1
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Richardson G, Kivell MJ, Dunbar MJ, Laende EK. Tibial Slope Is Not Associated With Implant Migration Following Cemented Total Knee Arthroplasty With a Single Implant Design. J Arthroplasty 2024; 39:2241-2247.e5. [PMID: 38677348 DOI: 10.1016/j.arth.2024.04.021] [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: 11/17/2023] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The influence of tibial slope on tibial component migration following total knee arthroplasty has not been widely studied, although excessive posterior slope has been implicated in some failures. As implant micromotion measured with radiostereometric analysis can indicate successful fixation, the purpose of this study was to determine the associations between tibial slope, tibial component migration, and inducible displacement. METHODS Radiostereometric analyses at 6 visits over 2 years quantified implant migration for 200 cemented total knee arthroplasties. Longitudinal data analysis examined the influence of postoperative tibial slope on implant migration (overall maximum total point motion (MTPM) migration and anterior-posterior tilt migration), accounting for age, sex, and body mass index. The correlations of tibial slope with 1-year migration, continuous migration, and inducible displacements were also examined. Additionally, the amount of change in slope was compared to migration. RESULTS The mean posterior tibial slope was 8.0° (standard deviation [SD] 3.8°) preoperatively and 3.8° (SD 3.1°) postoperatively, with a mean reduction in slope of 4.2° (SD 4.7°). Postoperative tibial slope (range 14.0° posterior slope to 3.4° anterior slope) was not associated with longitudinal overall migration (P = .671) or anterior-posterior tilt migration (P = .704). There was no association between postoperative tibial slope and migration at 1 year postoperatively (P = .441 for MTPM migration, P = .570 for tilt migration), change in migration from 1 to 2 years (P = .951), or inducible displacement (P = .970 MTPM, P = .730 tilt). The amount of change in tibial slope was also not associated with migration or inducible displacement. CONCLUSIONS Residual and change in postoperative tibial slope were not associated with implant migration into tilt or overall migration, or inducible displacement for a single implant design. These findings support positioning tibial implants in a range of slopes, which may support patient-specific approaches to implant alignment.
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Affiliation(s)
- Glen Richardson
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Matthew J Kivell
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Michael J Dunbar
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Elise K Laende
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Mechanical and Materials Engineering, Queen's University, Kingston, Ontario, Canada
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2
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Ollivier B, Luyckx T, Stragier B, Vandenneucker H. Kinematic alignment adequately restores trochlear anatomy, patellar kinematics and kinetics in total knee arthroplasty: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39101252 DOI: 10.1002/ksa.12401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Patellofemoral pain, maltracking and instability remain common and challenging complications after total knee arthroplasty. Controversy exists regarding the effect of kinematic alignment on the patellofemoral joint, as it generally leads to more femoral component valgus and internal rotation compared to mechanical alignment. The aim of this systematic review is to thoroughly examine the influence of kinematic alignment on the third space. METHODS A systematic search of the Pubmed, Cochrane and Web of Science databases was performed to screen for relevant articles published before 7 April 2024. This led to the final inclusion of 42 articles: 2 cadaveric, 9 radiographic, 12 computer simulation and 19 clinical studies. The risk of bias was evaluated with the risk of bias in non-randomised studies - of interventions tool as the lowest level of evidence of the included clinical studies was IV. The effects of kinematic alignment on patellar kinematics and kinetics, trochlear anatomy reconstruction and patellofemoral complication rate were investigated. RESULTS Kinematic alignment closely restores native patellar kinematics and kinetics, better reproduces native trochlear anatomy than mechanical alignment and leads to a 0%-11.4% incidence of patellofemoral complications. A more valgus joint line of the distal femur can cause lateral trochlear undercoverage and a trochlear angle orientation medial to the quadriceps vector when applying kinematic alignment, both of which can be solved by using an adjusted design with a 20.5° valgus trochlea. CONCLUSION Kinematic alignment appears to be a safe strategy for the patellofemoral joint in most knees, provided that certain precautions are taken to minimize the risk of complications. LEVEL OF EVIDENCE Level IV clinical studies, in vitro research.
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Affiliation(s)
- Britt Ollivier
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Luyckx
- Department of Orthopaedic Surgery, AZ Delta, Roeselare, Belgium
| | - Bruno Stragier
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Hilde Vandenneucker
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
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3
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Karasavvidis T, Pagan CA, Debbi EM, Mayman DJ, Jerabek SA, Vigdorchik JM. No Difference in Limb Alignment Between Kinematic and Mechanical Alignment Robotic-Assisted Total Knee Arthroplasty. J Arthroplasty 2024; 39:S200-S205. [PMID: 38548234 DOI: 10.1016/j.arth.2024.03.050] [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: 11/20/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Individualized alignment techniques have gained major interest in an effort to increase satisfaction among total knee arthroplasty patients. This study aimed to compare postoperative alignment between kinematic alignment (KA) and mechanical alignment (MA) and assess whether KA significantly deviates from the principle of aligning the limb as close to neutral alignment as possible. METHODS There were 234 patients who underwent robotic-assisted total knee arthroplasty using an unrestricted KA and a strict MA technique (KA: 145, MA: 89). The lateral distal femoral angle, medial proximal tibia angle, and the resultant arithmetic hip-knee-ankle angle (aHKA) were measured. The aHKA < 0 indicated varus alignment, while the aHKA > 0 indicated valgus knee alignment. The primary outcome was the frequency of cases that resulted in an aHKA of ± 4° of neutral (0°), as assessed on full-leg standing radiographs obtained at 6 weeks postoperatively. The secondary outcome was the change in coronal plane alignment of the knee classification type from preoperative to postoperative between the MA and KA groups. RESULTS The mean preoperative aHKA was similar between the 2 groups (P = .19). The KA group had a mean postoperative aHKA of -1.4 ± 2.4°, while the MA group had a mean postoperative aHKA of -0.5 ± 2.1°. No significant difference in limb alignment was identified between KA and MA cases that resulted in hip-knee-ankle angle of ± 4° being neutral (91.7 versus 96.6%, P = .14). There were 97.2% of cases in the KA group that fell within the ± 5° range. The MA group was associated with a significantly higher rate of coronal plane alignment of the knee classification type change from preoperatively to postoperatively (P < .001). CONCLUSIONS Kinematic alignment achieved similar postoperative aHKA compared to MA, and thus did not significantly deviate from the principle of aligning the limb as close to neutral alignment as possible. Surgeons should feel comfortable starting to introduce individualized alignment techniques. Without being restricted by boundaries, postoperative alignment will be within 5 degrees of neutral 97% of the time.
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Affiliation(s)
- Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Cale A Pagan
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Eytan M Debbi
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - David J Mayman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Seth A Jerabek
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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4
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Vendittoli PA, Beckers G, Massé V, de Grave PW, Ganapathi M, MacDessi SJ. Why we should use boundaries for personalised knee arthroplasty and the lack of evidence for unrestricted kinematic alignment. Knee Surg Sports Traumatol Arthrosc 2024; 32:1917-1922. [PMID: 38804654 DOI: 10.1002/ksa.12266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Pascal-André Vendittoli
- Department of Orthopaedic Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Québec, Canada
- Clinique Orthopédique Duval, Laval, Québec, Canada
- Personalised Arthroplasty Society, Atlanta, Georgia, USA
| | - Gautier Beckers
- Personalised Arthroplasty Society, Atlanta, Georgia, USA
- Department of Orthopaedic Surgery, Klinikum Großhadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Vincent Massé
- Department of Orthopaedic Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Québec, Canada
- Clinique Orthopédique Duval, Laval, Québec, Canada
- Personalised Arthroplasty Society, Atlanta, Georgia, USA
| | - Philip Winnock de Grave
- Personalised Arthroplasty Society, Atlanta, Georgia, USA
- Department of Orthopaedic Surgery, AZ Delta Hospital, Roeselare, Belgium
- European Knee Society, Haacht, Belgium
| | - Muthu Ganapathi
- Personalised Arthroplasty Society, Atlanta, Georgia, USA
- Department of Trauma and Orthopaedics, Ysbyty Gwynedd Hospital, Betsi Cadwaladr University Health Board, Penrhosgarnedd, Bangor, UK
| | - Samuel J MacDessi
- School of Clinical Medicine, St George Hospital, University of NSW Medicine and Health, Kogarah, Sydney, Australia
- Sydney Knee Specialists, Kogarah, New South Wales, Australia
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5
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Nedopil AJ, Howell SM, Hull ML, Hirschmann MT. A TKA can be kinematically aligned without restrictions: Current evidence. Knee Surg Sports Traumatol Arthrosc 2024; 32:1354-1358. [PMID: 38501289 DOI: 10.1002/ksa.12132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California at Davis, Davis, California, USA
| | - Maury L Hull
- Department of Biomedical Engineering, University of California at Davis, Davis, California, USA
- Department of Mechanical Engineering, University of California at Davis, Davis, California, USA
- Department of Orthopaedic Surgery, University of California at Davis, Davis, California, USA
| | - Michael T Hirschmann
- Department of Orthopedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
- Research Group Michael T. Hirschmann, Regenerative Medicine & Biomechanics, Department of Clinical Research, University of Basel, Basel, Switzerland
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6
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Segura-Nuez J, Martín-Hernández C, Segura-Nuez JC, Segura-Mata JC. Methods of alignment in total knee arthroplasty, systematic review. Orthop Rev (Pavia) 2024; 16:117769. [PMID: 38827414 PMCID: PMC11142931 DOI: 10.52965/001c.117769] [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: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Although total knee arthroplasty (TKA) is a very frequent surgery, one in five patients is not completely satisfied. Mechanical alignment (MA) is the most popular technique for implanting TKA. However, to improve clinical outcomes, new techniques that aim to rebuild the native alignment of the knee have been developed. Objective The aim of this study is to perform a systematic review of the available clinical trials and observational studies comparing clinical and radiological outcomes of different methods of alignment (kinematic, anatomic, functional) to MA. Methods A systematic review is performed comparing results of patient reported outcome measures (PROMs) questionnaires (WOMAC, OKS, KSS, KOOS, FJS), radiological angles (HKA, mLDFA, MPTA, JLOA, femoral rotation and tibial slope) and range of motion (ROM). Results Kinematic and functional alignment show a slight tendency to obtain better PROMs compared to mechanical alignment. Complication rates were not significantly different between groups. Nevertheless, these results are not consistent in every study. Anatomic alignment showed no significant differences compared to mechanical alignment. Conclusion Kinematic alignment is an equal or slightly better alternative than mechanical alignment for patients included in this study. However, the difference between methods does not seem to be enough to explain the high percentage of dissatisfied patients. Studies implementing lax inclusion and exclusion criteria would be needed to resemble conditions of patients assisted in daily surgical practice. It would be interesting to study patient's knee phenotypes, to notice if any method of alignment is significantly better for any constitutional deviation.
