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Perelli S, Costa GG, Russo A, Hinarejos P, Torres-Claramunt R, Sanchez-Soler J, Morales-Avalos R, Monllau JC. The distal tibiofibular syndesmosis is a reliable landmark for 3° varus tibial resection in total knee arthroplasty: a radiological evaluation on 1296 cases. Arch Orthop Trauma Surg 2024; 144:879-885. [PMID: 37864591 DOI: 10.1007/s00402-023-05099-z] [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: 05/31/2023] [Accepted: 09/30/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the reproducibility and the accuracy of distal tibiofibular syndesmosis (DTFS) as landmark to perform controlled varus tibial resections during total knee arthroplasty (TKA). The hypothesis was that DTFS can be used to perform an accurate 3° varus tibial cut. METHODS A retrospective analysis on a consecutive series of standard weightbearing full-length anteroposterior views of the lower limbs radiographic images was conducted. For each radiograph, the hip-knee-ankle (HKA) angle, the angle between the tibial mechanical axis and the line connecting the centre of the tibial spines and the DTFS (tibiofibular angle, TFA) and the medial proximal tibial angle (MPTA) were calculated. Each measurement was carried out twice by three independent observers, and intra- and inter-observer measurement reliability were assessed using the intraclass correlation coefficient (ICC) analysis. RESULTS A total of 1296 lower limbs were analysed from a series of 648 weightbearing full-length anteroposterior radiographs. The ICC were > 90% for all measurements. The mean TFA value was 2.94 ± 0.68 (range 2.38-3.51). No differences were detected comparing the mean TFA value on the right and left limb (p = 0.795) as well as comparing the values in male and female patients (p = 0.691). Linear regression analysis did not find statistically significant correlation between TFA and MPTA, or TFA and HKA angles, respectively. CONCLUSION The distal tibiofibular syndesmosis is a reliable and easy reproducible radiographic landmark that can be used when planning a 3° varus tibial cut. Future studies are needed to confirm the validity of this method also in clinical settings. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Simone Perelli
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Giuseppe Gianluca Costa
- Orthopaedic and Traumatologic Unit, Umberto I Hospital, Azienda Sanitaria Provinciale di Enna, C.da Ferrante, 94100, Enna, Italy.
| | - Arcangelo Russo
- Orthopaedic and Traumatologic Unit, Umberto I Hospital, Azienda Sanitaria Provinciale di Enna, C.da Ferrante, 94100, Enna, Italy
| | - Pedro Hinarejos
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Raul Torres-Claramunt
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Juan Sanchez-Soler
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Rodolfo Morales-Avalos
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autonoma de Nuevo León, Monterrey, Mexico
| | - Juan Carlos Monllau
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
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Sugimura N, Ozaki K, Aso K, Ikeuchi M. Precision of the ultrasonography-integrated tibial extramedullary guide for total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:967-972. [PMID: 37787971 DOI: 10.1007/s00590-023-03741-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE Precise determination of the tibial mechanical axis in total knee arthroplasty (TKA) requires intraoperative identification of the talus center. We present the ultrasonography-integrated tibial extramedullary guide (USG) that enables real-time visualization of the talus. This study assesses the precision of USG compared to computer-assisted surgery (CAS) and validates the efficacy of USG. METHODS We evaluated 58 patients (62 knees) who underwent primary TKA retrospectively, categorizing them into USG and CAS groups (31 each). We statistically analyzed demographic data, the preoperative alignment of the tibial plateau to the mechanical axis, the postoperative alignment of the tibial component to planned alignment on 3D-CT, pain visual analog scale, and WOMAC scores. Additionally, the frequency of postoperative outlier from planned alignment over 2° was statistically compared. RESULTS No significant differences were observed in the preoperative data between the groups. The accuracy (mean deviation from the planned alignment) in both groups was not statistically different. However, in terms of the precision of coronal alignment, the USG group exhibited lower variance than the CAS group in the F-test (F value = 2.76, p = 0.023). Moreover, there were no postoperative deviations beyond 2 degrees in the USG group, in contrast to a 20% outlier frequency in the CAS group (p = 0.024). Concerning the precision of sagittal alignment (variance and deviations over 2°), no statistical differences were identified. CONCLUSION The USG demonstrated higher precision in the tibial coronal plane than CAS in coronal alignment. Direct identification of the individual talus may enhance precision.
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Affiliation(s)
- Natsuki Sugimura
- Department of Orthopedic Surgery, Kochi Medical School, Kochi University, 185-1 Oko-Cho Kohasu, Nankoku, Kochi, 783-8505, Japan.
| | - Kazuki Ozaki
- Department of Orthopedic Surgery, Kochi Medical School, Kochi University, 185-1 Oko-Cho Kohasu, Nankoku, Kochi, 783-8505, Japan
| | - Koji Aso
- Department of Orthopedic Surgery, Kochi Medical School, Kochi University, 185-1 Oko-Cho Kohasu, Nankoku, Kochi, 783-8505, Japan
| | - Masahiko Ikeuchi
- Department of Orthopedic Surgery, Kochi Medical School, Kochi University, 185-1 Oko-Cho Kohasu, Nankoku, Kochi, 783-8505, Japan
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Sadoghi P, Draschl A, Leitner L, Fischerauer S, Koutp A, Clar C, Leithner A, Klasan A. Restoring Tibial Slope and Sagittal Alignment of the Femoral Component in Unrestricted Kinematically Aligned Total Knee Arthroplasty Using Conventional versus Patient-Specific Instrumentation. J Knee Surg 2024; 37:2-7. [PMID: 37734408 DOI: 10.1055/a-2179-8364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Restoring sagittal alignment in kinematically aligned (KA) total knee arthroplasty (TKA) is crucial to avoid patellofemoral joint instability or overstuffing and to restore an adequate range of motion. This prospective study compared the accuracy of conventional instrumentation (CI) versus patient-specific instrumentation (PSI) in restoring sagittal alignment of KA TKA measured by the tibial slope and degree of flexion of the femoral component to the sagittal femoral axis. One hundred patients were randomized to receive either CI (n = 50) or PSI (n = 50) for KA TKA. Two observers measured pre- and postoperative X-rays to assess restoration of the tibial slope and sagittal flexion. Inter- and intraclass correlations were calculated, and postoperative tibial and femoral components were compared with preoperative anatomy. In 50 CI patients, 86% (n = 43) had the tibial slope restored exactly, and no deviation more than 1 degree was found. Deviations of 0 to 1 degree were detected in 14% (n = 7). In 50 patients of the PSI group, 56% (n = 28) achieved an exact anatomic tibial slope restoration and 20% (n = 10) showed a deviation more than 2 degrees compared with the preoperative measurement. Deviations ranging between 0 to 1 and 1 to 2 degrees were found in 22% (n = 11) and 2% (n = 1) of cases, respectively. Sagittal alignment of the femoral component showed in both groups no deviation exceeding 1 degree. The restoration of sagittal alignment in KA TKA was statistically significantly differently distributed between CI and PSI (p = < 0.001) without clinical relevance. We found that PSI increased the odds for deviations >2 degrees in tibial slope reconstructions from 0 to 0.20 ([95% confidence interval: 0.09-0.31]; p = 0.001). Both CI and PSI revealed adequate results with respect to restoring sagittal alignment of the tibial and femoral components in KA TKA. The conventional technique requires adequate adjustment of the intramedullary rod to avoid hyperflexion of the femoral component and attention must be paid when restoring the tibial slope using PSI. This is a prospective Level II study.
