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Nagarkatti A, Strecker S, Nagarkatti D, Witmer D. The Role of Imageless Computer-Assisted Navigation During Total Knee Arthroplasty on Femoral Component Sagittal Alignment and Outcomes. Arthroplast Today 2024; 28:101455. [PMID: 39100414 PMCID: PMC11295699 DOI: 10.1016/j.artd.2024.101455] [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: 04/02/2024] [Revised: 05/13/2024] [Accepted: 06/08/2024] [Indexed: 08/06/2024] Open
Abstract
Background While total knee arthroplasty (TKA) is highly successful, 15%-20% of patients are not satisfied postoperatively, which may be due to alignment of the TKA components. Imageless computer navigation was developed to increase implant alignment accuracy and precision, but controversy surrounds the patient benefit of this technology. The target of femoral sagittal alignment and its role in patient-reported outcomes (PROMs) after TKA using assistive technology has not been well-defined. Methods Femoral sagittal alignment, 30-day complications, and PROMs through 1 year were collected retrospectively from unilateral elective TKA patients who underwent surgery between July 2020 and February 2023. Two surgeons equally versed in conventional and imageless navigation techniques participated in patient record identification. Students t-tests and chi-square tests of proportion were used to compare outcomes, 30-day complications, and alignment. Results Completed PROMs were available for 387 patients; 181 in the computer navigation group and 206 in the conventional arthroplasty group. PROMs were statistically significantly different between groups, favoring computer navigation (P = .014 at 12 months). Lateral femoral angle measurements were greater in females who underwent TKA with computer navigation (P < .001). Of note, 14 patients in the conventional technique group returned to the emergency department within 30 days, as compared to 4 in the navigation group (P = .033). Conclusions PROMs are improved in the navigation group compared to the conventional technique group. Fewer patients in the navigation group returned to the emergency department. Navigation appeared to provide a small benefit compared to conventional techniques, though final lateral femoral angle was not predictive of outcomes. Additional surgical characteristics may need to be examined to determine the reasons for the differences in outcomes between these techniques.
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Affiliation(s)
| | - Sara Strecker
- Orthopedics, Bone & Joint Institute, Hartford Hospital, Hartford, CT, USA
| | - Durgesh Nagarkatti
- Orthopedics, Bone & Joint Institute, Hartford Hospital, Hartford, CT, USA
| | - Dan Witmer
- Orthopedics, Bone & Joint Institute, Hartford Hospital, Hartford, CT, USA
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Banks SA, Catani F, Deckard ER, Mahoney OM, Matsuda S, Meneghini RM, Victor JMK. Total Knee Arthroplasty Kinematics Predict Patient-Reported Outcome Measures: Implications for Clinical Kinematic Examinations. J Arthroplasty 2024; 39:S224-S229. [PMID: 38360280 DOI: 10.1016/j.arth.2024.02.014] [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: 11/14/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND A core tenet of total knee arthroplasty (TKA) is that achieving more natural kinematics will lead to superior patient outcomes. Yet this relationship has not been proven for large representative cohorts of TKA patients because accurately measuring 3-dimensional TKA kinematics is time-consuming and expensive. But advanced imaging systems and machine learning-enhanced analysis software will soon make it practical to measure knee kinematics preoperatively and postoperatively in the clinic using radiographic methods. The purpose of this study was to assess the reported relationships between TKA kinematics and outcomes and distill those findings into a proposal for a clinically practical protocol for a clinical kinematic exam. METHODS This study reviewed the recent literature relating TKA kinematics to patient outcomes. There were 10 studies that reported statistical associations between TKA kinematics and patient outcome scores utilizing a range of functional activities. We stratified these activities by the complexity of the radiographic examination to create a proposed examination protocol, and we generated a list of requirements and characteristics for a practical TKA clinical kinematic examination. RESULTS Given considerations for a clinically practical kinematic exam, including equipment, time and other resources, we propose 3 exam levels. With basic radiographs, we suggest studying single-leg stance in extension, lunge or squat, and kneeling. For fluoroscopic systems with X-ray pulses up to 20 ms, we propose chair-rise or stair ascent to provide additional dynamic information. For fluoroscopic systems with X-ray pulses of less than 10 ms, we propose rapid open-chain knee flexion-extension to simulate the highly dynamic swing phase of gait. CONCLUSIONS It is our hope that this proposed examination protocol spurs discussion and debate so that there can be a consensus approach to clinical examination of knee and TKA kinematics when the rapidly advancing hardware and software capabilities are in place to do so.