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Affiliation(s)
- Juan Segura-Nuez
- Orthopaedic surgery and Traumatology Hospital Universitario Miguel Servet
| | - Carlos Martín-Hernández
- Orthopaedic surgery and Traumatology Hospital Universitario Miguel Servet
- Orthopaedic surgery and Traumatology Universidad de Zaragoza
| | | | - Julián Carlos Segura-Mata
- Orthopaedic surgery and Traumatology FREMAP Zaragoza
- Orthopaedic surgery and Traumatology Hospital Quirónsalud Zaragoza
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Wang G, Chen L, Luo F, Luo J, Xu J. Superiority of kinematic alignment over mechanical alignment in total knee arthroplasty during medium- to long-term follow-up: A meta-analysis and trial sequential analysis. Knee Surg Sports Traumatol Arthrosc 2024; 32:1240-1252. [PMID: 38488220 DOI: 10.1002/ksa.12093] [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: 10/22/2023] [Revised: 01/17/2024] [Accepted: 02/01/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE To compare and determine the reliability and conclusiveness of the medium- and long-term efficacy in terms of patient-reported outcome measures and the risk of revisions or reoperations (RRRs) of kinematic alignment (KA) and mechanical alignment (MA) in total knee arthroplasty. METHODS A comprehensive search was conducted in Medline, EMBASE, Web of Science and Cochrane Database Library to identify relevant literature. Only randomised clinical trials (RCTs) published before July 2023 were included. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Forgotten Joint Score (FJS) and RRR were compared. Additionally, OKS and RRR were subjected to a trial sequential analysis. RESULTS Seven RCTs involving 572 knees were identified. The pooled analysis of the included studies demonstrated that KA showed better medium-term WOMAC and OKS (mean difference [MD] = -6.3, 95% confidence interval [CI]: -9.52 to -2.99, p < 0.05 and MD = 1.1, 95% CI: 0.05-2.15, p < 0.05), respectively), but no significant differences were observed in the long-term follow-up (MD = 2.1, 95% CI: -3.21 to 7.31, not significant [n.s.] and MD = 0.01, 95% CI: -2.43 to 2.46, n.s., respectively). FJS (standardised MD = -0.03, 95% CI: -0.25 to 0.19, n.s.) and RRR (risk ratio = 1.0, 95% CI: 0.57 to 1.74, n.s.) showed no significant intergroup differences (n.s.). The evidence quality ranged from moderate to high, and the trial sequential analysis indicated the need for additional high-quality RCTs to draw more conclusive results. CONCLUSIONS KA showed better medium-term WOMAC and OKS, while KA and MA had similar FJS without increasing the RRR in medium- and long-term follow-up. Further research is needed for more conclusive results. LEVEL OF EVIDENCE Level II (meta-analyses).
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Affiliation(s)
- Guiguan Wang
- Shengli Clinical College of Fujian Medical University, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Fujian Provincial Clinical Medical Research Center for Spinal Nerve and Joint Diseases, Fuzhou, Fujian, China
| | - Long Chen
- Shengli Clinical College of Fujian Medical University, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Fujian Provincial Clinical Medical Research Center for Spinal Nerve and Joint Diseases, Fuzhou, Fujian, China
| | - Fenqi Luo
- Shengli Clinical College of Fujian Medical University, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Fujian Provincial Clinical Medical Research Center for Spinal Nerve and Joint Diseases, Fuzhou, Fujian, China
| | - Jun Luo
- Shengli Clinical College of Fujian Medical University, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Fujian Provincial Clinical Medical Research Center for Spinal Nerve and Joint Diseases, Fuzhou, Fujian, China
| | - Jie Xu
- Shengli Clinical College of Fujian Medical University, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Fujian Provincial Clinical Medical Research Center for Spinal Nerve and Joint Diseases, Fuzhou, Fujian, China
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8
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Nogalo C, Farinelli L, Meena A, di Maria F, Abermann E, Fink C. Robotic-assisted total knee arthroplasty is not associated with improved accuracy in implant position and alignment compared to conventional instrumentation in the execution of a preoperative digital plan. J Exp Orthop 2024; 11:e12019. [PMID: 38572393 PMCID: PMC10985632 DOI: 10.1002/jeo2.12019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
Purpose The primary objective of the present study was to evaluate if robotic-assisted total knee arthroplasty (RO-TKA) results in improved accuracy compared to conventional TKA (CO-TKA) with respect to alignment and component positioning executing a preoperative digital plan. The secondary objective was to compare patient-reported outcome measures (PROMs) between the two groups at 6 months of follow-up (FU). Methods Patients who underwent primary TKA using the concept of constitutional alignment were identified from the database. Each patient underwent preoperative digital planning as well as postoperative evaluation of the preoperative plan (alignment and component position) using mediCAD® software (Hectec GmbH). Two groups were formed: (i) The RO-TKA group (n = 30) consisted of patients who underwent TKA with a robotic surgical system (ROSA®, Zimmer Biomet) and (ii) the CO-TKA group (n = 67) consisted of patients who underwent TKA with conventional instrumentation. To assess accuracy, all qualitative variables were analysed using the χ 2 test. Tegner activity scale, Oxford Knee Score and visual analogue scale were assessed preop and at 6-month FU. To assess differences between the two groups, a 2 × 2 repeated measures analysis of variance was performed. Results There was no significant (p > 0.05) difference in the accuracy of alignment as well as tibial and femoral component position between the two groups. At the 6-month FU, there was no significant (p > 0.05) difference in PROMs between the two groups. Conclusion While robotic TKA may have some potential advantages, no significant difference was found between robotic and conventional TKA with respect to limb alignment, clinical outcomes and component positioning. Level of Evidence Level III.
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Affiliation(s)
- Christian Nogalo
- Gelenkpunkt—Sports and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
| | - Luca Farinelli
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
- Department of Clinical and Molecular SciencesClinical OrthopaedicsAnconaItaly
| | - Amit Meena
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
- Division of OrthopedicsShalby HospitalJaipurIndia
| | - Fabrizio di Maria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico “Rodolico‐San Marco”University of CataniaCataniaItaly
| | - Elisabeth Abermann
- Gelenkpunkt—Sports and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
| | - Christian Fink
- Gelenkpunkt—Sports and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI)UMIT TIROL—Private University For Health Sciences and Health TechnologyHall in TirolAustria
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9
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Howell SM, Akhtar M, Nedopil AJ, Hull ML. Reoperation, Implant Survival, and Clinical Outcome After Kinematically Aligned Total Knee Arthroplasty: A Concise Clinical Follow-Up at 16 Years. J Arthroplasty 2024; 39:695-700. [PMID: 37659680 DOI: 10.1016/j.arth.2023.08.080] [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: 07/10/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND The preceding study reported a 10-year follow-up of 222 kinematically aligned total knee arthroplasties (TKA) performed in 217 patients in 2007. As 35% of tibial components and 8% of limbs were in >3° varus, the present study assessed whether this adversely affected reoperation, implant survival, and function at 16 years. METHODS We retrospectively reviewed a single surgeon's private practice database to determine the patients who underwent reoperation as well as Forgotten Joint Score and Oxford Knee Score. RESULTS There were 7 patients who had a major reoperation (revision of a loose tibial component [n = 2], and revision of well-fixed component due to stiffness [n = 1], patella instability [n = 1], pain [n = 1], and infection [n = 2]). There were 5 who had a minor reoperation that retained the components, and 91 patients (94 TKAs) died. Implant survivorship was 93% using reoperation for any reason as the endpoint. The median (interquartile range) Forgotten Joint and Oxford Knee scores were 88 (57 to 100) and 45 (39 to 48) points, respectively. CONCLUSION The kinematically aligned TKA had a 7% reoperation rate at 16 years follow-up, comparable to or lower than reports of mechanically aligned TKA, which supports the concept of the unrestricted version of kinematic alignment in which the patient's prearthritic alignment is fully restored regardless of deformity.
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Affiliation(s)
- Stephen M Howell
- Department of Biomedical Engineering, University of California at Davis, Davis, California
| | - Muzammil Akhtar
- College of Medicine, California Northstate University, Elk Grove, California
| | - Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany
| | - Maury L Hull
- Department of Biomedical Engineering, University of California at Davis, Davis, California
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10
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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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11
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Khatri C, Metcalfe A, Wall P, Underwood M, Haddad FS, Davis ET. Robotic trials in arthroplasty surgery. Bone Joint J 2024; 106-B:114-120. [PMID: 38295854 DOI: 10.1302/0301-620x.106b2.bjj-2023-0711.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.
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Affiliation(s)
- Chetan Khatri
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Warwick Orthopaedics Specialist Training Programme, University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Andrew Metcalfe
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Warwick Orthopaedics Specialist Training Programme, University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Peter Wall
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Martin Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Warwick Orthopaedics Specialist Training Programme, University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospitals, London, UK
- The Bone & Joint Journal , London, UK
| | - Edward T Davis
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
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12
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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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13
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Puijk R, Puijk RH, Laende EK, Dunbar MJ, Plevier JWM, Nolte PA, Pijls BGCW. 6-month migration sufficient for evaluation of total knee replacements: a systematic review and meta-analysis. Acta Orthop 2023; 94:577-587. [PMID: 38038237 PMCID: PMC10690979 DOI: 10.2340/17453674.2023.24579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 10/22/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND PURPOSE This updated meta-analysis evaluates the migration pattern of the tibial component of primary total knee replacements measured with radiostereometric analysis (RSA). We aimed to evaluate whether 6-month maximum total point motion (MTPM) values could be used instead of 1-year MTPM for RSA threshold testing and to present the pooled migration patterns for different implant designs that can be used as a benchmark. PATIENTS AND METHODS The search included all published RSA studies on migration patterns of tibial components until 2023. Study groups were classified according to their prosthesis brand, fixation, and insert (PFI). Sub-analyses were performed to compare the mean tibial component migration patterns of different implant variables, stratified according to fixation. RESULTS 96 studies (43 new studies), including 197 study groups and 4,706 knees, were included. Most migration occurred within the first 6 postoperative months (126 study groups: mean 0.58 mm, 95% confidence interval [CI] 0.50-0.65), followed by minimal migration between 6 and 12 months (197 study groups: mean 0.04 mm, CI 0.03-0.06), irrespective of the fixation method used. Distinct migration patterns were observed among the different fixation methods. No differences were found in migration patterns among cemented components in any of the sub-group analyses conducted. For uncemented implants, trabecular metal surfaced components seemed to migrate less than porous-coated or uncoated components Conclusion: Based on the small difference between MTPM values at 6 months and 1 year, MTPM at 6 months could be used instead of MTPM at 1 year for RSA threshold testing. The pooled migration patterns can be used as benchmark for evaluation of new implants by defining fixation-specific RSA thresholds when combined with implant survival.
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Affiliation(s)
- Raymond Puijk
- Department of Orthopaedics, Spaarne Gasthuis, Hoofddorp, the Netherlands.
| | - Rowan H Puijk
- Department of Orthopaedics, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Elise K Laende
- Mechanical and Materials Engineering, Queen's University, Kingston, Ontario, Canada; Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Michael J Dunbar
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| | - José W M Plevier
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter A Nolte
- Department of Orthopaedics, Spaarne Gasthuis, Hoofddorp, the Netherlands; Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Bart G C W Pijls
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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Karasavvidis T, Pagan Moldenhauer CA, Lustig S, Vigdorchik JM, Hirschmann MT. Definitions and consequences of current alignment techniques and phenotypes in total knee arthroplasty (TKA) - there is no winner yet. J Exp Orthop 2023; 10:120. [PMID: 37991599 PMCID: PMC10665290 DOI: 10.1186/s40634-023-00697-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/16/2023] [Indexed: 11/23/2023] Open
Abstract
Dissatisfaction following total knee arthroplasty (TKA) has been extensively documented and it was attributed to numerous factors. In recent years, significant focus has been directed towards implant alignment and stability as potential causes and solutions to this issue. Surgeons are now exploring a more personalized approach to TKA, recognizing the importance of thoroughly understanding each individual patient's anatomy and functional morphology. A more comprehensive preoperative analysis of alignment and knee morphology is essential to address the unresolved questions in knee arthroplasty effectively. The crucial task of determining the most appropriate alignment strategy for each patient arises, given the substantial variability in bone resection resulting from the interplay of phenotype and the alignment strategy chosen. This review aims to comprehensively present the definitions of different alignment techniques in all planes and discuss the consequences dependent on knee phenotypes.Level of evidence V.