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Affiliation(s)
- Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Alexander Draschl
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Stefan Fischerauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Amir Koutp
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Clemens Clar
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Antonio Klasan
- Department of Orthopaedics and Traumatology, AUVA UKH Steiermark, Graz, Austria
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
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Koutp A, Clar C, Leitner L, Fischerauer S, Reinbacher P, Leithner A, Klasan A, Sadoghi P. Accuracy of Conventional Instrumentation is Dependent on Alignment Philosophy Using the Identical Surgical Technique in Total Knee Arthroplasty. J Knee Surg 2024; 37:20-25. [PMID: 37714215 DOI: 10.1055/a-2176-4767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The objective of this prospective study was to assess the precision of restoring the anatomical tibial obliquity, as measured by the medial proximal tibial angle (MPTA) on conventional X-rays, in relation to the surgical technique employed. Specifically, the study aimed to compare the accuracy of tibial obliquity restoration between kinematic alignment (KA) and conventional mechanical alignment (MA) in total knee arthroplasty (TKA). Two-hundred-and-sixty patients underwent either mechanically aligned TKA (n = 139) or kinematically aligned TKA (n = 121) using conventional instrumentation (CI). Pre- and postoperative X-rays were measured twice by two observers, with a 2-week interval. Inter- and intraclass correlations were calculated, and postoperative tibial obliquity was compared to the preoperative anatomy. In the group of 139 patients with mechanically aligned TKA, no cases with an MPTA deviation greater than 1 degree from 90 degrees were observed. Sixteen percent of the cases (n = 22) had a deviation of 0 to 1 degree. The remaining 84% of the cases (n = 117) had their MPTA of 90 degrees achieved. In the group of 121 patients with kinematically aligned TKA, no cases had a deviation greater than 1 degree compared with the preoperative MPTA. Thirty-one percent of the cases (n = 37) had a deviation of 0 to 1 degree with respect to preoperative MPTA. The remaining 69% of the cases (n = 84) had their tibial obliquity restored. Mechanically aligned TKA revealed statistically significant smaller deviations of accuracy compared to kinematically aligned TKA (p = 0.005). The inter- and intraclass correlations indicated substantial agreement of all measurements (intraclass correlation coefficient [ICC] < 0.90). Both mechanically aligned and kinematically aligned TKA demonstrated satisfactory outcomes in terms of restoring tibial obliquity or a neutral MPTA of 90 degrees using CI. However, MA showed superior results regarding precision compared to KA. When starting with kinematical alignment using CI, the surgeons should be aware that the learning curve according to accuracy differs to MA. It was a Prospective Level II study.
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Affiliation(s)
- Amir Koutp
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Clemens Clar
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Stefan Fischerauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Patrick Reinbacher
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Antonio Klasan
- Department of Orthopaedics and Traumatology, AUVA UKH Steiermark, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
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Sasaki R, Kaneda K, Yamada Y, Niki Y, Nakamura M, Nagura T, Jinzaki M. Extra-articular location of the three-dimensional mechanical axis in advanced knee osteoarthritis: an upright computed tomography study. Jpn J Radiol 2023; 41:1405-1413. [PMID: 37440161 DOI: 10.1007/s11604-023-01468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE One of the most widely used benchmarks of lower-limb alignment is the mechanical axis (MA), which passes through the centers of the femoral head and the ankle in the weight-bearing position. However, where the MA passes through three-dimensionally (3D) is unclear. We investigated the MA in 3D (3D-MA) in knee osteoarthritis (OA) using upright computed tomography (CT). MATERIALS AND METHODS This study included 66 varus OA knees from 38 patients [age 70.0 (64.8-77.0) years; median (interquartile range)]. The 3D-MA was determined using upright CT data and compared among Kellgren-Lawrence (KL) grades. Further, correlations between the 3D-MA and other parameters were evaluated. RESULTS The 3D-MA was located at 5.3 (1.3-14.4)% medially and 7.1 (0.7-15.3)% posteriorly on the tibial plateau in KL-1, and was translated medioposteriorly with increased KL grade. The 3D-MA in KL-3 [30.6 (22.6-42.6)% medially and 50.9 (45.8-80.2)% posteriorly] and KL-4 [56.7 (48.5-62.9)% medially and 92.3 (50.2-127.1)% posteriorly] was located extra-articularly. The mediolateral position of the 3D-MA correlated with the femorotibial angle [correlation coefficient (CC) = - 0.85, p < 0.001], and the anteroposterior position of the 3D-MA correlated with the knee flexion angle (CC = - 0.93, p < 0.001). CONCLUSION Our analysis demonstrated that the 3D-MA in low-grade OA knees passes slightly medial and posterior to the knee center, and the 3D-MA is translated medioposteriorly with the progression of knee OA. Further, the 3D-MA is translated medially with varus progression and posteriorly with the progression of knee flexion contracture.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kazuya Kaneda
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Yoshitake Yamada
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Yasuo Niki
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Takeo Nagura
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Smolle MA, Koutp A, Clar C, Leitner L, Leithner A, Sadoghi P. Restoring tibial obliquity for kinematic alignment in total knee arthroplasty: conventional versus patient-specific instrumentation. Arch Orthop Trauma Surg 2023; 143:5867-5872. [PMID: 36939891 PMCID: PMC10449675 DOI: 10.1007/s00402-023-04845-7] [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: 12/06/2022] [Accepted: 03/01/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION In total knee arthroplasty (TKA), tibial obliquity-restoration using kinematic alignment (KA) poses a major difference to conventional mechanical alignment. This study aimed at analysing the accuracy of conventional instrumentation (CI) versus patient-specific instrumentation (PSI) to restore anatomic tibial obliquity measured by the medial proximal tibial angle (MPTA) on conventional X-rays. MATERIALS AND METHODS One-hundred patients were randomized to receive CI (n = 50) or PSI (n = 50) for TKA. Further 100 patients received CI without randomisation, resulting in 200 patients in total (127 women, mean age: 70.7 (range: 48-90 years). Pre- and postoperative X-rays were measured twice by two observers with a 2-week break in-between. Inter- and intraclass correlations were calculated and postoperative tibial obliquity compared to preoperative anatomy. RESULTS In 150 patients with CI, no case with tibial obliquity-deviation greater than 2° was found, whilst 21.3% (n = 32) and 0.7% (n = 1) of cases and had a deviation of 0°-1°, and 1°-2°, respectively. In the remaining 78.0% (n = 117), tibial obliquity was restored. In 50 patients with PSI, no single case with a deviation greater than 1° was found. Sixty percent (n = 30) had a deviation of 0°-1°. In the remaining 40.0% (n = 20), no deviation from preoperative measurements was found. Consequently, CI resulted in a significantly smaller change in tibial obliquity from preoperative to postoperative than PSI (p < 0.001). Inter- and intra-class correlations showed a substantial agreement (any ICC > 0.90). CONCLUSION Both conventional and patient-specific instrumentation revealed adequate results with respect to restoring tibial obliquity in kinematically aligned TKA, with conventional instrumentation achieving superior results.
