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Hernández-Hermoso JA, Nescolarde L, Yañez-Siller F, Calle-García J, Garcia-Perdomo D, Pérez-Andres R. Combined femoral and tibial component total knee arthroplasty device rotation measurement is reliable and predicts clinical outcome. J Orthop Traumatol 2023; 24:40. [PMID: 37535276 PMCID: PMC10400495 DOI: 10.1186/s10195-023-00718-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 07/19/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The optimal total knee arthroplasty (TKA) rotational alignment and how best to obtain and measure it are debatable. The aim was to analyse the reliability of the Berger femoral, three different tibial and four different combined two-dimensional computer tomography (2D-CT) TKA component rotation measurements, and to ascertain which rotational values best predict a successful clinical outcome. METHODS The 2D-CT scans were obtained post-operatively on 60 patients who had TKA. We determined one femoral [Berger's femoral angle (BFA)], three tibial [Berger's tibial angle (BTA), anatomical tibial angle (ATA) and bimalleolar posterior tibial component angle (BM_PTCA)] and four combined [transepicondylar posterior tibial component angle (TE_PTCA), bicondylar posterior tibial component angle (BC_PTCA, transepicondylar bimalleolar angle (TE_BM) and bicondylar bimalleolar angle (BC_BM)] TKA rotation angles. We made all measures in 23 patients twice by three observers and determined inter- and intra-observer agreement using the Bland-Altman plot method. We analysed measures of 55 patients using the area under the ROC curve (AUC) analysis to ascertain the discriminative capacity of BFA, ATA, TE_PTCA and BC_PTCA for predicting a successful clinical outcome according to the Knee Society Score (KSS) threshold. RESULTS ATA showed the smaller inter- and intra-observer average of differences (-0.1° and 1.6°, respectively) of the studied methods followed by BFA (-0.9° and 1.4°), TE_PTCA (-2.1° and 2.7°) and BC_PTCA (-0.5° and 1.8°). BFA (-4° to 2.1° and -6.1° to 8.8°) and BC_PTCA (-4.4° to 3.4° and -7.9° to 4.4°) showed the narrower inter- and intra-observer limits of agreement. A TKA device rotation (BC_PTCA) < 0.8° of external rotation (ER) predicted a KSS and KSS knee successful outcome, and < 3.8° ER for KSS functional (AUC = 0.889; 0.907 and 0.764, respectively). BFA and ATA < 0.9° ER and < 3.9° internal rotation (IR) predicted a successful KSS knee outcome (AUC = 0.796 and 0.889, respectively). CONCLUSION The ATA tibial component rotation measurement was the most reliable of those studied. BFA, TE_PTCA and BC_PTCA were reliable measures for TKA femoral and combined rotation. The presence of a minimal rotation between the TKA components (BC_PTCA) and a small femoral ER or tibial IR predicted a successful KSS outcome. LEVEL OF EVIDENCE II
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Affiliation(s)
- José A Hernández-Hermoso
- Department of Orthopedic Surgery and Traumatology, Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Barcelona, Spain.
- Department of Surgery, Faculty of medicine, Universitat Autònoma de Barcelona, Campus UAB, 08913, Bellaterra, Spain.
| | - Lexa Nescolarde
- Biomedical Engineering, Department of Electronic Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Federico Yañez-Siller
- Department of Orthopedic Surgery and Traumatology, Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Barcelona, Spain
| | - Juan Calle-García
- Department of Orthopedic Surgery and Traumatology, Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Barcelona, Spain
| | - Damian Garcia-Perdomo
- Department of Radiology, Hospital, Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Barcelona, Spain
| | - Ricard Pérez-Andres
- Department of Radiology, Hospital, Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916, Badalona, Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, Campus UAB, 08913, Bellaterra, Spain
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Jang ES, Davignon R, Geller JA, Cooper HJ, Shah RP. Reference Axes for Tibial Component Rotation in Total Knee Arthroplasty: Computed Tomography-Based Study of 1,351 Tibiae. J Bone Joint Surg Am 2023; 105:1-8. [PMID: 36367766 DOI: 10.2106/jbjs.22.00520] [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: 11/13/2022]
Abstract
BACKGROUND Many anatomic landmarks have been described for setting tibial component rotation intraoperatively. There is no consensus as to which axis is best for reducing outliers and preventing malrotation. METHODS The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,351 computed tomography (CT) scans of the entire tibia. Several reference axes for the tibia (including the Mayo axis, Akagi line, Insall line, anterior condylar axis [ACA], posterior condylar axis [PCA], lateral tibial cortex [LTC], Cobb axis, tibial crest line [TCL], and transmalleolar axis [TMA]) were constructed according to published guidelines. The Berger method served as the reference standard. RESULTS The Mayo method (involving a line connecting the medial and middle one-thirds of the tibial tubercle and the geometric center of the tibia) and the Insall line (involving a line connecting the posterior cruciate ligament [PCL] insertion and the intersection of the middle and medial one-thirds of the tibial tubercle) both had low variability relative to the Berger method (7.8° ± 1.0° and 5.1° ± 2.2°, respectively) and a low likelihood of internal rotation errors (0.7% and 1.8%, respectively). No clinically significant gender-based differences were found (<0.7° for all). The same was true for ethnicity, with the exception of consistently greater tibial intorsion in Asian versus Caucasian individuals (mean difference in TCL position, +4.5° intorsion for Asian individuals; p < 0.001). CONCLUSIONS This CT-based study of 1,351 tibiae (which we believe to be the largest study of its kind) showed that the Mayo and Insall methods (both of which reference the medial and middle one-thirds of the tibial tubercle) offer an ideal balance of accuracy, low variability, and a reduced likelihood of internal rotation errors. Setting rotation on the basis of distal landmarks (tibial shaft and beyond) may predispose surgeons to substantial malrotation errors, especially given the differences in tibial torsion found between ethnic groups in this study. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eugene S Jang