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Affiliation(s)
- Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Cale A Pagan Moldenhauer
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Sébastien Lustig
- Department of Orthopaedic Surgery and Sports Medicine, Croix-Rousse Hospital, Lyon, 69004, France
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, CH-4101, Switzerland
- Department of Clinical Research, Research Group Michael T. Hirschmann, Regenerative Medicine & Biomechanics, University of Basel, Basel, CH-4001, Switzerland
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15
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Wang G, Chen L, Xu J. Kinematic and mechanical alignments in total knee arthroplasty: A meta-analysis with ≥1-year follow-up. J Orthop Sci 2023:S0949-2658(23)00210-5. [PMID: 37573180 DOI: 10.1016/j.jos.2023.08.001] [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: 01/27/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Kinematic and mechanical alignment outcomes in total knee arthroplasty remain controversial. This study compared the clinical and radiological outcomes of total knee arthroplasty using kinematic and mechanical alignments. METHODS We systematically searched PubMed, EMBASE, Web of Science, and Cochrane Library databases for randomized controlled trials and cohort studies published before November 2022. The data of interest were extracted and analyzed using Review Manager V.5.4. RESULTS Nineteen randomized controlled trials and cohort studies involving 880 kinematic alignment total knee arthroplasties and 965 mechanical alignment total knee arthroplasties were included. In this meta-analysis, the kinematic alignment group achieved better knee joint function scores, including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and Knee Society Score, and better flexion angles. No statistical differences were detected in the Western Ontario and McMaster Universities Osteoarthritis Index, extension angle, Forgotten Joint Score, European Quality of Life five-dimension measure, hip-knee-ankle angle, or complications between the kinematic and mechanical alignment groups. CONCLUSION This meta-analysis indicated that kinematic alignment total knee arthroplasty provides clinical benefits in terms of the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Knee Society Score (knee), Knee Society Score (function), and better flexion angles. In addition, kinematic alignment total knee arthroplasty led to similar clinical outcomes as mechanical alignment total knee arthroplasty without increasing complications. SYSTEMATIC REVIEW REGISTRATION http://www.crd.york.ac.uk/PROSPERO/CRD42022373227.
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Affiliation(s)
- Guiguan Wang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou 350001, China; Department of Orthopedic, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Long Chen
- Department of Orthopedic, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Jie Xu
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou 350001, China; Department of Orthopedic, Fujian Provincial Hospital, Fuzhou 350001, China.
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16
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Karasavvidis T, Pagan Moldenhauer CA, Haddad FS, Hirschmann MT, Pagnano MW, Vigdorchik JM. Current Concepts in Alignment in Total Knee Arthroplasty. J Arthroplasty 2023; 38:S29-S37. [PMID: 36773657 DOI: 10.1016/j.arth.2023.01.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND In an effort to increase satisfaction among total knee arthroplasty (TKA) patients, emphasis has been placed on implant positioning and limb alignment. Traditionally, the aim for TKA has been to achieve a neutral mechanical alignment (MA) to maximize implant longevity. However, with the recent spike in interest in individualized alignment techniques and with the advent of new technologies, surgeons are slowly evolving away from classical MA. METHODS This review elucidates the differences in alignment techniques for TKA, describes the concept of knee phenotypes, summarizes comparative studies between MA and individualized alignment, and provides a simple way to incorporate the latter into surgeons' practice. RESULTS In order to manage patients by applying these strategies in day-to-day practice, a basic understanding of the aforementioned concepts is essential. Transition to an individualized alignment technique should be done gradually with caution in a stepwise approach. CONCLUSION Alignment and implant positioning are now at the heart of the debate and surgeons are investigating a more personalized approach to TKA.
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Affiliation(s)
- Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Cale A Pagan Moldenhauer
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospital, London
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Mark W Pagnano
- Deparment of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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17
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Shekhar A, Dungy D, Stewart SL, Jamali AA. Patient-Reported Outcomes of Kinematic vs Mechanical Alignment in Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroplast Today 2023; 21:101127. [PMID: 37193540 PMCID: PMC10182176 DOI: 10.1016/j.artd.2023.101127] [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: 08/22/2022] [Revised: 01/28/2023] [Accepted: 02/27/2023] [Indexed: 05/18/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is an effective treatment method for severe osteoarthritis of the knee. Poor alignment of a knee replacement has been associated with suboptimal clinical results. Traditionally, mechanical alignment (MA) has been considered the gold standard. In light of reports of decreased satisfaction with TKA, a new technique called kinematic alignment (KA) has been developed. The purpose of this study is to (1) review the results of KA and MA for TKA in randomized controlled trials based on the Western Ontario and McMaster Universities Arthritis Index score, the Oxford Knee Score, and the Knee Society Scores, (2) perform a meta-analyses of the randomized controlled trials with baseline and follow-up values of these parameters, and (3) discuss other shortcomings of this literature from the perspective of study design and execution. Methods Two independent reviewers performed a systematic review of the English literature using the Embase, Scopus, and PubMed databases searching for randomized controlled trials of MA vs KA in TKA. Of the initial 481 published reports, 6 studies were included in the final review for meta-analysis. The individual studies were then analyzed to evaluate for risks of bias and inconsistencies of methodology. Results A majority of studies demonstrated low risk of bias. All studies had fundamental technical issues by utilizing different techniques to achieve KA vs MA. There was no significant difference between KA and MA in these studies. Conclusions There is no significant difference in any outcomes measured between KA and MA in TKA. Both statistical and methodological factors diminish the value of these conclusions.
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Affiliation(s)
| | | | - Susan L. Stewart
- UC Davis Cancer Center, UC Davis Medical Center, Sacramento, CA, USA
| | - Amir A. Jamali
- Joint Preservation Institute, Walnut Creek, CA, USA
- Corresponding author. Joint Preservation Institute, 100 N. Wiget Lane, Suite 200, Walnut Creek, CA 94598, USA. Tel.: +1 925 322 2908.
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18
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Miura T, Takahashi T, Watanabe J, Kataoka Y, Ae R, Saito H, Takeshita K, Miyakoshi N. Postoperative clinical outcomes for kinematically, restricted kinematically, or mechanically aligned total knee arthroplasty: a systematic review and network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:322. [PMID: 37095485 PMCID: PMC10124064 DOI: 10.1186/s12891-023-06448-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/20/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Mechanically aligned total knee arthroplasty (MATKA) is a well-established procedure. Kinematically aligned TKA (KATKA) has been proposed to restore and preserve pre-arthritic knee anatomy. However, normal knee anatomy varies widely, and there have been concerns regarding restoring unusual anatomy. Accordingly, restricted KATKA (rKATKA) was introduced to reproduce constitutional knee anatomy within a safe range. This network meta-analysis (NMA) aimed to evaluate the clinical and radiological outcomes of the surgeries. METHODS We performed a database search on August 20, 2022, which included randomized controlled trials (RCTs) comparing any two of the three surgical TKA techniques for knee osteoarthritis. We conducted a random-effects NMA within the frequentist framework and evaluated confidence in each outcome using the Confidence in Network Meta-Analysis tool. RESULTS Ten RCTs with 1,008 knees and a median follow-up period of 1.5 years were included. The three methods might result in little to no difference in range of motion (ROM) between methods. In patient-reported outcome measures (PROMs), the KATKA might result in a slight improvement compared with the MATKA (standardized mean difference, 0.47; 95% confidence interval [CI], 0.16-0.78; very low confidence). There was little to no difference in revision risk between MATKA and KATKA. KATKA and rKATKA showed a slight valgus femoral component (mean difference [MD], -1.35; 95% CI, -1.95-[-0.75]; very low confidence; and MD, -1.72; 95% CI, -2.63-[-0.81]; very low confidence, respectively) and a slight varus tibial component (MD, 2.23; 95% CI, 1.22-3.24; very low confidence; and MD, 1.25; 95% CI, 0.01-2.49; very low confidence, respectively) compared with MATKA. Tibial component inclination and hip-knee-ankle angle might result in little to no difference between the three procedures. CONCLUSIONS KATKA and rKATKA showed similar ROM and PROMs and a slight variation in the coronal component alignment compared with MATKA. KATKA and rKATKA are acceptable methods in short- to mid-term follow-up periods. However, long-term clinical results in patients with severe varus deformity are still lacking. Surgeons should choose surgical procedures carefully. Further trials are warranted to evaluate the efficacy, safety, and subsequent revision risk.
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Affiliation(s)
- Takanori Miura
- Department of Orthopedic Surgery, Tazawako Hospital, 17-1 Ukiyozaka Obonai, Tazawako, Senboku, Akita, 014-1201, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, Ishibashi General Hospital, 1-15-4 Shimokoyama, Shimotsuke, Tochigi, 329-0596, Japan.
| | - Jun Watanabe
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
- Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Tanaka Asukai-Cho 89, Sakyo-Ku, Kyoto, 606-8226, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Yoshida Konoe-Cho, Sakyo-Ku, Kyoto, 606-8501, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / Public Health, Yoshida Konoe-Cho, Sakyo-Ku, Kyoto, 606-8501, Japan
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Hidetomo Saito
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, 329-0498, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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19
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Nedopil AJ, Hernandez AM, Boone JM, Howell SM, Hull ML. Correcting for distal femoral asymmetry is necessary to determine postoperative alignment deviations from planned alignment of the femoral component. Knee 2023; 42:193-199. [PMID: 37054496 DOI: 10.1016/j.knee.2023.01.013] [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: 02/23/2022] [Revised: 08/07/2022] [Accepted: 01/26/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND One method for assessing the accuracy of manual, patient-specific, navigational, and robotic-assisted total knee arthroplasty (TKA) instrumentation is to use a post-operative computer tomogram and determine the deviation of the femoral component alignment relative to the planned alignment in the native (i.e. healthy) contralateral distal femoral epiphysis. However, side-to-side asymmetry might introduce errors which inflate alignment deviations. This study quantified asymmetry in the distal femoral epiphysis. METHODS High resolution CT images (0.5 mm slice thickness) were acquired from bilateral lower limb specimens of 13 skeletally mature subjects with no skeletal abnormalities. Images were segmented to generate 3D femur models. Asymmetry was quantified by differences in positions and orientations required to shape-match the distal epiphysis of the mirror 3D femur model to the distal epiphysis of the contralateral 3D femur model. RESULTS Asymmetry was due to random rather than systematic differences. Random differences (i.e. standard deviations) in proximal-distal (P-D) and anterior-posterior (A-P) positions were 1.1 mm and in varus-valgus (V-V) and internal-external (I-E) orientations were 0.9° and 1.3°, respectively. These represented substantial relative errors of up to 50 % in previously reported overall alignment deviations. CONCLUSIONS Although small in an absolute sense, asymmetry of the distal femur epiphysis introduced substantial relative errors when assessing accuracy of femoral component alignment in TKA. When post-operative computer tomograms are used to assess the accuracy of manual, patient specific, navigational, and robotic-assisted TKA instrumentation, the overall deviation should be corrected for asymmetry to better indicate the accuracy of the surgical technique.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97074 Würzburg, Germany.
| | - Andrew M Hernandez
- Department of Radiology, University of California at Davis, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
| | - John M Boone
- Department of Radiology, University of California at Davis, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California at Davis, 451 E. Health Sciences Drive, Room 2303, Davis, CA 95616, United States.
| | - Maury L Hull
- Department of Biomedical Engineering, University of California at Davis, 451 E. Health Sciences Drive, Room 2303, Davis, CA 95616, United States; Department of Mechanical Engineering, University of California at Davis, One Shields Avenue, Davis, CA 95616 USA; Department of Orthopaedic Surgery, University of California at Davis Medical Center, Sacramento, CA 95817 USA.
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20
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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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Tuecking LR, Savov P, Ettinger M, Windhagen H. [Kinematic Alignment of Total Knee Arthroplasty]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:93-107. [PMID: 36796373 DOI: 10.1055/a-1689-5118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Nowadays, kinematic alignment is a widely used alignment philosophy in total knee arthroplasty. The concept of kinematic alignment respects the patient's individual prearthrotic anatomy and is based on the reconstruction of the femoral anatomy and thus the axes of motion of the knee joint. Only then the alignment of the tibial component is adapted to the femoral component. By means of this technique soft tissue balancing is reduced to a minimum. Due to the risk of excessive outlier alignment technical assistance or calipered techniques are recommended for precise implementation. This article attempts to provide an understanding of the fundamentals of kinematic alignment, and it focusses on how it differs from alternative alignment strategies and the way the philosophy is implemented in different surgical techniques.