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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Amir Koutp
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Clemens Clar
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
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Tibesku CO, Haas SB, Saunders C, Harwood DA. Comparison of clinical outcomes of VISIONAIRE patient-specific instrumentation with conventional instrumentation in total knee arthroplasty: a systematic literature review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:4379-4393. [PMID: 36449066 PMCID: PMC10293358 DOI: 10.1007/s00402-022-04698-6] [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: 06/09/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Malalignment and resulting complications are major challenges in total knee arthroplasty (TKA) which patient-specific instrumentation (PSI) is proposed to alleviate. Previous PSI meta-analyses of TKA outcomes typically do not differentiate between PSI systems and assess relatively few outcomes, so the value of their findings is limited. VISIONAIRE™ cutting guides (Smith + Nephew Inc., Memphis, TN, USA) is a PSI system based on preoperative magnetic resonance and X-ray imaging. A systematic literature review (SLR) and meta-analysis, focussed specifically on VISIONAIRE, were conducted to assess TKA accuracy, intraoperative outcomes, and postoperative outcomes, compared with conventional instrumentation (CI). MATERIALS AND METHODS The SLR was performed using PubMed, Embase, and Google Scholar databases to identify relevant studies published until March 2022. Depending on statistical heterogeneity, meta-analyses were performed for outcome measures with fixed effect (I2 < 50%) or random-effects models (I2 ≥ 50%). Dichotomous outcomes were reported as odds ratios and continuous outcomes were reported as mean differences. Descriptive analyses were performed for outcomes not amenable to meta-analysis. RESULTS Outcomes for VISIONAIRE versus CI were reported in 25 studies. Compared with CI, VISIONAIRE reduced odds of mechanical outliers by 40% (p < 0.0001), with no statistically significant differences in odds of overall coronal, sagittal, or rotational plane component outliers. VISIONAIRE improved surgical efficiency (operating room, turnover, and tourniquet times reduced by 7.3% (p = 0.02), 42% (p = 0.022), and 15.9% (p = 0.01), respectively), lowering the odds of blood transfusion by 53% (p = 0.01) and shortening patients' hospital stays (11.1% reduction; p < 0.0001). There were no significant differences between groups in incidence of postoperative complications and (descriptively analyzed) return-to-function outcomes. CONCLUSION Options for PSI in TKA differ substantially, and it is important to assess the outcomes of individual systems. The current findings suggest that VISIONAIRE guides can lead to improved alignment accuracy and surgical efficiency compared with CI, without compromising postoperative safety and return-to-function outcomes.
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Affiliation(s)
| | - Steven B Haas
- Knee Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
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Treu EA, Frandsen JJ, Woodly C, Loughmiller S, Blackburn BE, Peters CL. Accelerometer-Based Navigation in Primary TKA Leads to Improved Alignment but No Change in PROs. J Arthroplasty 2023; 38:S222-S226. [PMID: 36889523 DOI: 10.1016/j.arth.2023.02.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/23/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Computer and accelerometer-based navigation tools have demonstrated improved mechanical alignment in primary total knee arthroplasty (TKA). Accelerometer-based navigation (ABN), in particular, is attractive due to avoidance of pins and trackers. Prior literature has yet to demonstrate an associated improvement in functional outcomes using ABN compared to conventional instrumentation (CONV). The purpose of this study was to compare alignment and functional outcomes between CONV and ABN in primary TKA in a large patient series. METHODS A retrospective study of 1,925 TKAs performed by a single surgeon sequentially was performed. There were 1,223 TKAs performed with CONV and measured resection technique. There were 702 TKAs performed with distal femoral ABN and restricted kinematic alignment goals. We compared radiographic alignment, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, rates of manipulation under anesthesia (MUA), and needs for aseptic revisions between cohorts. Chi-squared, Fisher's exact, and t-tests were used to compare demographics and outcomes. RESULTS The ABN cohort had higher rates of neutral alignment postoperatively than the CONV cohort (ABN 74 vs CONV 56%, P<0.001). Rates of MUA (ABN 2.8 vs CONV 3.4%, P=0.382) and aseptic revision (ABN 0.9 vs CONV 1.6%, P=0.189) were similar. The PROMIS physical function (ABN 42.6 vs CONV 42.9, P=0.4554), physical health (ABN 63.4 vs CONV 63.3, P=0.944), mental health (ABN 51.4 vs CONV 52.7, P=0.4349), and pain (ABN 32.7 vs CONV 30.9, P=0.256) scores were similar. CONCLUSION Accelerometer-based navigation is valuable in its ability to improve postoperative alignment, but does not improve complication rates or patient reported functional outcomes.
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Kaneko T, Yamamoto A, Takada K, Yoshizawa S. Coronal alignment classes after robotic-assisted total knee arthroplasty are not associated with variation in patient-reported outcome measurements: A single-center cohort study. Knee 2023; 41:274-282. [PMID: 36774917 DOI: 10.1016/j.knee.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/04/2022] [Accepted: 01/26/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND The aims of this study were (1) to use three-dimensional computed tomography (3DCT) measurements to determine whether patients undergoing imageless robotic-assisted total knee arthroplasty (RA-TKA) develop a variety of postoperative distal femoral mechanical angle (FMA), proximal tibial mechanical angle (TMA), and hip-knee-ankle angle (HKA) phenotypes as described by Hirschmann et al, and (2) to compare postoperative patient-reported outcome measurements (PROMs) between these phenotypes. METHOD Fifty patients with knee osteoarthritis underwent RA-TKA. All surgeries were performed using bicruciate-stabilized TKA. In each case, the postoperative HKA, FMA and TMA were classified into one of Hirschmann's five FMA, five TMA, and seven HKA phenotype categories. We investigated how these phenotypes affected patient satisfaction, 2011 Knee Society Score (KSS) subscale scores, the Forgotten Joint Score-12 (FJS-12) score, and patella scores with anterior knee pain at a mean of 15.1 months after RA-TKA. RESULTS Coronal alignment angles were assigned to three FMA, four TMA, and five HKA phenotypes. The most common FMA, TMA, and HKA phenotypes were valgus FMA 3° (58%), valgus TMA 3° (60%), and varus HKA 3° (38%). The FMA, TMA, and HKA phenotypes showed no significant differences in any PROMs. CONCLUSIONS RA-TKA led to various HKA, FMA and TMA phenotypes in the coronal plane, none of which affected PROMs.
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Affiliation(s)
- Takao Kaneko
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
| | - Ayakane Yamamoto
- Ichinomiya Onsen Hot Hospital, Adult Reconstruction Center, Japan.
