1
|
Kim CH, Park YB, Baek SH. Clinical and Radiological Outcomes of Computer-Assisted Navigation in Primary Total Knee Arthroplasty for Patients with Extra-articular Deformity: Systematic Review and Meta-Analysis. Clin Orthop Surg 2024; 16:430-440. [PMID: 38827763 PMCID: PMC11130617 DOI: 10.4055/cios23261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 06/05/2024] Open
Abstract
Background Computer-assisted navigation surgery (CAS) during primary total knee arthroplasty (TKA) may help improve outcomes for patients with extra-articular deformity (EAD); however, this has not been extensively studied. Therefore, we aimed to investigate the clinical and radiological outcomes following primary TKA using CAS in patients with EAD. Methods We searched Medline, Embase, and the Cochrane Library up to March 3, 2023 for studies investigating surgical outcomes of using the navigation system for TKA to treat patients with EAD. From 14 studies, 539 knees with EAD that underwent navigation TKA were enrolled. We investigated the knee range of motion (ROM), outcome scores at final follow-up (Knee Society Score [KSS] and Knee Functional Score [KFS]), and pre- and postoperative mechanical hip-knee-ankle (mHKA) angle using lower extremity scanogram. The meta-analysis was based on the single-arm method, and all data were pooled using a random-effects model. Results Following our meta-analyses, the mean knee ROM changed from 87.0° (95% confidence interval [CI], 75.9°-98.1°) preoperatively to 109.4° (95% CI, 97.9°-120.8°) postoperatively. The adjusted KSS was 93.45 points (95% CI, 88.36-98.54 points), and the adjusted KFS was 91.57 points (95% CI, 86.80-96.33 points) in knees with EAD that underwent CAS-TKA. As a radiological outcome, the mHKA angle changed from 169.53° (95% CI, 166.90°-172.16°) preoperatively to 178.81° (95% CI, 178.31°-179.30°) postoperatively. Conclusions CAS-TKA yielded positive clinical results and demonstrated a satisfactory alignment of the lower limb's mechanical axis. CAS-TKA showed promise for primary TKA procedures, demonstrating favorable clinical and radiological outcomes even in complex cases involving EAD.
Collapse
Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Suk Ho Baek
- Department of Orthopedic Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| |
Collapse
|
2
|
John R, Sherman K, Sharma H. Surgical principles for complex primary total knee arthroplasty in the presence of extra-articular deformity. J Orthop 2022; 34:295-303. [PMID: 36164287 PMCID: PMC9508380 DOI: 10.1016/j.jor.2022.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/15/2022] [Indexed: 12/13/2022] Open
Abstract
Background Accurate restoration of alignment is vital to the success of a total knee arthroplasty (TKA) procedure. Deformities, whether these are intra-articular and/or extra-articular AND/OR whether these are uniplanar/multiplanar/complex, can impose varying technical challenges in surgical planning and execution. Literature on performing TKA in presence of limb deformity is limited, especially for extra-articular deformities. Objectives The objectives of this narrative review are twofold. Firstly, we analyse the existing English literature for studies focussed on TKA and deformity correction and summarise the important points about deformity pathomechanics, clinical and radiological assessment, pre-operative planning and surgical techniques. The second objective is to provide the readers with a simplistic and wholistic management algorithm to assist surgeons in meticulous planning to tackle the technical challenges imposed by lower limb deformities while performing a TKA. Discussion Approach to each patient must be holistic and customised on an individual basis according to patient characteristics, deformity characteristics and surgeon experience. The three main options available are: (1) Primary TKA (symmetric cuts/asymmetric cuts with/without computer navigation assistance) (2) Single stage corrective osteotomy and TKA and (3) Two-staged deformity correction and TKA. A multi-disciplinary team approach is required and a knee surgeon well-versed in revision arthroplasty and a limb reconstruction surgeon specialising in deformity correction, should be involved from the outset. The use of computer navigation technology, particularly for deformity correction and TKA, has increased over the last couple of decades and is recommended by the authors for these challenging cases.