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | | | - Jeffrey A Geller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | - H John Cooper
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | - Roshan P Shah
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
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CT measures of femoral and tibial version and rotational position of femoral and tibial components of knee replacements: limitations in reliability and suitability for routine clinical practice. Eur Radiol 2022; 32:3790-3798. [PMID: 35142899 PMCID: PMC9122870 DOI: 10.1007/s00330-021-08483-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/31/2021] [Accepted: 11/25/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rotational malalignment of knee replacements as measured on CT is understood to be associated with poor outcomes. The aim of this study is to measure the inter-rater and intra-rater reliability of measures of femoral and tibial version in the native arthritic knee and postoperative TKR component position using CT. METHODS Eighty patients underwent CT of the knee before and after total knee replacement. Preoperative femoral and tibial version and component rotation were independently measured by two musculoskeletal radiologists. RESULTS Mean differences between and within raters were small (< 1.6°). Maximum 95% limits of agreement for inter-rater and intra-rater comparisons were 8.1° and 7.6° for preoperative femoral version, 9.0° and 7.9° for postoperative femoral rotation, 26.0° and 20.5° for preoperative tibial version, and 24.9° and 23.6° for postoperative tibial rotation respectively. Postoperative ICCs varied from 0.68 to 0.81 (lower 95% CI:0.55-0.72) for both intra- and inter-rater comparisons. Preoperative ICCs were lower: 0.55-0.75 (lower 95% CI:0.40-0.65). CONCLUSION The lower 95% confidence level for ICC of version and rotational measurements using the Berger protocol of TKRs on CT are all less than 0.73 and that the normal range of differences between observers is up to 9° for the femoral component and 26° for the tibial component. This suggests that CT measurements derived from the Berger protocol may not be consistent enough for clinical practice. KEY POINTS • CT is commonly used to measure the rotational profile of knee replacements in symptomatic patients using the Berger protocol. • The limits of agreement for both femoral and tibial component rotation are wide even for experienced observers. • CT measurements of the rotation of knee arthroplasty are not reliable enough for routine clinical use.
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András G, Németh G, Oláh CZ, Lénárt G, Drén Z, Papp M. The personalized Berger method is usable to solve the problem of tibial rotation. J Exp Orthop 2021; 8:116. [PMID: 34897564 PMCID: PMC8665959 DOI: 10.1186/s40634-021-00432-0] [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: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose The revision of any total knee replacement is carried out in a significant number of cases, due to the excessive internal rotation of the tibial component. The goal was to develop a personalized method, using only the geometric parameters of the tibia, without the femoral guidelines, to calculate the postoperative rotational position of tibial component malrotation within a tolerable error threshold in every case. Methods Preoperative CT scans of eighty-five osteoarthritic knees were examined by three independent medical doctors twice over 7 weeks. The geometric centre of the tibia was produced by the ellipse annotation drawn 8 mm below the tibial plateau, the sagittal and frontal axes of the ellipse were transposed to the slice of the tibial tuberosity. With the usage of several guide lines, a right triangle was drawn within which the personalized Berger angle was calculated. Results A very good intra-observer (0.89-0.925) and inter-observer (0.874) intra-class correlation coefficient (ICC) was achieved. Even if the average of the personalized Berger values were similar to the original 18° (18.32° in our case), only 70.6% of the patients are between the clinically tolerable thresholds (12.2° and 23.8°). Conclusion The method, measured on the preoperative CT scans, is capable of calculating the required correction during the planning of revision arthroplasties which are necessary due to the tibial component malrotation. The personalized Berger angle isn’t altered during arthroplasty, this way it determines which one of the anterior reference points of the tibia (medial 1/3 or the tip of the tibial tuberosity, medial border or 1/6 or 1/3 or the centre of the patellar tendon) can be used during the positioning of the tibial component. Level of evidence Level II, Diagnostic Study (Methodological Study).