| | - Kazutaka Takada
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
| | - Shu Yoshizawa
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
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Ryu JJ, Kim YH, Choi CH. The additional tibial stem extension is not mandatory for the stability of 5 mm metal block augmented tibial prosthesis construct in primary total knee arthroplasty: 5-year minimum follow-up results. Knee Surg Relat Res 2023; 35:5. [PMID: 36726180 PMCID: PMC9890779 DOI: 10.1186/s43019-023-00174-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/31/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To determine whether additional stem extension for stability is necessary, we performed mid-term follow-up of patients who had been managed with 5-mm metal block augmentation for a tibial defect, where tibial prosthesis was fixed using bone cement without stem extension. Also, we evaluated clinical and radiologic results including survival rate of patients without stem extension. METHODS We retrospectively analyzed patients with tibial bone defect, had undergone primary total knee arthroplasty, and had been treated with 5-mm metal block augmentation without stem extension between March 2003 and September 2013. Among 74 patients (80 cases), 47 patients (52 cases) were followed up for at least 5 years. RESULTS Mean flexion contracture improved from 8.8° (0-40°) preoperatively to 0.4° (-5° to 15°) at final follow-up (P < 0.01), but there was no significant change in the mean angle of great flexion: 124.6° (75-150°) preoperatively and 126.2° (90-145°) at final follow-up (P = 0.488). Mean range of motion improved from 115.8° (35-150°) preoperatively to 125.5° (90-145°) at final follow-up (P < 0.01). Mean knee score improved from 38.7 points (0-66 points) preoperatively to 93.2 points (79-100 points) at final follow-up (P < 0.01), and mean functional score also improved from 50.4 points (10-70 points) preoperatively to 81.8 points (15-100 points) at final follow-up (P < 0.01). The mean postoperative Western Ontario and McMaster University osteoarthritis score was 19.5 points (0-66.0 points). The mean femorotibial angle was corrected from 9.0° varus (23.0° varus-6.3° valgus) preoperatively to 5.5° valgus (2.2° varus-11.1° valgus) at final follow-up (P < 0.01). There was no change in the mean β-angle, which was 90.7° (87.2-94.9°) immediately postoperative and 90.8° (87.2-94.9°) at final follow-up (P = 0.748) and in the mean δ-angle, which was 86.2° (81.3-90.0°) immediately postoperative and 87.2° (83.1-96.5°) at final follow-up (P = 0.272). Radiolucent lines (RLL) were observed in ten cases (26.3%), and the mean RLL scores at final follow-up were 0.34 points (0-3 points) in the anteroposterior view and 0.42 points (0-6 points) in the lateral view. Scores for the RLL were ≤ 4 points in 36 cases, 5-9 points in two cases. Revision surgery due to aseptic loosening (three cases) is rarely required, and the Kaplan-Meier survival rate at 10 postoperative years was 96.4% CONCLUSION: When performing 5-mm metal block augmentation for a proximal tibial defect, no additional tibial stem extension can be a good surgical option for the stability of tibial prosthetic construct and mid-term clinical and radiologic results. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jae Joon Ryu
- grid.49606.3d0000 0001 1364 9317Department of Orthopaedic Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Yeong Hwan Kim
- grid.49606.3d0000 0001 1364 9317Department of Orthopaedic Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Choong Hyeok Choi
- grid.49606.3d0000 0001 1364 9317Department of Orthopaedic Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Lee SS, Seo MK, Kim IS, Moon YW. Comparison of Survival Rate and Outcomes Between Conventional and Navigation-Assisted Primary Total Knee Arthroplasty in Severe Varus Knees: A Minimum 10-Year Follow-Up. J Arthroplasty 2022; 37:2164-2170. [PMID: 35618215 DOI: 10.1016/j.arth.2022.05.038] [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] [Received: 02/01/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to compare the long-term clinical and radiographic outcomes and survival rates between navigation-assisted (NAV) total knee arthroplasty (TKA) and conventional (CON) TKA in patients with preoperative severe varus deformity. METHODS From January 2005 to December 2011, 152 TKAs and 62 TKAs with preoperative hip-knee-ankle (HKA) angles more than 15° were enrolled in the CON-TKA and NAV-TKA group with 135.7 months follow-up. Clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index and Knee Society Scores), radiographic outcomes (HKA, α, β, γ, and δ angles), and survivorship were compared between the groups. RESULTS The mean value of radiographic outcomes was not statistically different; however, outliers of the HKA angle were significantly higher in the CON-TKA group (18.4% versus 8.1%, P = .04). However, long-term clinical outcomes were similar between both groups. The cumulative survival rate was 96.1% in the CON-TKA group and 96.8% in the NAV-TKA group, with no difference between the groups (P = .962). CONCLUSION NAV-TKA showed fewer outliers in the HKA angle for severe preoperative varus deformity compared with CON-TKA. The long-term clinical outcomes and survival rates were similar between the 2 techniques. A survival rate of more than 96% was observed in both groups. STUDY DESIGN Level III, retrospective comparative study.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, South Korea
| | - Min Kyu Seo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Il Su Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wan Moon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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What is the "safe zone" for transition of coronal alignment from systematic to a more personalised one in total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:419-427. [PMID: 34973095 PMCID: PMC8866271 DOI: 10.1007/s00167-021-06811-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE In total knee arthroplasty (TKA), implants are increasingly aligned based on emerging patient-specific alignment strategies, such as unrestricted kinematic alignment (KA), according to their constitutional limb alignment (phenotype alignment), which results in a large proportion of patients having a hip-knee angle (HKA) outside the safe range of ± 3° to 180° traditionally considered in the mechanical alignment strategy. The aim of this systematic review is to investigate whether alignment outside the safe zone of ± 3° is associated with a higher revision rate and worse clinical outcome than alignment within this range. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane and World of Science, with search terms including synonyms and plurals for "total knee arthroplasty", "alignment", "outlier", "malalignment", "implant survival" and "outcome". Five studies were identified with a total number of 927 patients and 952 implants. The Oxford Knee Score (OKS) and the WOMAC were used to evaluate the clinical outcome. The follow-up period was between 6 months and 10 years. RESULTS According to HKA 533 knees were aligned within ± 3°, 47 (8.8%) were varus outliers and 121 (22.7%) were valgus outliers. No significant differences in clinical outcomes were found between implants positioned within ± 3° and varus and valgus outliers. Likewise, no significant differences were found regarding revision rates and implant survival. CONCLUSION The universal use of the "safe zone" of ± 3° derived from the mechanical alignment strategy is hardly applicable to modern personalised alignment strategies in the light of current literature. However, given the conflicting evidence in the literature on the risks of higher revision rates and poorer clinical outcomes especially with greater tibial component deviation, the lack of data on the outcomes of more extreme alignments, and regarding the use of implants for KA TKA that are actually designed for mechanical alignment, there is an urgent need for research to define eventual evidence-based thresholds for new patient-specific alignment strategies, not only for HKA but also for FMA and TMA, also taking into account the preoperative phenotype and implant design. It is of utmost clinical relevance for the application of modern alignment strategies to know which native phenotypes may be reproduced with a TKA. LEVEL OF EVIDENCE IV.
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Choi HU, Kim DH, Lee SW, Choi BC, Bae KC. Comparison of Lower-Limb Alignment in Patients with Advanced Knee Osteoarthritis: EOS Biplanar Stereoradiography versus Conventional Scanography. Clin Orthop Surg 2022; 14:370-376. [PMID: 36061834 PMCID: PMC9393278 DOI: 10.4055/cios21050] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Accurate measurement of the lower limb alignment is one of the most crucial factors in advanced knee osteoarthritis patients scheduled for surgery. Recently, EOS biplanar stereoradiography with three-dimensional reconstruction was developed. The purpose of this study was to compare radiographic parameters between conventional scanography and EOS in patients with advanced knee osteoarthritis who need surgical treatment. Methods A total of 52 consecutive patients (104 knees) with bilateral knee osteoarthritis of advanced stage (Kellgren-Lawrence [KL] grade 3 or 4) were retrospectively reviewed. We measured the hip-knee-ankle angle (HKA) on conventional scanograms. In EOS, we measured HKA, hip-knee-shaft angle, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle. To evaluate sagittal and axial plane alignment, knee flexion angle (KFA), and knee joint rotation (KJR) were also measured. Results Ninety knees were KL grade 4, and 14 knees were grade 3. The average HKA was 10.14° ± 6.16° on conventional scanograms and 11.26° ± 6.21° in EOS. HKA was greater in EOS than on conventional scanograms, and the difference (1.12°; range, −1.07° to 3.22°) was statistically significant (p < 0.001). Significant correlations were observed on the difference in HKA and mechanical medial proximal tibial angle (r = –0.198, p = 0.044), KFA (r = 0.193, p = 0.049), and KJR (r = 0.290, p = 0.003). In multivariable linear regression analysis, the difference in HKA had significant relationship with KFA (β = 0.286, p = 0.003) and KJR (β = 0.363, p < 0.001). Conclusions HKA measured on conventional scanograms and in EOS differed significantly and the difference had a significant correlations with KFA, KJR, and medial proximal tibial angle. Surgeons can consider these results before orthopedic surgery in patients who have advanced knee osteoarthritis.