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22
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Yamada M, Nakajima A, Sonobe M, Akatsu Y, Yamamoto K, Saito J, Norimoto M, Koyama K, Taniguchi S, Aoki Y, Suguro T, Nakagawa K. The impact of postoperative inclination of the joint line on clinical outcomes in total knee arthroplasty using a prosthesis with anatomical geometry. Sci Rep 2023; 13:979. [PMID: 36653469 PMCID: PMC9849260 DOI: 10.1038/s41598-023-28182-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
The goal of this study was to investigate the impact of postoperative inclination of the joint line on clinical results after total knee arthroplasty (TKA) using a prosthesis with anatomical geometry. This study included 145 primary cruciate-retaining type of knee prosthesis with anatomical geometry. Three years postoperatively, clinical outcomes including the patient-reported outcomes (PROs) were recorded. Limb alignment was evaluated by the hip-knee-ankle (HKA) axis and inclination of the joint line was assessed by the joint line orientation angle (JLOA). Knees were divided into two groups according to the HKA: in-range (- 3 to 3°) and outlier group (< - 3° or > 3°) or the JLOA: in-range (2-4°) and outlier group (< 2° or > 4°), and clinical outcomes were compared between the groups. Postoperative Knee Society Function Score (KS-FS) was significantly higher in the HKA in-range group than the outlier group (p = 0.01). The Knee Society Knee Score and all subscales of the Knee injury Osteoarthritis Outcome Score were comparable between the groups. A multivariate analysis revealed a significant association between age at operation and postoperative KS-FS > of 80 points. Neither HKA in-range nor JLOA in-range were associated with the higher knee function. In conclusion, TKA-postoperative inclination of the joint line was not relevant to the short-term PROs. Treatment strategies that attempt to make joint line inclination in order to improve postoperative PROs should be avoided, and alignment goals such as kinematic alignment should be considered carefully.
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Affiliation(s)
- Manabu Yamada
- Department of Orthopaedic Surgery, Toho University Graduate School of Medicine, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan. .,Department of Orthopaedic Surgery and Rehabilitation, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Keiichiro Yamamoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Masaki Norimoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Keita Koyama
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Shinji Taniguchi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686, Japan.,Department of General Medical Sciences, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8677, Japan
| | - Toru Suguro
- Japan Research Institute of Artificial Joint, 725-1 Sugo, Kisarazu, Chiba, 292-0036, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan
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23
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Massé V, Cholewa J, Shahin M. Personalized alignment™ for total knee arthroplasty using the ROSA ® Knee and Persona ® knee systems: Surgical technique. Front Surg 2023; 9:1098504. [PMID: 36733674 PMCID: PMC9888495 DOI: 10.3389/fsurg.2022.1098504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Total knee arthroplasty (TKA) procedures are expected to increase up to 565% in the United States over the next 3 decades. TKAs were traditionally performed with neutral mechanical alignments that provided equal medial and lateral gaps in extension and flexion to reduce implant wear but were less successful at restoring native knee function and associated with high patient dissatisfaction. Kinematic alignment (KA) restores native anatomy and minimizes soft tissue release; however, KAs that recreate severe deformities and/or biomechanically inferior alignments result in significant increases in implant stress and risk of aseptic loosening. Restricted kinematic alignment (rKA) recreates pre-arthritic anatomy within a range of acceptable alignment boundaries, and improved patient clinical scores and faster recoveries have been reported with rKA techniques. Personalized Alignment™ is an evolution of rKA that relies heavily upon robotic assistance to reliably recreate patient anatomy, native soft tissue laxity, and accurate component placement to improve patients' clinical outcomes. The purpose of this surgical technique report is to describe the Personalized Alignment TKA method using the ROSA® Knee System and Persona® The Personalized Knee® implants. Herein we provide specific procedures for pre-operative planning, anatomical landmarking and evaluation, intra-operative planning and adjustment of resections and cuts, cut validation and soft tissue evaluation with robotic-assisted personalized TKA.
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Affiliation(s)
- Vincent Massé
- Hôpital Maisonneuve-Rosemont, Surgery Department, Université de Montréal, Montreal, Quebec, Canada,Personalized Arthroplasty Society, Atlanta, GA, United States,Duval Orthopaedic Clinic, Laval, Québec, Canada,Correspondence: Vincent Massé
| | | | - Maged Shahin
- Personalized Arthroplasty Society, Atlanta, GA, United States,Duval Orthopaedic Clinic, Laval, Québec, Canada
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24
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Van Essen J, Stevens J, Dowsey MM, Choong PF, Babazadeh S. Kinematic alignment results in clinically similar outcomes to mechanical alignment: Systematic review and meta-analysis. Knee 2023; 40:24-41. [PMID: 36403396 DOI: 10.1016/j.knee.2022.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/28/2022] [Accepted: 11/03/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE It is unclear whether a difference in functional outcome exists between kinematically aligned (KA) and mechanically aligned (MA) knee replacements. The aim of this study is to perform a comprehensive systematic review and meta-analysis of the available level I-IV evidence. METHODS A meta-analysis of randomised controlled trials and observational studies comparing patient reported outcome measures (PROMs), range of motion (ROM), gait analysis and complications in TKA with KA and MA was performed. Quality assessment was performed for each study using the Joanna Briggs Institute (JBI) critical appraisal tools. RESULTS Twelve randomised controlled trials and fourteen observational studies published between 2014 and 2022 were included in the final analysis. Meta-analysis revealed KA to have significantly better Oxford Knee Score (OKS) (p = 0.02), Forgotten Joint Score (FJS) (p = 0.006), Knee Society Score (KSS) Objective Knee (p = 0.03) and KSS Functional Activity (p = 0.008) scores. However, these improvements did not exceed the minimum clinically important difference (MCID) values reported in the literature. Subgroup analysis showed robotic assisted KA-TKA to have a clinically superior FJS (p = 0.0002) and trend towards KSS Objective Knee score (p = 0.10), compared to PSI. Gait and plantar pressure distribution of KA cohorts more closely represented healthy cohorts, and KA showed a weak association of a decreased knee adduction moment (KAM) compared to MA. Differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), range of motion and complications were not significant between groups. CONCLUSION Although KA results in several improved functional outcomes, these do not reach clinical significance. Further standardised large-scale randomised studies are required to improve the quality of evidence. As it stands, it is difficult to recommend one philosophy over the other.
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Affiliation(s)
- James Van Essen
- University of Melbourne, Parkville, Victoria 3010, Australia
| | - Jarrad Stevens
- St. Vincent's Hospital (Melbourne) - Department of Orthopaedics, PO Box 2900, Fitzroy, Victoria 3065, Australia
| | - Michelle M Dowsey
- University of Melbourne, Parkville, Victoria 3010, Australia; St. Vincent's Hospital (Melbourne) - Department of Orthopaedics, PO Box 2900, Fitzroy, Victoria 3065, Australia.
| | - Peter F Choong
- University of Melbourne, Parkville, Victoria 3010, Australia; St. Vincent's Hospital (Melbourne) - Department of Orthopaedics, PO Box 2900, Fitzroy, Victoria 3065, Australia.
| | - Sina Babazadeh
- University of Melbourne, Parkville, Victoria 3010, Australia; St. Vincent's Hospital (Melbourne) - Department of Orthopaedics, PO Box 2900, Fitzroy, Victoria 3065, Australia; Australian Orthopaedic Research Group, Kew East, Victoria 3102, Australia.
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25
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Nedopil AJ, Zamora T, Delman C, Howell SM, Hull ML. Which Asymmetric Tibial Component Is Optimally Designed for Calipered Kinematically Aligned Total Knee Arthroplasty? J Knee Surg 2022; 35:1610-1618. [PMID: 33932950 DOI: 10.1055/s-0041-1728815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Calipered kinematically aligned (KA) total knee arthroplasty (TKA) restores the patient's prearthritic joint lines and sets internal-external rotation of the tibial component parallel to the flexion-extension (FE) plane, which is not a mechanical alignment (MA) target. Two asymmetric tibial components designed for MA set the tibial component to either a femoral component (FC) target or a tibial tubercle (TT) target. The study determined the optimal asymmetric tibial component to use with KA as the one with smaller IE deviation from the MA target, greater coverage of tibial resection, and lower incidence of cortical overhang. The study included 40 patients treated with bilateral calipered KA TKA with different asymmetric tibial components in opposite knees. A best-fit of a kinematic tibial template to the tibial resection set the template's slot parallel to the knee's FE plane. Each asymmetric tibial component's anterior-posterior (AP) axis was set parallel to the slot. Computer tomography analysis determined the IE deviation (-internal/+ external) of each tibial component from its MA target, tibial resection coverage by the baseplate and insert, and incidence of cortical overhang. The patient-reported Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) determined outcomes. The mean IE deviation from the MA target was 2 degrees external for the FC-target asymmetric tibial component and -8 degrees internal for the TT-target asymmetric tibial component (p < 0.001). Tibial resection coverage by the baseplate (insert) was 88% (84%) for the FC target and 84% (79%) for the TT target (p < 0.001 for baseplate and insert). The FC target insert covered 3 mm more of the posterolateral resection (p < 0.001). Posteromedial coverage was comparable. The incidence of cortical overhang was 2.5% for each baseplate. There was no difference in FJS and OKS. When performing calipered KA, the more optimal design was the asymmetric tibial component with the FC target because of the smaller deviation from its MA target and the greater coverage of the tibial resection by the baseplate and insert.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany
| | - Tomas Zamora
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Connor Delman
- Department of Orthopaedics, University of California, Davis, Davis, California
| | - Stephen M Howell
- Biomedical Engineering Graduate Group, University of California, Davis, Davis, California
| | - Maury L Hull
- Department of Mechanical Engineering, University of California, Davis, Davis, California
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26
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Preliminary outcomes of kinematically aligned robot-assisted total knee arthroplasty with patient-specific cartilage thickness measurement. J Robot Surg 2022; 17:979-985. [DOI: 10.1007/s11701-022-01503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
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27
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Time for return to sport following total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2022; 142:3427-3436. [PMID: 34564735 DOI: 10.1007/s00402-021-04180-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The frequency of total knee arthroplasty (TKA) is increasing, particularly in younger and more active patients. In these patients, there may be greater functional demands, with an expectation to return to sporting activities (RTS) following TKA. There is a paucity of data on the time to RTS following TKA and the aim of this meta-analysis is to determine the time to RTS following TKA. METHODS Using the PRISMA guidelines, an electronic search of PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trails was performed on TKA and RTS in English language, published since the inception of the database to 31st October 2020. Data evaluating the time to RTS and functional outcomes were recorded by two authors independently that were included in the analysis. Pooled analysis using random effect model on overall proportions at the different time intervals and at the end of the follow-up was carried out for all studies. RESULTS In total, 1,611 studies were retrieved from literature search. Of these, nine studies met the inclusion criteria with 1,307 patients. Two studies with 148 patients demonstrated an overall pooled proportion of 18.7% (95% CI 8.2-32.3%) of patients RTS at 3 month post-TKA; Three studies reported RTS rate at 6 months 70.% (95% CI 48-88.4). Two studies with 123 patients demonstrated an overall pooled proportion of 84.0% (95% CI 77.1-89.9%) patients RTS at 12 months. 986 patients returned to sport from total of 1307, with an overall adjusted proportion return to sport of 87.9 (95% CI 80.5-93.8%) at the end of follow-up; mean 14 months (range 3-36 months). CONCLUSION Patients undergoing TKA were found to successfully RTS, pooled proportion analysis showed an increasing rate of RTS with time, at a mean of 14 months following TKA, where 87.9% of patients had returned to sports. The findings of this study will enable more informed discussions and rehabilitation planning between patients and clinicians on RTS following TKA.
