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Erard J, Olivier F, Kafelov M, Servien E, Lustig S, Batailler C. Enhancing soft tissue balance: Evaluating robotic-assisted functional positioning in varus knees across flexion and extension with quantitative sensor-guided technology. Knee Surg Sports Traumatol Arthrosc 2024; 32:2318-2327. [PMID: 38738818 DOI: 10.1002/ksa.12255] [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: 03/02/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Functional implant positioning (FIP) for total knee arthroplasty (TKA) is an evolution of kinematic alignment based on preoperative CT scan and robotic-assisted technology. This study aimed to assess the ligament balancing of image-based robotic-assisted TKA in extension, mid-flexion and flexion with an FIP using intraoperative sensor-guided technology. The hypothesis was that image-based robotic-assisted TKA performed by FIP would achieve ligament balancing all along the arc of knee flexion. METHODS This prospective monocentric study included 47 consecutive patients with varus knees undergoing image-based robotic-assisted TKA performed with FIP. After robotic-assisted bone cuts, trial components were inserted, and soft tissue balance was assessed using sensor-guided technology at 10°, 45° and 90° of knee flexion. A mediolateral balanced knee was defined by an intercompartmental pressure difference (ICPD) ≤ 15 lbf and medial and lateral compartment pressure ≤60 lbf. The mean age was 71.6 years old ±6.7, the mean BMI was 29.0 kg/m2 ± 4.9 and the mean preoperative HKA was 174° ± 5 [159; 183]. RESULTS The mean postoperative knee alignment was 177.0° ± 2.2° [172; 181]. There were 93.6% of balanced knees (n = 44) at 10 and 90° of knee flexion versus 76.6% (n = 36) at 45° of knee flexion with a significant difference (p = 0.014). Median ICPD at 10, 45 and 90° of knee flexion were, respectively, 7.0 (interquartile range [IQR]: 9), 11.0 (IQR: 9.5) and 8.0 (IQR: 9.0). Pairwise analyses revealed differences for ICPD at 45° versus ICPD at 10° (p = 0.003) and ICPD at 90° versus ICPD at 45° (p = 0.007). CONCLUSION FIP with an image-based robotic-assisted system allowed the restoration of a well-balanced knee at 10° and 90° of flexion in varus knees. Nevertheless, some discrepancies occurred in midflexion, and more work is needed to understand ligament behaviour all along the arc of knee flexion. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Julien Erard
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | | | - Moussa Kafelov
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- University Multiprofile Hospital for Active Treatment and Emergency Medicine 'N. I. Pirogov', Sofia, Bulgaria
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- LIBM - EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, Lyon, France
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, Lyon, France
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Eachempati KK, Parameswaran A, Ponnala VK, Sunil A, Sheth NP. 'Extended' restricted kinematic alignment results in decreased residual medial gap tightness among osteoarthritic varus knees during robotic-assisted total knee arthroplasty. Bone Jt Open 2024; 5:628-636. [PMID: 39089685 PMCID: PMC11299516 DOI: 10.1302/2633-1462.58.bjo-2024-0054.r1] [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] [Indexed: 08/04/2024] Open
Abstract
Aims The aims of this study were: 1) to describe extended restricted kinematic alignment (E-rKA), a novel alignment strategy during robotic-assisted total knee arthroplasty (RA-TKA); 2) to compare residual medial compartment tightness following virtual surgical planning during RA-TKA using mechanical alignment (MA) and E-rKA, in the same set of osteoarthritic varus knees; 3) to assess the requirement of soft-tissue releases during RA-TKA using E-rKA; and 4) to compare the accuracy of surgical plan execution between knees managed with adjustments in component positioning alone, and those which require additional soft-tissue releases. Methods Patients who underwent RA-TKA between January and December 2022 for primary varus osteoarthritis were included. Safe boundaries for E-rKA were defined. Residual medial compartment tightness was compared following virtual surgical planning using E-rKA and MA, in the same set of knees. Soft-tissue releases were documented. Errors in postoperative alignment in relation to planned alignment were compared between patients who did (group A) and did not (group B) require soft-tissue releases. Results The use of E-rKA helped restore all knees within the predefined boundaries, with appropriate soft-tissue balancing. E-rKA compared with MA resulted in reduced residual medial tightness following surgical planning, in full extension (2.71 mm (SD 1.66) vs 5.16 mm (SD 3.10), respectively; p < 0.001), and 90° of flexion (2.52 mm (SD 1.63) vs 6.27 mm (SD 3.11), respectively; p < 0.001). Among the study population, 156 patients (78%) were managed with minor adjustments in component positioning alone, while 44 (22%) required additional soft-tissue releases. The mean errors in postoperative alignment were 0.53 mm and 0.26 mm among patients in group A and group B, respectively (p = 0.328). Conclusion E-rKA is an effective and reproducible alignment strategy during RA-TKA, permitting a large proportion of patients to be managed without soft-tissue releases. The execution of minor alterations in component positioning within predefined multiplanar boundaries is a better starting point for gap management than soft-tissue releases.
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Affiliation(s)
| | | | - Vinay K. Ponnala
- Department of Orthopaedics, Medicover Hospitals, Hyderabad, India
| | - Apsingi Sunil
- Department of Orthopaedics, Medicover Hospitals, Hyderabad, India
| | - Neil P. Sheth
- Penn Orthopaedics at Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sakakibara Y, Yasutani Y, Oyama A, Teramoto A. A Novel Technique for Restricted Kinematic Alignment Total Knee Arthroplasty Without Computer-Assisted Devices. Cureus 2024; 16:e67233. [PMID: 39301339 PMCID: PMC11412279 DOI: 10.7759/cureus.67233] [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] [Accepted: 08/18/2024] [Indexed: 09/22/2024] Open
Abstract
Kinematic-alignment total knee arthroplasty (KA-TKA) aims to restore natural limb alignment and joint line obliquity, thereby improving patient satisfaction. Restricted KA-TKA (rKA-TKA) addresses abnormal knee anatomies and seeks to replicate natural anatomical structures within safe alignment boundaries. This study introduces a novel device and technique that enables rKA-TKA without computer-assisted surgery (CAS). The new device allows for precise cartilage thickness measurement and adjustment of osteotomy angles, facilitating accurate alignment. A heel-lift technique for tibial osteotomy is presented, offering a reproducible method for determining the osteotomy volume and angle. These innovations make KA and rKA-TKA feasible in any surgical setting, avoiding the high costs and limited availability associated with CAS.
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Affiliation(s)
- Yuzuru Sakakibara
- Orthopedic Surgery, Muroran City General Hospital, Muroran, JPN
- Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, JPN
| | - Yusuke Yasutani
- Orthopedic Surgery, Muroran City General Hospital, Muroran, JPN
| | - Akimitsu Oyama
- Orthopedic Surgery, Muroran City General Hospital, Muroran, JPN
| | - Atsushi Teramoto
- Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, JPN
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Franceschetti E, Campi S, Giurazza G, Tanzilli A, Gregori P, Laudisio A, Hirschmann MT, Samuelsson K, Papalia R. Mechanically aligned total knee arthroplasty does not yield uniform outcomes across all coronal plane alignment of the knee (CPAK) phenotypes. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38984905 DOI: 10.1002/ksa.12349] [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: 05/20/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE Patient dissatisfaction rates following total knee arthroplasty (TKA) reported in the literature reach 20%. The optimal coronal alignment is still under debate. The aim of this retrospective study was to compare clinical outcomes in different coronal plane alignment of the knee (CPAK) phenotypes undergoing mechanically aligned (MA) TKA. The hypothesis was that knees with preoperative varus arithmetic hip-knee-ankle angle (aHKA) would achieve inferior clinical outcomes after surgery compared to other aHKA categories. Additionally, another objective was to assess CPAK phenotypes distribution in the study population. METHODS A retrospective selection was made of 180 patients who underwent MA TKA from April 2021 to December 2022, with a 1-year follow-up. Coronal knee alignment was classified according to the CPAK classification. Clinical outcome evaluations were measured using the Knee Society Score (KSS), Oxford Knee Score (OKS), Short Form Survey 12 and Forgotten Joint Score (FJS). Differences in clinical outcomes were considered statistically significant with a p value <0 .05. RESULTS Patients with varus aHKA achieved significantly inferior outcomes at final follow-up compared to other aHKA categories in KSS pt. 1 (79.7 ± 17.2 vs. 85.6 ± 14.7; p = 0.028), OKS (39.2 ± 9.2 vs. 42.2 ± 7.2; p = 0.019) and FJS (75.4 ± 31.0 vs. 87.4 ± 22.9; p =0 .003). The most common aHKA category was the varus category (39%). The most common CPAK phenotypes were apex distal Types I (23.9%), II (22.8%) and III (13.3%). CONCLUSION MA TKA does not yield uniform outcomes across all CPAK phenotypes. Varus aHKA category shows significantly inferior results at final follow-up. The most prevalent CPAK categories are varus aHKA and apex distal JLO, with phenotypes I, II and III being the most common. However, their gender distribution varies significantly. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Edoardo Franceschetti
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Stefano Campi
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Giancarlo Giurazza
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Andrea Tanzilli
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Pietro Gregori
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Alice Laudisio
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
- University of Basel, Basel, Switzerland
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Rocco Papalia
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
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Hara J, Maeyama A, Ishimatsu T, Matsunaga T, Nakayama S, Yamamoto T. A Morphological Study of Distal Femoral Varus Deformity. Cureus 2024; 16:e64822. [PMID: 39156422 PMCID: PMC11330162 DOI: 10.7759/cureus.64822] [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] [Accepted: 07/16/2024] [Indexed: 08/20/2024] Open
Abstract
Background In the management of medial compartment knee osteoarthritis via around-knee osteotomy (AKO) and total knee arthroplasty (TKA), evaluating the lateral distal femoral angle (LDFA) is crucial. This angle reflects the presence of distal femoral varus deformity. This study aims to explore the relationship between LDFA and lower extremity bone morphology and identify factors contributing to a high LDFA. Methods A retrospective analysis was conducted on 59 patients who underwent AKO or TKA at our hospital. Alignment of the lower extremity was assessed using X-rays, and bone morphology was investigated through computed tomography (CT) employing the ZedKnee® system (LEXI, Tokyo, Japan). Each measured parameter was analyzed. Results Our findings indicate a significant correlation between LDFA and several parameters, including age, femoral tibial angle (FTA), hip knee ankle angle (HKA), percentage of mechanical axis (% MA), femoral bowing angle, femoral tibial joint torsion, and the height of lateral and medial femoral condyles. A multiple-regression analysis determined that the most significant influences on LDFA were the heights of the femoral condyle, age, and HKA. Conclusion LDFA is significantly affected by the heights of the medial and lateral femoral condyles and tends to increase with age, possibly as a result of attrition of the medial femoral condyle. Given its significance, LDFA should be carefully considered as a preoperative indicator in AKO and TKA to guide surgical caution when LDFA is elevated.
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Affiliation(s)
- Junya Hara
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Akira Maeyama
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Tetsuro Ishimatsu
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Taiki Matsunaga
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Shizuhide Nakayama
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, JPN
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Jiang X, Xie K, Chen H, Zhang K, Hu Y, Kan T, Sun L, Ai S, Zhu X, Zhang L, Yan M, Wang L. A Radiographic Analysis of Coronal Morphological Parameters of Lower Limbs in Chinese Non-knee Osteoarthritis Populations. Orthop Surg 2024; 16:452-461. [PMID: 38088238 PMCID: PMC10834221 DOI: 10.1111/os.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Analyzing the lower limb coronal morphological parameters in populations without knee osteoarthritis (KOA) holds significant value in predicting, diagnosing, and formulating surgical strategies for KOA. This study aimed to comprehensively analyze the variability in these parameters among Chinese non-KOA populations, employing a substantial sample size. METHODS A cross-sectional retrospective analysis was performed on the Chinese non-KOA populations (n = 407; 49.9% females). The study employed an in-house developed artificial intelligence software to meticulously assess the coronal morphological parameters of all 814 lower limbs. The parameters evaluated included the hip-knee-ankle angle (HKAA), weight-bearing line ratio (WBLR), joint line convergence angle (JLCA), mechanical lateral-proximal-femoral angle (mLPFA), mechanical lateral-distal-femoral angle (mLDFA), mechanical medial-proximal-tibial angle (mMPTA), and mechanical lateral-distal-tibial angle (mLDTA). Differences in these parameters were compared between left and right limbs, different genders, and different age groups (with 50 years as the cut-off point). RESULTS HKAA and JLCA exhibited left-right differences (left vs. right: 178.2° ± 3.0° vs. 178.6° ± 2.9° for HKAA, p = 0.001; and 1.8° ± 1.5° vs. 1.4° ± 1.6° for JLCA, p < 0.001); except for the mLPFA, all other parameters show gender-related differences (male vs. female: 177.9° ± 2.8° vs. 179.0° ± 3.0° for HKAA, p < 0.001; 1.5° ± 1.5° vs. 1.8° ± 1.7° for JLCA, p = 0.003; 87.1° ± 2.1° vs. 88.1° ± 2.1° for mMPTA, p < 0.001; 90.2° ± 4.0° vs. 91.1° ± 3.2° for mLDTA, p < 0.001; 38.7% ± 12.9% vs. 43.6% ± 14.1% for WBLR, p < 0.001; and 87.7° ± 2.3° vs. 87.4° ± 2.7° for mLDTA, p = 0.045); mLPFA increase with age (younger vs. older: 90.1° ± 7.2° vs. 93.4° ± 4.9° for mLPFA, p < 0.001), while no statistical difference exists for other parameters. CONCLUSIONS There were differences in lower limb coronal morphological parameters among Chinese non-KOA populations between left and right sides, different genders, and age.
