSI. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Martijn G M Schotanus
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands.
| | - Elke Thijs
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
| | - Marion Heijmans
- Zuyderland Academy, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nanne P Kort
- Zuyderland Medical Centre, Dr H vd Hoffplein 1, 6162 AG, Sittard-Geleen, The Netherlands
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27
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Parisi TJ, Levy DL, Dennis DA, Harscher CA, Kim RH, Jennings JM. Radiographic Changes in Nonoperative Contralateral Knee After Unilateral Total Knee Arthroplasty. J Arthroplasty 2018; 33:S116-S120. [PMID: 29548619 DOI: 10.1016/j.arth.2018.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Some patients perceive symptomatic improvement in the contralateral knee after unilateral total knee arthroplasty (TKA). This so-called "splinting effect" has been observed but has not been radiographically evaluated. METHODS A retrospective review of patients with bilateral knee osteoarthritis treated with unilateral TKA was performed. Patients were subcategorized into 2 groups based on whether contralateral TKA was performed within the 2-year period. Contralateral radiographic measurements were performed. RESULTS Forty-four of 203 patients had contralateral TKA performed within 2 years. Preoperative parameters were significantly worse in the bilateral group. By 6 weeks postoperatively, mechanical axis plumbline improved approximately 1°, with more change in those patients with preoperative varus alignment. Larger delta changes were also present in bilateral group preoperative to 1-year radiographs for tibiofemoral angle and joint space widening. CONCLUSION In patients with bilateral knee osteoarthritis who undergo unilateral TKA, a splinting effect may be present and measurable radiographically with improvement of contralateral mechanical axis plumbline. Further research is necessary to determine whether this improvement may delay contralateral TKA implantation.
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Affiliation(s)
| | - Daniel L Levy
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN; Department of Mechanical and Materials Engineering, Denver University, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO
| | - Cole A Harscher
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO
| | | | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Mechanical and Materials Engineering, Denver University, Denver, CO
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Abane L, Zaoui A, Anract P, Lefevre N, Herman S, Hamadouche M. Can a Single-Use and Patient-Specific Instrumentation Be Reliably Used in Primary Total Knee Arthroplasty? A Multicenter Controlled Study. J Arthroplasty 2018; 33:2111-2118. [PMID: 29576488 DOI: 10.1016/j.arth.2018.02.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/25/2018] [Accepted: 02/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this controlled multicenter study is to evaluate the clinical and radiologic outcomes of primary total knee arthroplasty (TKA) using single-use fully disposable and patient-specific cutting guides (SU) and compare the results to those obtained with traditional patient-specific cutting guides (PSI) vs conventional instrumentation (CI). METHODS Seventy consecutive patients had their TKA performed using SU. They were compared to 140 historical patients requiring TKA that were randomized to have the procedure performed using PSI vs CI. The primary measure outcome was mechanical axis as measured on a standing long-leg radiograph using the hip-knee-ankle angle. Secondary outcome measures were Knee Society and Oxford knee scores, operative time, need for postoperative transfusion, and length of hospital stay. RESULTS The mean hip-knee-ankle value was 179.8° (standard deviation [SD] 3.1°), 179.2° (SD 2.9°), and 178.3° (SD 2.5°) in the CI, PSI and SU groups, respectively (P = .0082). Outliers were identified in 16 of 65 (24.6%), 15 of 67 (22.4%), and 14 of 70 (20.0%) knees in the CI, PSI, and SU group, respectively (P = .81). There was no significant difference in the clinical results (P = .29 and .19, respectively). Operative time, number of unit transfusion, and length of hospital stay were not significantly different between the 3 groups (P = .45, .31, and 0.98, respectively). CONCLUSION The use of an SU in TKA provided similar clinical and radiologic results to those obtained with traditional PSI and CI. The potential economic advantages of single-use instrumentation in primary TKA require further investigation.
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Affiliation(s)
- Laurent Abane
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | - Amine Zaoui
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | - Philippe Anract
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
| | | | | | - Moussa Hamadouche
- Department of Orthopaedic and Reconstructive Surgery, Clinical Orthopaedics Research Center, Centre Hospitalo-Universitaire Cochin-Port Royal, Paris, France
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29
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[Review of patient-specific instrumentation for total knee prosthesis]. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:228-234. [PMID: 29397920 DOI: 10.1016/j.pharma.2017.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Single use patient-specific instruments (PSI) for total knee prosthesis are introduced as a new alternative to conventional ancillaries and computer assisted surgery by improving implants positioning. An exhaustive review was carried out to identify their specific characteristics, with their advantages and disadvantages. METHODS Medical devices suppliers were consulted in 2015 for reviewing their PSI. Their technical, clinical and economic data were compared. The results had been submitted to an orthopaedics expert commission of our university hospital for clinical and financial opinion. RESULTS Ten companies have provided the documentation for the analysis. PSI are manufactured by suppliers using a three dimensional printing method based on CT scans or MRI images. PSI are produced according to the surgeon's preferences after a preliminary data check, which can be performed by the suppliers' engineers, the surgeon and automatic calculation. Five suppliers can produce sterile PSI with optional delivery of 3D bone models. According to the experts, the studies failed to demonstrate the superiority of a PSI or hospital economic gain. The prices listed remain high and operating room time is not always significantly reduced. CONCLUSIONS With the development of personalized medicine, the role of PSI grows in importance. They facilitate the surgeon's work by fully respecting the anatomy. These systems offer an interesting perspective in their technical and pedagogical aspects. But it seems premature to take them into routine use given the low number of high-level studies that were currently done.