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Affiliation(s)
- Hyeong-Uk Choi
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Du-Han Kim
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Si-Wook Lee
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Byung-Chan Choi
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Ki-Cheor Bae
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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Jenny JY, Saragaglia D, Bercovy M, Cazenave A, Gaillard T, Châtain F, Jolles-Haeberli B, Rouvillain JL. Navigation Improves the Survival Rate of Mobile-Bearing Total Knee Arthroplasty by Severe Preoperative Coronal Deformity: A Propensity Matched Case-Control Comparative Study. J Knee Surg 2021; 34:1080-1084. [PMID: 32074654 DOI: 10.1055/s-0040-1701441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The primary hypothesis of this study was that the survival rate over 10 years of total knee arthroplasties (TKAs) implanted with a navigation system was superior to that of TKAs implanted with a conventional technique. The secondary hypothesis was that the severity of the initial coronal deformity had a negative influence on the survival rate. A national, multicentric, retrospective study was performed in France, including eight university or private centers with high volumes in knee surgery. Cases operated on with either a conventional (control group) or a navigated (study group) technique were matched after calculating the propensity score using the logistic regression technique. All patients were contacted after 10 years or more to determine the survival of the TKA. The need for date and cause of revision were noted. The primary end point of the study was the occurrence of a revision for any mechanical reason. Survival curves were calculated using the Kaplan-Meier's technique, with the primary criterion as end point. The influence of the implantation technique was analyzed by a log-rank test at a 5% level of significance. The influence of severity of the preoperative coronal deformity was analyzed using the same technique. A total of 513 cases were included in each group. The survival rates after 13 years were 96.5% in the study group and 92.9% in the control group (not significant). There was no significant difference between both groups for the survival rates after 13 years for small deformity (96.0 vs. 97.0%), but the difference was significant for large deformity (97.0 vs. 89.0%, p = 0.04). The results suggest that the use of a navigation system, allowing a more consistent correction of the preoperative coronal deformity, thus allows a better long-term prosthetic survival in cases with a large initial coronal deformity. A navigation system should be routinely used in cases of initial coronal deformity greater than or equal to 10 degrees, as conventional techniques do not routinely provide satisfactory axial correction in these difficult cases.
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Affiliation(s)
- Jean-Yves Jenny
- Department of Orthopaedics and Trauma, Strasbourg University Hospital, Strasbourg, France
| | - Dominique Saragaglia
- Department of Osteoarthritis and Sport Surgery, Traumatology of the Limbs, Grenoble-Alpes South Teaching Hospital, Echirolles, France
| | - Michel Bercovy
- Department of Orthopaedics, Clinique Arago, Paris, France
| | - Alain Cazenave
- Department of Orthopedic Surgery, Institut CALOT, Berck-sur-Mer, France
| | - Thierry Gaillard
- Department of Orthopaedics, Polyclinique du Beaujolais, Arnas, France
| | - Frédéric Châtain
- Department of Orthopaedics, Pole Santé Axone, Saint-Martin-d'Hères, France
| | - Brigitte Jolles-Haeberli
- Swiss BioMotion Lab, Department of Musculoskeletal Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.,Institute of Micro Engineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Jean-Louis Rouvillain
- Department of Orthopaedic and Trauma Surgery, Hôpital Zobda Quitman, Fort-de-France, France
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Bridging the Gap: The Influence of Foot and Ankle Pathomechanics in Total Knee Arthroplasty. J Am Acad Orthop Surg 2021; 29:e693-e701. [PMID: 33902070 DOI: 10.5435/jaaos-d-20-00786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 03/23/2021] [Indexed: 02/01/2023] Open
Abstract
Altered spinopelvic mechanics can have dramatic influences on the success of hip arthroplasty as seen with concomitant hip and spine disease. Interestingly, limited focus has been directed toward a similar codependent relationship between concurrent knee and foot deformities. By bridging this interdisciplinary gap, we attempt to explore the current understanding and clinical implications of concomitant knee and foot pathology while reviewing management options for addressing this unique yet ubiquitous patient population. Multiple authors have demonstrated an inverse relationship between progressive coronal plane deformities concerning the knee and hindfoot. The utility of a conventional mechanical axis during total knee arthroplasty may be limited in the presence of foot deformity where ground reactive forces often markedly deviate with the hindfoot, potentially leading to eccentric knee loading. The use of alternative indices, such as ground mechanical axis deviation, may offer a more reliable metric for achieving an accurate neutral mechanical axis. In addition, although foot deformity and compensation can often improve to a limited degree after total knee arthroplasty, residual deformity may have deleterious effects on the success of the procedure. A comprehensive understanding of the functional relationship between the foot and the knee can allow surgeons to better guide appropriate treatment sequence, often beginning with the more symptomatic deformity. Future research is needed to further elucidate the implications and appropriate management of concomitant knee and foot deformity.
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Comparison of the clinical and radiological outcomes between an isolated tibial component revision and total revision knee arthroplasty in aseptic loosening of an isolated tibial component. J Orthop Sci 2021; 26:435-440. [PMID: 32620342 DOI: 10.1016/j.jos.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/24/2020] [Accepted: 05/06/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND An isolated tibial component revision could be a treatment option for isolated tibial side loosening; however, few studies have proved its efficacy. This study aimed to compare the clinical and radiological outcomes between isolated (tibial component) and total (femoral and tibial component) revision total knee arthroplasty (TKA). METHODS Between January 2008 and February 2017, 31 patients underwent revision TKA for isolated tibial side loosening; 14 underwent an isolated tibial component revision (isolated group) and 17 underwent total (both femoral and tibial components) revision surgery (total group). The postoperative range of motion (ROM), Western Ontario and McMaster Universities osteoarthritis (WOMAC) index, Knee Society knee score (KSKS), Knee Society function score (KSFS), and mechanical axis (MA) were compared between the two groups. The intraoperative tourniquet time and amount of blood drainage were also compared. RESULTS The mean follow-up durations in the isolated and total groups were 40.7 and 56.1 months, respectively. Both groups had similar postoperative ROM, WOMAC index, KSKS, KSFS, and MA; however, significantly shorter tourniquet time (105.2 vs. 154.6 min, P < 0.001) and less blood drainage (417.2 vs. 968.1 ml, P < 0.001) were noted in the isolated group than in the total group. CONCLUSION Isolated tibial component revision TKA for tibial component loosening showed comparable clinical and radiological outcomes to those of total revision TKA. The advantages of the isolated tibial component revision surgery were short operation time and small blood loss. STUDY DESIGN Level III, Retrospective comparative study.