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Affiliation(s)
- Xu Jiang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Xie
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Hongyu Chen
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Zhang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Yuqi Hu
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Tianyou Kan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Lin Sun
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Songtao Ai
- Department of RadiologyShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Xianping Zhu
- Department of Orthopaedic SurgeryTaizhou Central HospitalTaizhouChina
| | - Lichi Zhang
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Mengning Yan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Liao Wang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
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Davis KR, Soti V. Effectiveness of Kinematic Alignment-Total Knee Arthroplasty in Treating Preoperative Varus and Valgus Deformities in Patients With Knee Osteoarthritis. Cureus 2024; 16:e53230. [PMID: 38293678 PMCID: PMC10826793 DOI: 10.7759/cureus.53230] [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] [Accepted: 01/30/2024] [Indexed: 02/01/2024] Open
Abstract
Knee osteoarthritis (OA) is surgically treated with total knee arthroplasty (TKA). Traditionally, TKA has been performed using a mechanical alignment (MA) philosophy. However, due to significant patient dissatisfaction with surgical outcomes, an alternate alignment approach, kinematic alignment (KA), has gained popularity. KA-TKAs have improved functional patient outcomes by restoring the patient's native joint line orientation and minimizing soft tissue releases compared to neutral alignment in MA-TKAs. This review explores the postoperative effectiveness of utilizing KA-TKA to treat knee OA in patients with preoperative varus and valgus deformities. A comprehensive literature search was conducted on PubMed and Biomed Central databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search focused on studies analyzing the postoperative TKA outcomes in knee OA patients with preoperative varus or valgus deformities whose surgeries followed a KA philosophy and those comparing KA-TKA with MA-TKA. The available clinical evidence indicates that KA-TKA can be a viable treatment option for individuals with knee OA. The alignment of phenotypes has little clinical significance concerning functional outcomes and implant survival rates following KA-TKA. Furthermore, surgery outcomes in patients with preoperative deformities who underwent KA-TKA were similar to those who underwent MA-TKA. KA-TKA produced significantly better functional outcomes than MA-TKA in certain aspects. However, studies with larger sample sizes and more extended follow-up periods that directly compare KA-TKA with MA-TKA in treating knee OA patients are needed to fully demonstrate the efficacy of each technique. Furthermore, further research into the effects of KA-TKA on implant survival rates will provide a better understanding of the benefits of this technique and ultimately lead to improved patient outcomes.
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Affiliation(s)
- Kyle R Davis
- Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Elmira, USA
| | - Varun Soti
- Pharmacology and Therapeutics, Lake Erie College of Osteopathic Medicine, Elmira, USA
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Colyn W, Cleymans A, Bruckers L, Truijen J, Smeets K, Bellemans J. The pre-diseased coronal alignment can be predicted from conventional radiographs taken of the varus arthritic knee. Arch Orthop Trauma Surg 2023; 143:4425-4436. [PMID: 36494462 DOI: 10.1007/s00402-022-04709-6] [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: 10/09/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The concept of restoring the constitutional, pre-diseased alignment has gained lots of interest among knee surgeons. Previous attempts to use the contralateral limb to bridge the gap between the arthritic and the constitutional alignment were unsuccessful. We investigated the usability of a mathematical formula to predict the constitutional (pre-diseased) coronal alignment once arthritis has occurred. It is our hypothesis that by using the KL grade, CPAK classification and four radiographic measurements of the arthritic knee, the pre-diseased coronal alignment could be predicted. MATERIAL AND METHODS Hundred arthritic patients with consecutive X-rays were used to determine a mathematical formula. Five alignment parameters were determined on full-length X-rays: HKA angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA) and the tibial joint line angle (TJLA). A refinement of the algorithm was implemented based on a reference cohort, consisted of 250 young adults aged between 20 and 27 years. Moreover, all knees were subdivided based on their CPAK-phenotype and the Kellgren-Lawrence scale (KL scale). An independent arthritic cohort of 289 patients scheduled for primary total knee arthroplasty was included to verify the accuracy of the predicted HKAs (HKAPRED). RESULTS In CPAK type 1, the HKAPRED was 3.86° varus (STD 1.39) and the HKAYHA was 4.0° varus. In CPAK type 2, the HKAPRED was 1.68° varus (STD 1.95) compared to a HKAYHA of 1.34° (STD 0.81). The average constitutional HKA is not different in both CPAK 1 (p = 0.61) and CPAK 2 (p = 0.25), and the difference in the mean is estimated to be equal to - 0.14 (95CI - 0.68 to 0.40) in CPAK 1 and 0.35 (95CI - 0.06 to 0.75) in CPAK 2. CONCLUSION Using the KL grade, CPAK classification and four radiographic measurements of the arthritic knee, the pre-diseased coronal alignment can be predicted in 80% of the varus knees with an accuracy of ≤ 0.5°. The predicted HKA (HKAPRED) can be very useful in the current and future clinical practice.
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Affiliation(s)
- William Colyn
- Department of Orthopedic Surgery, AZ Turnhout, Steenweg Op Merksplas 44, 2300, Turnhout, Belgium.
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
- Limburg Clinical Research Center, ZOL Genk, Genk, Belgium.
| | - A Cleymans
- Department of Orthopedic Surgery, AZ Turnhout, Steenweg Op Merksplas 44, 2300, Turnhout, Belgium
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - L Bruckers
- I-BioStat, University Hasselt, Hasselt, Belgium
| | - J Truijen
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium
| | - K Smeets
- Department of Orthopedic Surgery, AZ Vesalius, Tongeren, Belgium
- Faculty of Rehabilitation Science, Hasselt University, Diepenbeek, Belgium
- GRIT Belgian Sports Clinic, Leuven, Belgium
| | - J Bellemans
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium
- GRIT Belgian Sports Clinic, Leuven, Belgium
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What are the perceived benefits and barriers to the use of robot-assisted total knee arthroplasty? A survey of members of the European Knee Society. INTERNATIONAL ORTHOPAEDICS 2023; 47:405-412. [PMID: 36355081 DOI: 10.1007/s00264-022-05623-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Members of the European Knee Society (EKS) recently took part in an online questionnaire on robot-assisted TKA. The purpose of this study was to report and analyse the questionnaire results on the demographics of users versus non-users, the drivers for users of the technology, and the barriers or limitations that hinder the uptake of robot-assisted TKA. METHODS The questionnaire was composed of 16 questions covering surgeon demographics and drivers for or barriers to the use of robotics. Responses on four- or five-point Likert scales were trichotomised depending on the type of question ("not important" - "moderately important" - "important/very important" or "fully disagree/disagree" - "neutral" - "agree/fully agree"). Consensus on a statement was defined as at least 75% agreement. RESULTS There was a 67% response rate. Forty-five surgeons performed conventional TKA, of which 78% aimed for systematic alignment, while 22 performed robot-assisted TKA, of which 82% aimed for individualised alignment, and 16 performed technology-assisted TKA, of which 56% aimed for systematic alignment. Respondents agreed that robotics significantly impact accuracy of bone cuts (51/62, 82%), intra-operative feedback on ligament balancing (56/62, 90%) as well as bone cut orientation and implant positioning (57/ 62, 92%), and assistance to customise alignment (56/62, 90%). Respondents agreed that associated costs (14/18, 78%) are an important aspect for not using or to stop using robotics. CONCLUSION The majority of respondents still perform conventional TKA (54%), while only a small portion perform robot-assisted TKA (27%) or other technology-assisted TKA (19%). Most robot users aim for individualised lower limb alignment, whereas most other surgeons aimed for systematic lower limb alignment. There is consensus that robotic assistance has a positive impact on accuracy of bone cuts and alignment, but no consensus on its impact on other peri- or post-operative outcomes. Finally, the associated cost of robot-assisted TKA remains the main barrier to its uptake. LEVEL OF EVIDENCE V.
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MacDessi SJ, Oussedik S, Abdel MP, Victor J, Pagnano MW, Haddad FS. The language of knee alignment : updated definitions and considerations for reporting outcomes in total knee arthroplasty. Bone Joint J 2023; 105-B:102-108. [PMID: 36722056 DOI: 10.1302/0301-620x.105b2.bjj-2022-1345] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Orthopaedic surgeons are currently faced with an overwhelming number of choices surrounding total knee arthroplasty (TKA), not only with the latest technologies and prostheses, but also fundamental decisions on alignment philosophies. From 'mechanical' to 'adjusted mechanical' to 'restricted kinematic' to 'unrestricted kinematic' - and how constitutional alignment relates to these - there is potential for ambiguity when thinking about and discussing such concepts. This annotation summarizes the various alignment strategies currently employed in TKA. It provides a clear framework and consistent language that will assist surgeons to compare confidently and contrast the concepts, while also discussing the latest opinions about alignment in TKA. Finally, it provides suggestions for applying consistent nomenclature to future research, especially as we explore the implications of 3D alignment patterns on patient outcomes.Cite this article: Bone Joint J 2023;105-B(2):102-108.
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Affiliation(s)
- Samuel J MacDessi
- Sydney Knee Specialists, Sydney, Australia.,The University of New South Wales, Sydney, Australia
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan Victor
- Department of Orthopaedics, University Hospital of Ghent, Ghent, Belgium
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fares S Haddad
- University College London Hospitals, London, UK.,The Bone & Joint Journal, London, UK
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11
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Shatrov J, Coulin B, Batailler C, Servien E, Walter B, Lustig S. Alignment philosophy influences trochlea recreation in total knee arthroplasty: a comparative study using image-based robotic technology. INTERNATIONAL ORTHOPAEDICS 2023; 47:329-341. [PMID: 36112197 PMCID: PMC9877070 DOI: 10.1007/s00264-022-05570-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/28/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE The ability of kinematic alignment (KA) to consistently restore trochlea anatomy in total knee arthroplasty (TKA) is unknown despite recreation of constitutional anatomy being its rationale for use. The purpose of this study was to assess if alignment choice in TKA effects the ability to restore the native trochlea groove. METHODS One hundred and twenty-two consecutive patients undergoing robotic-assisted TKA using the MAKO image-based robotic platform had simulated femoral components placed according to kinematic, mechanical and functional alignment principals. Implant position and trochlea restoration between groups were compared. Restoration was assessed by shift (medial-lateral) and depth relative to the native groove from three consistent points; full extension (0°), mid-flexion (30°-40°) and deep flexion (70°-80°). RESULTS Three hundred and sixty-six alignment options were analysed. Femoral alignment was significantly different between groups. Of KA, 13.1% compared to 3.3% of FA plans were outside safe coronal boundaries. The trochlear groove was translated the most by MA compared to KA and FA (full extension, MA 7.84 ± 1.99 mm lateral to the native groove, KA 6.40 ± 2.43 mm and FA 6.88 ± 1.74 mm, p ≤ 0.001). In full extension, FA most closely restored the trochlear groove depth in all three positions of flexion. CONCLUSION Alignment philosophy led to significant differences in trochlea groove recreation. A kinematically placed femoral component led to positioning considered unsafe in over 13% of cases. A functionally placed femoral component most closely restored trochlea depth in all three positions of flexion.