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30
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Okada Y, Teramoto A, Suzuki T, Kii Y, Watanabe K, Yamashita T. Preoperative corrections are required for planning of patient-specific instrumentation in total knee arthroplasty. Knee 2017; 24:1492-1497. [PMID: 29046242 DOI: 10.1016/j.knee.2017.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 09/18/2017] [Accepted: 09/29/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patient-specific instrumentation (PSI) is attracting attention as a mechanical method of ensuring the accuracy of osteotomy during total knee arthroplasty (TKA). Few studies have focused on preoperative plans; thus, it is unclear how often initial plans have to be corrected preoperatively and intraoperatively. We investigated the frequency of corrections, the accuracy of intraoperative osteotomy, and postoperative alignment. METHODS We analyzed 45 knees of 40 patients who underwent TKA using magnetic resonance imaging (MRI)-based PSI. We evaluated the frequency of corrections to preoperative plans and intraoperative corrections for each part. We also evaluated osteotomy error, defined as the difference between the planned and actual thickness of resected bone. Hip-knee-ankle angle (HKA), femoral component angle (FCA), and tibial component angle (TCA) on plain X-rays were evaluated for postoperative alignment. RESULTS Corrections were made to the initial plans in 91.1% of cases with a mean of 3.3 corrections per knee. Intraoperative corrections were made in 57.8% of cases, with a mean of 0.6 corrections per knee. Mean absolute osteotomy error was around one millimeter, and values were within two millimeters over 80% of cases on most parts except the proximal lateral tibia. In terms of postoperative alignment, HKA was 178.5±1.7°, FCA was 89.0±1.6°, and TCA was 89.4±1.9°. Proportions of outliers were 11.1%, 15.6%, and 20.0%, respectively. CONCLUSIONS Most of the cases required preoperative corrections for planning of PSI. PSI may be useful for ensuring the accuracy of osteotomy and postoperative alignment.
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Affiliation(s)
- Yohei Okada
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan.
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan
| | - Yuichiro Kii
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, S1 W17, Chuo-ku, Sapporo 060-8556, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan
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Wei Y, Jia J, Jin X, Tong W, Tian H. Resveratrol ameliorates inflammatory damage and protects against osteoarthritis in a rat model of osteoarthritis. Mol Med Rep 2017; 17:1493-1498. [PMID: 29138829 PMCID: PMC5780088 DOI: 10.3892/mmr.2017.8036] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 07/13/2017] [Indexed: 12/11/2022] Open
Abstract
Resveratrol is a non-flavonoid polyphenol compound with a stilbene structure. As a type of phytoalexin produced under stress in plants, it improves the plant's resistance against pathogens and environment deterioration, and performs important functions beneficial to human health, such as anti-cancer, anti-oxidation, regulating blood lipid levels and prolonging life span. The effects of resveratrol were examined in a rat model of osteoarthritis (OA) and observed to ameliorate inflammatory damage and protect against OA. In the present study, resveratrol significantly inhibited the induction of clinical scores in rats with OA. Resveratrol inhibited tumor necrosis factor-α, interleukin (IL)-1β, IL-6 and IL-18 expression levels, and decreased caspase-3/9 activity in rats with OA. Inducible nitric oxide synthase, nuclear factor (NF)-κB, phosphorylated-(p)-AMP-activated protein kinase and sirtuin 1 protein expression were significantly suppressed and heme oxygenase 1 (HO-1) and nuclear factor erythroid 2-related factor 2 (Nrf-2) protein expression was stimulated in rats with OA treated with resveratrol. The current results indicate that resveratrol ameliorates inflammatory damage and protects against OA in a rat model of OA via NF-κB and HO-1/Nrf-2 signaling.