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Nam JH, Song SK, Cho MR, Kang DW, Choi WK. The advantage of navigation for knee with lateral femoral bowing in total knee arthroplasty. J Orthop Surg (Hong Kong) 2021; 28:2309499020965679. [PMID: 33078670 DOI: 10.1177/2309499020965679] [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] [Indexed: 01/05/2023] Open
Abstract
PURPOSE We have analyzed the surgical outcomes of primary total knee arthroplasty (TKA) using computer-assisted (CA) navigation in terms of postoperative coronal alignment depending on preoperative lateral femoral bowing. METHODS We conducted a retrospective study of patients who have undergone navigated primary TKA from January 2016 through January 2020. Two hundred and ninety-nine cases with lateral femoral bowing of 3° or less were assigned to group 1, 95 cases of lateral femoral bowing between 3° and 5° were assigned to group 2, and 89 cases with lateral femoral bowing of more than 5° were assigned to group 3. The postoperative mechanical hip-knee-ankle (mHKA) angle was measured from scanograms, which were taken 3 months after surgery. The appropriate range of coronal alignment was set as 0 ± 3°. RESULTS The number of outliers of mHKA occurred was 31 cases (10.4%) in group 1, 17 cases (17.9%) in group 2, and 17 cases (19.1%) in group 3. There was a significant correlation between the degree of lateral femoral bowing and the occurrence rate of mHKA outliers. Multiple variables logistic regression analysis showed occurrence rate of outliers in group 3 to be 2.04 times higher than group 1. After adjusting the patient's age, sex, body mass index, and preoperative HKA deformity, the occurrence rate of outliers in group 3 was still 1.96 times higher than group 1. CONCLUSION The benefit of CA navigation during TKA in obtaining coronal alignment within 0 ± 3° may be lessened when the preoperative lateral femoral bowing is severely advanced.
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Affiliation(s)
- Jun Ho Nam
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Suk-Kyoon Song
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Myung-Rae Cho
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Dae-Won Kang
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Won-Kee Choi
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
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Kim SG, Choi GW, Kim HK, Kim JG. Hip-to-calcaneus alignment differs from hip-to-talus alignment in patients with genu varum deformity. Knee Surg Sports Traumatol Arthrosc 2021; 29:975-981. [PMID: 32458031 DOI: 10.1007/s00167-020-06060-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/10/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE To (1) compare the weight-bearing line (WBL) ratios of the knee joints measured using the conventional (hip-to-talus radiographs, HTRs) and novel (hip-to-calcaneus radiographs, HCRs) orthoradiograms, (2) compare the hip-knee-ankle (HKA) angle between cases with < 5% and > 5% differences in WBL ratios between two orthoradiograms, and (3) investigate the optimal cutoff value (COV) of the HKA angle causing inconsistency in the orthoradiograms. METHODS Sixty limbs of 31 patients with HTR and HCR records were retrospectively reviewed. After drawing the mechanical axis on each radiograph, the WBL ratios of the knees were calculated and compared between the conventional and novel orthoradiograms. In subgroup analysis, cases with < 5% and > 5% differences in WBL ratios between two orthoradiograms were classified as consistent and inconsistent groups, respectively. Receiver operating characteristic curve based on the HKA angles of the lower limbs was used to identify the COV causing the inconsistency between the orthoradiograms. RESULTS Inter- and intra-rater reliabilities of all radiologic measurements were > 0.75. The WBL ratios showed no significant difference between the two orthoradiograms. However, the HKA angle was significantly larger in the inconsistent group than in the consistent group (7.0° ± 1.8° vs. 4.4° ± 2.5°; P < 0.001). The COV of the HKA angle that caused inconsistency in the two orthoradiograms was 4.0° (area under the curve, 0.774). CONCLUSION The hip-to-calcaneus alignment differed significantly from the hip-to-talus alignment in patients with genu varum deformity. HCR measurement can be a complementary method for planning corrective osteotomy for patients with genu varum deformity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, Republic of Korea
| | - Gi Won Choi
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, Republic of Korea
| | - Hak Kyu Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, Republic of Korea
| | - Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, Republic of Korea.
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Song SK, Cho MR, Lee SH, Kim HC, Kang DW, Choi WK. Acquisition of coronal alignment according to the degree of varus deformity in total knee arthroplasty using computer-assisted navigation. J Orthop Surg (Hong Kong) 2021; 28:2309499020926268. [PMID: 32468906 DOI: 10.1177/2309499020926268] [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] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We have analyzed the surgical outcomes of primary total knee arthroplasty (TKA) using computer-assisted navigation that were performed by a single surgeon in terms of postoperative coronal alignment depending on preoperative varus deformity. METHODS We conducted a retrospective study of patients who have undergone navigated primary TKA from January 2016 through December 2019. Two hundred and fifty-six cases with varus deformity of 10° or less were assigned to group 1, and 216 cases with varus deformity of more than 10° were assigned to group 2. The postoperative mechanical hip-knee-ankle (mHKA) angle was measured from scanograms which were taken preoperatively and 3 months after surgery. The postoperative mHKA angle was targeted to be 0°, and the appropriate range of coronal alignment was set as 0 ± 3°. RESULTS The Pearson correlation showed a significant correlation with the degree of preoperative varus deformity and with the absolute error of postoperative mHKA (p = 0.01). Among all patients, 64 cases (13.6%) were detected as outliers (mHKA > 0° ± 3°) at 3 months after surgery. Of the 64 cases, 25 cases (9.8%) were affiliated to group 1 and 39 cases (18.1%) were affiliated to group 2. Group 2 showed significantly higher occurrence of outliers than group 1 (p = 0.01). Multiple variables logistic regression analysis, which analyzed the difference in the occurrence rate of outliers (mHKA > 0° ± 3°), showed that the occurrence rate of group 2 was 2.04 times higher than group 1. After adjusting for patient's age, gender, and body mass index, the occurrence rate of outliers in group 2 was 2.01 times higher than group 1. CONCLUSION The benefit of computer-assisted navigation during TKA in obtaining coronal alignment within 0 ± 3° may be lessened when the preoperative varus deformity is severely advanced.
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Affiliation(s)
- Suk Kyoon Song
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Myung Rae Cho
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Seo Ho Lee
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Hee Chan Kim
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Dae Won Kang
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Won-Kee Choi
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University Hospital, Daegu, Korea
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Posterior stabilized total knee arthroplasty reproduces natural joint laxity compared to normal in kinematically aligned total knee arthroplasty: a matched pair cadaveric study. Arch Orthop Trauma Surg 2021; 141:119-127. [PMID: 33040208 DOI: 10.1007/s00402-020-03624-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE As the goal of kinematic aligned (KA) total knee arthroplasty (TKA) is to preserve soft tissue tension to the native knee, many KA surgeons recommend cruciate-retaining (CR) prosthesis. However, how a posterior-stabilizing (PS) prosthesis affects the biomechanics of a KA TKA remains unclear. This cadaveric study tested the hypothesis that a PS prosthesis in KA TKA would produce biomechanics similar to CR prosthesis and KA TKA with a PS prosthesis would produce more native knee biomechanics than mechanical aligned (MA) TKA with PA prosthesis. METHODS Fourteen cadaver knees (7 pairs) were mounted on a knee-testing system to measure knee motion during flexion. For each pair, 1 knee was assigned to KA TKA and the other to MA TKA. In the KA TKA group, the native knee, CR TKA, and PS TKA were tested sequentially. MA TKA was performed using conventional measured resection techniques with a PS prosthesis. All kinematics were measured and compared with the native knee before and after surgery. RESULTS A PS prosthesis restored femoral rollback similar to a CR prosthesis. CR TKA showed less lateral rollback at knee flexion ≤ 60° than the native knee. There were no differences in soft tissue tensions among the native knee, CR, and PS prosthesis, except in varus tension at 30° of flexion. Varus tension of CR TKA was larger than those of PS TKA and the native knee after KA TKA with < 1 degree difference. Meanwhile, KA TKA achieved knee motion that was closer to the native knee than did MA TKA at ≥ 60° of flexion when using a PS prosthesis. There were no differences in soft tissue tension between KA-PS and MA-PS TKA. CONCLUSIONS After KA TKA, a PS prosthesis affords similar femoral rollback and soft tissue tension when compared with a CR prosthesis. A PS TKA may be a feasible strategy for patients requiring a PS prosthesis when performing KA TKA. LEVEL OF EVIDENCE Therapeutic Laboratory study, I.