Collapse
Affiliation(s)
- Rakesh John
- Department of Trauma & Orthopaedics, Hull University Teaching Hospital, Hull, East Yorkshire, UK
| | - Kevin Sherman
- University of Cambridge, Human Anatomy Centre, Department of Physiology, Development and Neuroscience, UK
| | - Hemant Sharma
- Department of Trauma & Orthopaedics, Hull University Teaching Hospital, Hull, East Yorkshire, UK
| |
Collapse
|
3
|
Pietsch M, Hochegger M, Djahani O, Mlaker G, Eder-Halbedl M, Hofstädter T. Handheld computer-navigated constrained total knee arthroplasty for complex extra-articular deformities. Arch Orthop Trauma Surg 2021; 141:2245-2254. [PMID: 34255171 DOI: 10.1007/s00402-021-04053-1] [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: 02/08/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The present study aimed to assess the postoperative alignment and clinical outcomes of patients with complex extra-articular deformities (EADs) undergoing computer-assisted surgery (CAS) for constrained total knee arthroplasty (TKA) with modular stem extensions. MATERIALS AND METHODS From May 2015 to July 2018, ten patients with EADs scheduled for constrained TKA were enrolled retrospectively. The preoperative average deviation from neutral (= 180°) mechanical axis was 15.3° (range of coronal alignment: 150.9° varus-202.9° valgus). Alignment was assessed using an accelerometer-based handheld CAS system. On long-leg films, the positions of the components and possible stems were analysed and templated preoperatively. The average follow-up was 3.3 years (range: 2.0-4.6 years). RESULTS The postoperative mechanical axis was within ± 3.0° from neutral in nine patients. In all patients, the Knee Society score (KSS) and range of motion improved significantly. A constrained condylar and a rotating hinge prosthesis were used in five patients each. In eight patients, the 100-mm cementless stem that was preferred by the authors was found to be unusable for the femur or the tibia in the planning stage. For the femur, a cementless 100-mm stem was used in three, and a cemented 30-mm stem in five patients; a femoral stem was not usable in two patients. For the tibia, a cementless 100-mm stem was used in six, and a cemented 30-mm stem in two patients; a monoblock rotating hinge tibia was used in two patients. CONCLUSIONS Complex EADs were excellently managed during constrained TKA implantation using the handheld CAS system. Templating allowed the possible stem lengths to be identified and prevented anatomical conflict with the CAS-configured mechanical alignment. Limb alignment and function improved significantly after surgery. No intra- or postoperative complications occurred. LEVEL OF EVIDENCE Level IV, retrospective study.
Collapse
Affiliation(s)
- M Pietsch
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria.
| | - M Hochegger
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria
| | - O Djahani
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria
| | - G Mlaker
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria
| | - M Eder-Halbedl
- Department of Orthopaedic Surgery, Orthopaedic Hospital Stolzalpe (LKH Murtal), Stolzalpe 38, 8852, Stolzalpe, Austria
| | - Th Hofstädter
- Department of Orthopaedic and Trauma Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| |
Collapse
|
4
|
Ross KA, Wiznia DH, Long WJ, Schwarzkopf R. The Use of Computer Navigation and Robotic Technology in Complex Total Knee Arthroplasty. JBJS Rev 2021; 9:e20.00200. [PMID: 33999911 DOI: 10.2106/jbjs.rvw.20.00200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The potential benefits of computer-assisted surgical (CAS) navigation and robotic total knee arthroplasty (TKA) systems, such as increased reliability of restoring the mechanical axis, fewer outliers, more rapid hospital discharge, less physical therapy requirements, decreased blood loss, and decreased revision rates, have led to their application not only in primary cases but also in complex cases such as preoperative deformity and revision. » Early evidence demonstrates that CAS navigation may help to improve alignment in complex cases of femoral and tibial deformity and in cases of femoral bowing. » Data regarding deformity correction with robotic systems are similar to CAS navigation with regard to alignment, but are more limited. There are also scant data regarding revision cases and cases of previous intramedullary canal instrumentation. » Concerns remain regarding cost, learning curves, and operative times. There are potential long-term cost savings associated with a decrease in revisions and readmissions that require additional investigation. » Early evidence for the use of these emerging technologies for deformity correction and revision cases is promising, but their impact on long-term functional outcomes remains to be demonstrated. Additional well-designed comparative studies are warranted.
Collapse
Affiliation(s)
- Keir A Ross
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY
| | - Daniel H Wiznia
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - William J Long
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY
| |
Collapse
|
5
|
Matassi F, Cozzi Lepri A, Innocenti M, Zanna L, Civinini R, Innocenti M. Total Knee Arthroplasty in Patients With Extra-Articular Deformity: Restoration of Mechanical Alignment Using Accelerometer-Based Navigation System. J Arthroplasty 2019; 34:676-681. [PMID: 30685259 DOI: 10.1016/j.arth.2018.12.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/27/2018] [Accepted: 12/31/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) in patients with post-traumatic extra-articular deformity (EAD) is difficult to manage using conventional instrumentation techniques. In this study, we evaluate whether accelerometer navigation system can be a valuable option to make accurate bone resections and restore the neutral mechanical axis in complex TKA patients with EAD. METHODS From May 2015 to June 2017, 18 consecutive TKA were performed in 18 patients with knee osteoarthritis with associated EAD. An accelerometer-based navigation system was used to guide tibial and femoral resection in the coronal and sagittal plane. Postoperative lower limb alignment in coronal plane and component position in coronal and sagittal plane was measured through full-leg weight-bearing X-ray. Clinical score were recorded using the Knee Society Score at the final follow-up. RESULTS The mean hip-knee-ankle angle was 0.9° ± 1.4° varus alignment. The coronal alignment of the femoral component was 89.2° ± 1.9°, and the coronal alignment of the tibial component was 89.4° ± 2.1°. The sagittal alignment of the femoral component was 93.2°± 1.9°, and the sagittal alignment of the tibial component was 84.4° ± 3.1°. At the final follow-up, the Knee Society Score was 89 points (range, 82-100), and the functional score was 86.7 points (range, 60-100). No intraoperative and postoperative surgical complications were reported using this technology. CONCLUSION Accelerometer-based navigation is accurate in achieving neutral mechanical alignment and optimal implant position after TKA in patients with EAD. This system should be considered a valuable option to the more complex technique of computer navigation or robotic surgery.