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Affiliation(s)
- Yulong Wei
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jie Jia
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Xin Jin
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Wei Tong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Hongtao Tian
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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Three-dimensional analysis of accuracy of patient-matched instrumentation in total knee arthroplasty: Evaluation of intraoperative techniques and postoperative alignment. J Orthop Sci 2017; 22:1077-1083. [PMID: 28888738 DOI: 10.1016/j.jos.2017.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/24/2017] [Accepted: 08/12/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is questionable that the accuracies of patient-matched instrumentation (PMI) have been controversial, even though many surgeons follow manufacturers' recommendations. The purpose of this study was to evaluate the accuracy of intraoperative procedures and the postoperative alignment of the femoral side using PMI with 3-dimensional (3D) analysis. METHODS Eighteen knees that underwent total knee arthroplasty using MRI-based PMI were assessed. Intraoperative alignment and bone resection errors of the femoral side were evaluated with a CT-based navigation system. A conventional adjustable guide was used to compare cartilage data with that derived by PMI intraoperatively. Postoperative alignment was assessed using a 3D coordinate system with a computer-assisted design software. We also measured the postoperative alignments using conventional alignment guides with the 3D evaluation. RESULTS Intraoperative coronal alignment with PMI was 90.9° ± 1.6°. Seventeen knees (94.4%) were within 3° of the optimal alignment. Intraoperative rotational alignment of the femoral guide position of PMI was 0.2° ± 1.6°compared with the adjustable guide, with 17 knees (94.4%) differing by 3° or less between the two methods. Maximum differences in coronal and rotation alignment before and after bone cutting were 2.0° and 2.8°, respectively. Postoperative coronal and rotational alignments were 89.4° ± 1.8° and -1.1° ± 1.3°, respectively. In both alignments, 94.4% of cases were within 3° of the optimal value. The PMI group had less outliers than conventional group in rotational alignment (p = 0.018). CONCLUSIONS Our 3D analysis provided evidence that PMI system resulted in reasonably satisfactory alignments both intraoperatively and postoperatively. Surgeons should be aware that certain surgical techniques including bone cutting, and the associated errors may affect postoperative alignment despite accurate PMI positioning.
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Biau DJ, Boulezaz S, Casabianca L, Hamadouche M, Anract P, Chevret S. Using Bayesian statistics to estimate the likelihood a new trial will demonstrate the efficacy of a new treatment. BMC Med Res Methodol 2017; 17:128. [PMID: 28830464 PMCID: PMC5568256 DOI: 10.1186/s12874-017-0401-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/02/2017] [Indexed: 12/29/2022] Open
Abstract
Background The common frequentist approach is limited in providing investigators with appropriate measures for conducting a new trial. To answer such important questions and one has to look at Bayesian statistics. Methods As a worked example, we conducted a Bayesian cumulative meta-analysis to summarize the benefit of patient-specific instrumentation on the alignment of total knee replacement from previously published evidence. Data were sourced from Medline, Embase, and Cochrane databases. All randomised controlled comparisons of the effect of patient-specific instrumentation on the coronal alignment of total knee replacement were included. The main outcome was the risk difference measured by the proportion of failures in the control group minus the proportion of failures in the experimental group. Through Bayesian statistics, we estimated cumulatively over publication time of the trial results: the posterior probabilities that the risk difference was more than 5 and 10%; the posterior probabilities that given the results of all previous published trials an additional fictive trial would achieve a risk difference of at least 5%; and the predictive probabilities that observed failure rate differ from 5% across arms. Results Thirteen trials were identified including 1092 patients, 554 in the experimental group and 538 in the control group. The cumulative mean risk difference was 0.5% (95% CrI: −5.7%; +4.5%). The posterior probabilities that the risk difference be superior to 5 and 10% was less than 5% after trial #4 and trial #2 respectively. The predictive probability that the difference in failure rates was at least 5% dropped from 45% after the first trial down to 11% after the 13th. Last, only unrealistic trial design parameters could change the overall evidence accumulated to date. Conclusions Bayesian probabilities are readily understandable when discussing the relevance of performing a new trial. It provides investigators the current probability that an experimental treatment be superior to a reference treatment. In case a trial is designed, it also provides the predictive probability that this new trial will reach the targeted risk difference in failure rates. Trial registration CRD42015024176. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0401-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David J Biau
- INSERM U1153, Paris, France. .,Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France. .,Université Paris-Descartes, Paris 5, Paris, France.
| | - Samuel Boulezaz
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Laurent Casabianca
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Moussa Hamadouche
- Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Philippe Anract
- INSERM U1153, Paris, France.,Service de chirurgie orthopédique,Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014, Paris, France
| | - Sylvie Chevret
- INSERM U1153, Paris, France.,Université Paris-Diderot, Paris 7, Paris, France
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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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Wu XD, Xiang BY, Schotanus MGM, Liu ZH, Chen Y, Huang W. CT- versus MRI-based patient-specific instrumentation for total knee arthroplasty: A systematic review and meta-analysis. Surgeon 2017; 15:336-348. [PMID: 28756064 DOI: 10.1016/j.surge.2017.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/06/2017] [Accepted: 06/12/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND To determine whether computed tomography (CT) or magnetic resonance imaging (MRI) is more suitable for the patient-specific instrumentation (PSI) systems for total knee arthroplasty (TKA). METHODS PubMed, Embase, and the Cochrane Library were searched from inception to June 2016 for prospective comparative trials that compared CT- versus MRI-based PSI systems for TKA. Our predefined primary outcome was the outliers incidence of coronal overall limb alignment. RESULTS Six studies with a total of 336 knees meeting the eligibility criteria, and four trials were included in the meta-analysis. Compared with MRI-based PSI systems, CT-based PSI systems were associated with a higher outliers incidence of coronal overall limb alignment (risk ratio: 1.67; 95% confidence interval (CI): 1.03-2.72; P = 0.04), more angular errors of coronal overall limb alignment (mean difference (MD): 1.01°; 95% CI: 0.47-1.56; P = 0.0003), and longer operation time (MD: 5.02 min; 95% CI: 1.26-8.79; P = 0.009). While no significant differences in the coronal/sagittal alignment of the femoral/tibial component outliers, the angular errors of coronal overall limb alignment, the angular errors of the femoral/tibial component in coronal plane, or incidence of change of implant size of the femoral/tibial component were observed. CONCLUSIONS The current limited evidence suggests that MRI-based PSI systems exhibit higher accuracy for TKA regarding the coronal limb axis than CT-based PSI systems. However, well-designed studies comparing CT-versus MRI-based PSI systems for TKA are warrant to confirm these results before widespread use of this technique can be recommended.