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Affiliation(s)
- Jobe Shatrov
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- Sydney Orthopaedic Research Institute at Landmark Orthopaedics, St. Leonards, Sydney, Australia
| | - Benoit Coulin
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Bill Walter
- University of Sydney, St Leonards, Sydney, Australia
- Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Sebastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
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12
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Kim R, Wakelin EA, Plaskos C, Gupta S, Putman S. Variation in knee balance as a function of hip-knee-ankle angle and joint line obliquity in robotic assisted total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2023; 47:479-484. [PMID: 36416899 DOI: 10.1007/s00264-022-05636-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To describe the mediolateral (ML) gap balance in pre-resection arthritic knees undergoing robot-assisted (RA) total knee arthroplasty (TKA) within the nine phenotypes of the Coronal Plane Alignment of the Knee (CPAK) classification. METHODS A total of 1124 RA TKA cases were retrospectively reviewed. ML balance was calculated using a digital ligament tensioning device following tibial resection and prior to any femoral resection throughout flexion (10°, 40°, and 90°). Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were landmarked intra-operatively and adjusted for wear based on hip-knee-ankle angle (HKA). Knees were then subdivided into CPAK categories based on the arithmetic HKA (aHKA) and joint line obliquity (JLO). Differences in balance between CPAK phenotypes were compared. RESULTS For aHKA, a greater medial gap was observed in varus compared to neutral or valgus knees at 10° (5.2 ± 3.0 mm vs 3.3 ± 3.2 mm vs - 0.4 ± 5.0 mm respectively; p < 0.0001). A similar trend was observed for JLO in distal apex compared to neutral and proximal apex knees at 10° (3.4 ± 3.6 vs 1.1 ± 5.0 vs - 2.4 ± 6.3 respectively; p < 0.0001). The greatest ML balance differences were found when combining JLO and aHKA at 10° (type I vs type VI: ∆6.6 mm; p < 0.0001). CONCLUSION There is a high degree of variability in arthritic ML balance within and between each CPAK phenotype. A single alignment philosophy based on bony landmarks alone may not be sufficient to balance all knees. Utilisation of robotics and digital ligament tensioning devices serves as important adjuncts to characterize the patient-specific soft tissue profile.
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Affiliation(s)
- Raymond Kim
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | | | - Sanjeev Gupta
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sophie Putman
- Département Universitaire de Chirurgie Orthopédique Et de Traumatologie, Hôpital Salengro, CHRU de Lille, Rue Emile-Laine, 59037, Lille, France.
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13
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Wen L, Wang Z, Ma D, Zhao X. An early clinical comparative study on total knee arthroplasty with kinematic alignment using specific instruments versus mechanical alignment in varus knees. Front Surg 2023; 9:1097302. [PMID: 36743893 PMCID: PMC9889970 DOI: 10.3389/fsurg.2022.1097302] [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: 11/13/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023] Open
Abstract
Background The kinematic alignment technique, as one of the alignment options for total knee arthroplasty, has attracted increasing attention from orthopedic surgeons and has been increasingly performed in the most populous countries in the world. The purpose of this study is to explore and compare the early clinical outcomes of total knee arthroplasty with KA using specific instruments vs. mechanical alignment in our nation. Methods A retrospective analysis was performed on patients who underwent unilateral total knee arthroplasty for knee osteoarthritis with varus deformity. Depending on the alignment method, patients were divided into a kinematically aligned total knee arthroplasty (KA-TKA) group and a mechanically aligned total knee arthroplasty (MA-TKA) group. The hip-knee-ankle (HKA) angle before and after surgery, the knee joint clinical score (KS-C), the knee joint functional score (KS-F) and the forgotten joint score (FJS) at 3 months and 2 years after surgery were recorded and statistically analyzed. Results A total of 126 patients were enrolled, including 65 in the KA-TKA group and 61 in the MA-TKA group. The mean follow-up period was 30.8 months. The postoperative HKA angle was not significantly different at the 2-year follow-up between the two groups (P > 0.05). The KS-C, KS-F and FJS scores in the KA-TKA group were higher than those in the MA-TKA group at 3 months after surgery, and the difference was statistically significant (P < 0.05). At the 2-year follow-up, the KS-C, KS-F and FJS scores in the KA-TKA group were higher than those in the MA-TKA group, and the difference in the KS-C and FJS scores was statistically significant (P < 0.05). Conclusion Patients who underwent KA-TKA had a postoperative lower limb alignment similar to that of those who underwent MA-TKA. The clinical outcomes of KA-TKA were superior to those of MA-TKA in terms of clinical performance, knee function and subjective sensation up to 2 years after surgery.
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14
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Femoral bowing affects varus femoral alignment but not patient satisfaction in mechanically aligned total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:89-96. [PMID: 34779926 DOI: 10.1007/s00590-021-03164-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/04/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE This study evaluated whether patients with particular lower limb morphological factors have femoral and tibial component malpositioning during mechanically aligned total knee arthroplasty (TKA) and lower postoperative satisfaction. METHODS This study included 146 knees in 117 Asian patients undergoing TKA for medial osteoarthritis. Preoperative bony morphological factors such as the angle between the femoral mechanical and anatomical axes (MA-AA angle), angle between the anatomical axes of the proximal and distal femur (lateral bowing femoral angle, LBFA), mechanical lateral distal femoral angle, medial proximal tibial angle, and % anatomical axis of the tibia were evaluated, as well as preoperative and 1-year postoperative 2011 Knee Society scores (KSSs). RESULTS MA-AA angle and LBFA were significantly larger in knees with varus femoral component alignment versus neutral alignment. Preoperative MA-AA angle was underestimated in patients with larger MA-AA angle or LBFA, especially by inexperienced surgeons. Tibial morphological factors did not affect tibial component alignment. Changes in 2011 KSSs were similar among groups by lower limb alignment or femoral and tibial component alignment. CONCLUSION Femoral bowing affects varus femoral component alignment by obscuring preoperative planning, but it had little impact on patient satisfaction when mechanical alignment is targeted during TKA.
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15
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Tian G, Wang L, Liu L, Zhang Y, Zuo L, Li J. Kinematic alignment versus mechanical alignment in total knee arthroplasty: An up-to-date meta-analysis. J Orthop Surg (Hong Kong) 2022; 30:10225536221125952. [PMID: 36250421 DOI: 10.1177/10225536221125952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE The purpose of this meta-analysis was to compare the efficacy and imaging parameters of kinematic alignment (KA) and mechanical alignment (MA) in total knee arthroplasty (TKA) and to evaluate whether patients undergoing KA-TKA benefited more than those undergoing MA-TKA. METHODS Studies comparing the efficacy of KA-TKA and MA-TKA were included after searching and screening in the database, including PubMed, Embase, Web of Science and Cochrane Database Library. A total of 1420 patients were enrolled in the study, with 736 MA-TKA and 738 KA-TKA. The primary outcomes were postoperative knee function scores including KSS series, WOMAC, KOOS and OKS. Secondary outcomes included the operative time, the length of hospital stay, knee extension/flexion angle, and some imaging parameters. The risk of bias for included studies was assessed using the Cochrane Collaborative risk-of-bias assessment tool or the Newcastle-Ottawa Scale(NOS). RESULTS Sixteen studies were included in this meta-analysis (11 randomized controlled studies and 5 cohort studies). Primary outcomes: Knee Society score (KSS, MD = 8.36, 95% Cl: 0.83-15.90) and combined KSS (MD = 15.24, 95% CI: 5.41-25.07) were higher in KA-TKA than in MA-TKA, and other functional scores were not statistically significant in KA-TKA and MA-TKA, including knee injury and osteoarthritis outcome score (KOOS), Oxford knee score (OKS), Knee Function score (KFS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes: KA-TKA resulted in smaller medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) compared to MA-TKA. For other outcome measures, KA-TKA showed similar results compared to MA-TKA, including hip-knee-ankle (HKA) angle, extension/flexion angle, tibial component slope angle, joint line orientation angle (JLOA), the operation time, the length of hospital stay and ligament release rate. CONCLUSIONS In our analysis results, patients undergoing KA-TKA benefit as much as patients undergoing MA-TKA. KA may be a viable reference in total knee replacement.
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Affiliation(s)
- Gengshuang Tian
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
| | - Lishan Wang
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
| | - Linzhou Liu
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
| | - Yali Zhang
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
| | - Lixiong Zuo
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
| | - Jianpeng Li
- Department of Joint Surgery, 594331North China Medical&Health Group XingTai General Hospital, Hebei, China
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16
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Fernandez A, Sappey-Marinier E, Lavoie F, Batailler C, Servien E, Lustig S. Arthroscopic-assisted robotic bi-unicompartmental knee arthroplasty: a pilot cadaveric study. Arch Orthop Trauma Surg 2022; 143:3439-3446. [PMID: 36251075 DOI: 10.1007/s00402-022-04647-3] [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: 12/16/2021] [Accepted: 10/09/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although bicondylar arthroplasty showed great functional results, it encounters some difficulties to be performed routinely. On the other hand, arthroscopic techniques tend to replace open surgical techniques in sports medicine but strive to be developed in the field of arthroplasty. This study aimed to assess the feasibility of a micro-invasive bi-compartmental knee arthroplasty using both arthroscopic and robotic technologies (A-BiUKA). MATERIALS AND METHODS The study was conducted on complete fresh-frozen and embalmed cadaveric specimens. The main criterion of judgment was the successful positioning of trial implants through a minimal quad-sparing approach. Arthroscopy was used for bone-morphing and burring, supported by an image-free robotic system. Secondary criteria of judgment were axial deviation (measured using the navigation system), operating time, and incision length. RESULTS Ten A-BiUKA were performed. Implantation was successful in all cases. The mean preoperative frontal deviation was 179.8° ± 3.2 [175: 185], the mean postoperative frontal deviation was 178.5° ± 2.2 [175: 182], without any outliers. The mean correction was 1.7° ± 1.6 [0: 5]. Once the eight first A-UKA were performed, constituting the learning curve, the mean operative time for the remaining twelves surgeries was 90 min ± 6. The mean skin incision length was 3.35 cm ± 0.13 [3: 4]. CONCLUSION Associated arthroscopic and robotic technologies allows to perform Bi-UKA procedure using a quad sparing mini-invasive approach. Clinical prospective studies have to confirm the feasibility and the clinical outcomes of this surgery.
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Affiliation(s)
- Andrea Fernandez
- Emile Gallé Surgical Center, Nancy University Hospital, Nancy, France.
| | - Elliot Sappey-Marinier
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Frederic Lavoie
- Orthopedic Surgery Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.,Interuniversity Laboratory of Biology of Mobility, LIBM, EA 7424, Claude Bernard Lyon 1 University, Lyon, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622, Lyon, France
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17
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Nakajima A, Sonobe M, Akatsu Y, Yamada M, Yamamoto K, Saito J, Norimoto M, Koyama K, Taniguchi S, Takahashi H, Aoki Y, Suguro T, Nakagawa K. Lateral shift of the femoral condyle after total knee arthroplasty: simulation using 2D-templates of the medial pivot design on knee radiographs of young Japanese patients. J Orthop Surg Res 2022; 17:450. [PMID: 36224662 PMCID: PMC9559023 DOI: 10.1186/s13018-022-03342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background Total knee arthroplasty (TKA) is an established surgical treatment for advanced knee osteoarthritis by which patients can expect improvement of knee pain and function. Although many surgeons have investigated limb alignment after TKA, changes in coronal positional relation between the femur and tibia are not known well. Methods Radiographs of 105 knees of young Japanese patients between 20 and 49 years-old (60 men and 45 women) without osteoarthritic changes who received arthroscopic surgeries at our hospital were used in this study. Using 2D-templates of the medial pivot design (the FINE total knee), we simulated TKA on a SYNAPSE-PACS software. First, the femoral component was placed in normal knee alignment and then was merged to the medial concave of the insert where the tibial component was placed in neutral alignment. The length of the mediolateral shift of the femoral component was measured as an estimate of lateral shift of the femoral condyle, of which association with radiographic parameters including the femorotibial angle (FTA), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) was analyzed. Subjects were classified into three groups according to the femoral component size that was chosen in simulation of TKA, and the lateral shift of the femoral condyle was compared between groups. Results The estimated mean lateral shift of the femoral condyle was 5.99 ± 1.98 mm and was greater in males than females (p < 0.05). Also, it was most highly correlated with the medial proximal tibial angle (MPTA) (r = − 0.553, p < 0.01). A group receiving larger component sizes significantly shifted more laterally compared with a group receiving smaller component sizes (p < 0.01). Conclusions These results suggest that the coronal positional relation between the femur and tibia is altered and subsequent ligament imbalance may occur after mechanically aligned TKA using the medial pivot design.