Collapse
Affiliation(s)
| | | | | | - Luigi Zanna
- University of Florence, Orthopaedic Clinic CTO, Florence, Italy
| | | | | |
Collapse
|
6
|
Khanna V, Sambandam SN, Ashraf M, Mounasamy V. Extra-articular deformities in arthritic knees-a grueling challenge for arthroplasty surgeons: An evidence-based update. Orthop Rev (Pavia) 2018; 9:7374. [PMID: 29564077 PMCID: PMC5850062 DOI: 10.4081/or.2017.7374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 12/21/2022] Open
Abstract
Critical to the success of a total knee arthroplasty (TKA) is the anatomical alignment. This may appear as a challenge in an extra-articular deformity (EAD) that may be inherent in certain people or result from fracture malunion, congenital disorders, nutritional, metabolic and infective causes. This appraisal aimed at providing the reader with an up-todate overview of the research carried out on, and existent evidence of EAD correction while planning a TKA. We reviewed the current English literature on TKA in extra-articular knee deformities. Among the published data, a common initial approach of mandatory clinical and radiological assessment emerges as an obligatory step while handling cases with EAD. While several methods of managing the deformity and arthritis have been described, a broad division into intra-articular and extra-articular means can be deciphered. The relatively old-school, yet reliable thought process of extra-articular correction allows an all-inclusive restoration of alignment with the inherent complications related to the necessary osteotomy. A cohort of younger and more venturesome surgeons seem inclined towards performing navigated, intra-articular correction for mild to moderate and sometimes, severe deformities. The crux of the matter lies is obtaining a well-balanced knee without violating the all-important cruciates. Restoring the patient’s ambulatory status seems sooner with the intra-articular methods which are also more precise in determining the axes and while removing minimum bone. Greatest satisfaction is accomplished in those with less grotesque, rotationallyaligned knees while meticulously balancing soft-tissues and encouraging earlier weightbearing.
Collapse
Affiliation(s)
| | | | - Munis Ashraf
- K.G. Hospital and Post Graduate Medical Institute, Arts College Road, Coimbatore, Tamil Nadu, India
| | | |
Collapse
|
7
|
Mai CMY, Leuk TW, Kwan WM, Bong LO, Ho LK. Comparison of Postoperative Alignment of Total Knee Replacement Using Computer-Assisted Navigation with Conventional Guiding System in Chinese Population with Significant Coronal Femoral Bowing. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2015. [DOI: 10.1016/j.jotr.2014.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Background/Purpose Coronal femoral bowing is common in Chinese population. This might affect the restoration of mechanical alignment in conventional total knee replacement (TKR). The aim of the study was to compare the postoperative alignment of conventional TKR with computer-assisted navigation TKR (CAN-TKR), to investigate the effect of femoral bowing on postoperative alignment in conventional TKR and to understand the role of CAN-TKR in limbs with significant femoral bowing. Methods This is a retrospective study of 331 knees that underwent TKR (either conventional or CAN-TKR) in our centre from January 2010 to June 2012. The incidence of coronal femoral bowing was measured. The postoperative alignments were compared between the two groups. Results The incidence of excessive coronal femoral bowing was 41.4%. For patients with or without significant coronal femoral bowing, the CAN-TKR group was significantly better in restoring postoperative mechanical axis and the coronal femoral angle (p < 0.05). Proportions of outliers were also much less in the CAN-TKR group. Conclusion CAN-TKR reduces outliers in all patients, and is especially superior in restoring mechanical alignments in patients with significant coronal femoral bowing.
Collapse
Affiliation(s)
- Chow Mei Yee Mai
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Tsang Wai Leuk
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Wong Man Kwan
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Lee On Bong
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Leung Kin Ho
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| |
Collapse
|
8
|
Navigation-Assisted Total Knee Arthroplasty for Osteoarthritis with Extra-Articular Femoral Deformity and/or Retained Hardware. Case Rep Orthop 2013; 2013:174384. [PMID: 24191210 PMCID: PMC3794565 DOI: 10.1155/2013/174384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 08/21/2013] [Indexed: 11/18/2022] Open
Abstract
Total knee arthroplasty (TKA) for osteoarthritis (OA) patients with extra-articular deformity is still challenging because angular deformity, canal sclerosis, or the retained hardware that precludes the use of the traditional intramedullary guide. In addition, atypical bone cut for intra-articular correction leads to imbalanced soft tissue gap. Furthermore, corrective osteotomy should be considered for severe deformity or para-articular deformity cases. Recently, navigation-assisted TKA has been reported to increase the accuracy of prosthetic positioning and limb alignment. This system can calculate mechanical axis regardless of extra-articular deformity, canal sclerosis, or retained hardware. Accordingly, navigation surgery has been considered to be a powerful option especially in TKAs with extra-articular deformity cases. Here, we report 3 successful navigation-assisted TKAs for osteoarthritis with extra-articular deformities and/or retained hardware. Navigation-assisted TKA is an effective and reliable alternative for patients with extra-articular deformities.
Collapse
|