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Affiliation(s)
- Xiang-Dong Wu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China; Evidence-Based Perioperative Medicine 07 Collaboration Group, China
| | - Bing-Yan Xiang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China; Department of Orthopaedic Surgery, The First People's Hospital of Zunyi City, Zunyi, 563000, Guizhou Province, China
| | - Martijn G M Schotanus
- Department of Orthopedics, Zuyderland Medical Center, Sittard-Geleen, 6162 BG, The Netherlands
| | - Zun-Han Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yu Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Colombelli A, Belluati A, Rizqallah Y, Guerra G, Busatto C. Patient specific instrumentation in total knee arthroplasty. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:45-47. [PMID: 28657562 DOI: 10.23750/abm.v88i2 -s.6511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. METHODS Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. RESULTS The percentage of knees that had a HKA within ±3° of the desired value was 92.2. CONCLUSION the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.
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Alcelik I, Blomfield M, Öztürk C, Soni A, Charity R, Acornley A. A comparison of short term radiological alignment outcomes of the patient specific and standard instrumentation for primary total knee arthroplasty: A systematic review and meta-analysis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:215-222. [PMID: 28502570 PMCID: PMC6197451 DOI: 10.1016/j.aott.2017.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 11/19/2016] [Accepted: 12/03/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to review the radiological alignment outcomes of patient Specific (PS) cutting blocks and Standard Instrumentation in Primary Total Knee Arthroplasty. METHODS We hypothesized that the use of PS techniques would significantly improve sagittal, coronal and rotational alignment of the prosthesis on short term. We performed a systematic review and a meta-analysis including all the randomised controlled trials (RCT) using PS and standard (ST) total knee arthroplasty to date. RESULTS A total of 538 PS TKA and 549 ST TKA were included in the study. Statistical analysis of the outliers for femoral component sagittal, coronal and rotational positioning, tibial component sagittal and coronal positioning and the overall mechanical axis were assessed. We found that there was no significant benefit from using PS instrumentation in primary knee arthroplasty to aid in the positioning of either the tibial or femoral components. Furthermore sagittal plane tibial component positioning was worse in the PS than the traditional ST group. CONCLUSION Our results suggest that at present PS instrumentation is not superior to ST instrumentation in primary total knee arthroplasty. LEVEL OF EVIDENCE Level 1, Systematic review of therapeutic studies.
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Affiliation(s)
| | | | | | - Ashish Soni
- Airedale Hospital, Orthopaedics Department, UK
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Kazarian GS, Chen AF. Patients experience mixed results with respect to sexual quality and frequency after total knee arthroplasty: a systematic review. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Schotanus MGM, Sollie R, van Haaren EH, Hendrickx RPM, Jansen EJP, Kort NP. A radiological analysis of the difference between MRI- and CT-based patient-specific matched guides for total knee arthroplasty from the same manufacturer: a randomised controlled trial. Bone Joint J 2017; 98-B:786-92. [PMID: 27235521 DOI: 10.1302/0301-620x.98b6.36633] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 01/15/2016] [Indexed: 11/05/2022]
Abstract
AIMS This prospective randomised controlled trial was designed to evaluate the outcome of both the MRI- and CT-based patient-specific matched guides (PSG) from the same manufacturer. PATIENTS AND METHODS A total of 137 knees in 137 patients (50 men, 87 women) were included, 67 in the MRI- and 70 in the CT-based PSG group. Their mean age was 68.4 years (47.0 to 88.9). Outcome was expressed as the biomechanical limb alignment (centre hip-knee-ankle: HKA-axis) achieved post-operatively, the position of the individual components within 3° of the pre-operatively planned alignment, correct planned implant size and operative data (e.g. operating time and blood loss). RESULTS The patient demographics (e.g. age, body mass index), correct planned implant size and operative data were not significantly different between the two groups. The proportion of outliers in the coronal and sagittal plane ranged from 0% to 21% in both groups. Only the number of outliers for the posterior slope of the tibial component showed a significant difference (p = 0.004) with more outliers in the CT group (n = 9, 13%) than in the MRI group (0%). CONCLUSION The post-operative HKA-axis was comparable in the MRI- and CT-based PSGs, but there were significantly more outliers for the posterior slope in the CT-based PSGs. TAKE HOME MESSAGE Alignment with MRI-based PSG is at least as good as, if not better, than that of the CT-based PSG, and is the preferred imaging modality when performing TKA with use of PSG. Cite this article: Bone Joint J 2016;98-B:786-92.