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Chapleau J, Sullivan T, Lambert B, Clyburn TA, Incavo SJ. Postoperative alignment in revision total knee arthroplasty, a comparison between intra and extra-medullary tibial alignment. Knee 2021; 28:319-325. [PMID: 33482622 DOI: 10.1016/j.knee.2020.12.013] [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: 07/30/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Revision total knee arthroplasty commonly involves stemmed components. If the diaphysis is engaged, this technique may be problematic for mechanical alignment (MA) in cases of tibial bowing, which are not infrequent (up to 30%). The aim of this study is to compare an intra-medullary(IM) and extra-medullary(EM) alignment method. We hypothesized that IM technique and canal-filling stems may result more frequently in valgus MA. On the other hand, an EM technique could produce less valgus knees but is at risk of creating MA outliers. METHOD A retrospective radiographic analysis of revision TKAs was performed. The patients were divided to either the EM or IM alignment group and compared on the overall post-operative MA. The following parameters were measured on standing, long leg x-rays: Hip-knee-Ankle angle (HKA), mechanical lateral distal femoral angle and mechanical medial proximal tibial angle (mMPTA). RESULTS 119 cases of revision TKAs were included (EM = 80, IM = 39). There was a difference between the EM and IM group for the mean mMPTA (89.94° vs 90.92°, effect size = 0.45, p = 0.013) and HKA angle (1.64° vs 0.05°, effect size = 0.52, p = 0.0064). A higher proportion of IM patients were in overall valgus alignment (16/39, 41%) vs EM group (16/80, 20%, p = 0.0134). Both techniques showed the same proportion of outliers, defined as HKA angle more than 5 degrees from neutral mechanical alignment (11/80 vs 5/39, p = 0.286). CONCLUSION The extra-medullary alignment method with short cemented stems creates less valgus mechanical alignment than the intra-medullary technique with press-fit stems, without creating more MA outliers.
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Affiliation(s)
- Julien Chapleau
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX 77030, United States
| | - Thomas Sullivan
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX 77030, United States.
| | - Bradley Lambert
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX 77030, United States.
| | - Terry A Clyburn
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX 77030, United States.
| | - Stephen J Incavo
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, 6445 Main St., Outpatient Center, Suite 2500, Houston, TX 77030, United States.
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Lee SW, Lee KJ, Cho CH, Ye HU, Yon CJ, Choi HU, Kim YH, Song KS. Affecting Factors and Correction Ratio in Genu Valgum or Varum Treated with Percutaneous Epiphysiodesis Using Transphyseal Screws. J Clin Med 2020; 9:jcm9124093. [PMID: 33353069 PMCID: PMC7766970 DOI: 10.3390/jcm9124093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022] Open
Abstract
This study evaluated the correction rates of idiopathic genu valgum or varum after percutaneous epiphysiodesis using transphyseal screws (PETS) and analyzed the affecting factors. A total of 35 children without underlying diseases were enrolled containing 64 physes (44 distal femoral (DT), 20 proximal tibial (PT)). Anatomic tibiofemoral angle (aTFA) and the mechanical axis deviation (MAD) were taken from teleroentgenograms before PETS surgery and screw removal. The correction rates of the valgus and varus deformities for patients treated with PETS were 1.146°/month and 0.639°/month using aTFA while using MAD showed rates of 4.884%/month and 3.094%/month. After aTFA (p < 0.001) and MAD (p < 0.001) analyses, the correction rate of DF was significantly faster than that of PT. Under multivariable analysis, the aTFA correction rate was significantly faster in younger patients (p < 0.001), in males (p < 0.001), in patients with lower weights (p < 0.001), and in the group that was screwed at DF (p < 0.001). Meanwhile, the MAD correction rate was significantly faster in patients with lower heights (p = 0.003). PETS is an effective treatment method for valgus and varus deformities in growing children and clinical characters should be considered to estimate the correction rate.
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Banger MS, Johnston WD, Razii N, Doonan J, Rowe PJ, Jones BG, MacLean AD, Blyth MJG. Robotic arm-assisted bi-unicompartmental knee arthroplasty maintains natural knee joint anatomy compared with total knee arthroplasty: a prospective randomized controlled trial. Bone Joint J 2020; 102-B:1511-1518. [PMID: 33135443 PMCID: PMC7954184 DOI: 10.1302/0301-620x.102b11.bjj-2020-1166.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to compare robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) in order to determine the changes in the anatomy of the knee and alignment of the lower limb following surgery. METHODS An analysis of 38 patients who underwent TKA and 32 who underwent bi-UKA was performed as a secondary study from a prospective, single-centre, randomized controlled trial. CT imaging was used to measure coronal, sagittal, and axial alignment of the knee preoperatively and at three months postoperatively to determine changes in anatomy that had occurred as a result of the surgery. The hip-knee-ankle angle (HKAA) was also measured to identify any differences between the two groups. RESULTS The pre- to postoperative changes in joint anatomy were significantly less in patients undergoing bi-UKA in all three planes in both the femur and tibia, except for femoral sagittal component orientation in which there was no difference. Overall, for the six parameters of alignment (three femoral and three tibial), 47% of bi-UKAs and 24% TKAs had a change of < 2° (p = 0.045). The change in HKAA towards neutral in varus and valgus knees was significantly less in patients undergoing bi-UKA compared with those undergoing TKA (p < 0.001). Alignment was neutral in those undergoing TKA (mean 179.5° (SD 3.2°)) while those undergoing bi-UKA had mild residual varus or valgus alignment (mean 177.8° (SD 3.4°)) (p < 0.001). CONCLUSION Robotic-assisted, cruciate-sparing bi-UKA maintains the natural anatomy of the knee in the coronal, sagittal, and axial planes better, and may therefore preserve normal joint kinematics, compared with a mechanically aligned TKA. This includes preservation of coronal joint line obliquity. HKAA alignment was corrected towards neutral significantly less in patients undergoing bi-UKA, which may represent restoration of the pre-disease constitutional alignment (p < 0.001). Cite this article: Bone Joint J 2020;102-B(11):1511-1518.
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Affiliation(s)
- Matthew S. Banger
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | | | - Nima Razii
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - James Doonan
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Philip J. Rowe
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Bryn G. Jones
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Angus D. MacLean
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Mark J. G. Blyth
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
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Agarwal N, To K, McDonnell S, Khan W. Clinical and Radiological Outcomes in Robotic-Assisted Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2020; 35:3393-3409.e2. [PMID: 32234326 DOI: 10.1016/j.arth.2020.03.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/07/2020] [Accepted: 03/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this systematic review is to determine if robotic-assisted total knee arthroplasty (RATKA) results in improved clinical and radiological outcomes, and to elucidate the breadth and depth of studies conducted on this topic. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using 4 databases (MEDLINE, EMBASE, Cochrane, and Web of Science) to identify all clinical studies that investigate clinical or radiological outcomes using RATKA. The Critical Appraisal Skills Program checklist for cohort studies was employed for critical appraisal and evaluation of all 22 studies that met the inclusion criteria. RESULTS All studies reviewed determined that knee arthroplasty improved clinical outcomes. Twelve studies found statistically better clinical outcomes with RATKA compared with conventional TKA, whereas 9 studies found no difference. One study did not assess clinical outcomes. When assessing radiological outcomes, 14 studies reported that RATKA resulted in more consistent and accurate postoperative mechanical alignment, whereas 2 studies reported no difference. Six studies did not assess radiological outcomes. CONCLUSION Although knee arthroplasty is one of the most commonly performed orthopedic operations, the level of patient satisfaction varies. The meta-analyses conducted in our systematic review shows that RATKA results in greater improvements in postoperative Hospital for Special Surgery score and Western Ontario and McMaster Universities scores compared to conventional TKA. Furthermore, it shows that RATKA results in more accurate postoperative alignment of prostheses. These together can explain the improved postoperative outcomes. More randomized controlled trials must be conducted before this technique is integrated into routine clinical practice.