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Affiliation(s)
- Scott A Banks
- Department of Mechanical & Aerospace Engineering, University of Florida, Gainesville, Florida
| | - Fabio Catani
- Department of Orthopaedic Surgery, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio-Emilia, Modena, Italy
| | - Evan R Deckard
- Indiana Joint Replacement Institute, Indianapolis, Indiana
| | - Ormonde M Mahoney
- Athens Orthopedic Clinic, Athens, Georgia; Department of Orthopedics, Medical College of Georgia, Augusta, Georgia
| | - Shuichi Matsuda
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Robert M Meneghini
- Indiana Joint Replacement Institute, Indianapolis, Indiana; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jan M K Victor
- Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, Ghent, Belgium; Department of Human Structure and Repair, Ghent University, Ghent, Belgium
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Patel SK, Buller LT, Deckard ER, Meneghini RM. Survivorship and Patient Outcomes of Conforming Bearings in Modern Primary Total Knee Arthroplasty: Mean 3.5 Year Follow-Up. J Arthroplasty 2024:S0883-5403(24)00435-2. [PMID: 38734325 DOI: 10.1016/j.arth.2024.04.084] [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: 11/07/2023] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The use of conforming and congruent bearings in total knee arthroplasty (TKA) have rapidly increased due to the benefits of increased stability and the potential for replicating normal knee kinematics. However, limited data exist for these newly available bearings. This study evaluated revision-free survivorship and patient-reported outcome measures (PROMs) of a large granular database of primary TKAs using a single conforming bearing design. METHODS A total of 1,306 consecutive primary TKAs performed using a single conforming bearing design (85% cemented and 15% cementless) were retrospectively reviewed. Kaplan-Meier survivorship estimates were calculated based on the latest clinical follow-up. The PROMs and minimal clinically important differences were evaluated. A total of 93% of cases achieved minimum 1-year clinical follow-up (mean 3.5 years; range, 1 to 7), with a subset of 261 cases that achieved minimum 5-year follow-up (mean 5.8 years; range, 5 to 7). RESULTS All-cause and aseptic Kaplan-Meier survivorship estimates were 97.6 (95% CI [confidence interval], 97 to 99) and 98.1% (95% CI, 97 to 99) at 7.0 years. Revision-free survivorship did not differ by cemented or cementless fixation (98 versus 97%, P = .163). All PROM scores significantly improved from preoperative baseline (P < .001), and ≥ 86% of patients achieved minimal clinically important differences for Knee Society pain and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement total scores. A total of 89% of cases reported their knees to 'sometimes or always' feel normal. For cases with minimum 5-year PROMs, 93% were 'very satisfied' or 'satisfied.' CONCLUSIONS Conforming-bearing TKA demonstrated excellent survivorship up to 7.0 years. In addition, PROMs were comparable to other designs reported in the literature. While mid-term (mean 3.5-year) results are promising, long-term data are warranted on survivorship due to potential polyethylene wear in conforming bearings with more surface area in contact with articulating surfaces. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sohum K Patel
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Evan R Deckard
- Indiana Joint Replacement Institute, Indianapolis, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Indiana Joint Replacement Institute, Indianapolis, Indiana
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Beckers G, Meneghini RM, Hirschmann MT, Kostretzis L, Kiss MO, Vendittoli PA. Ten Flaws of Systematic Mechanical Alignment Total Knee Arthroplasty. J Arthroplasty 2024; 39:591-599. [PMID: 38007204 DOI: 10.1016/j.arth.2023.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023] Open
Abstract
Mechanical alignment (MA) and its tenets have been considered essential for total knee arthroplasty (TKA) success since they were introduced in 1973. However, over time, there have been colossal advances in our knowledge and understanding of the anatomy and kinematics of the knee, as well as in surgical precision and implants. However, the MA systematic principles of prosthetic arthroplasty and implant position related to the lower-extremity mechanical axis, have only recently been called into question. The high rates of dissatisfaction and residual pain reported after MA TKA prompted this questioning, and that leaves plenty of room for improvement. Despite the general consensus that there is great variability between patients' anatomy, it is still the norm to carry out a systematic operation that does not consider individual variations. Evolving to a more personalized arthroplasty surgery was proposed as a rational and reasonable option to improve patient outcomes. Transitioning to a personalized TKA approach requires questioning and even disregarding certain MA TKA principles. Based on current knowledge, we can state that certain principles are erroneous or unfounded. The aim of this narrative review was to discuss and challenge 10 previously accepted, yet we believe, flawed, principles of MA, and to present an alternative concept, which is rooted in personalized TKA techniques.