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Affiliation(s)
- M G M Schotanus
- Zuyderland Medical Center, Dr H van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - R Sollie
- Sint Maartenskliniek, Hengstdal 3, 6574 NA Ubbergen, The Netherlands
| | - E H van Haaren
- Zuyderland Medical Center, Dr H van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - R P M Hendrickx
- Zuyderland Medical Center, Dr H van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - E J P Jansen
- Zuyderland Medical Center, Dr H van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
| | - N P Kort
- Zuyderland Medical Center, Dr H van der Hoffplein 1, Sittard-Geleen, 6162 BG, The Netherlands
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An VVG, Sivakumar BS, Phan K, Levy YD, Bruce WJM. Accuracy of MRI-based vs. CT-based patient-specific instrumentation in total knee arthroplasty: A meta-analysis. J Orthop Sci 2017; 22:116-120. [PMID: 27823847 DOI: 10.1016/j.jos.2016.10.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/06/2016] [Accepted: 10/10/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The technical objective of total knee arthroplasty (TKA) is to restore normal mechanical parameters to the knee. Patient-specific instrumentation (PSI) was developed to streamline the operative process and improve accuracy. PSI produces individualized cutting guides based on three-dimensional models of the patient's anatomy acquired from computed-tomography (CT) or magnetic-resonance imaging (MRI). However, the superiority of one modality over the other remains unclear. Therefore, we aimed to compare the accuracy of patient-specific cutting guides produced from MRI or CT imaging methods in TKA. METHODS Electronic databases were systematically searched using relevant keywords and MeSH terms for original-data English-language publications comparing the accuracy of CT and MRI-based PSI cutting guides in TKA. Data was extracted from the text, tables and figures of studies and meta-analysed. RESULTS MRI-based PSI cutting guides produced a lower proportion of coronal plane outliers (>3°) with regard to overall limb mechanical axis (OR 2.75, p = 0.01). There were no significant differences between the two in terms of sagittal femoral and tibial component placement, or coronal femoral and tibial placement, or femoral component axial rotation. Tibial rotation was not analysed in the literature. CONCLUSIONS MRI-based patient-specific cutting guides produced a lower proportion of outliers in the overall coronal alignment of the limb compared to CT, with no significant difference between the two in terms of femoral or tibial component placement. Future studies should investigate the differences in resource usage and operative time between the two to inform surgeons' decision making when choosing an ideal imaging modality for PSI TKA. STUDY DESIGN Meta-analysis. LEVEL OF EVIDENCE III, systematic review of cohort and comparative studies.
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Affiliation(s)
- Vincent V G An
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia.
| | - Brahman S Sivakumar
- Department of Orthopaedics, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Kevin Phan
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
| | - Yadin David Levy
- Department of Orthopaedics, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Warwick J M Bruce
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia; Department of Orthopaedics, Concord Repatriation General Hospital, Concord, NSW, Australia
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Colombelli A, Belluati A, Rizqallah Y, Guerra G, Busatto C. Patient specific instrumentation in total knee arthroplasty. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017. [PMID: 28657562 PMCID: PMC6178995 DOI: 10.23750/abm.v88i2-s.6511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND AIM OF THE WORK The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. METHODS Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. RESULTS The percentage of knees that had a HKA within ±3° of the desired value was 92.2. CONCLUSION the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.
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Affiliation(s)
- Andrea Colombelli
- Correspondence: Andrea Colombelli Via vicoli 50, 48121 Ravenna (Italy) Tel. 0039.3288274767 E-mail:
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Lim M, Hacihaliloglu I. Structure-enhanced local phase filtering using L0 gradient minimization for efficient semiautomated knee magnetic resonance imaging segmentation. J Med Imaging (Bellingham) 2016; 3:044503. [PMID: 27981068 DOI: 10.1117/1.jmi.3.4.044503] [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: 03/28/2016] [Accepted: 11/04/2016] [Indexed: 11/14/2022] Open
Abstract
The segmentation of bone surfaces from magnetic resonance imaging (MRI) data has applications in the quantitative measurement of knee osteoarthritis, surgery planning for patient-specific total knee arthroplasty, and its subsequent fabrication of artificial implants. However, due to the problems associated with MRI imaging, such as low contrast between bone and surrounding tissues, noise, bias fields, and the partial volume effect, segmentation of bone surfaces continues to be a challenging operation. A framework is presented for the enhancement of knee MRI scans prior to segmentation in order to obtain high contrast bone images. During the first stage, a contrast enhanced relative total variation regularization method is used in order to remove textural noise from the bone structures and surrounding soft tissue interface. This salient bone edge information is further enhanced using a sparse gradient counting method based on [Formula: see text] gradient minimization, which globally controls how many nonzero gradients are resulted in order to approximate prominent bone structures in a structure-sparsity-management manner. The last stage of the framework involves incorporation of local phase bone boundary information in order to provide an intensity invariant enhancement of contrast between the bone and surrounding soft tissue. The enhanced images are segmented using a fast random walker algorithm. Validation against expert segmentation was performed on 20 clinical knee MRI volumes and achieved a mean dice similarity coefficient of 0.949.