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28
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Low tibial baseplate migration 1 year after unrestricted kinematically aligned total knee arthroplasty using a medial conforming implant design. Knee Surg Sports Traumatol Arthrosc 2022; 31:1433-1442. [PMID: 36201009 DOI: 10.1007/s00167-022-07171-4] [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: 06/30/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Varus alignment of the tibial baseplate and limb > 3° might adversely affect baseplate fixation after total knee arthroplasty (TKA), especially for unrestricted kinematically aligned (KA) TKA which aligns a majority of baseplates in varus. The purposes of this study were to determine whether baseplate migration at 1 year (1) was significantly less than a stability limit of 0.5 mm, (2) increased over time, and (3) was related to varus alignment of the baseplate and limb after unrestricted KA TKA. METHODS Thirty-five patients underwent unrestricted KA TKA using a fixed-bearing, cemented, medial conforming tibial insert with posterior cruciate ligament retention. Using model-based radiostereometric analysis, maximum total point motion (MTPM) (i.e., largest displacement on the baseplate) was computed at 6 weeks, 3 months, 6 months, and 1 year postoperatively relative to the day of surgery. Baseplate and limb alignment were measured postoperatively on long-leg CT scanograms. RESULTS At 1 year, mean MTPM of 0.35 mm was significantly less than the 0.5 mm stability limit (p = 0.0002). Mean MTPM did not increase from 6 weeks to 1 year (p = 0.3047). Notably, 89% (31/35) of tibial baseplates and 46% (16/35) of limbs were > 3° varus. Baseplate and limb alignment had no relationship to MTPM at 1 year (|r|≤ 0.173, p ≥ 0.3276). CONCLUSION Low and non-progressive tibial baseplate migration 1 year after unrestricted KA TKA with a medial conforming design should allay any concern that unrestricted KA TKA increases risk of baseplate loosening due to varus alignment of the baseplate and limb. LEVEL OF EVIDENCE Level II, therapeutic prospective cohort study.
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29
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The rebirth of computer-assisted surgery. Precise prosthetic implantation should be considered when targeting individualized alignment goals in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:2886-2889. [PMID: 32975623 DOI: 10.1007/s00167-020-06295-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
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30
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Hazratwala K, O'Callaghan WB, Dhariwal S, Wilkinson MPR. Wide variation in tibial slopes and trochlear angles in the arthritic knee: a CT evaluation of 4116 pre-operative knees. Knee Surg Sports Traumatol Arthrosc 2022; 30:3049-3060. [PMID: 34487188 DOI: 10.1007/s00167-021-06725-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 08/24/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE As surgeons continue to grapple with persistent issues of patient dissatisfaction post-TKA, the literature has focused on the coronal plane when considering alignment strategies but has largely ignored the sagittal and axial planes. The purpose of this retrospective observational cohort study is to evaluate variability in knee anatomy and alignment beyond the coronal plane and rationalise how this relates to existing arthroplasty alignment philosophies. METHODS 4116 knee CTs from 360 Knee Systems© database of arthritic pre-operative TKA patients were evaluated. Standardised bony landmarks were used in each CT to determine the hip-knee angle, medial proximal tibial angle, lateral distal femoral angle, medial plateau posterior tibial slope, lateral plateau posterior tibial slope, trochlea angle (TA) to distal femoral angle (TA-DFA) and TA to posterior condylar angle (TA-PCA). Analysis was performed to determine the distributions of each measure across the cohort population. RESULTS Both the medial and lateral PTS ranged from 5° anterior to 25° posterior. 22.6% of patients had differential PTS greater than 5°. 14.5% have greater lateral PTS (mean difference to medial PTS of 4.8° ± 5.0°), whilst 31.0% have greater medial PTS (mean difference to lateral PTS of 5.7° ± 3.2°). 14% of TA-DFAs and 5.2% of TA-PCAs vary greater than 10°. CONCLUSION This study demonstrates a wide variation in tibial slope, differential slope between the medial and lateral tibial plateau as well as variation in the trochlear geometry. There has been an overemphasis in the literature on coronal alignment, ignoring the considerable variability present in tibial and patellofemoral morphology. Existing arthroplasty techniques are based on assumptions that may not adequately address the anatomy of morphologic outliers and could lead to dissatisfaction. LEVEL OF EVIDENCE III-retrospective cohort study.
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Affiliation(s)
- Kaushik Hazratwala
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, QLD, 4812, Australia.
| | - William B O'Callaghan
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, QLD, 4812, Australia
| | | | - Matthew P R Wilkinson
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, QLD, 4812, Australia
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31
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Wen L, Wang Z, Ma D, Qu T. Surgeon Dominated Design Can Improve the Accuracy of Patient-Specific Instruments in Kinematically Aligned TKA. J Pers Med 2022; 12:jpm12081192. [PMID: 35893286 PMCID: PMC9332028 DOI: 10.3390/jpm12081192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/04/2022] [Accepted: 07/16/2022] [Indexed: 11/16/2022] Open
Abstract
Precise bone resection is mandatory for kinematically aligned total knee arthroplasty (KA-TKA). This study is to investigate whether surgeon-dominated design can alter the accuracy of patient-specific instrumentation (PSI) in KA-TKA compared with the engineer design. A total of 24 patients (24 knees) who underwent KA-TKA in our institution were assigned to an engineer design group (10 knees) and surgeon design group (14 knees) chronologically. A novel portable medical-engineer interactive application can greatly enhance the surgeon’s participation in PSI design. The bone resection discrepancies were used to evaluate the accuracy of PSI in bone resection. The overall discrepancy of bone resection was reduced by surgeon-designed PSI compared to engineer-designed PSI by 0.33 mm. Surgeon-designed PSI seems to reduce the outliers in terms of relative discrepancies in bone resection as well, but it does not reach statistical significance. Moreover, surgeon-designed PSI could significantly improve the accuracy of PSI in the restoration of the joint line in terms of medial proximal tibial angle and mechanical lateral distal femoral angle. This study indicates that the dominance of surgeons in both PSI design and subsequent surgical operation should be emphasized in efforts to improve the accuracy of PSI.
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Affiliation(s)
- Liang Wen
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
| | - Zhiwei Wang
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
- Correspondence: ; Tel.: +86-10-85231228
| | - Desi Ma
- Department of Orthopeadics, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; (L.W.); (D.M.)
| | - Tiebing Qu
- The Center of Diagnosis and Treatment for Joint Disease, China Rehabilitation Research Center, Beijing 100068, China;
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Lv SJ, Wang XJ, Huang JF, Mao Q, He BJ, Tong PJ. Total knee arthroplasty in Ranawat II valgus deformity with enlarged femoral valgus cut angle: A new technique to achieve balanced gap. World J Clin Cases 2022; 10:6406-6416. [PMID: 35979319 PMCID: PMC9294892 DOI: 10.12998/wjcc.v10.i19.6406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/10/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nearly 10% of patients undergoing primary total knee arthroplasty (TKA) have valgus deformity (VD) of the knee. For severe VD of the knee, a more lateral structural release is needed to achieve balance between medial and lateral space and neutral femorotibial mechanical axis (FTMA), which is challenging and technical.
AIM To introduce a new surgical technique of resection, soft tissue release, and FTMA for Ranawat type-II VD with a 5-year follow-up.
METHODS A retrospective study was conducted on patients who underwent TKA from December 2011 to December 2014. Hip-knee-ankle (HKA), range of motion (ROM), Oxford knee score (OKS), and knee society score (KSS) were used to assess the joint activity of patients in the new theory TKA group (NT-TKA) and were compared with those of the conventional TKA group (C-TKA).
RESULTS A total of 103 people (103 knees) were included in this study, including 42 patients with an average follow-up period of 83 mo in the C-TKA group and 61 patients with an average follow-up period of 76 mo in the NT-TKA group. Six patients had constrained prosthesis, one had common peroneal nerve injury, and two had joint instability in the C-TKA group, but none of these occurred in the NT-TKA group. There were significant statistical differences in constrained prosthesis usage and complications between the groups (P = 0.002 and P = 0.034, respectively). The KSS at 1 mo post-operation for the C-TKA and NT-TKA groups were 11.2 ± 3.8 and 13.3 ± 2.9, respectively, with a significant difference (P = 0.007). However, the data of HKA, ROM, OKS KSS, and prosthesis survival rate were insignificant (P > 0.05) in both the preoperative and follow-up periods.
CONCLUSION Adopting 5°-7° valgus cut angle for VD and sacrificing 2° neutral FTMA for severe VD which cannot be completely corrected during TKA can reduce the need for soft tissue release, maintain early joint stability, reduce the use of constrained prostheses, and minimize postoperative complications.
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Affiliation(s)
- Shuai-Jie Lv
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xiao-Jian Wang
- The First Clinical Medical School, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jie-Feng Huang
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Qiang Mao
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Bang-Jian He
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Pei-Jian Tong
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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Hiyama S, Takahashi T, Takeshita K. Kinematically Aligned Total Knee Arthroplasty Did Not Show Superior Patient-Reported Outcome Measures: An Updated Meta-analysis of Randomized Controlled Trials with at Least 2-Year Follow-up. J Knee Surg 2022; 35:634-639. [PMID: 32927492 DOI: 10.1055/s-0040-1716494] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Kinematically aligned total knee arthroplasty (KATKA) was developed to improve the anatomical alignment of knee prostheses, assisting in restoring the native alignment of the knee and promoting physiological kinematics. Early clinical results were encouraging, showing better functional outcomes than with mechanically aligned total knee arthroplasty (MATKA). However, there have been concerns about implant survival, and follow-up at 10 years or more has not been reported. In addition, randomized controlled trials (RCTs) comparing KATKA with MATKA have reported inconsistent results. The current meta-analysis of RCTs with a minimum of 2 years of follow-up investigated the clinical and radiological differences between KATKA and MATKA. A systematic review of the English language literature resulted in the inclusion of four RCTs. The meta-analysis found no significant difference in any of the following parameters: postoperative range of motion for flexion (mean difference for KATKA - MATKA [MD], 1.7 degrees; 95% confidence interval [CI], -1.4 to 4.8 degrees; p = 0.29) and extension (MD, 0.10 degrees; 95% CI, -0.99 to 1.2 degrees; p = 0.86); Oxford Knee Score (MD, 0.10 points; 95% CI, -1.5 to 1.7 points; p = 0.90); Knee Society Score (MD, 1.6 points; 95% CI, -2.8 to 6.0 points; p = 0.49); and Knee Function Score (MD, 1.4 points; 95% CI, -4.9 to 7.8 points; p = 0.66). In addition, there was no significant difference between KATKA and MATKA in the rate of complications requiring reoperation or revision surgery (odds ratio, 1.01; 95% CI, 0.25-4.09; p = 0.99) or in the length of hospital stay (MD, 1.0 days; 95% CI, -0.2 to 2.2 days; p = 0.092). KATKA did not increase the number of patients with poor clinical results due to implant position, particularly for varus placement of the tibial component. In this meta-analysis based on four RCTs with a minimum of 2 years of follow-up, KATKA were only relevant to cruciate retaining TKA and could not be extrapolated to posterior stabilized TKA. Patient-reported outcome measures with KATKA were not superior to those with MATKA.