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Affiliation(s)
- Gautier Beckers
- Surgery Department, Hôpital Maisonneuve-Rosemont, Montreal University, Montreal, Quebec, Canada; Personalized Arthroplasty Society, Atlanta, Georgia
| | - R Michael Meneghini
- Indiana Joint Replacement Institute, Indianapolis, Indiana; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael T Hirschmann
- Personalized Arthroplasty Society, Atlanta, Georgia; Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Lazaros Kostretzis
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Thessaloniki, Central Macedonia, Greece
| | - Marc-Olivier Kiss
- Surgery Department, Hôpital Maisonneuve-Rosemont, Montreal University, Montreal, Quebec, Canada; Personalized Arthroplasty Society, Atlanta, Georgia; Clinique Orthopédique Duval, Laval, Quebec, Canada
| | - Pascal-André Vendittoli
- Surgery Department, Hôpital Maisonneuve-Rosemont, Montreal University, Montreal, Quebec, Canada; Personalized Arthroplasty Society, Atlanta, Georgia; Clinique Orthopédique Duval, Laval, Quebec, Canada
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Roche M, Law TY. Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection. J Knee Surg 2024; 37:104-113. [PMID: 37852287 DOI: 10.1055/a-2194-0970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
This review discusses the correction of coronal deformity and intercompartmental imbalance through bone resection in total knee arthroplasty (TKA). To achieve functional knee balance, coronal, rotational, and sagittal alignment are critical to successful patient outcomes. Though variations in coronal alignment are debated as a correlate to positive results, advancements in utilizing implant position, alignment, and soft tissue balance to improve patient outcomes and function are an evolving discussion. This study draws upon existing literature, clinical studies, and surgical techniques related to TKA, including advancements in navigation and robotics. The study highlights the importance of individualized alignment strategies for varus and valgus knees. While mechanical neutral alignment has shown excellent long-term data, reevaluating the anatomic recreation of the patient's joint line obliquity is now being studied extensively. Sensor data and navigation systems contribute to improved outcomes and patient satisfaction. The evolution of navigation and robotics has led surgeons to achieve their target angles consistently and accurately; now, the discussion is around the most effective alignment targets. The classification of various phenotypes assists in the proposed starting points for implant position, but soft tissue tension is required in the input data to achieve global balance and stable motion. Each approach's advantages and limitations are considered. In conclusion, achieving optimal coronal alignment, joint line obliquity, and soft tissue balance is crucial for successful TKA outcomes. Personalized alignment philosophies, supported by three-dimensional data and sensor technology, are evolving to minimize critical errors and enhance functional results. Robotic assistance and future advancements in artificial intelligence and machine learning hold promise for further improving TKA outcomes in the quest for soft tissue stabilization.
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Affiliation(s)
- Martin Roche
- Department of Orthopedic Surgery, Hospital for Special Surgery, West Palm Beach, Florida
| | - Tsun Yee Law
- Department of Orthopedic Surgery, Hospital for Special Surgery, West Palm Beach, Florida
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Ogawa H, Nakamura Y, Akiyama H. Restricted kinematically aligned total knee arthroplasty with an anatomically designed implant can restore constitutional coronal lower limb alignment. Knee Surg Sports Traumatol Arthrosc 2024; 32:47-53. [PMID: 38226728 DOI: 10.1002/ksa.12019] [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: 10/11/2023] [Revised: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Restricted kinematically aligned total knee arthroplasty (rKA-TKA) may not restore the constitutional varus alignment in most patients with knee osteoarthritis. This study aimed to investigate (1) the extent to which constitutional lower limb alignment can be restored by rKA-TKA using an anatomically designed implant and (2) which lower limb alignment parameters are associated with patient-reported outcome measures (PROMs). METHODS This study included 60 patients who underwent rKA-TKA using an anatomically designed implant. Radiographic alignment parameters, including mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), coronal hip-knee-ankle angle (HKA), coronal joint line obliquity (JLO), posterior tibial slope (PTS), single-leg standing knee flexion angle (KFA), sagittal JLO, and arithmetic HKA (aHKA), were evaluated preoperatively and postoperatively. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used for clinical evaluation. RESULTS The mLDFA, MPTA, and aHKA showed no significant differences before and after surgery. Coronal HKA and PTS have significantly changed from 8.1 ± 8.7° and 9.9 ± 8.6° preoperatively to 3.5 ± 3.1° and 2.5 ± 2.0° postoperatively, respectively (p < 0.001 for each comparison). The postoperative WOMAC total score was significantly correlated with the KFA (r = 0.4063, p = 0.0034) and sagittal JLO (r = -0.3435, p = 0.0157). Postoperative KFA is a causal factor for the increased postoperative WOMAC total score (r = 1.416, 95% confidence interval: 0.491-2.342, p = 0.003). CONCLUSION rKA-TKA using an anatomically designed implant can restore constitutional coronal lower limb alignment, while postoperative KFA and sagittal JLO were associated with poor PROMs. Care should be taken for the postoperative KFA because it is a risk factor for poor PROMs. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Hiroyasu Ogawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yutaka Nakamura
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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