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Affiliation(s)
- Mikhiel Lim
- Rutgers, The State University , Department of Biomedical Engineering, 599 Taylor Road, Piscataway, New Jersey 08854, United States
| | - Ilker Hacihaliloglu
- Rutgers, The State University , Department of Biomedical Engineering, 599 Taylor Road, Piscataway, New Jersey 08854, United States
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Tack P, Victor J, Gemmel P, Annemans L. 3D-printing techniques in a medical setting: a systematic literature review. Biomed Eng Online 2016; 15:115. [PMID: 27769304 PMCID: PMC5073919 DOI: 10.1186/s12938-016-0236-4] [Citation(s) in RCA: 535] [Impact Index Per Article: 66.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/09/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Three-dimensional (3D) printing has numerous applications and has gained much interest in the medical world. The constantly improving quality of 3D-printing applications has contributed to their increased use on patients. This paper summarizes the literature on surgical 3D-printing applications used on patients, with a focus on reported clinical and economic outcomes. METHODS Three major literature databases were screened for case series (more than three cases described in the same study) and trials of surgical applications of 3D printing in humans. RESULTS 227 surgical papers were analyzed and summarized using an evidence table. The papers described the use of 3D printing for surgical guides, anatomical models, and custom implants. 3D printing is used in multiple surgical domains, such as orthopedics, maxillofacial surgery, cranial surgery, and spinal surgery. In general, the advantages of 3D-printed parts are said to include reduced surgical time, improved medical outcome, and decreased radiation exposure. The costs of printing and additional scans generally increase the overall cost of the procedure. CONCLUSION 3D printing is well integrated in surgical practice and research. Applications vary from anatomical models mainly intended for surgical planning to surgical guides and implants. Our research suggests that there are several advantages to 3D-printed applications, but that further research is needed to determine whether the increased intervention costs can be balanced with the observable advantages of this new technology. There is a need for a formal cost-effectiveness analysis.
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Affiliation(s)
- Philip Tack
- Department of Public Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Jan Victor
- Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Paul Gemmel
- Departement of Economics & Business Administration, Ghent University, Tweekerkenstraat 2, 9000, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
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Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: a Retrospective Matched Cohort Study. HSS J 2016; 12:224-234. [PMID: 27703415 PMCID: PMC5026651 DOI: 10.1007/s11420-015-9484-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proper alignment of total knee arthroplasty (TKA) is essential for TKA function and may reduce the risk of aseptic failure. Technologies that prevent malalignment may reduce the risk of revision surgery. QUESTIONS/PURPOSES The purpose of this study was to compare two competing TKA systems that purport improved alignment: patient-specific instrumentation (PSI), and a handheld portable navigation device (NAV). METHODS After IRB approval, 49 consecutive PSI TKAs (40 patients) were matched based on preoperative characteristics to 49 NAV TKAs (40 patients) performed by a single surgeon. A blinded observer measured alignment on digital radiographs. Operating room records were reviewed for procedure times. Two-tailed paired sample t tests and McNemar's test were used as appropriate. Alpha level was 0.05 for all tests. RESULTS Preoperative cohort characteristics were not different. Mean postoperative long-leg mechanical alignment was within ±1° of neutral for both groups, although statistically different (p = 0.026). There were no other significant differences in coronal alignment. PSI exhibited significantly greater posterior tibial slope (4.4°) compared to NAV (2.7°) (p = 0.004); PSI resulted in significantly more outliers (>6°; p = 0.004). Procedure time for unilateral TKAs was lower for PSI (74.4 min) compared to that for NAV (80.6 min; p = 0.023). CONCLUSION NAV and PSI technologies provided excellent coronal plane alignment. NAV was better for sagittal tibial slope, while PSI procedure times were shorter for unilateral TKA. The impact of these technologies on patient-reported outcomes and TKA survivorship is controversial and should be the focus of future research.