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Affiliation(s)
- Gömöri András
- Department of Traumatology, Semmelweis University - Medicine and Health Sciences, Borsod-Abaúj-Zemplén County Hospital, Üllői út 26., Budapest, 1085, Hungary.
| | - Gábor Németh
- Department of Ophthalmology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Csaba Zsolt Oláh
- Department of Neurosurgery, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Gábor Lénárt
- Department of Radiology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Zsanett Drén
- Department of Radiology, Borsod-Abaúj-Zemplén County Hospital, Szentpéteri kapu 72-76, Miskolc, 3526, Hungary
| | - Miklós Papp
- TritonLife Róbert Magánkórház, Department of Orthopaedics, Miskolci Egyetem, Egészségtudományi kar, Egyetemváros, Miskolc, 3515, Hungary
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Kazarian GS, Lieberman EG, Hansen EJ, Nunley RM, Barrack RL. Clinical impact of component placement in manually instrumented total knee arthroplasty : a systematic review. Bone Joint J 2021; 103-B:1449-1456. [PMID: 34465158 DOI: 10.1302/0301-620x.103b9.bjj-2020-1639.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The goal of the current systematic review was to assess the impact of implant placement accuracy on outcomes following total knee arthroplasty (TKA). METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Ovid Medline, Embase, Cochrane Central, and Web of Science databases in order to assess the impact of the patient-reported outcomes measures (PROMs) and implant placement accuracy on outcomes following TKA. Studies assessing the impact of implant alignment, rotation, size, overhang, or condylar offset were included. Study quality was assessed, evidence was graded (one-star: no evidence, two-star: limited evidence, three-star: moderate evidence, four-star: strong evidence), and recommendations were made based on the available evidence. RESULTS A total of 49 studies were identified for inclusion. With respect to PROMs, there was two-star evidence in support of mechanical axis alignment (MAA), femorotibial angle (FTA), femoral coronal angle (FCA), tibial coronal angle (TCA), femoral sagittal angle (FSA), femoral rotation, tibial and combined rotation/mismatch, and implant size/overhang or offset on PROMs, and one-star evidence in support of tibial sagittal angle (TSA), impacting PROMs. With respect to survival, there was three- to four-star evidence in support FTA, FCA, TCA, and TSA, moderate evidence in support of femoral rotation, tibial and combined rotation/mismatch, and limited evidence in support of MAA, FSA, and implant size/overhang or offset impacting survival. CONCLUSION Overall, there is limited evidence to suggest that PROMs are impacted by the accuracy of implant placement, and malalignment does not appear to be a significant driver of the observed high rates of patient dissatisfaction following TKA. However, FTA, FCA, TCA, TSA, and implant rotation demonstrate a moderate-strong relationship with implant survival. Efforts should be made to improve the accuracy of these parameters in order to improve TKA survival. Cite this article: Bone Joint J 2021;103-B(9):1449-1456.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Elizabeth G Lieberman
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Erik J Hansen
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Ryan M Nunley
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, USA
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Hiranaka T, Tanaka T, Fujishiro T, Anjiki K, Nagata N, Kitazawa D, Kotoura K, Okamoto K. The tibial lateral axis is a novel extraarticular landmark for detection of the tibial anteroposterior axis. Surg Radiol Anat 2020; 42:1195-1202. [PMID: 32514589 DOI: 10.1007/s00276-020-02513-8] [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: 12/30/2019] [Accepted: 06/02/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Although the tibial rotation axis is significant in knee arthroplasty, no reliable extraarticular landmark has been proposed. We hypothesized that the tibial lateral axis (TLA), a tangential line of the lateral tibial surface, is perpendicular to the surgical epicondylar axis (SEA) and compared it to other existing landmarks by 3D-CT. METHODS Fifty legs in 25 consecutive patients were studied. Using their preoperative CT, the TLAs were identified on slices at 10-50% of the total length of the tibia and the measured differences of angles against the line perpendicular to the SEA (the tibial AP axis) were calculated. The differences between the SEA and the femoral and tibial posterior condylar axis, Akagi's line and the line between the medial intercondylar spine and the medial border of the patellar tendon (sAP line)(intraarticular), the ankle axis, and the transmalleolar axis (extraarticular) were also calculated and compared. RESULTS The mean values of TLA at 10%, 20%, 30% were virtually parallel to the SEA (0.97° ± 4.84°, 0.02° ± 4.61°, 1.10° ± 4.97°, respectively). They were equivalent to existing intraarticular landmarks and superior to existing extraarticular landmarks, and these levels corresponded to the tip to the lower end of the tibial tubercle (at 10.8% and 17.0% of total tibial length). CONCLUSION The proximal TLAs can be an extraarticular bony landmark that indicates the line perpendicular to the SEA. A prospective study is needed to prove the validity and accuracy of the axes clinically.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan.