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Affiliation(s)
- Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan.
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Manabu Yamada
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Keiichiro Yamamoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Masaki Norimoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Keita Koyama
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Shinji Taniguchi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, 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, Japan
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Mannan A, Saber AY, Waterson B, Roberton A, Toms A. Mechanical Alignment in Total Knee Arthroplasty for Varus Knee Osteoarthritis Leads to Significant Tibial Bone Loss. Cureus 2022; 14:e30107. [DOI: 10.7759/cureus.30107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 11/06/2022] Open
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19
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Yamamura K, Inori F, Konishi S. Prosthetic Accuracy Depends on the Design of Patient-Specific Instrumentation: Results of a Retrospective Study Using Three-Dimensional Imaging. J Knee Surg 2022; 35:978-982. [PMID: 33241546 DOI: 10.1055/s-0040-1721127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To determine accuracy of patient-specific instrumentation (PSI), the preoperative three-dimensional (3D) plan should be superimposed on the postoperative 3D image to compare prosthetic alignment. We aimed to compare prosthetic alignment on a preoperative 3D computed tomography (CT) plan and postoperative 3D-CT image, and evaluate the accuracy of PSI during total knee arthroplasty (TKA). Thirty consecutive knees (30 patients) who underwent TKA using PSI were retrospectively evaluated. The preoperative plan was prepared using 3D CT acquisitions of the hip, knee, and ankle joints. The postoperative 3D CT image obtained 1 week after surgery was superimposed onto the preoperative 3D plan using computer software. Differences in prosthetic alignment between the preoperative and postoperative images were measured using six parameters: coronal, sagittal, and axial alignments of femoral and tibial prostheses. Differences in prosthetic alignment greater than 3 degrees were considered outliers. Two observers performed all measurements. All parameters were repeatedly measured over a 4-week interval. This measurement method's intraobserver and interobserver reliabilities were more than 0.81 (very good). For the femoral and tibial prostheses, absolute differences between the preoperative and postoperative 3D CT images were significantly larger in the sagittal than in the coronal and axial planes (p < 0.001). The outlier rate for the sagittal alignment of femoral and tibial prostheses was significantly higher than that for the alignment of coronal and axial planes (p < 0.001). However, there were no significant differences in the range of motion (ROM) before and after TKA when comparing cases with and without outliers in the sagittal plane. Even though the present study did not reveal any issues with the ROM that depended on the presence of an outlier, accurate verification of prosthetic alignment for individual PSI models may be necessary because the designs, referenced images, and accuracy are different in each model.
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Affiliation(s)
- Kazumasa Yamamura
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
| | - Fumiaki Inori
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
| | - Sadahiko Konishi
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Abeno-ku, Osaka, Japan
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20
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Kaneko T, Yamamoto A, Takada K, Yoshizawa S. Intraoperative joint balancing procedure using an imageless robotic assisted technique does not necessarily result in kinematically aligned bicruciate stabilized total knee arthroplasty. J Robot Surg 2022; 17:447-456. [PMID: 35771482 DOI: 10.1007/s11701-022-01429-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
The primary aim of this study was to retrospectively evaluate the hip- knee- ankle. (HKA) angle and prosthetic alignment with three-dimensional computed tomography (3DCT) measurements in patients who underwent robotic-assisted (RA) TKA, with consideration of the soft tissue envelope via an intraoperative joint-balancing procedure. We hypothesized that intraoperative consideration of soft tissue laxity in individual patients using imageless RA technology will not necessarily result in kinematically aligned bicruciate stabilized total knee arthroplasty (KA TKA). This retrospective study included consecutive patients who underwent RA TKA between 2019 and 2020. The indication for TKA was varus osteoarthritis of the knee. During this period, 60 RA bi-cruciate stabilized TKAs were performed. Prosthetic alignments were measured using computer software with 3DCT. We determined prosthetic positioning and bone resection volume with consideration of the soft tissue envelope using an intraoperative full range of motion joint-balancing procedure during RA TKA. 3DCT scans of the entire lower extremity were taken before and after surgery. Postoperative varus HKA alignment occurred in 58% of patients who underwent RA TKA, 31% of knees were in femoral valgus alignment and tibial varus alignment, and 42% had femoral components in internal rotation among knees with femoral valgus alignment and tibial varus alignment. The mean thickness of the osteotomized medial and lateral posterior condyles of the femur were 11.2 and 9.1 mm, respectively, based on 3DCT measurements. Intraoperative consideration of soft tissue laxity in individual patientsusing an imageless RA technique does not necessarily result in KA bicruciate TKA.
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Affiliation(s)
- Takao Kaneko
- Adult Reconstruction Center, Ichinomiya Onsen Hot Hospital, 1745 Tsuboi, Ichinomiyacho, Fuefuki-city, Yamanashi, 405-0077, Japan.
| | - Ayakane Yamamoto
- Adult Reconstruction Center, Ichinomiya Onsen Hot Hospital, 1745 Tsuboi, Ichinomiyacho, Fuefuki-city, Yamanashi, 405-0077, Japan
| | - Kazutaka Takada
- Adult Reconstruction Center, Ichinomiya Onsen Hot Hospital, 1745 Tsuboi, Ichinomiyacho, Fuefuki-city, Yamanashi, 405-0077, Japan
| | - Shu Yoshizawa
- Adult Reconstruction Center, Ichinomiya Onsen Hot Hospital, 1745 Tsuboi, Ichinomiyacho, Fuefuki-city, Yamanashi, 405-0077, Japan
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21
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MacDessi SJ, Wernecke GC, Bastiras D, Hooper T, Heath E, Lorimer M, Harris I. Robotic-assisted surgery and kinematic alignment in total knee arthroplasty (RASKAL study): a protocol of a national registry-nested, multicentre, 2×2 factorial randomised trial assessing clinical, intraoperative, functional, radiographic and survivorship outcomes. BMJ Open 2022; 12:e051088. [PMID: 35688590 PMCID: PMC9189838 DOI: 10.1136/bmjopen-2021-051088] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Robot-assisted surgery (RAS) and kinematic alignment (KA) are being increasingly adopted to improve patient outcomes in total knee arthroplasty (TKA). There is uncertainty around the individual or combined effect of these concepts compared with computer-assisted surgery (CAS) and mechanical alignment (MA), respectively. This study aims to assess the effectiveness of RAS, KA or both to improve clinical outcomes, functional measures, radiographic precision and prosthetic survivorship when compared with current gold standards of surgical care. METHODS AND ANALYSIS A national registry-nested, multicentre, double-blinded, 2×2 factorial, randomised trial will be undertaken with 300 patients undergoing primary unilateral TKA performed by 15 surgeons. The primary outcome will be the between-group differences in postoperative change over 2 years in the mean Knee injury and Osteoarthritis Outcome Score (KOOS-12), comparing first, RAS to CAS as its control, and second, KA to MA as its control. Secondary outcomes will include other knee-specific and general health patient-reported outcome measures (PROMs), intraoperative pressure loads as a measure of soft tissue balance, 6-month postoperative functional outcomes, radiological precision using CT imaging, complications and long-term prosthetic survivorship. The contribution of each patient's unique coronal plane alignment of the knee phenotype to primary and secondary PROMs will be investigated. OMERACT-OARSI criteria and Patient Acceptable Symptom State outcome score thresholds for the KOOS-12 and Oxford Knee Score will be used in secondary analyses. Primary intention-to-treat and secondary per-protocol analyses will be performed. Statistical analysis will include a generalised linear mixed model for repeated measures for continuous KOOS-12 scores. Kaplan-Meier estimates with adjusted HRs of implant survivorship will be calculated. ETHICS AND DISSEMINATION Ethics approval was obtained from Sydney Local Health District-Royal Prince Alfred Hospital (Approval X20-0494 and 2020/ETH02896 10.24/DEC20). Results will be submitted for publication in a peer-reviewed journal and presented in national, state and international meetings. TRIAL REGISTRATION NUMBER ACTRN12621000205831.
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Affiliation(s)
- Samuel J MacDessi
- Orthopaedics, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Tamara Hooper
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Emma Heath
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ian Harris
- University of New South Wales, Sydney, New South Wales, Australia
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22
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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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23
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A Study of Surgical Accuracy with X-Ray-Based Patient-Specific Instrument (X3DPSI ®) vs Conventional Instrument in Total Knee Arthroplasty Surgeries. Indian J Orthop 2022; 56:1240-1250. [PMID: 35813546 PMCID: PMC9232679 DOI: 10.1007/s43465-022-00623-6] [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: 10/15/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Patient-specific instruments (PSI) have been shown to be a good solution in getting accurate bone cuts in total knee arthroplasty (TKA) in many studies. However, the need for an extra CT/MRI makes the existing PSI method costly and unsafe. X-ray-based PSI can solve these problems, if proven to be accurate. The purpose of this study was to introduce a novel method to measure the performance of X-ray to 3D-based PSI (X3DPSI ® ) in achieving planned bone cuts by comparing with conventional instruments (CI). MATERIALS AND METHODS This was a prospective study of a total of ten patients undergoing TKA surgery. Preoperative full length lower limb scanogram was done with specialized calibration strap-on marker to develop X3DPSI ® which was used intraoperatively for the placement of guiding pins for the cutting jig. Similarly, intraoperative guide pins were placed using CI also. Calibrated intraoperative X-ray images, in AP and LAT view, were taken while the cutting-block guiding pins were placed on the distal femur and proximal tibia. These X-ray images were used to calculate the cutting plane alignments for femur and tibia and to simulate the postoperative hip-knee-ankle (HKA) angle and MAD (mechanical axis deviation), in a virtual Tabplan3D environment for both the methods. RESULTS The results showed that there was a significant difference between the two methods in terms of femoral cutting plane angles and in terms of the HKA angles and MAD. There was no significant difference in the tibial cutting plane angles in the coronal plane. CONCLUSION The mechanical axis alignment achieved based on the virtual cuts made using the X3DPSI ® was significantly better than the alignment achieved based on the cuts made using the CI, in terms of both HKA and MAD. This novel method of X-ray-based PSI is a low-cost alternative to CT/MRI-based PSI if found to be accurate in future planned studies.
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24
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Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W, Peng H, Wang W, Lin J, Jin J, Weng X. Degree of coronal alignment correction can't predict knee function in total knee replacement. BMC Surg 2021; 21:383. [PMID: 34717621 PMCID: PMC8557487 DOI: 10.1186/s12893-021-01372-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whether neutral alignment brings better clinical outcomes is controversial. Consideration of the preoperative knee condition of patients and some limitations of previous studies, we suggested that other index may be more important than a generic target of 0° ± 3° of a neutral axis to reflect changes in coronal alignment after total knee replacement (TKR). The purpose of this study was to explore the relationship between alignment and functional outcome with a new grouping method and the concept of correction rate. METHODS The study included 358 knees, the mean follow-up period was 3.62 years. A new grouping method was adopted to divide patients into three groups based on the degree of correction of mechanical femoral-tibial angle (MFTA): under-correction (n = 128), neutral (n = 209) and over-correction (n = 21). Hospital for Special Surgery (HSS) score were compared among the 3 groups (ANOVA with or without LSD t-test). In addition, we also attempt to further explore whether the concept of correction rate can predict postoperative functional score (Simple linear correlation analysis). RESULTS HSS score showed significant improvement in all groups. There was no difference in HSS score (88.27 vs 88 vs 85.62) (p = 0.88) or incremental scores (26.23 vs 25.22 vs 22.88) (p = 0.25) based on the postoperative alignment category for the degree of correction of MFTA at the last follow-up. The correlational analyses also didn't show any positive results (r = -0.01 p = 0.95, r = -0.01 p = 0.97, r = 0.11 p = 0.15, r = 0.01 p = 0.90). CONCLUSION Categorization of optimal coronal alignment after TKR may be impractical. But we still believe that the concept of correction rate and new grouping method are worthy of research which can reflects the preoperative knee condition and the change of coronal alignment. Perhaps it can be better used in TKR in the future. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shibai Zhu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.,Department of Orthopedics, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Xiaotian Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xi Chen
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yiou Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shanni Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wenwei Qian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Huiming Peng
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jin Lin
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jin Jin
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
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25
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Wang Q, Zhang X. [Optimal lower limb alignment and soft tissue balancing strategy for robot-assisted total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1221-1226. [PMID: 34651472 DOI: 10.7507/1002-1892.202107069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lower limb alignment and soft tissue balance are important factors affecting patient satisfaction, clinical functional outcome, and prosthetic long-term survival rate after total knee arthroplasty (TKA). Robot-assisted TKA (rTKA) has the advantages of achieving precise osteotomy and soft tissue balance. However, rTKA under the guidance of classic mechanical alignment principles does not significantly improve the functional outcome after operation. The new TKA alignment principles, such as kinematic alignment (KA) and functional alignment (FA), can better consider the patient's own knee joint morphology and kinematic characteristics, which may help improve the clinical results of TKA. With the help of more objective and accurate soft tissue balance assessment tool such as pressure sensors, KA and FA have been proven to better achieve soft tissue balance. rTKA can achieve non-neutral alignment goals such as KA or FA more accurately and reproducibly. The use of these lower limb alignment and soft tissue balancing strategies will be expected to further increase the patients' satisfaction rate after rTKA.