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Verification of in vivo accuracy of Trumatch™ patient-specific instrumentation in total knee replacement using pin-less computer navigation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:125-132. [PMID: 27604905 DOI: 10.1007/s00590-016-1849-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Accurate component alignment in total knee replacement (TKR) is one of the important factors in determining long-term survivorship. This has been achieved by conventional jigs, computer-assisted technology (CAS) and more recently patient-specific instrumentation (PSI). The purpose of the current study was to investigate the in vivo accuracy of Trumatch™ PSI using validated pin-less computer navigation system. METHOD Twenty consecutive selected patients that fulfilled our inclusion/exclusion criteria underwent TKR using PSI. Coronal alignment, posterior slope, resection thickness and femoral sagittal alignment were recorded using pin-less navigation. The position of the actual cutting block was appropriately adjusted prior to proceeding to definitive resections. RESULTS The coronal alignment using PSI without the assistance of navigation would have resulted in 14 (70 %) within ±3°, 11 (55 %) within ±2° and 6 (30 %) outside acceptable alignment. Thirty-five percentage of proposed femur sagittal alignment and 55 % of posterior tibial slope were achieved within ±3°. Components size was accurately predicted in 95 % of femurs and 90 % of tibia. CONCLUSION The purported advantages in restoring alignments using Trumatch™ PSI alone over standard equipment are debatable. However, it predicts sizing well, and femoral coronal alignment is reasonable. Combining Trumatch™ PSI with CAS will allow in vivo verification and necessary corrections. LEVEL OF EVIDENCE IV.
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Zahn RK, Fussi J, von Roth P, Perka CF, Hommel H. Postoperative Increased Loading Leads to an Alteration in the Radiological Mechanical Axis After Total Knee Arthroplasty. J Arthroplasty 2016; 31:1803-7. [PMID: 26923499 DOI: 10.1016/j.arth.2016.01.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/04/2016] [Accepted: 01/20/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Standing long-leg radiographs allow assessment of the mechanical axis in the frontal plane before and after total knee arthroplasty (TKA). An alteration in loading, and hence in the forces acting on the knee joint, occurs postoperatively. We therefore postulated that the mechanical axis measured in the long-leg standing radiograph would change within the first year after TKA. METHODS Standing long-leg radiographs of 156 patients were performed 7 days, 3 months, and 12 months after TKA with determination of mechanical axis of the lower limb. RESULTS Seven days after surgery, the mechanical axis amounted 0.8° ± 1.7° valgus. Three months after the operation, at 1.3° ± 1.3° varus, it was significantly different (P < .001) from the primary measurement. No further alteration in the mechanical axis occurred during the first year after TKA. This difference was even more pronounced (P < .001) in patients with a postoperative lack of complete extension. Seven days after surgery, they had a valgus axis deviation of 1.6° ± 1.6°; after 3 months, the measurement amounted 1.2° ± 1.3° varus. CONCLUSION Measured by a standing long-leg radiograph, the frontal mechanical axis after TKA changes over time. The predictive power of a standing long-leg radiograph in the first week after surgery is limited because limb loading is altered because of pain and is therefore nonphysiological. The actual mechanical axis resulting after TKA can only be assessed in a standing long-leg radiograph at physiological loading.
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Affiliation(s)
- Robert Karl Zahn
- Department of Orthopaedics and Traumatology, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jasmin Fussi
- Department of Orthopaedics and Traumatology, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp von Roth
- Department of Orthopaedics and Traumatology, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten F Perka
- Department of Orthopaedics and Traumatology, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hagen Hommel
- Orthopedic Department, Hospital Märkisch Oderland, Wriezen, Germany
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Huijbregts HJTAM, Khan RJK, Sorensen E, Fick DP, Haebich S. Patient-specific instrumentation does not improve radiographic alignment or clinical outcomes after total knee arthroplasty. Acta Orthop 2016; 87:386-94. [PMID: 27249110 PMCID: PMC4967282 DOI: 10.1080/17453674.2016.1193799] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) has been introduced to improve alignment and reduce outliers, increase efficiency, and reduce operation time. In order to improve our understanding of the outcomes of patient-specific instrumentation, we conducted a meta-analysis. Patients and methods - We identified randomized and quasi-randomized controlled trials (RCTs) comparing patient-specific and conventional instrumentation in TKA. Weighted mean differences and risk ratios were determined for radiographic accuracy, operation time, hospital stay, blood loss, number of surgical trays required, and patient-reported outcome measures. Results - 21 RCTs involving 1,587 TKAs were included. Patient-specific instrumentation resulted in slightly more accurate hip-knee-ankle axis (0.3°), coronal femoral alignment (0.3°, femoral flexion (0.9°), tibial slope (0.7°), and femoral component rotation (0.5°). The risk ratio of a coronal plane outlier (> 3° deviation of chosen target) for the tibial component was statistically significantly increased in the PSI group (RR =1.64). No significance was found for other radiographic measures. Operation time, blood loss, and transfusion rate were similar. Hospital stay was significantly shortened, by approximately 8 h, and the number of surgical trays used decreased by 4 in the PSI group. Knee Society scores and Oxford knee scores were similar. Interpretation - Patient-specific instrumentation does not result in clinically meaningful improvement in alignment, fewer outliers, or better early patient-reported outcome measures. Efficiency is improved by reducing the number of trays used, but PSI does not reduce operation time.