| | - Toshikazu Tanaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Kensuke Anjiki
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Naosuke Nagata
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Daiya Kitazawa
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Ken Kotoura
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki City, Osaka, 561-1115, Japan
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Clarke C, Pomeroy V, Clark A, Creelman G, Hancock N, Horton S, Killett A, Mann C, Payerne E, Toms A, Roberts G, Smith T, Swart AM, McNamara I. CAPAbility: comparison of the JOURNEY II Bi-Cruciate Stabilised and GENESIS II total knee arthroplasty in performance and functional ability: protocol of a randomised controlled trial. Trials 2020; 21:222. [PMID: 32093769 PMCID: PMC7041243 DOI: 10.1186/s13063-020-4143-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/05/2020] [Indexed: 12/26/2022] Open
Abstract
Background Osteoarthritis of the knee is a common condition that is expected to rise in the next two decades leading to an associated increase in total knee replacement (TKR) surgery. Although there is little debate regarding the safety and efficacy of modern TKR, up to 20% of patients report poor functional outcomes following surgery. This study will investigate the functional outcome of two TKRs; the JOURNEY II Bi-Cruciate Stabilised knee arthroplasty, a newer knee prosthesis designed to provide guided motion and improve knee kinematics by more closely approximating a normal knee, and the GENESIS II, a proven existing design. Aim To compare the change in Patient-reported Outcome Measures (PROMs) scores of the JOURNEY II BCS and the GENESIS II from pre-operation to 6 months post operation. Methods CAPAbility is a pragmatic, blinded, two-arm parallel, randomised controlled trial recruiting patients with primary osteoarthritis due to have unilateral TKR surgery across two UK hospitals. Eligible participants (n = 80) will be randomly allocated to receive either the JOURNEY II or the GENESIS II BCS knee prosthesis. Baseline measures will be taken prior to surgery. Patients will be followed at 1 week, 6 to 8 weeks and 6 months post-operatively. The primary outcome is the Oxford Knee Score (OKS) at 6 months post-operatively. Secondary outcomes include: other PROMs, biomechanical, radiological (computerised tomography, (CT)), clinical efficacy and safety outcomes. An embedded qualitative study will also investigate patients’ perspectives via interview pre and post surgery on variables known to affect the outcome of TKR surgery. A sub-sample (n = 30) will have additional in-depth interviews to explore the themes identified. The surgeons’ perspectives on the operation will be investigated by a group interview after all participants have undergone surgery. Discussion This trial will evaluate two generations of TKR using PROMS, kinematic and radiological analyses and qualitative outcomes from the patient perspective. Trial registration International Standard Randomised Controlled Trials Number Registration, ID: ISRCTN32315753. Registered on 12 December 2017.
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Affiliation(s)
- Celia Clarke
- School of Health Sciences, University of East Anglia, Norwich, UK.