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Affiliation(s)
- Qiaojie Wang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai, 200233, P.R.China
| | - Xianlong Zhang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai, 200233, P.R.China
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26
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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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27
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Ho JPY, Merican AM, Ayob KA, Sulaiman SH, Hashim MS. Tibia vara in Asians: Myth or fact? Verification with three-dimensional computed tomography. J Orthop Surg (Hong Kong) 2021; 29:2309499021992618. [PMID: 33632009 DOI: 10.1177/2309499021992618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is a common perception among surgeons that Asian tibiae are significantly more varus compared to non-Asians, contributed both by an acute medial tibial proximal angle (MPTA) and diaphyseal bowing. Insight into the normative morphology of the tibia allows generation of knowledge towards disease processes and subsequently planning for corrective surgeries. METHODS Computed tomography (CT) scans of 100 normal adult knees, aged 18 years and above, were analysed using a 3-dimensional (3D) analysis software. All tibiae were first aligned to a standard frame of reference and then rotationally aligned to the tibial centroid axis (TCAx) and the transmalleolar axis (tmAx). MPTA was measured from best-fit planes on the surface of the proximal tibia for each rotational alignment. Diaphyseal bowing was assessed by dividing the shaft to three equal portions and establishing the angle between the proximal and distal segments. RESULTS The mean MPTA was 87.0° ± 2.2° (mean ± SD) when rotationally aligned to TCAx and 91.6° ± 2.7° when aligned to tmAx. The mean diaphyseal bowing was 0.1° ± 1.9° varus when rotationally aligned to TCAx and 0.3° ± 1.6° valgus when aligned to tmAx. The mean difference when the MPTA was measured with two different rotational alignments (TCAx and tmAx) was 4.6° ± 2.3°. No statistically significant differences were observed between males and females. Post hoc tests revealed statistically significant difference in MPTA between different ethnic sub-groups. CONCLUSION The morphology of the proximal tibiae in the disease-free Asian knee is inherently varus but not more so than other reported populations. The varus profile is contributed by the MPTA, with negligible diaphyseal bowing. These implications are relevant to surgical planning and prosthesis design.
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Affiliation(s)
- Jade Pei Yuik Ho
- Department of Orthopaedic Surgery, Sarawak General Hospital, Kuching, Malaysia
| | - Azhar Mahmood Merican
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khairul Anwar Ayob
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shahrul-Hisham Sulaiman
- Department of Orthopaedic Surgery, Faculty of Medicine, University Teknologi MARA, Sungai Buloh, Malaysia
| | - Muhammad Sufian Hashim
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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28
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Wang ZW, Wen L, Luan YC, Ma DS, Dong X, Cheng CK, Qu TB. Restoration of Joint Inclination in Total Knee Arthroplasty Offers Little Improvement in Joint Kinematics in Neutrally Aligned Extremities. Front Bioeng Biotechnol 2021; 9:673275. [PMID: 33996784 PMCID: PMC8116507 DOI: 10.3389/fbioe.2021.673275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/08/2021] [Indexed: 11/28/2022] Open
Abstract
Kinematically aligned total knee replacements have been shown to better restore physiological kinematics than mechanical alignment and also offer good postoperative satisfaction. The purpose of this study is to evaluate the extent to which an inclined joint line in a kinematically aligned knee can alter the postoperative kinematics. A multi-body dynamic simulation was used to identify kinematic changes in the joint. To accurately compare mechanical alignment, kinematic alignment and a natural knee, a “standard” patient with neutral alignment of the lower extremities was selected for modeling from a joint database. The arthroplasty models in this study were implanted with a single conventional cruciate-retaining prosthesis. Each model was subjected to a flexion movement and the anteroposterior translation of the femoral condyles was collected for kinematic analysis. The results showed that the mechanical alignment model underwent typical paradoxical anterior translation of the femoral condyles. Incorporating an inclined joint line in the model did not prevent the paradoxical anterior translation, but a 3° varus joint line in the kinematic alignment model could reduce the peak value of this motion by about 1 mm. Moreover, the inclined joint line did not restore the motion curve back to within the range of the kinematic curve of the natural knee. The results of this study suggest that an inclined joint line, as in the kinematic alignment model, can slightly suppress paradoxical anterior translation of the femoral condyles, but cannot restore kinematic motions similar to the physiological knee. This finding implies that prostheses intended to be used for kinematic alignment should be designed to optimize knee kinematics with the intention of restoring a physiological motion curve.
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Affiliation(s)
- Zhi-Wei Wang
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liang Wen
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yi-Chao Luan
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - De-Si Ma
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiang Dong
- Beijing Naton Medical Technology Innovation Center Co., Ltd., Beijing, China
| | - Cheng-Kung Cheng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Tie-Bing Qu
- The Center of Diagnosis and Treatment for Joint Disease, China Rehabilitation Research Center, Capital Medical University, Beijing, China
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29
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Massé V, Ghate RS. Using standard X-ray images to create 3D digital bone models and patient-matched guides for aiding implant positioning and sizing in total knee arthroplasty. Comput Assist Surg (Abingdon) 2021; 26:31-40. [PMID: 33721547 DOI: 10.1080/24699322.2021.1894239] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
X-Atlas™ is a new imaging technology intended to advance the state of the art in patient-specific instrumentation. It uses standard AP and lateral radiographs instead of CT or MRI scans to create 3D bone models, which can be used to perform pre-operative surgical planning and fabricate TKA personalized guides. The aim of this study was to validate X-Atlas™ and evaluate the accuracy of personalized guides created with this imaging technology. Its ability to predict implant size was also determined. The accuracy of the X-Atlas™ imaging technology was evaluated by comparing the landmarks of X-Atlas™ 3D Bone models to MRI-reconstructed bone models. The accuracy of PSI guides created with X-Atlas™ (X-PSI™ guides) was evaluated during a validation study (16 specimen knees) and a clinical study (50 patients; Health Canada #CSU2015-12K). Optical navigation was used to measure positioning accuracy. In addition, the ability of X-Atlas™ to predict implant size was assessed. The accuracy of the X-Atlas™ imaging technology was below 0.87 and 1.28 mm for the femoral and tibial landmarks, respectively. The accuracy of X-PSI™ guides to reproduce the pre-operative planned HKA was within ± 3° in 100% and 86.1% of cases, for the laboratory and clinical study respectively, which was significantly better than historical data for conventional instrumentation. X-Atlas™ was able to predict implant size to ± 1 size in 95.6% and 100%, for the femur and tibia component respectively. The X-Atlas™ imaging technology demonstrated excellent accuracy for reconstructing a 3D bone model. The results show that PSI guides created with X-Atlas™ (X-PSI™ guides) provide greater implant positioning accuracy than conventional instrumentation, without the requirement of advanced imaging. Furthermore, the X-Atlas™ imaging technology could effectively predict implant sizing, potentially reducing the number of instrument trays and improving surgical efficiency.
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Affiliation(s)
- Vincent Massé
- Department of Orthopaedic Surgery, Maisonneuve-Rosemont Hospital, Montreal University, Montreal, Canada
| | - Raju S Ghate
- Department of Orthopaedic Surgery, NorthShore University HealthSystem, Skokie, IL, USA.,Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
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30
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Tuecking LR, Ettinger M, Nebel D, Welke B, Schwarze M, Windhagen H, Savov P. 3D-surface scan based validated new measurement technique of femoral joint line reconstruction in total knee arthroplasty. J Exp Orthop 2021; 8:16. [PMID: 33634333 PMCID: PMC7907296 DOI: 10.1186/s40634-021-00330-5] [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: 11/18/2020] [Accepted: 01/20/2021] [Indexed: 01/16/2023] Open
Abstract
Purpose This study aimed to validate a new joint line measurement technique in total knee arthroplasty for separated assessment of the medial and lateral femoral joint line alteration with 3D-surface scan technology. Separate assessment of the medial and lateral joint line alteration may improve TKA alignment assessment regarding to joint line restoration in kinematic alignment and use of robotic-assisted TKA surgery. Methods The medial and lateral joint line difference after TKA implantation on an artificial bone model was analyzed and compared with a 3D-scan and full femoral radiographs pre- and postoperatively. Radiographic analysis included the perpendicular distance between the most distal point of the medial and lateral condyle and the reproduced preoperative lateral distal femoral angle (LDFA). For evaluation of validity and reliability, radiographs were captured initially with true anteroposterior view and subsequently with combined flexion and rotation malpositioning. Reliability of the introduced measurement technique in between three observers was tested with intraclass correlation coefficient (ICC). Results Radiographic measurement showed a mean difference of 0.9 mm on the medial side and 0.6 mm on the lateral side when compared to the 3D-surface scan measurement. The reliability of measurement accuracy was ≤ 1 mm in x-rays with < 10° flexion error regardless to malrotation in these images. The ICC test showed very good reliability for the medial joint line evaluation and good reliability for lateral joint line evaluation (ICC 0.92, ICC 0.86 respectively). Conclusion The new introduced joint line measurement method showed a sufficient reliability, accuracy and precision. It provides separated information about medial and lateral joint line alteration in TKA surgery in absolute values. Level of evidence V - Experimental Study
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Affiliation(s)
- Lars-Rene Tuecking
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Max Ettinger
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Dennis Nebel
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Bastian Welke
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Michael Schwarze
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Peter Savov
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.
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Abstract
Aims A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). Methods A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type. Results There was similar frequency distribution between healthy and arthritic groups across all CPAK types. The most common categories were Type II (39.2% healthy vs 32.2% OA), Type I (26.4% healthy vs 19.4% OA) and Type V (15.4% healthy vs 14.6% OA). CPAK Types VII, VIII, and IX were rare in both populations. Across all CPAK types, a greater proportion of KA TKAs achieved optimal balance compared to MA. This effect was largest, and statistically significant, in CPAK Types I (100% KA vs 15% MA; p < 0.001), Type II (78% KA vs 46% MA; p = 0.018). and Type IV (89% KA vs 0% MA; p < 0.001). Conclusion CPAK is a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO, that can be used in healthy and arthritic knees. CPAK identifies which knee phenotypes may benefit most from KA when optimization of soft tissue balance is prioritized. Further, it will allow for consistency of reporting in future studies. Cite this article: Bone Joint J 2021;103-B(2):329–337.