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Affiliation(s)
- Henricus J T A M Huijbregts
- The Joint Studio, Hollywood Medical Centre, Nedlands; ,Hollywood Private Hospital, Nedlands, WA; ,Correspondence:
| | - Riaz J K Khan
- The Joint Studio, Hollywood Medical Centre, Nedlands; ,Hollywood Private Hospital, Nedlands, WA; ,Curtin University, Bentley, WA; ,University of Notre Dame, Fremantle, WA, Australia
| | - Emma Sorensen
- The Joint Studio, Hollywood Medical Centre, Nedlands;
| | - Daniel P Fick
- The Joint Studio, Hollywood Medical Centre, Nedlands; ,Hollywood Private Hospital, Nedlands, WA; ,Curtin University, Bentley, WA;
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Abstract
Total knee arthroplasty has been an effective treatment for advanced degenerative joint disease. Traditional knee designs and surgical approaches have resulted in consistently high performance, but some patients may remain dissatisfied after their surgery. Several surgical innovations, including accelerometer-based navigation, patient-specific instrumentation, and robotic-assisted total knee arthroplasty, have been developed to improve the accuracy and precision of total knee arthroplasty surgery, with anticipated secondary benefits of improved functional outcomes and implant survivorship. This article reviews the current status of these technologies as reported in contemporary orthopedic literature. [Orthopedics. 2016; 39(4):217-220.].
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[Total and unicompartmental knee replacement. Patient-specific Instrumentation]. DER ORTHOPADE 2016; 45:302-13. [PMID: 27025869 DOI: 10.1007/s00132-016-3245-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The objective of patient-specific instrumentation (PSI Zimmer®) technology is to optimize positioning and selection of components as well as surgical procedure in uni- and bicompartimental knee replacement. The article contains a description of the planning and surgical technique and evaluates the method based on own results and literature. METHODS Using MRI or CT scans a virtual 3D model of the joint is created in order to simulate and plan the implant positioning. According to these data, pin placement and/or cutting guides are produced, which enable the surgeon to transfer the planning to the surgical procedure. In a prospective comparative study 88 patients (44 per each of the two techniques) were operated by one surgeon receiving the same TKA using either MRI-based PSI or a conventional technique. The number of surgical trays, operating time, intraoperative changes and frontal alignment using a full leg x‑ray (70 cases) were compared. In 17 patients the method was applied with unicondylar knee replacement. RESULTS Anatomical abnormalities could be detected preoperatively and considered during the operation. With PSI the number of trays could be reduced and predictability of the component size was more precise. Intraoperative changes became necessary only for distal femoral (25 %) and proximal tibial (36 %) resection and tibial rotation (40 %). Alignment was more precise in the PSI cases DISCUSSION PSI using the applied technique proved to be practicable and reliable. The advantages of precise planning became obvious. Results concerning alignment are inconsistent in the literature. Soft tissue balancing has only been included in the technique to a limited degree so far. PSI is still in an early stage of development and further development opportunities should be exploited before final assessment.
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Mannan A, Smith TO. Favourable rotational alignment outcomes in PSI knee arthroplasty: A Level 1 systematic review and meta-analysis. Knee 2016; 23:186-90. [PMID: 26782300 DOI: 10.1016/j.knee.2015.08.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/08/2015] [Accepted: 08/07/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Implant malposition in total knee arthroplasty (TKA) often results in unsatisfactory outcomes. Rotational malalignment leads to impaired patellar tracking, stability and joint biomechanics. Patient-specific instrumentation aims to improve three-dimensional implant positioning while reducing overall costs of instrumentation. METHODS A PRISMA compliant search of all relevant literature between 2000 and 2014 was performed. The primary outcome of interest was deviation from a neutral femoral and tibial axial alignment of patient-specific instrumentation (PSI) vs conventional instrumentation. Femoral rotation was measured with reference to the transepicondylar axis. Tibial rotation was reported with reference to the anterior tibial tuberosity and a "best fit" with the anterior tibial cortex. RESULTS Six randomised studies met the inclusion criteria reporting on a total of 444 knees. Computed tomography (CT) based PSI systems were used exclusively in three studies, and two further studies in association with magnetic resonance imaging (MRI). MRI was used exclusively in one study. Mean femoral rotation in the conventional group was: -1.7 to 1.6° (vs -1.7 to 1° in the PSI group). Meta-analysis demonstrated a significant treatment effect favouring PSI with increased accuracy in "three-degree outliers" with femoral rotation: Z=2.07, P=0.04. A single study reported tibial rotational outcomes with no significant difference demonstrated in conventional instrumentation vs PSI. CONCLUSIONS This Level 1 meta-analysis demonstrates favourable femoral rotational alignment outcomes in PSI knee arthroplasty. Only limited data is available for tibial rotational outcomes. Further studies with standardised "gold-standard" measurement criteria are required to clarify tibial rotational outcomes in PSI TKA. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- A Mannan
- Bradford Teaching Hospitals NHS Trust, Bradford, UK.
| | - T O Smith
- University of East Anglia, Norwich, UK
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