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Affiliation(s)
- Shuhei Hiyama
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Katsushi Takeshita
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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Hiranaka T, Suda Y, Saitoh A, Tanaka A, Arimoto A, Koide M, Fujishiro T, Okamoto K. Current concept of kinematic alignment total knee arthroplasty and its derivatives. Bone Jt Open 2022; 3:390-397. [PMID: 35532356 PMCID: PMC9134837 DOI: 10.1302/2633-1462.35.bjo-2022-0021.r2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The kinematic alignment (KA) approach to total knee arthroplasty (TKA) has recently increased in popularity. Accordingly, a number of derivatives have arisen and have caused confusion. Clarification is therefore needed for a better understanding of KA-TKA. Calipered (or true, pure) KA is performed by cutting the bone parallel to the articular surface, compensating for cartilage wear. In soft-tissue respecting KA, the tibial cutting surface is decided parallel to the femoral cutting surface (or trial component) with in-line traction. These approaches are categorized as unrestricted KA because there is no consideration of leg alignment or component orientation. Restricted KA is an approach where the periarthritic joint surface is replicated within a safe range, due to concerns about extreme alignments that have been considered ‘alignment outliers’ in the neutral mechanical alignment approach. More recently, functional alignment and inverse kinematic alignment have been advocated, where bone cuts are made following intraoperative planning, using intraoperative measurements acquired with computer assistance to fulfill good coordination of soft-tissue balance and alignment. The KA-TKA approach aims to restore the patients’ own harmony of three knee elements (morphology, soft-tissue balance, and alignment) and eventually the patients’ own kinematics. The respective approaches start from different points corresponding to one of the elements, yet each aim for the same goal, although the existing implants and techniques have not yet perfectly fulfilled that goal.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Yoshihito Suda
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Akira Saitoh
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Atsuki Tanaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Akihiko Arimoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Motoki Koide
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Japan
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Liu B, Feng C, Tu C. Kinematic alignment versus mechanical alignment in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:201. [PMID: 35379289 PMCID: PMC8981671 DOI: 10.1186/s13018-022-03097-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/23/2022] [Indexed: 01/02/2023] Open
Abstract
Background The purpose of this study was to perform an updated meta-analysis to compare the outcomes of kinematic alignment (KA) and mechanical alignment (MA) in patients undergoing total knee arthroplasty. Methods PubMed, EMBASE, Web of Science, Google Scholar, and the Cochrane Library were systematically searched. Eligible randomized controlled trials regarding the clinical outcomes of patients undergoing total knee arthroplasty with KA and MA were included for the analysis. Results A total of 1112 participants were included in this study, including 559 participants with KA and 553 patients with MA. This study revealed that the Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score (knee and combined), and knee flexion range were better in the patients with kinematic alignment than in the mechanical alignment. In terms of radiological results, the femoral knee angle, mechanical medial proximal tibial angle, and joint line orientation angle were significantly different between the two techniques. Perioperatively, the walk distance before discharge was longer in the KA group than in the MA group. In contrast, other functional outcomes, radiological results, perioperative outcomes, and postoperative complication rates were similar in both the kinematic and mechanical alignment groups. Conclusions The KA technique achieved better functional outcomes than the mechanical technique in terms of KSS (knee and combined), WOMAC scores, and knee flexion range. PROSPERO trial registration number CRD42021264519. Date registration: July 28, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03097-2.
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Affiliation(s)
- Binfeng Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.,Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan, Zhengzhou, 450003, China.,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Chengyao Feng
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Chao Tu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China. .,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
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Shatrov J, Battelier C, Sappey-Marinier E, Gunst S, Servien E, Lustig S. Functional Alignment Philosophy in Total Knee Arthroplasty – Rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning. SICOT J 2022; 8:11. [PMID: 35363136 PMCID: PMC8973302 DOI: 10.1051/sicotj/2022010] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/07/2022] [Indexed: 12/19/2022] Open
Abstract
Introduction: Alignment techniques in total knee arthroplasty (TKA) continue to evolve. Functional alignment (FA) is a novel technique that utilizes robotic tools to deliver TKA with the aim of respecting individual anatomical variations. The purpose of this paper is to describe the rationale and technique of FA in the varus morphotype with the use of a robotic platform. Rationale: FA reproduces constitutional knee anatomy within quantifiable target ranges. The principles are founded on a comprehensive assessment and understanding of individual anatomical variations with the aim of delivering personalized TKA. The principles are functional pre-operative planning, reconstitution of native coronal alignment, restoration of dynamic sagittal alignment within 5° of neutral, maintenance of joint-line-obliquity and height, implant sizing to match anatomy and a joint that is balanced in flexion and extension through manipulation of implant positioning rather than soft tissue releases. Technique: An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable method of soft tissue laxity assessment is performed in extension and flexion that accounts for individual variation in soft tissue laxity. A dynamic virtual 3D model of the joint and implant position that can be manipulated in all three planes is modified to achieve target gap measurements while maintaining the joint line phenotype and a final limb position within a defined coronal and sagittal range. Conclusion: Functional alignment is a novel knee arthroplasty technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that it respects the variations in individual anatomy. This paper presents the approach for the varus morphotype.
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Affiliation(s)
- Jobe Shatrov
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Sydney Orthopaedic Research Institute Chatswood 2065 Australia
| | - Cécile Battelier
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Elliot Sappey-Marinier
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Stanislas Gunst
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Elvire Servien
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Sebastien Lustig
- Department of Orthopaedics, Croix Rousse Hospital, University of Lyon 1 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
- Corresponding author:
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O’Callaghan WB, Gouk C, Wilkinson MP, Haztratwala K. Computer-Aided Surgery-Navigated, Functional Alignment Total Knee Arthroplasty: A Surgical Technique. Arthroplast Today 2022; 14:121-127. [PMID: 35295192 PMCID: PMC8919216 DOI: 10.1016/j.artd.2022.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/22/2022] [Indexed: 11/30/2022] Open
Abstract
The decision on which technique to use to perform a total knee arthroplasty has become much more complicated over the last decade. The shortfalls of mechanical alignment and kinematic alignment has led to the development of a new alignment philosophy, functional alignment. Functional alignment uses preoperative radiographic measurements, computer-aided surgery, and intraoperative assessment of balance, to leave the patient with the most “normal” knee kinematics achievable with minimal soft-tissue release. The purpose of this surgical technique article is to describe in detail the particular technique needed to achieve these alignment objectives.
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Affiliation(s)
- William B. O’Callaghan
- The Orthopaedic Research institute of Queensland (ORIQL), Pimlico Townsville, Queensland, Australia
- Mater Health Services North Queensland Ltd, Pimlico Townsville, Queensland, Australia
- Townsville University Hospital, Douglas Townsville, Queensland, Australia
- Cairn Base Hospital, Cairns, Queensland, Australia
| | - Conor Gouk
- The Orthopaedic Research institute of Queensland (ORIQL), Pimlico Townsville, Queensland, Australia
- Townsville University Hospital, Douglas Townsville, Queensland, Australia
- Cairn Base Hospital, Cairns, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
- Corresponding author. Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner Street, Pimlico Townsville, Queensland, Australia 4812. Tel.: +61 07 47550564.
| | - Matthew P.R. Wilkinson
- The Orthopaedic Research institute of Queensland (ORIQL), Pimlico Townsville, Queensland, Australia
- University of Tasmania, Hobart, Tasmania, Australia
| | - Kaushik Haztratwala
- The Orthopaedic Research institute of Queensland (ORIQL), Pimlico Townsville, Queensland, Australia
- Mater Health Services North Queensland Ltd, Pimlico Townsville, Queensland, Australia
- Townsville University Hospital, Douglas Townsville, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
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Laforest G, Kostretzis L, Kiss MO, Vendittoli PA. Restricted kinematic alignment leads to uncompromised osseointegration of cementless total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:705-712. [PMID: 33452903 PMCID: PMC8866348 DOI: 10.1007/s00167-020-06427-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/23/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE While kinematic alignment (KA) total knee arthroplasty (TKA) with cemented implants has been shown to provide equivalent or better results than mechanical alignment, its combination with cementless fixation has not yet been documented. The purpose of this study is to report (1) revision rate and causes, (2) clinical results based on patient report outcome measures (PROMs), and (3) radiological signs of implant dysfunction in patients with an uncemented TKA implanted with restricted KA (rKA), after a minimum follow-up of 2 years. METHODS This study included the first 100 consecutive uncemented cruciate retaining TKAs implanted between November 2015 and February 2018 by a single surgeon following rKA principles. At last follow-up, all adverse events and PROMs assessed by WOMAC, KOOS, and FJS scores were documented. Radiographic evaluation was performed to identify signs of implant loosening. RESULTS After a mean follow-up of 49 months (32, 60), no implant revision was performed for aseptic loosening. Three revisions were performed: one for malalignment, one for a deep infection, and one for instability. The mean WOMAC score was 20.1 (0-79, 21.3), the mean KOOS score was 71.5 (19.0-96.6, 19.8), and the mean FJS score was 65.9 (0-100, 29.6). No radiological evidence of implant aseptic loosening or osteolysis was identified. CONCLUSION This study shows that in 99% of our cases, rKA combined with the tested cementless TKA implant allowed for adequate secondary fixation and good functional outcomes in the short term. Favourable mid- to long-term implant survivorship is anticipated. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Guillaume Laforest
- grid.414216.40000 0001 0742 1666Surgery Department, Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 Boul l’Assomption, Montreal, QC H1T 2M4 Canada
| | - Lazaros Kostretzis
- grid.414216.40000 0001 0742 1666Surgery Department, Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 Boul l’Assomption, Montreal, QC H1T 2M4 Canada
| | - Marc-Olivier Kiss
- grid.414216.40000 0001 0742 1666Surgery Department, Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 Boul l’Assomption, Montreal, QC H1T 2M4 Canada ,Clinique Orthopédique Duval, Laval, QC Canada
| | - Pascal-André Vendittoli
- Surgery Department, Hôpital Maisonneuve-Rosemont, Université de Montréal, 5415 Boul l'Assomption, Montreal, QC, H1T 2M4, Canada. .,Clinique Orthopédique Duval, Laval, QC, Canada. .,Personalized Arthroplasty Society, Montreal, Canada.
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What is the "safe zone" for transition of coronal alignment from systematic to a more personalised one in total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:419-427. [PMID: 34973095 PMCID: PMC8866271 DOI: 10.1007/s00167-021-06811-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [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: 11/17/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE In total knee arthroplasty (TKA), implants are increasingly aligned based on emerging patient-specific alignment strategies, such as unrestricted kinematic alignment (KA), according to their constitutional limb alignment (phenotype alignment), which results in a large proportion of patients having a hip-knee angle (HKA) outside the safe range of ± 3° to 180° traditionally considered in the mechanical alignment strategy. The aim of this systematic review is to investigate whether alignment outside the safe zone of ± 3° is associated with a higher revision rate and worse clinical outcome than alignment within this range. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane and World of Science, with search terms including synonyms and plurals for "total knee arthroplasty", "alignment", "outlier", "malalignment", "implant survival" and "outcome". Five studies were identified with a total number of 927 patients and 952 implants. The Oxford Knee Score (OKS) and the WOMAC were used to evaluate the clinical outcome. The follow-up period was between 6 months and 10 years. RESULTS According to HKA 533 knees were aligned within ± 3°, 47 (8.8%) were varus outliers and 121 (22.7%) were valgus outliers. No significant differences in clinical outcomes were found between implants positioned within ± 3° and varus and valgus outliers. Likewise, no significant differences were found regarding revision rates and implant survival. CONCLUSION The universal use of the "safe zone" of ± 3° derived from the mechanical alignment strategy is hardly applicable to modern personalised alignment strategies in the light of current literature. However, given the conflicting evidence in the literature on the risks of higher revision rates and poorer clinical outcomes especially with greater tibial component deviation, the lack of data on the outcomes of more extreme alignments, and regarding the use of implants for KA TKA that are actually designed for mechanical alignment, there is an urgent need for research to define eventual evidence-based thresholds for new patient-specific alignment strategies, not only for HKA but also for FMA and TMA, also taking into account the preoperative phenotype and implant design. It is of utmost clinical relevance for the application of modern alignment strategies to know which native phenotypes may be reproduced with a TKA. LEVEL OF EVIDENCE IV.