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Affiliation(s)
- Samuel J MacDessi
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Ian A Harris
- Orthopaedic Surgery, University of New South Wales, South Western Sydney Clinical School, Liverpool, NSW, Australia.,Whitlam Orthopaedic Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Johan Bellemans
- CPAK Research Group, Sydney, Australia.,Department of Orthopaedic Surgery, Hasselt University, ZOL Hospitals, Genk, Belgium.,ArthroClinic, Leuven, Belgium
| | - Darren B Chen
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia
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Hsu CE, Huang JT, Tong KM, Huang KC. Total knee arthroplasty according to the original knee phenotypes with kinematic alignment surgical technique-early clinical and functional outcomes. BMC Musculoskelet Disord 2020; 21:839. [PMID: 33308196 PMCID: PMC7731459 DOI: 10.1186/s12891-020-03862-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background The kinematic alignment (KA) technique in total knee arthroplasty (TKA) aims to restore the native alignment of pre-disease knee joint anatomy. Determining the individualized alignment targets is crucial for pre-operative planning, which can be set according to different original knee phenotypes. Five most common knee phenotypes have been categorized for KA-TKA alignment target setting in our previous study. The purpose of this study was to investigate the distribution of the five phenotypes in advanced OA knee patients and evaluate the clinical outcomes of this phenotype-oriented KA-TKA using the generic instrument, with particular emphasis on alignment strategy, surgical technique, survivorship, radiographic and functional outcomes. Methods The clinical data of 123 patients (88 women, 35 men) who had undergone 140 TKAs in our hospital were reviewed. All the TKAs were performed with alignment targets set according to the original phenotypes of the knee, with the KA method, using the generic total knee instrument. The patients’ demographics, preoperative and postoperative knee alignment angles, one-year postoperative range of motion (ROM), Oxford knee scores (OKS), Combined knee society score (CKSS) were collected and analyzed. Results The 3 years survivorship was 99.3% for all cause of revision, and 100% with revision other than infection as the endpoint. The preoperative phenotypes of the knee were as follows: neutral alignment 20.1% (type 1: 3.6%, type 2: 16.5%), varus alignment 71.2% (type 3: 46.0%, type 4: 25.2%), and valgus alignment (type 5: 8.6%). Using our protocol, patients with different knee phenotypes could get similar great functional improvement though the postoperative alignment parameters were significantly different between the knee phenotypes (P < 0.05). Conclusion The early outcomes of this phenotype-oriented KA-TKA using generic total knee instruments are promising. Setting individualized alignment target according to original knee phenotype is rational and practical. The residual varus alignment did not cause any aseptic loosening in the 3 years follow-up. Long-term survivorship and functional outcomes need to be evaluated in future studies.
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Affiliation(s)
- Cheng-En Hsu
- Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, 407, Taiwan.,Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Ting Huang
- Department of Orthopedics Surgery, Asia University Hospital, 222 Fuxin Rd., Wufeng District, Taichung City, 41354, Taiwan.,Department of Occupational Therapy, Asia University, Taichung, Taiwan
| | - Kwok-Man Tong
- Department of Orthopedics Surgery, Asia University Hospital, 222 Fuxin Rd., Wufeng District, Taichung City, 41354, Taiwan.,Department of Occupational Therapy, Asia University, Taichung, Taiwan
| | - Kui-Chou Huang
- Department of Orthopedics Surgery, Asia University Hospital, 222 Fuxin Rd., Wufeng District, Taichung City, 41354, Taiwan. .,Department of Occupational Therapy, Asia University, Taichung, Taiwan.
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Scanlon CM, Sun DQ, Alvarez AM, Webb ML, Perez BA, Yu AS, Hume EL. In Kinematically Aligned Total Knee Arthroplasty, Failure to Recreate Native Tibial Alignment Is Associated With Early Revision. J Arthroplasty 2020; 35:3166-3171. [PMID: 32660798 DOI: 10.1016/j.arth.2020.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The goal of kinematically aligned (KA) total knee arthroplasty (TKA) is to restore native knee anatomy. However, there are concerns about patellofemoral tracking problems with this technique that lead to early revision. We measured the differences between preoperative anatomic alignment and postoperative component alignment in a consecutive series of KA TKA and evaluated the association between alignment changes and the likelihood of early revision. METHODS The charts of 219 patients who underwent 275 KA TKA procedures were reviewed. Preoperative anatomic alignment and postoperative tibial and femoral component alignment were measured radiographically. The difference in component alignment compared with preoperative anatomic alignment was compared between patients who underwent aseptic revision and those who did not at a minimum of 12 months of follow-up. Receiver operating characteristic curves were created for statistically significant variables, and the Youden index was used to determine optimal alignment thresholds with regard to likelihood of revision surgery. RESULTS Change in tibial component alignment compared with native alignment was greater (P = .005) in the revision group (5.0° ± 3.7° of increased varus compared with preoperative anatomic tibial angle) than in the nonrevision group (1.3° ± 4.2° of increased varus). The Youden index indicated that increasing tibial varus by >2.2° or more is associated with increased likelihood of revision. Preoperative anatomic alignment and change in femoral alignment and overall joint alignment (ie, Q angle) were not associated with increased likelihood of revision. CONCLUSION Small increases in tibial component varus compared with native alignment are associated with early aseptic revision in patients undergoing KA TKA.
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Affiliation(s)
- Christopher M Scanlon
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David Q Sun
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Matthew L Webb
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brian A Perez
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Austin S Yu
- Drexel University College of Medicine, Philadelphia, PA
| | - Eric L Hume
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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Gao ZX, Long NJ, Zhang SY, Yu W, Dai YX, Xiao C. Comparison of Kinematic Alignment and Mechanical Alignment in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Clinical Trials. Orthop Surg 2020; 12:1567-1578. [PMID: 33099892 PMCID: PMC7767667 DOI: 10.1111/os.12826] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/31/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to estimate whether kinematic alignment (KA) improves knee function or clinical outcomes compared with mechanical alignment (MA) in the short term after total knee arthroplasty (TKA). We searched the literature for randomized controlled trials published before January 2020 from PubMed, EMBASE, Google, Web of Science, Cochrane Library, and other databases. The observation markers included "The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index," "Knee Society Score (KSS)," "Oxford Knee Score (OKS)," "combined Knee Society Score (KSS)," "Knee injury and Osteoarthritis Outcome Score (KOOS)," "European Quality of Life Measure-5 Domain-5-Level (EQ-5D-5L)," range of motion (ROM), lower limb alignment, ligament release, and complications. A total of 11 randomized controlled trial studies were included in the study. During the follow-up of 6-24 months, the KA-TKA group was superior to the MA-TKA group in terms of WOMAC scores, combined KSS, KSS, knee function scores, and knee range of flexion, but there was no significant difference in EQ-5D-5L, KOOS, KOOS (symptoms, pain, ADL, sports, and quality of life), complications, knee range of extension, hip-knee-ankle (HKA) angle, tibial component slope angle, lateral distal femoral angle (LDFA) or medial proximal tibial angle (MPTA) angle between the MA-TKA group and the MA-TKA group (P > 0.05). Our meta-analysis revealed that the incidence of ligament release in the MA-TKA group was higher than that in the KA-TKA group. This meta-analysis shows that the KA-TKA group had better clinical outcomes and knee range of flexion than the MA-TKA group at short-term follow-up.
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Affiliation(s)
- Zhi-Xiang Gao
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
| | - Neng-Ji Long
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
| | - Shao-Yun Zhang
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
| | - Wei Yu
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
| | - Yi-Xin Dai
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
| | - Cong Xiao
- Department of Orthopaedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, China
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Magan AA, Kayani B, Chang JS, Roussot M, Moriarty P, Haddad FS. Artificial intelligence and surgical innovation: lower limb arthroplasty. Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 33135934 DOI: 10.12968/hmed.2020.0309] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The number of patients requiring hip and knee arthroplasty continues to rise each year. Patients are living longer and expecting to remain active into later life following joint replacement. Developments in computer-assisted surgery and robotic technology may optimise surgical outcomes and patient satisfaction following lower limb arthroplasty. The use of artificial intelligence in healthcare is rapidly growing and has gained momentum in lower limb arthroplasty. This article reviews the use of artificial intelligence and surgical innovation in lower limb arthroplasty, with a particular focus on robotic-assisted surgery in total knee arthroplasty.
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Affiliation(s)
- A A Magan
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK.,Department of Orthopaedics, The Princess Grace Hospital, London, UK
| | - B Kayani
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK
| | - J S Chang
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK
| | - M Roussot
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK
| | - P Moriarty
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK
| | - F S Haddad
- Department of Trauma and Orthopaedics, University College London Hospital NHS Foundation Trust, London, UK.,Department of Trauma and Orthopaedics, The Princess Grace Hospital, London, UK
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Nedopil AJ, Howell SM, Hull ML. Deviations in femoral joint lines using calipered kinematically aligned TKA from virtually planned joint lines are small and do not affect clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2020; 28:3118-3127. [PMID: 31768572 DOI: 10.1007/s00167-019-05776-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Kinematically aligned total knee arthroplasty (KA TKA) strives to restore the native distal and posterior joint lines of the femur. Because the joint lines of a virtually planned femoral component on the native femur can serve as surrogates of those of the native femur, the present study determined position and orientation deviations of the femoral joint lines following calipered KA TKA from virtually planned joint lines and whether these alignment deviations affect clinical outcomes. Our hypotheses were that the alignment deviations for most knees would be less than 2 mm and/or 2° and that larger alignment deviations would not be associated with lower clinical outcome scores. METHODS A review of lower extremity CT scanograms and CT scans of the knee identified 36 patients treated with calipered KA TKA in one limb and no other skeletal deformities in either limb. 3D models of the operated femur with the implanted femoral component and the native femur were created. The articular surfaces of a 3D model of the implanted femoral component in the TKA knee were shape-matched to the condyles of the native femur to create a virtual plan. The shape-matched femoral component served as a reference from which to determine alignment deviations of the femoral component implanted in the ipsilateral femur. The Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) were obtained at an average of 20 months. RESULTS For proximal-distal and anterior-posterior positions and varus-valgus and internal-external orientations of the femoral component, the root mean square deviations from the planned joint lines ranged from 1.4 to 1.5 (mm or degrees). The mean differences ranged from - 0.1 to 0.2 (mm or degrees) indicating an absence of systematic alignment deviations. The proportion of knees with joint lines within ± 2 mm and ± 2° of the joint lines of virtually planned knees ranged from 83 to 92%. For the FJS and OKS, the median values were 79 (out of 100) and 45 (out of 48), respectively, and there were no significant correlations between deviations in the positions and orientations and either the FJS or the OKS. CONCLUSION Alignment deviations were bounded by 2 mm and 2° for most knees, which previous biomechanical studies have shown reduce the risks of stiffness, loss of extension, loss of flexion, and tibial compartment forces higher than those of the native knee. Moreover, because median FJS and OKS were relatively high, and because larger alignment deviations did not correlate with lower outcome scores, deviations did not affect clinical outcomes. These results validate calipered KA TKA as a surgical technique which closely restores the distal and posterior femoral joint lines to those planned and achieves concomitant high patient-reported outcome scores. Thus, surgeons can use the calipered KA TKA technique with confidence that the surgical alignment goal will be satisfied with sufficient accuracy that high patient-reported outcomes are achieved. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA
| | - Maury L Hull
- Department of Biomedical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA.
- Department of Mechanical Engineering, University of California Davis, One Shields Avenue, Davis, CA, 95616, USA.
- Department of Orthopaedic Surgery, Ambulatory Care Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA.
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Similar Risk of Revision After Kinematically Aligned, Patient-Specific Instrumented Total Knee Arthroplasty, and All Other Total Knee Arthroplasty: Combined Results From the Australian and New Zealand Joint Replacement Registries. J Arthroplasty 2020; 35:2872-2877. [PMID: 32620297 DOI: 10.1016/j.arth.2020.05.065] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Kinematic alignment (KA) in total knee arthroplasty (TKA) replicates individual knee joint line orientation and physiological soft tissue balance. There are limited data on the effect of KA on survivorship compared with other methods of implanting a TKA. The aim of this study was to compare the survivorship of the same design of TKA implanted with either patient-specific instrument (PSI) KA or with computer-assisted surgery and conventionally instrumented. METHODS We performed an observational study of data from 2 national joint registries on all patients who underwent a TKA with a Triathlon cruciate-retaining TKA (Stryker, Mahwah, NJ) from January 2011 to December 31, 2013. The outcomes of knees performed with unrestricted KA using patient-specific instrument were compared with computer-assisted surgery and conventionally instrumented Triathlon cruciate-retaining TKA. The principal outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Cox proportional hazard ratios, adjusted for age and gender, were used to compare the 2 groups. RESULTS There were 20,512 TKA procedures recorded, of which 416 were performed using KA-PSI. The KA-PSI group was younger (66.8 ± 8.2 vs 68.3 ± 9.2, P = .001), with an identical gender distribution. The cumulative revision rate at 7 years was 3.1% for the KA-PSI Triathlon cohort and 3.0% for the other Triathlon TKA cohort (P = .89). The most common reasons for revision in the KA-PSI group were maltracking, patella erosion, and arthrofibrosis. CONCLUSION Kinematically aligned Triathlon TKA using PSI has similar revision rate as all other Triathlon TKA.
