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Kanna R, Kumar VS, Karthikeyan V, Anand S, Ravichandran C, Murali SM. Influence of Preoperative Deformity on Flexion Gap Asymmetry in Measured Resection Technique: A Theoretical Study in Navigated Gap Balancing Total Knee Arthroplasties, Done for Varus Knee Osteoarthritis. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00007. [PMID: 38354198 PMCID: PMC11136515 DOI: 10.5435/jaaosglobal-d-23-00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 11/15/2023] [Accepted: 12/07/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Disagreement exists on (a) achieving a symmetrical flexion gap and (b) the influence of varus deformity on the flexion gap asymmetry (FGA) in measured resection (MR) total knee arthroplasty (TKA). We aimed to determine the FGA and influence of preoperative deformity on the FGA, based on the MR technique, in varus knee osteoarthritis. METHODS In 321 navigated TKAs, we released the soft tissues in extension. In 90° flexion, with the tensioner in situ, we calculated the FGA, the angle between the posterior femoral cut (planned 3° external rotation to the posterior condylar line, parallel to the surgical transepicondylar axis, or perpendicular to the Whiteside line) and the proximal tibial resection plane. RESULTS The FGA values varied widely, and the risk of >2° and >3° FGA was present in at least 60% and 40% knees, respectively. These risks were high in knees with moderate and severe varus deformity. CONCLUSIONS In varus knee osteoarthritis, the risk of FGA (based on the MR technique) was high, especially when the deformity was moderate to severe. Caution is required in MR TKA, and surgeons must consider safer alternatives (gap balancing or hybrid technique) to achieve a symmetrical flexion gap in these knees.
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Affiliation(s)
- Raj Kanna
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - V. Senthil Kumar
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Vijaya Karthikeyan
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Sumit Anand
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - Chandramohan Ravichandran
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
| | - S. M. Murali
- From the Madha Medical College and Research Institute, Chennai, Tamil Nadu, India (Dr. Kanna); Department of Orthopaedics, Prashanth Super Speciality Hospital, Chennai, Tamil Nadu, India (Dr. Kanna); Government Headquarters Hospital, Perambalur, Tamil Nadu, India (Dr. Kumar); Department of Radiodiagnosis, Bhaarath Medical College Hospital, Chennai, Tamil Nadu, India (Dr. Karthikeyan); Department of Orthopaedics, Primus Hospital, Delhi, India (Dr. Anand); WYE Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK (Dr. Ravichandran), Department of Orthopaedics,SMMCH&RI, Chennai, Tamil Nadu, India (Dr. Murali)
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Shekhar A, Chowdhry M, Subramaniam D, Dipane MV, Michael Mynatt H, Tapasvi SR, McPherson EJ. CT scan analysis of implant mating comparing APA versus TEA in simultaneous bilateral TKA: One technique per knee. Knee 2023; 43:89-96. [PMID: 37343354 DOI: 10.1016/j.knee.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 04/17/2023] [Accepted: 05/29/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND The optimal landmark for setting femoral component rotation in primary TKA remains a debate. This study compares the Anterior-Posterior Axis (APA) versus the Transepicondylar Axis (TEA) in patients undergoing simultaneous bilateral TKA, where one reference line was randomized to each knee. Implant mating was assessed via post-operative CT scans. METHOD The study included 32 patients with osteoarthritis in both knees with similar varus deformities. All patients underwent the same surgical procedure on both knees, aside from the selected femoral rotation axis line: APA randomized to one side and TEA to the contralateral. Post-operative CT scans were performed in extension to assess in-vivo mating. RESULTS CT scan analysis showed mean rotation of the femoral implant externally rotated relative to the radiographic TEA with no significant difference between the APA and TEA groups (p = 0.28). Tibial implant rotation was also externally rotated to the radiographic TEA with no significant difference (p = 0.59). Femoral-tibial implant mating showed a mean external rotation of the tibia relative to the femur in both groups: 0.86 ± 4.0° external rotation in the APA group and 0.23 ± 3.7° external rotation in the TEA group. There was no significant difference between groups (p = 0.52). The range of mating mismatch was 15° in the APA group and 16.5° in the TEA group. CONCLUSIONS When using a measured resection, posterior referencing technique, post-operative femoral-tibial implant mating measured by CT scan showed no superiority comparing the APA method versus the TEA method. LEVEL OF EVIDENCE 2 Randomized prospective study.