| | - Valerie Pomeroy
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Nicola Hancock
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Simon Horton
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Anne Killett
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Charles Mann
- Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Andoni Toms
- Norwich Medical School, University of East Anglia, Norwich, UK.,Norwich Radiology Academy, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Toby Smith
- School of Health Sciences, University of East Anglia, Norwich, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ann Marie Swart
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Iain McNamara
- Norwich Medical School, University of East Anglia, Norwich, UK.,Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, UK
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Popescu R, Haritinian EG, Cristea S. Methods of intra- and post-operative determination of the position of the tibial component during total knee replacement. INTERNATIONAL ORTHOPAEDICS 2019; 44:119-128. [PMID: 31655885 DOI: 10.1007/s00264-019-04424-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022]
Abstract
AIM OF THE STUDY To identify the most reliable anatomical landmarks and imaging techniques for assessing the rotation of the tibial component in total knee arthroplasty (TKA). METHODS An extensive literature review (from January 2016 to March 2019) was performed. We included studies about primary TKA with details concerning the anatomical landmarks used for implanting the tibial component and also imaging studies assessing tibial component rotation. The final selection comprises only thirty-five articles consistent with the inclusion criteria. RESULTS Extra-articular landmarks are not always reliable (even though the tibial tubercle is one of the most popular extra-articular landmarks used to assess the rotation of the tibial component), mainly because they vary and can lead to malrotation of the tibial component. Akagi's line (an intra-articular landmark) is considered to be the most reliable and easy to find during surgery and likewise is not affected by articular deformities. The anterior tibial cortex (intra-articular landmark) also proved to be accurate and reliable with the main advantage being that is palpable after tibial resection. Radiography provides a good and inexpensive option for imaging, but it is insufficient. Magnetic resonance imaging (MRI) is used in some cases but not routinely for assessing TKA components or their orientation. Computed tomography (CT), used together with a well-defined protocol (Berger's method being the preferred choice), remains the "gold standard" for evaluating the rotation of the tibial component after TKA. CONCLUSION Currently, the most accurate and reliable anatomical landmarks are represented by Akagi's line and the anterior cortex of the tibia. Post-operatively, through CT and well-established protocols, the rotation of the tibial component can be accurately determined.
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Affiliation(s)
- Roman Popescu
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania
| | - Emil G Haritinian
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania. .,Clinical Hospital of Orthopedics and Traumatology and Osteoarticular TB "Foișor", Ferdinand Blvd, no. 35-37, District 2, 021382, Bucharest, Romania.
| | - Stefan Cristea
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania. .,Department of Orthopaedics and Traumatology, Saint Pantelimon Emergency Hospital, Pantelimon Road, no. 340-342, District 2, 021659, Bucharest, Romania.
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Wakelin EA, Tran L, Twiggs JG, Theodore W, Roe JP, Solomon MI, Fritsch BA, Miles BP. Accurate determination of post-operative 3D component positioning in total knee arthroplasty: the AURORA protocol. J Orthop Surg Res 2018; 13:275. [PMID: 30376865 PMCID: PMC6208069 DOI: 10.1186/s13018-018-0957-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022] Open
Abstract
Background Successful component alignment is a major metric of success in total knee arthroplasty. Component translational placement, however, is less well reported despite being shown to affect patient outcomes. CT scans and planar X-rays are routinely used to report alignment but do not report measurements as precisely or accurately as modern navigation systems can deliver, or with reference to the pre-operative anatomy. Methods A method is presented here that utilises a CT scan obtained for pre-operative planning and a post-operative CT scan for analysis to recreate a computation model of the knee with patient-specific axes. This model is then used to determine the post-operative component position in 3D space. Results Two subjects were investigated for reproducibility producing 12 sets of results. The maximum error using this technique was 0.9° ± 0.6° in rotation and 0.5 mm ± 0.3 mm in translation. Eleven subjects were investigated for reliability producing 22 sets of results. The intra-class correlation coefficient for each of the three axes of rotation and three primary resection planes was > 0.93 indicating excellent reliability. Conclusions Routine use of this analysis will allow surgeons and engineers to better understand the effect of component alignment as well as the placement on outcome.
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Affiliation(s)
- Edgar A Wakelin
- 360 Knee Systems, Suite 3, Building 1, Sydney, NSW, 2073, Australia.
| | - Linda Tran
- 360 Knee Systems, Suite 3, Building 1, Sydney, NSW, 2073, Australia
| | - Joshua G Twiggs
- 360 Knee Systems, Suite 3, Building 1, Sydney, NSW, 2073, Australia.,Department of Biomedical Engineering, University of Sydney, Sydney, NSW, 2006, Australia
| | - Willy Theodore
- 360 Knee Systems, Suite 3, Building 1, Sydney, NSW, 2073, Australia
| | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Hospital, North Sydney, NSW, 2065, Australia
| | - Michael I Solomon
- Prince of Wales Private Hospital, Barker Street, Kensington, NSW, 2030, Australia
| | - Brett A Fritsch
- Sydney Orthopaedic Research Institute, 445 Victoria Ave, Sydney, NSW, 2067, Australia
| | - Brad P Miles
- 360 Knee Systems, Suite 3, Building 1, Sydney, NSW, 2073, Australia
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