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Risitano S, Sabatini L, Barberis L, Fusini F, Malavolta M, Indelli PF. Combining kinematic alignment and medial stabilized design in total knee arthroplasty: Basic rationale and preliminary clinical evidences. J Orthop 2020; 21:427-431. [PMID: 32943829 DOI: 10.1016/j.jor.2020.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/23/2020] [Indexed: 10/23/2022] Open
Abstract
Objective: kinematic alignment technique has been recently described as a new surgical procedure able to restore the patient specific physiological knee alignment; furthermore, new prosthesis, as medial stabilized (MS) third generation TKA, were designed to better reproduce the anatomical shape of the knee. In this prospective study, the authors evaluated early clinical improvement and radiological outcomes of patients having pre-operative small coronal limb deformity underwent TKA using a surgical technique combining a "restricted kinematic alignment" with medial stabilized polyethylene insert. Methods Fifteen consecutive patients (8 female and 7 male) scheduled for a total knee replacement have been enrolled for this study and treated using a modern third generation knee implant with a medial congruent tibial polyethylene. Clinical improvements have been assessed pre-operatively and at 6 and 12 months Follow up (FU) using the Oxford knee Score (OKS)( Ishikawa et al., Jun. 2015) 12 the Knee Society Score (KSS)( Pinskerova and et al., Aug. 2004) 13 and Forgotten Joint Score (FJS) as patient reported outcomes measurement system (PROMs). A radiological evaluation was made by a single physician at 6 months. Results Average improvement in OKS was from 20.2 (SD 5.5) pre-operatively to 41.3 (SD 2.1) at the final FU. KSS pain/motion improved with a mean score from 40.1 (SD 4.0) pre-op to 89.1 (SD 6.3) while KSS function improved with an average score from 51.0 (SD 6.2) pre-op to 81.8 (SD 8.4) showing good to excellent results in all the knee treated. The mean FJS at 6 months follow up was 75.1 (SD 4.2) improving to 79.3 (SD 3.3) at one year FU. Post-operative XR showing an average varus Hip-Knee-Ankle (HKA) angle of 178.8° (range from 176° to 182°, SD 2,3°); We found no statistically significant difference between pre-operative and post-operative HKA (p < 0,05). Conclusion The current authors assumed appropriate to combine a modern TKA implant designed replicating the anatomical shape of the native knee with a surgical technique able to better reproduce the physiological, patient specific, knee biomechanics. Our findings suggest that combining MS implant with KA technique may results in better short-term functional results, helping the patient to "forget" their replaced joint and restoring their pre-arthritic quality of life.
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Affiliation(s)
- Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, "Maggiore" Hospital of Chieri, Chieri, Turin, Italy.,Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System(PAVAHCS), Palo Alto, CA, USA
| | - Luigi Sabatini
- Department of Orthopaedic Surgery and Traumatology. University of Turin. "Città della salute e della scienza"-CTO Hospital of Turin. Turin, Italy
| | - Luca Barberis
- Department of Orthopaedic Surgery and Traumatology. University of Turin. "Città della salute e della scienza"-CTO Hospital of Turin. Turin, Italy
| | - Federico Fusini
- Department of Orthopaedic Surgery and Traumatology. University of Turin. "Città della salute e della scienza"-CTO Hospital of Turin. Turin, Italy
| | - Michele Malavolta
- Knee Department, Paolo Pederzoli Private Hospital, Peschiera del Garda, Verona, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System(PAVAHCS), Palo Alto, CA, USA
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Roussot MA, Vles GF, Oussedik S. Clinical outcomes of kinematic alignment versus mechanical alignment in total knee arthroplasty: a systematic review. EFORT Open Rev 2020; 5:486-497. [PMID: 32953134 PMCID: PMC7484715 DOI: 10.1302/2058-5241.5.190093] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although mechanical alignment (MA) has traditionally been considered the gold standard, the optimal alignment strategy for total knee arthroplasty (TKA) is still debated. Kinematic alignment (KA) aims to restore native alignment by respecting the three axes of rotation of the knee and thereby producing knee motion more akin to the native knee. Designer surgeon case series and case control studies have demonstrated excellent subjective and objective clinical outcomes as well as survivorship for KA TKA with up to 10 years follow up, but these results have not been reproduced in high-quality randomized clinical trials. Gait analyses have demonstrated differences in parameters such as knee adduction, extension and external rotation moments, the relevance of which needs further evaluation. Objective improvements in soft tissue balance using KA have not been shown to result in improvements in patient-reported outcomes measures. Technologies that permit accurate reproduction of implant positioning and objective measurement of soft tissue balance, such as robotic-assisted TKA and compartmental pressure sensors, may play an important role in improving our understanding of the optimum alignment strategy and implant position.
Cite this article: EFORT Open Rev 2020;5:486-497. DOI: 10.1302/2058-5241.5.190093
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Affiliation(s)
- Mark Anthony Roussot
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK.,Department of Orthopaedic Surgery, University of Cape Town, South Africa
| | - Georges Frederic Vles
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
| | - Sam Oussedik
- Department of Trauma and Orthopaedics, University College London Hospitals, London, UK
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40
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[Limits of kinematic alignment and recommendations for its safe application]. DER ORTHOPADE 2020; 49:617-624. [PMID: 32494904 DOI: 10.1007/s00132-020-03931-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite the growing clinical evidence "pro" kinematic alignment (KA) in primary total knee arthroplasty, the idea of this individualized implant positioning has not (yet) become established throughout the community. Many surgeons have concerns about the safety of the method and the universality of its application. Interestingly, comparative studies with unlimited indications for KA showed only little or no advantage over standard mechanical alignment in contrast to studies with strict indications showing a significant benefit. QUESTION AND METHODOLOGY This results in a discussion about possible indication limits for KA. The aim of this article is to summarize the current evidence and theoretical considerations regarding ideal and possibly non-ideal patients. Furthermore, the paper describes the "lessons learned" of the past years as a recommendation for safe use of the method. RESULTS AND DISCUSSION Based on current evidence, primary varus osteoarthritis appears to be a good indication for KA. A limitation, however, is extra-articular deformities that lead to a pathologically joint line angle. Instabilities of the collateral ligaments are to be considered as a contraindication. In contrast to varus type osteoarthritis, valgus deformities appear to be more critical for KA. Even though there is yet only limited evidence, especially the accompanying extra-articular pathologies of the hip and ankle pose an increased risk of failure. In our opinion, a restricted KA with an individualized component position but neutral overall limb alignment makes sense here. To analyze the suitability of KA and estimate the post-operative component position, weight-bearing long-leg x‑rays are recommended. Additional stress radiography is helpful in certain cases, as is the three-dimensional analysis of the anatomy by CT or MRI scans.
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Sappey-Marinier E, Pauvert A, Batailler C, Swan J, Cheze L, Servien E, Lustig S. Kinematic versus mechanical alignment for primary total knee arthroplasty with minimum 2 years follow-up: a systematic review. SICOT J 2020; 6:18. [PMID: 32553101 PMCID: PMC7301633 DOI: 10.1051/sicotj/2020014] [Citation(s) in RCA: 32] [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: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The aim of this study was to perform a systematic review of the literature to determine whether there are any clinical or radiological differences in mechanically aligned Total Knee Arthroplasty (TKA) compared with kinematically aligned TKA. METHODS This study included retrospective cohort studies, prospective randomized controlled trials (PRCTs) and prospective cohort studies comparing clinical and radiological outcomes, and complications in TKA with kinematic alignment (KA) and mechanical alignment (MA). All studies had a minimum follow-up of 2 years. RESULTS Five PRCTs published between 2014 and 2020 were included. These studies showed a low risk of bias and were of very high quality. We did not find a superiority of KA compared to MA technique for clinical and radiological outcomes, except in one study which showed a significant difference favoring KA between the two groups for all clinical scores. CONCLUSION We found that KA in TKA achieved clinical and radiological results similar to those of MA. The complication rate was not increased for KA TKAs. Studies with longer follow-up and larger cohorts are required to prove any benefit of KA technique over MA technique.
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Affiliation(s)
- Elliot Sappey-Marinier
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
| | - Adrien Pauvert
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
| | - Cécile Batailler
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
| | - John Swan
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
| | - Laurence Cheze
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
| | - Elvire Servien
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
- LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University 69100 Villeurbanne France
| | - Sébastien Lustig
- FIFA medical center of excellence, Orthopaedics Surgery and Sports Medicine Department, Croix-Rousse Hospital, Hospices Civils de Lyon 103 Grande rue de la Croix Rousse 69004 Lyon France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
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42
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Ettinger M, Tücking LR, Savov P. [Kinematic alignment in total knee arthroplasty with image-based and image-independent robotic support]. DER ORTHOPADE 2020; 49:604-610. [PMID: 32447404 DOI: 10.1007/s00132-020-03924-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Ettinger
- Klinik für Orthopädie im Annastift, Medizinische Hochschule Hannover, Anna-von-Borries-Straße 1, 30625, Hannover, Deutschland.
| | - L-R Tücking
- Klinik für Orthopädie im Annastift, Medizinische Hochschule Hannover, Anna-von-Borries-Straße 1, 30625, Hannover, Deutschland
| | - P Savov
- Klinik für Orthopädie im Annastift, Medizinische Hochschule Hannover, Anna-von-Borries-Straße 1, 30625, Hannover, Deutschland
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43
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Kinematically aligned TKA restores physiological patellofemoral biomechanics in the sagittal plane during a deep knee bend. Knee Surg Sports Traumatol Arthrosc 2020; 28:1497-1507. [PMID: 31147726 DOI: 10.1007/s00167-019-05547-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Although patellofemoral complications after kinematically aligned (KA) TKA are infrequent, the patellar flexion angle and proximal-distal patellar contact location through flexion, and incidence of patellar loss of contact at full extension are unknown. The present study determined whether the patellar flexion angle and proximal-distal patellar contact location of a KA TKA performed with anatomic, fixed-bearing, posterior cruciate-retaining (PCR) components differed from those of the native contralateral knee during a deep knee bend, and determined the incidence of patellar loss of contact at full extension for KA TKA only. METHODS During a deep knee bend from full extension to maximum flexion, both knees were imaged in a lateral view using single-plane fluoroscopy for 25 patients with a calipered KA TKA and a healthy native knee in the contralateral limb. The patellar flexion angle and proximal-distal patellar contact location were measured on images from full extension to maximum flexion in 30° increments. Paired t tests at each flexion angle determined the significance of the difference between the KA TKA knees and the native contralateral knees. In the KA TKA knees, the incidence of patellar loss of contact at full extension was determined. Patient-reported outcome scores also were recorded including the Oxford Knee Score. RESULTS Mean patellar flexion angles were not different between the KA TKA knees and the native contralateral knees throughout the motion arc. The largest statistically significant difference in the mean proximal-distal patellar contact locations was 4 mm. The incidence of patellar loss of contact in the KA TKA knees at full extension was 8% (2 of 25 patients). The median Oxford Knee Score was 46 out of 48. CONCLUSIONS Calipered KA TKA performed with anatomic, fixed-bearing, PCR components restored patellar flexion angles to native and largely restored the proximal-distal patellar contact locations, which at most differed from the native contralateral knee by approximately 10% of the mean proximal-distal patellar length. In the KA TKA knees, the incidence of patellar loss of contact was infrequent. These objective biomechanical results are consistent with the relatively high subjective patient-reported outcome scores herein and support the low incidence of patellofemoral complications following KA TKA previously reported. LEVEL OF EVIDENCE Therapeutic, level III.