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Affiliation(s)
- Anshu Shekhar
- Department of Arthroplasty and Arthroscopy, The Orthopaedic Speciality Clinic, Tehmi Terace, Bund Garden Rd, Sangamvadi, Pune, Maharashtra 411001, India
| | - Madhav Chowdhry
- Nuffield Department of Primary Care Health Sciences & Department of Continuing Education, Kellogg College, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, United Kingdom
| | - Dhiyaneswaran Subramaniam
- Department of Arthroplasty and Arthroscopy, The Orthopaedic Speciality Clinic, Tehmi Terace, Bund Garden Rd, Sangamvadi, Pune, Maharashtra 411001, India
| | - Matthew V Dipane
- David Geffen School of Medicine at UCLA, Department of Orthopaedic Surgery, 1250 16th Street, Suite 2100, Santa Monica, CA 90404, USA.
| | - H Michael Mynatt
- Joint Replacement Institute, 1300 North Vermont Avenue, Doctors Tower, Suite 100, Los Angeles, CA 90027, USA
| | - Sachin R Tapasvi
- Department of Arthroplasty and Arthroscopy, The Orthopaedic Speciality Clinic, Tehmi Terace, Bund Garden Rd, Sangamvadi, Pune, Maharashtra 411001, India
| | - Edward J McPherson
- David Geffen School of Medicine at UCLA, Department of Orthopaedic Surgery, 1250 16th Street, Suite 2100, Santa Monica, CA 90404, USA
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Mulpur P, Masilamani A, Prakash M, Annapareddy A, Hippalgaonkar K, Reddy A. Comparison of patient reported outcomes after robotic versus manual total knee arthroplasty in the same patient undergoing staged bilateral knee arthroplasty. J Orthop 2022; 34:111-115. [PMID: 36060731 PMCID: PMC9428725 DOI: 10.1016/j.jor.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Robotic-assisted total knee arthroplasty (RATKA) has been proven to improve accuracy of component positioning and reducing alignment target outliers. However, the clinical benefit of robotics is often debated. Recent studies have shown reduced pain and faster recovery in the immediate post-operative period and may be associated with improved PROMs and satisfaction. The aim of this study was to assess PROMs and satisfaction in a unique patient population undergoing bilateral staged TKA to compare manual (MTKA) and RATKA in the same patient. Methods 55 patients underwent bilateral staged TKA, performed by a single surgeon at a single institute. Patients who underwent TKA for the first knee with manual technique and RATKA for the second side, were eligible for inclusion in the study. Primary outcome assessed was the Oxford Knee Score and secondary outcomes included the Forgotten Joint Score (FJS), patient satisfaction, mean duration for independent ambulation after TKA, and patient perspectives on recovery evaluated with a questionnaire. Results Both RATKA and MTKA were associated with comparable PROMs. Though RATKA was associated with improved joint perception (Mean FJS after MTKA surgery was 70.3 (SD = 10.66) and significantly lower than the mean FJS after RATKA (73, SD = 10.95, p-value < 0.01), but the difference was not clinically relevant. A higher proportion of patients were more likely to be very satisfied or satisfied after RATKA. A significant proportion of patients felt the knee operated with RATKA was less painful and felt more natural compared to MTKA at final follow-up (p < 0.01). Majority of patients would undergo RATKA again and recommend robotic-TKA to others. Conclusion Robotic-assisted surgery was associated with improved patient satisfaction, faster independent ambulation compared to manual techniques. PROMs however, were comparable without clinically significant differences. Patients preferred robotic-assisted surgery, with a significantly higher proportion perceiving knee operated by RATKA felt more natural.
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Affiliation(s)
- Praharsha Mulpur
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
| | | | - Mrinal Prakash
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
| | | | | | - A.V.Gurava Reddy
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
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