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Hasan S, Kaptein BL, Nelissen RGHH, van Hamersveld KT, Toksvig-Larsen S, Marang-van de Mheen PJ. The Influence of Postoperative Coronal Alignment on Tibial Migration After Total Knee Arthroplasty in Preoperative Varus and Valgus Knees: A Secondary Analysis of 10 Randomized Controlled Trials Using Radiostereometric Analysis. J Bone Joint Surg Am 2021; 103:2281-2290. [PMID: 34648477 DOI: 10.2106/jbjs.20.01659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons aim for mechanical alignment when performing total knee arthroplasty (TKA) as malalignment is associated with loosening. Loosening may be predicted by migration as measured with radiostereometric analysis (RSA), but previous RSA studies on postoperative alignment have shown contradictory results and have been limited to cemented implants and small numbers of patients. Therefore, we performed a secondary analysis of 10 previously published randomized controlled trials (RCTs) to compare migration between postoperative in-range and out-of-range cemented and uncemented TKA implants among patients with a preoperative varus or valgus knee. METHODS All RCTs involving the use of RSA that had been conducted at 2 centers were included. Alignment was classified, with use of the hip-knee-ankle angle (HKA), as in-range (0° ± 3°) or out-of-range (<-3° or >3°). The fixation methods included cemented, uncemented-coated, and uncemented-uncoated. Migration was measured at 3, 12, and 24 months. A linear mixed model was used, with adjustment for fixation method and clustering of patients within centers. RESULTS Of 476 TKA implants that had been out-of-range preoperatively, 290 were in-range postoperatively and 186 were out-of-range in either varus (n = 143) or valgus (n = 43) postoperatively. The mean migration at 3, 12, and 24 months was 0.73 mm (95% confidence interval [CI], 0.66 to 0.79 mm), 0.92 mm (95% CI, 0.85 to 1.00 mm), and 0.97 mm (95% CI, 0.90 to 1.05 mm), respectively, for the in-range group and 0.80 mm (95% CI, 0.72 to 0.87 mm), 0.98 (95% CI, 0.90 to 1.07 mm), and 1.04 mm (95% CI, 0.95 to 1.13 mm), respectively, for the out-of-range group (p = 0.07). The fixation method significantly influenced migration, with uncemented-uncoated implants migrating more than cemented and uncemented-coated implants (p < 0.001). CONCLUSIONS Postoperative alignment did not influence migration of TKAs in the first 2 postoperative years in patients with preoperative varus or valgus alignment of the knee. However, the fixation method significantly influenced migration, with uncemented-uncoated implants showing the greatest migration. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shaho Hasan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart L Kaptein
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen T van Hamersveld
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Sören Toksvig-Larsen
- Department of Orthopaedics, Hässleholm Hospital, Hässleholm, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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Song YD, Nakamura S, Kuriyama S, Nishitani K, Ito H, Morita Y, Yamawaki Y, Matsuda S. Biomechanical Comparison of Kinematic and Mechanical Knee Alignment Techniques in a Computer Simulation Medial Pivot Total Knee Arthroplasty Model. J Knee Surg 2021; 36:596-604. [PMID: 34891188 DOI: 10.1055/s-0041-1740392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several concepts may be used to restore normal knee kinematics after total knee arthroplasty. One is a kinematically aligned (KA) technique, which restores the native joint line and limb alignment, and the other is the use of a medial pivot knee (MPK) design, with a ball and socket joint in the medial compartment. This study aimed to compare motions, contact forces, and contact stress between mechanically aligned (MA) and KA (medial tilt 3° [KA3] and 5° [KA5]) models in MPK. An MPK design was virtually implanted with MA, KA3, and KA5 in a validated musculoskeletal computer model of a healthy knee, and the simulation of motion and contact forces was implemented. Anteroposterior (AP) positions, mediolateral positions, external rotation angles of the femoral component relative to the tibial insert, and tibiofemoral contact forces were evaluated at different knee flexion angles. Contact stresses on the tibial insert were calculated using finite element analysis. The AP position at the medial compartment was consistent for all models. From 0° to 120°, the femoral component in KA models showed larger posterior movement at the lateral compartment (0.3, 6.8, and 17.7 mm in MA, KA3, and KA5 models, respectively) and larger external rotation (4.2°, 12.0°, and 16.8° in the MA, KA3, and KA5 models, respectively) relative to the tibial component. Concerning the mediolateral position of the femoral component, the KA5 model was positioned more medially. The contact forces at the lateral compartment of all models were larger than those at the medial compartment at >60° of knee flexion. The peak contact stresses on the tibiofemoral joint at 90° and 120° of knee flexion were higher in the KA models. However, the peak contact stresses of the KA models at every flexion angle were <20 MPa. The KA technique in MPK can successfully achieve near-normal knee kinematics; however, there may be a concern for higher contact stresses on the tibial insert.
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Affiliation(s)
- Young Dong Song
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kuriyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Nishitani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yugo Morita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yusuke Yamawaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Joint line is restored in robotic-arm-assisted total knee arthroplasty performed with a tibia-based functional alignment. Arch Orthop Trauma Surg 2021; 141:2175-2184. [PMID: 34255176 DOI: 10.1007/s00402-021-04039-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Functional alignment (FA) in total knee arthroplasty (TKA) has been introduced to restore the native joint line obliquity, respect the joint line height and minimize the need of soft tissue releases. The purpose of this study was to assess the intraoperative joint line alignment and compare it with the preoperative epiphyseal orientation of the femur and tibia in patients undergoing robotic-arm-assisted (RA)-TKA using FA. MATERIALS AND METHODS This retrospective study included a consecutive series of patients undergoing RA-TKA between February 2019 and February 2021. The joint line orientation of the femur and tibia in the three-dimensions was calculated and classified on preoperative CT-scans and compared with the intraoperative implant alignment. The tibial cut was performed according to the tibial preoperative anatomy. The femoral cuts were fine-tuned based on tensioned soft tissues, aiming for balanced medial and lateral gaps in flexion and extension. RESULTS A total of 115 RA-TKAs were assessed. On average, the tibial component was placed at 1.8° varus (SD 1.3), while the femur was placed at 0.8° valgus (SD 2.2) and 0.6° external rotation (SD 2.6) relative to the surgical transepicondylar axis. Moderate to strong, statistically significant relationships were described between preoperative tibial coronal alignment and tibial cut orientation (r = 0.7, p < 0.0001), preoperative femoral orientation in the coronal and axial planes and intraoperative femoral cuts alignment (r = 0.7, p < 0.0001 and r = 0.5, p < 0.0001, respectively). One case (0.9%) of slight tibial component varus subsidence was reported 45-days post-operatively, but implant revision was not necessary. CONCLUSIONS The proposed robotic-assisted functional technique for TKA alignment, with a restricted tibial component coronal alignment, based on the preoperative phenotype and femoral component positioning as dictated by the soft tissues, provided joint line respecting resections. Further studies are needed to assess long-term implant survivorship, patient satisfaction and alignment-related failures.
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Niesen AE, Garverick AL, Hull ML. Maximum Total Point Motion of Five Points Versus All Points in Assessing Tibial Baseplate Stability. J Biomech Eng 2021; 143:114502. [PMID: 34076233 DOI: 10.1115/1.4051347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Indexed: 11/08/2022]
Abstract
Maximum total point motion (MTPM), the point on a baseplate that migrates the most, has been used to assess the risk of tibial baseplate loosening using radiostereometric analysis (RSA). Two methods for determining MTPM for model-based RSA are to use either five points distributed around the perimeter of the baseplate or to use all points on the three-dimensional model. The objectives were to quantify the mean difference in MTPM using five points versus all points, compute the percent error relative to the 6-month stability limit for groups of patients, and determine the dependency of differences in MTPM on baseplate size and shape. A dataset of 10,000 migration values was generated using the mean and standard deviation of migration in six-degrees-of-freedom at 6 months from an RSA study. The dataset was used to simulate the migration of three-dimensional models (two baseplate shapes and two baseplate sizes) and calculate the difference in MTPM using five virtual points versus all points and the percent error (i.e., the difference in MTPM/stability limit) relative to the 6-month stability limit. The difference in the MTPM was about 0.02 mm, or 4% relative to the 6-month stability limit, which is not clinically important. Furthermore, results were not affected by baseplate shape or size. Researchers can decide whether to use five points or all points when computing MTPM for model-based RSA. The authors recommend using five points to maintain consistency with marker-based RSA.
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Affiliation(s)
- Abigail E Niesen
- Department of Biomedical Engineering, University of California, Davis One Shields Avenue, Davis, CA 95616
| | - Anna L Garverick
- Department of Biomedical Engineering, University of California, Davis One Shields Avenue, Davis, CA 95616
| | - Maury L Hull
- Department of Biomedical Engineering, University of California, Davis One Shields Avenue, Davis, CA 95616; Department of Mechanical Engineering, University of California, Davis, One Shields Avenue, Davis, CA 95616; Department of Orthopaedic Surgery, University of California Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA 95817
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Nedopil AJ, Zamora T, Shelton T, Howell SM, Hull M. A Best-Fit of an Anatomic Tibial Baseplate Closely Parallels the Flexion-Extension Plane and Covers a High Percentage of the Proximal Tibia. J Knee Surg 2021; 34:1486-1494. [PMID: 32403149 DOI: 10.1055/s-0040-1710367] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are no reports of in vivo internal-external (I-E) rotational alignment and coverage of the proximal tibia after performing a best-fit method of an anatomically designed and asymmetrically shaped tibial baseplate during calipered kinematically aligned (KA) total knee arthroplasty (TKA). We hypothesized that a best-fit plane sets the anterior-posterior (A-P) axis of the anatomic baseplate closely parallel to the flexion-extension (F-E) plane of the knee and covers a high percentage of the proximal tibia. A total of 145 consecutive primary TKAs were prospectively collected. The calipered KA method and verification checks set the positions and orientations of the components without ligament release in all knees without restrictions on the preoperative deformities. A best-fit method selected one of six trials of anatomic baseplates that maximized coverage and set I-E rotation parallel to and within the cortical edge of the proximal tibia. The angle between the transverse axes of the components (i.e., the deviation of the A-P axis of the anatomic baseplate from the F-E plane of the native knee) and the cross-sectional area (CSA) of the proximal tibia were measured on postoperative computerized tomographic scans. The mean deviation of the anatomic baseplate from the F-E plane was 2-degree external ± 5 degrees. The mean coverage of the proximal tibia was 87 ± 6% (CSA of baseplate from the manufacturer/CSA of proximal tibia × 100). The anatomic baseplate and best-fit method adequately set I-E rotation of the baseplate closely parallel to the F-E plane of the knee and cover a high percentage of the proximal tibia.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Tomas Zamora
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile Facultad de Medicina, Santiago, Chile
| | - Trevor Shelton
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California, Davis, Sacramento, California
| | - Maury Hull
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, California.,Department of Mechanical Engineering, University of California, Davis, California.,Department of Biomedical Engineering, University of California, Davis, California
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Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal , London, UK
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Weber P, Gollwitzer H. Kinematic alignment in total knee arthroplasty. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:525-537. [PMID: 34414467 DOI: 10.1007/s00064-021-00729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/04/2020] [Accepted: 08/29/2020] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of kinematic alignment in total knee arthroplasty is to implant the prosthesis according to the individual joint line, leg axis and ligament tension. INDICATIONS Knee osteoarthritis with failure of nonsurgical treatment according to current guidelines. CONTRAINDICATIONS Severe deformity or instability requiring a constrained knee prosthesis. Necessity of intramedullary stems. SURGICAL TECHNIQUE Medial parapatellar approach to the knee. Resection of the cruciate ligaments, the meniscus and the osteophytes. Femur-first technique with distal resection of the femur, the intramedullary guide is only used for the extension/flexion positioning of the femoral component. The positioning in varus-valgus is orientated according to the native joint line after correction of chondral wear. The distal resection should be equal to the thickness of the prosthesis considering the chondral wear (up to 2 mm) and the thickness of the saw blade (1 mm). The rotation of the femoral component is set according to the posterior condylar axis under consideration of chondral wear. The amount of resected dorsal bone should correspond to the thickness of the dorsal condyles of the prosthesis. The alignment of the tibia is parallel to the individual joint line. This enables reconstruction of the individual physiological slope, rotation and the varus-valgus axis. Extension and flexion gap are controlled. Asymmetries between the lateral and medial joint space are corrected through a varus or valgus recut of the tibia as long as the surgical planning has not been achieved. The hip-knee angle is controlled; however, the aim in kinematic alignment is to reconstruct the individual axes and ligament tensions and not a straight leg axis. Persisting asymmetries in ligament tension are adjusted by classical soft tissue balancing techniques. Differences between the extension and flexion spaces are corrected by adapting the tibial slope. Release of the ligaments is usually not necessary; sometimes a stripping of the dorsal capsule is performed. After the trial implantation, the original prosthesis is implanted. POSTOPERATIVE MANAGEMENT Functional rehabilitation with weight bearing as tolerated. RESULTS Randomized studies showed a better function in the Knee Society Score and a better range of motion with kinematically aligned prostheses compared to mechanical alignment. Available meta-analyses also showed better results for kinematically aligned knees. The first mid-term results of this new technique with a follow-up of 10 years show a survival rate of 97.5% of the prosthesis.