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44
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Design improvement in patient-specific instrumentation for total knee arthroplasty improved the accuracy of the tibial prosthetic alignment in the coronal and axial planes. Knee Surg Sports Traumatol Arthrosc 2020; 28:1560-1567. [PMID: 31240377 DOI: 10.1007/s00167-019-05571-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 06/17/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE The accuracy of patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) is still controversial, especially in the tibial prosthesis. It was hypothesized that the design modification of PSI improved the tibial prosthetic alignment and reduced the associated complications. The aim of this study was to compare the accuracy of a conventional PSI with that of a newly designed PSI for total knee arthroplasty (TKA) using a new three-dimensional (3D) measurement method. METHODS Thirty TKAs each using the conventional and newly designed PSIs were studied. The postoperative 3D-computed tomography (3D CT) image was superimposed on the preoperative 3D CT plan. The absolute differences in the tibial prosthetic alignment between the preoperative and postoperative 3D CT images were directly measured in the coronal, sagittal, and axial planes. Knees in which the difference in the prosthetic alignment was > 3° were considered deviations. RESULTS The new PSI showed less mean absolute differences and lower rate of deviations than the conventional PSI in the coronal and axial planes (p = 0.045 and p = 0.004, respectively). The deviations (> 3°) of the tibial prosthesis using the conventional PSI were 27, 30, and 63% and of those using the new PSI were 0, 20, and 20% in the coronal, sagittal, and axial planes, respectively. CONCLUSIONS This is the first report to evaluate the effect of improvement in PSI design on the postoperative alignment using 3D method, and it clearly showed that the modification significantly improved the accuracy of alignment and reduced the deviations. LEVEL OF EVIDENCE Therapeutic study, case-control study, Level III.
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45
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Kim KK, Howell SM, Won YY. Kinematically Aligned Total Knee Arthroplasty with Patient-Specific Instrument. Yonsei Med J 2020; 61:201-209. [PMID: 32102120 PMCID: PMC7044694 DOI: 10.3349/ymj.2020.61.3.201] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/30/2019] [Indexed: 11/27/2022] Open
Abstract
Kinematically aligned total knee arthroplasty (TKA) is a new alignment technique. Kinematic alignment corrects arthritic deformity to the patient's constitutional alignment in order to position the femoral and tibial components, as well as to restore the knee's natural tibial-femoral articular surface, alignment, and natural laxity. Kinematic knee motion moves around a single flexion-extension axis of the distal femur, passing through the center of cylindrically shaped posterior femoral condyles. Since it can be difficult to locate cylindrical axis with conventional instrument, patient-specific instrument (PSI) is used to align the kinematic axes. PSI was recently introduced as a new technology with the goal of improving the accuracy of operative technique, avoiding practical issues related to the complexity of navigation and robotic system, such as the costs and higher number of personnel required. There are several limitations to implement the kinematically aligned TKA with the implant for mechanical alignment. Therefore, it is important to design an implant with the optimal shape for restoring natural knee kinematics that might improve patient-reported satisfaction and function.
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Affiliation(s)
- Kwang Kyoun Kim
- Department of Orthopaedic Surgery, Konyang University College of Medicine, Daejeon, Korea
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California at Davis, Davis, CA, USA
| | - Ye Yeon Won
- Department of Orthopedic Surgery, Ajou University College of Medicine, Suwon, Korea.
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46
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MacDessi SJ, Griffiths-Jones W, Chen DB, Griffiths-Jones S, Wood JA, Diwan AD, Harris IA. Restoring the constitutional alignment with a restrictive kinematic protocol improves quantitative soft-tissue balance in total knee arthroplasty: a randomized controlled trial. Bone Joint J 2020; 102-B:117-124. [PMID: 31888372 PMCID: PMC6974544 DOI: 10.1302/0301-620x.102b1.bjj-2019-0674.r2] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS It is unknown whether kinematic alignment (KA) objectively improves knee balance in total knee arthroplasty (TKA), despite this being the biomechanical rationale for its use. This study aimed to determine whether restoring the constitutional alignment using a restrictive KA protocol resulted in better quantitative knee balance than mechanical alignment (MA). METHODS We conducted a randomized superiority trial comparing patients undergoing TKA assigned to KA within a restrictive safe zone or MA. Optimal knee balance was defined as an intercompartmental pressure difference (ICPD) of 15 psi or less using a pressure sensor. The primary endpoint was the mean intraoperative ICPD at 10° of flexion prior to knee balancing. Secondary outcomes included balance at 45° and 90°, requirements for balancing procedures, and presence of tibiofemoral lift-off. RESULTS A total of 63 patients (70 knees) were randomized to KA and 62 patients (68 knees) to MA. Mean ICPD at 10° flexion in the KA group was 11.7 psi (SD 13.1) compared with 32.0 psi in the MA group (SD 28.9), with a mean difference in ICPD between KA and MA of 20.3 psi (p < 0.001). Mean ICPD in the KA group was significantly lower than in the MA group at 45° and 90°, respectively (25.2 psi MA vs 14.8 psi KA, p = 0.004; 19.1 psi MA vs 11.7 psi KA, p < 0.002, respectively). Overall, participants in the KA group were more likely to achieve optimal knee balance (80% vs 35%; p < 0.001). Bone recuts to achieve knee balance were more likely to be required in the MA group (49% vs 9%; p < 0.001). More participants in the MA group had tibiofemoral lift-off (43% vs 13%; p < 0.001). CONCLUSION This study provides persuasive evidence that restoring the constitutional alignment with KA in TKA results in a statistically significant improvement in quantitative knee balance, and further supports this technique as a viable alternative to MA. Cite this article: Bone Joint J. 2020;102-B(1):117-124.
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Affiliation(s)
- Samuel J MacDessi
- Sydney Knee Specialists, Kogarah, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | | | - Sam Griffiths-Jones
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jil A Wood
- Sydney Knee Specialists, Kogarah, Australia
| | - Ashish D Diwan
- St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | - Ian A Harris
- Orthopaedic Surgery, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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47
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Calliess T, Ettinger M, Savov P, Karkosch R, Windhagen H. Individualized alignment in total knee arthroplasty using image-based robotic assistance : Video article. DER ORTHOPADE 2019; 47:871-879. [PMID: 30218354 PMCID: PMC6182501 DOI: 10.1007/s00132-018-3637-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Introduction Over the past decades many innovations were introduced in total knee arthroplasty (TKA) focusing on implant longevity and higher procedural precision; however, there are still a high number of dissatisfied patients. It was reported that better anatomical alignment may result in improved patient outcome; however, current technologies have limitations to achieve this. The aim of this video article is to describe the technique of individualized alignment in TKA with the use of image-based robotic assistance. Methods The technology is based on an individual patient knee model computed from segmented computed tomography (CT) scans. A preoperative planning of prosthesis position is conducted following the principle of kinematic alignment. Intraoperatively the soft tissue envelope is recorded and the computer predicts the gap balance based on the virtual planning. The prosthesis position is then adapted to achieve balanced gaps and to avoid soft tissue release. This technique is shown in a cadaver operation and clinical examples of two patients are described. Results With the combination of anatomically oriented prosthesis positioning and minor adaptations with respect to the soft tissue, an individualized alignment is achieved with reduced need of soft tissue release. The robotic-assisted surgery guarantees a precise implementation of the planning. The initial experience showed a promising outcome in short-term follow-up. Video online The online version of this article (10.1007/s00132-018-3637-1) contains a video on patient individualized alignment in total knee arthroplasty. The article and video are available in the electronic full text archive at SpringerMedizin.de under http://www.springermedizin.de/der-orthopaede. The video can be found at the end of the article as supplementary material.
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Affiliation(s)
- Tilman Calliess
- Department for Orthopedic Surgery at Annastift Hospital, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.
| | - Max Ettinger
- Department for Orthopedic Surgery at Annastift Hospital, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Peter Savov
- Department for Orthopedic Surgery at Annastift Hospital, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Roman Karkosch
- Department for Orthopedic Surgery at Annastift Hospital, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Henning Windhagen
- Department for Orthopedic Surgery at Annastift Hospital, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
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48
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van der Merwe J, van den Heever DJ, Erasmus P. Variability, agreement and reliability of MRI knee landmarks. J Biomech 2019; 95:109309. [PMID: 31439332 DOI: 10.1016/j.jbiomech.2019.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
Abstract
Surface mesh reconstructions of bones are often required to define landmark-based coordinate systems, regions of interest and morphological features when studying the soft tissues of the knee from MRI scans. This study reports the variability, agreement and reliability of osseous landmarks to better understand their downstream effects. Fifteen landmarks were defined on the distal femur and twelve on the proximal tibia. Surface meshes were created from twenty right knee MRI scans with a mean subject age of 30.9 years. A single observer identified landmarks on all twenty knees, while three observers repeated the observations three times on a subset of eight knees. All observations were aligned to the Procrustes mean shapes. Principal component analysis was used to study inter-subject variability and two-way ANOVA for inter- and intra-observer agreement and reliability. Inter-subject landmark variation ranged from 0.6 to 5.26 mm, while inter- and intra-observer agreement were at most 5.1 and 5.69 mm respectively. Between-observer reliability ranged from 0.07 to 0.98 while within-observer values were between 0.51 and 0.98. Landmarks derived from fitted spheres or circles often performed well, while most others had their poorest agreement or greatest variation limited to only one or two cardinal directions.
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Affiliation(s)
- Johan van der Merwe
- Biomedical Engineering Research Group, Department of Mechanical and Mechatronic Engineering, Stellenbosch University, Stellenbosch 7600, South Africa.
| | - Dawie J van den Heever
- Biomedical Engineering Research Group, Department of Mechanical and Mechatronic Engineering, Stellenbosch University, Stellenbosch 7600, South Africa
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Laende EK, Richardson CG, Dunbar MJ. A randomized controlled trial of tibial component migration with kinematic alignment using patient-specific instrumentation versus mechanical alignment using computer-assisted surgery in total knee arthroplasty. Bone Joint J 2019; 101-B:929-940. [PMID: 31362561 DOI: 10.1302/0301-620x.101b8.bjj-2018-0755.r3] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement. PATIENTS AND METHODS A total of 47 patients due to undergo TKA were randomized to KA+PSI (n = 24) or MA+CAS (n = 23). In the KA+PSI group, there were 16 female and eight male patients with a mean age of 64 years (sd 8). In the MA+CAS group, there were 17 female and six male patients with a mean age of 63 years (sd 7). Surgery was performed using cemented, cruciate-retaining Triathlon total knees with patellar resurfacing, and patients were followed up for two years. The effect of alignment on tibial component migration and inducible displacement was analyzed irrespective of study group. RESULTS There was no difference over two years in longitudinal migration of the tibial component between the KA+PSI and MA+CAS groups (reaching median maximum total point motion migration at two years of 0.40 mm for the KA+PSI group and 0.37 mm for the MA+CAS group, p = 0.82; p = 0.68 adjusted for age, sex, and body mass index (BMI) for all follow-ups). Both groups had mean migrations below acceptable thresholds. There was no difference in inducible displacement (p = 0.34) or PROMS (p = 0.61 for the Oxford Knee Score) between groups. There was no correlation between alignment and tibial component migration or alignment and inducible displacement. These findings support non-neutral alignment as a viable option with this component, with no evidence that it compromises fixation. CONCLUSION Kinematic alignment using patient-specific instrumentation in TKA was associated with acceptable tibial component migration, indicating stable fixation. These results are supportive of future investigations of kinematic alignment. Cite this article: Bone Joint J 2019;101-B:929-940.
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Affiliation(s)
- E K Laende
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
| | - C G Richardson
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
| | - M J Dunbar
- Department of Surgery, Dalhousie University, Halifax, Canada.,QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Canada
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50
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Roussot MA, Haddad FS. The evolution of patellofemoral prosthetic design in total knee arthroplasty: how far have we come? EFORT Open Rev 2019; 4:503-512. [PMID: 31538000 PMCID: PMC6719608 DOI: 10.1302/2058-5241.4.180094] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Total knee arthroplasty (TKA) has evolved into a successful, cost-effective treatment for end-stage knee arthrosis.The patellofemoral articulation in TKA has largely been ignored during its development despite being an important determinant of outcome.New technologies still need further development to incorporate the patella in TKA surgical planning and operative technique.Alternative approaches to alignment in TKA will have a secondary impact on patellofemoral mechanics and possibly future implant designs.Technologies that assist with precise implant positioning may alter our understanding and overall practice of TKA. Cite this article: EFORT Open Rev 2019;4:503-512. DOI: 10.1302/2058-5241.4.180094.
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Affiliation(s)
- Mark Anthony Roussot
- University College London Hospitals NHS Foundation Trust, London, UK.,Department of Orthopaedic Surgery, University of Cape Town, SA
| | - Fares Sami Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
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