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Affiliation(s)
- Patrick Weber
- ECOM-Excellent Center of Medicine, Arabellastr. 17, 81925, Munich, Germany. .,Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany. .,ATOS Klinik München, Munich, Germany.
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Steer R, Tippett B, Khan RN, Collopy D, Clark G. A prospective randomised control trial comparing functional with mechanical axis alignment in total knee arthroplasty: study protocol for an investigator initiated trial. Trials 2021; 22:523. [PMID: 34372888 PMCID: PMC8351154 DOI: 10.1186/s13063-021-05433-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background A drive to improve functional outcomes for patients undergoing total knee arthroplasty (TKA) has led to alternative alignment being used. Functional alignment (FA) uses intraoperative soft tissue tension to determine the optimal position of the prosthesis within the patient’s soft tissue envelope. Angular limits for bone resections are followed to prevent long-term prosthesis failure. This study will use the aid of robotic assistance to plan and implement the final prosthesis position. This method has yet to be compared to the traditional mechanically aligned (MA) knee in a randomised trial. Methods A blinded randomised control trial with 100 patients will be undertaken via Perth Hip and Knee Clinic. Fifty patients will undergo a MA TKA and fifty will undergo a FA TKA. Both alignment techniques will be balanced via computer-assisted navigation to assess prosthetic gaps, being achieved via the initial bony resection and further soft tissue releases as required to achieve satisfactory balance. The primary outcome will be the Forgotten Joint Score (FJS) 2 years after surgery, with secondary outcomes being other patient-reported outcome measures, clinical functional assessment, radiographic position and complications. Other data that will be collected will be patient demography (sex, age, level of activity) and medical information (grade of knee injury, any other relevant medical information). The linear statistical model will be fitted to the response (FJS), including all the other variables as covariates. Discussion Many surgeons are utilising alternative alignment techniques with a goal of achieving better functional outcomes for their patients. Currently, MA TKA remains the gold standard with good outcomes and excellent longevity. There is no published RCTs comparing FA to MA yet and only two registered studies are planned or currently in progress. This study utilises a FA technique which differs from the two studies. This study will help determine if FA TKA has superior functional results for patients. Trial registration This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) http://www.anzctr.org.au: U1111-1257-2291, registered 25th Jan 2021. It is also listed on www.clinicaltrials.gov: NCT04748510. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05433-z.
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Affiliation(s)
- Richard Steer
- Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, Australia.,University of Queensland, St Lucia, Queensland, Australia.,Perth Hip and Knee Clinic, 1 Wexford St, Subiaco, Western Australia, Australia
| | - Beth Tippett
- Perth Hip and Knee Clinic, 1 Wexford St, Subiaco, Western Australia, Australia.,St John of God Hospital, Subiaco, Western Australia, Australia
| | - R Nazim Khan
- University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
| | - Dermot Collopy
- Perth Hip and Knee Clinic, 1 Wexford St, Subiaco, Western Australia, Australia.,St John of God Hospital, Subiaco, Western Australia, Australia
| | - Gavin Clark
- Perth Hip and Knee Clinic, 1 Wexford St, Subiaco, Western Australia, Australia. .,St John of God Hospital, Subiaco, Western Australia, Australia. .,University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia.
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Vendittoli PA, Martinov S, Blakeney WG. Restricted Kinematic Alignment, the Fundamentals, and Clinical Applications. Front Surg 2021; 8:697020. [PMID: 34355018 PMCID: PMC8329359 DOI: 10.3389/fsurg.2021.697020] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: After a better understanding of normal knee anatomy and physiology, the Kinematic Alignment (KA) technique was introduced to improve clinical outcomes of total knee arthroplasty (TKA). The goal of the KA technique is to restore the pre-arthritic constitutional lower limb alignment of the patient. There is, however, a large range of normal knee anatomy. Unusual anatomies may be biomechanically inferior and affect TKA biomechanics and wear patterns. In 2011, the leading author proposed the restricted kinematic alignment (rKA) protocol, setting boundaries to KA for patients with an outlier or atypical knee anatomy. Material and Equipment: rKA aims to reproduce the constitutional knee anatomy of the patient within a safe range. Its fundamentals are based on sound comprehension of lower limb anatomy variation. There are five principles describing rKA: (1) Combined lower limb coronal orientation should be ± 3° of neutral; (2) Joint line orientation coronal alignment should be within ± 5° of neutral; (3) Natural knee's soft tissues tension/ laxities should be preserved/restored; (4) Femoral anatomy preservation is prioritized; (5) The unloaded/most intact knee compartment should be resurfaced and used as the pivot point when anatomical adjustment is required. An algorithm was developed to facilitate the decision-making. Methods: Since ~50% of patients will require anatomic modification to fit within rKA boundaries, rKA is ideally performed with patient-specific instrumentation (PSI), intra-operative computer navigation or robotic assistance. rKA surgical technique is presented in a stepwise manner, following the five principles in the algorithm. Results: rKA produced excellent mid-term clinical results in cemented or cementless TKA. Gait analysis showed that rKA TKA patients had gait patterns that were very close to a non-operated control group, and these kinematics differences translated into significantly better postoperative patient-reported scores than mechanical alignment (MA) TKA cases. Discussion: Aiming to improve the results of MA TKA, rKA protocol offers a satisfactory compromise that recreates patients' anatomy in most cases, omitting the need for extensive corrections and soft tissue releases that are often required with MA. Moreover, it precludes the reproduction of extreme anatomies seen with KA.
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Affiliation(s)
- Pascal-André Vendittoli
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hôpital Maisonneuve Rosemont, Montréal, QC, Canada
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
- Clinique Orthopédique Duval, Laval, QC, Canada
- Personalized Arthroplasty Society, Montréal, QC, Canada
| | - Sagi Martinov
- Department of Surgery, CIUSSS-de-L'Est-de-L'Ile-de-Montréal, Hôpital Maisonneuve Rosemont, Montréal, QC, Canada
| | - William G. Blakeney
- Department of Orthopedic Surgery, Royal Perth Hospital, Perth, WA, Australia
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Laende EK, Richardson CG, Meldrum AR, Dunbar MJ. Tibial Component Migration After Total Knee Arthroplasty With High-Viscosity Bone Cement. J Arthroplasty 2021; 36:2000-2005. [PMID: 33632580 DOI: 10.1016/j.arth.2021.01.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/11/2021] [Accepted: 01/29/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High-viscosity (HV) bone cements have been formulated to offer potentially advantageous handling characteristics. However, alteration in the handling characteristics could influence implant fixation and survival. The primary objective of this study was to use radiostereometric analysis after total knee arthroplasty to assess the migration of the Triathlon tibial component fixed with HV cement (Simplex HV). METHODS Twenty-three patients were followed for two years with radiostereometric analysis examinations at 6 visits. Migration was compared with published thresholds and with a control group from a previously published study from the same center using the same implants fixed with a medium viscosity cement. Inducible displacement was assessed, and Oxford 12 Knee Scores and satisfaction were recorded. RESULTS Mean maximum total point motion migration reaching 0.40 mm (SD 0.16) at one year, and 0.41mm (SD 0.17) at two years, demonstrating a pattern of stable fixation, below published thresholds of acceptable migration, and not significantly different from the control group. One implant had continuous migration between 1 and 2 years but was clinically asymptomatic. Mean maximum total point motion inducible displacement measured at least one year postoperatively was 0.3 mm (SD 0.12). Mean Oxford 12 Knee Scores improved from 19 (SD 7) preoperatively to 42 (SD 8) 2 years postoperatively. CONCLUSIONS The use of HV cement demonstrated an acceptable pattern of migration at 2 years, indicating low risk for aseptic loosening.
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Affiliation(s)
- Elise K Laende
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; School of Biomedical Engineering, Faculty of Engineering & Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - C Glen Richardson
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Alexander R Meldrum
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Michael J Dunbar
- Division of Orthopaedics, Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; School of Biomedical Engineering, Faculty of Engineering & Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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50
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Deng T, Liu T, Lei Q, Cai L, Chen S. Patient-specific instrumentation combined with a new tool for gap balancing is useful in total knee replacement: a 3-year follow-up of a retrospective study. J Orthop Surg Res 2021; 16:309. [PMID: 33980282 PMCID: PMC8114523 DOI: 10.1186/s13018-021-02467-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
Objective The purpose of this study was to determine whether the gap-balancing technique with patient-specific instrumentation (PSI) and a new balancing device in total knee arthroplasty (TKA) can improve knee function to a greater extent than can the measured resection technique. Materials and methods Data from 150 patients who underwent TKA from August 2014 to June 2016 were studied retrospectively. The gap-balancing technique assisted by PSI and the new balancing device was used in 80 patients (82 knees), and the measured resection technique was used in 70 patients (70 knees). The surgical, imaging, and knee function data were compared. Results The gap-balancing technique assisted by PSI and the new balancing device was found to be feasible in all operated knees and reliable. In total, 150 patients (152 knees) of ages ranging from 52 to 78 years (mean 67 years) underwent TKA during the study period. The follow-up period ranged from 35 to 52 months (mean 45 months). Only one patient, who was included in the gap-balancing group, underwent a revision surgery at 2 years postoperatively due to infection. There were no differences in the incidence of anterior knee pain between the two groups. The mean flexion angle, KSS scores, and VAS scores did not significantly differ between the measured resection group and gap-balancing group at 12 weeks or 36 weeks postoperatively. The average joint line displacement was 1.3 ± 1.1 mm (range 0–3) proximally in the GB (gap-balancing) group and 1.2 ± 1.4 mm in the MR (measured-resection) group. No outliers >5 mm in either group were recorded. The mean leg axis deviation from the neutral mechanical axis was 1.8°±1.5° varus (range 0°–3°varus) versus the neutral mechanical axis in the GB group and 1.4°±1.2°(range 0°–3°)in the MR group. No outliers with >3° deviation in either group were recorded. Conclusions The gap-balancing technique performed with the new balancing device and PSI can yield accurate femoral component alignment as well as outcomes similar to those of measured resection at 3 years. The new balancing device can be taken into consideration by surgeons who prefer performing the gap-balancing technique with PSI.
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Affiliation(s)
- Ting Deng
- Department of Orthopaedics, The Third Hospital of Changsha, Changsha, China
| | - Tangyou Liu
- Department of Orthopaedics, The Third Hospital of Changsha, Changsha, China
| | - Qing Lei
- Department of Orthopaedics, The Third Hospital of Changsha, Changsha, China.
| | - Lihong Cai
- Department of Radiology, The Third Hospital of Changsha, Changsha, China
| | - Song Chen
- Department of Orthopaedics, The Third Hospital of Changsha, Changsha, China
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