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Affiliation(s)
- Nikhil Agarwal
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; University of Aberdeen College of Life Sciences and Medicine, Aberdeen, United Kingdom
| | - Kendrick To
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Stephen McDonnell
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Varus deformity in the proximal tibia and immediate postoperative varus alignment result in varus progression in limb alignment in the long term after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:3287-3293. [PMID: 31900497 DOI: 10.1007/s00167-019-05841-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/16/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to examine and evaluate the factors associated with changes in limb alignment 10 years after total knee arthroplasty (TKA). The hypothesis was that bone morphology and immediate postoperative alignment could be correlated with long-term post-operative alignment changes following TKA. METHODS This study retrospectively analysed 136 consecutive primary TKA cases for varus deformity, performed from 2006 to 2008, that could be followed for at least 10 years postoperatively. Anteroposterior long-leg weight-bearing radiographs were obtained within 1 month and at least 10 years after surgery. The hip-knee-ankle (HKA) angle immediately after surgery was compared with that 10 years later; factors correlating with the change in HKA angle (δHKA) were evaluated. RESULTS The mean HKA angles were significantly different between immediate and long-term postoperative assessments (0.1° ± 1.9° vs. 1.2° ± 2.9°, p < 0.001). Furthermore, a significant difference was observed in the outlier ratio (> 3° deviation from the 0° of HKA angle) (10% vs. 24%, p = 0.002). δHKA strongly correlated with a higher preoperative tibial plateau tip-to-proximal tibial shaft (TPTPS) angle, higher postoperative HKA angle, lateral distal femoral angle, and lower postoperative medial proximal tibial angle. CONCLUSION Varus deformity in the proximal part of the tibia, immediate postoperative varus alignment, and varus position of the femoral and tibial components may lead to varus progression in limb alignment in the long term, even 10 years after TKA; the surgeon should, therefore, weigh the risks of leaving a varus alignment during surgery. Moreover, if the preoperative TPTPS angle is high, the alignment may become varus after TKA, even in patients who have acquired neutral alignment. LEVEL OF EVIDENCE IV.
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Kim JG, Suh DH, Choi GW, Koo BM, Kim SG. Change in the weight-bearing line ratio of the ankle joint and ankle joint line orientation after knee arthroplasty and high tibial osteotomy in patients with genu varum deformity. INTERNATIONAL ORTHOPAEDICS 2020; 45:117-124. [PMID: 32975681 DOI: 10.1007/s00264-020-04799-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/01/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Several studies reported that excessive correction of severe genu varum deformity with total knee arthroplasty or high tibial osteotomy (HTO) could result in ankle joint pain and osteoarthritis progression. However, few studies have evaluated the change in the weight-bearing-line (WBL) ratio of the ankle joint after knee arthroplasty or HTO in patients with genu varum deformities. This study aimed to investigate the change in the WBL ratio of the ankle joint and ankle joint line orientation after knee arthroplasty or HTO in patients with genu varum deformities. METHODS We retrospectively evaluated 40 patients (mean age, 69.9 ± 8.0 years) with genu varum deformities of > 5° and underwent knee arthroplasty or HTO. Three radiologic parameters, including (1) the hip-knee-ankle (HKA) angle, (2) WBL ratio of the ankle joint, and (3) ankle joint line orientation relative to the ground (AJLO-G), were assessed using pre-operative and post-operative orthoradiographs. A paired t test was used to evaluate post-operative changes in the three parameters. Correlations between the change in HKA angle and that in the WBL ratio of the ankle joint and AJLO-G were analyzed. RESULTS The mean HKA angle significantly decreased post-operatively (10.6° ± 5.3° to 1.1° ± 3.4°; P < 0.001). The WBL ratio of the ankle joint increased from 35.8% ± 15.2% to 53.0% ± 17.4% (P < 0.001), with a lateral shift of the mechanical axis. The AJLO-G decreased with valgization of ankle orientation (7.8° ± 4.8° to 0.4° ± 3.8°; P < 0.001). The change in the HKA angle was significantly correlated with that in the AJLO-G (correlation coefficient = 0.716; P < 0.001) but not with the change in the WBL ratio of the ankle joint. CONCLUSION Knee arthroplasty and HTO corrected the genu varum deformity, which influenced the lateral shift of the WBL of the ankle joint and valgization of the ankle joint line orientation.
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Affiliation(s)
- Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, Republic of Korea
| | - Dong Hun Suh
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, Republic of Korea
| | - Gi Won Choi
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, Republic of Korea
| | - Bong Mo Koo
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, Republic of Korea.
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Rajan PV, Ng MK, Klika A, Kamath AF, Muschler GF, Higuera CA, Piuzzi NS. The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis. J Bone Joint Surg Am 2020; 102:e104. [PMID: 32453118 DOI: 10.2106/jbjs.19.01446] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Use of platelet-rich-plasma (PRP) injections for treating knee osteoarthritis has increased over the past decade. We used cost-effectiveness analysis to evaluate the value of PRP in delaying the need for total knee arthroplasty (TKA). METHODS We developed a Markov model to analyze the baseline case: a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis undergoing a series of 3 PRP injections with a 1-year delay to TKA versus a TKA from the outset. Both health-care payer and societal perspectives were included. Transition probabilities were derived from systematic review of 72 studies, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry, and individual costs from Medicare reimbursement schedules. Primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs) and evaluated against willingness-to-pay thresholds of $50,000 and $100,000. One and 2-way sensitivity analyses were performed as well as a probabilistic analysis varying PRP-injection cost, TKA delay intervals, and TKA outcomes over 10,000 different simulations. RESULTS From a health-care payer perspective, PRP resulted in 14.55 QALYs compared with 14.63 for TKA from the outset, with total health-care costs of $26,619 and $26,235, respectively. TKA from the outset produced a higher number of QALYs at a lower cost, so it dominated. From a societal perspective, PRP cost $49,090 versus $49,424 for TKA from the outset. The ICER for TKA from the outset was $4,175 per QALY, below the $50,000 willingness-to-pay threshold. Assuming the $728 published cost of a PRP injection, no delay time that was <10 years produced a cost-effective course. When the QOL value was increased from the published value of 0.788 to >0.89, PRP therapy was cost-effective with even a 1-year delay to TKA. CONCLUSIONS When considering direct and unpaid indirect costs, PRP injections are not cost-effective. The primary factor preventing PRP from being cost-effective is not the price per injection but rather a lack of established clinical efficacy in relieving pain and improving function and in delaying TKA. PRP may have value for higher-risk patients with high perioperative complication rates, higher TKA revision rates, or poorer postoperative outcomes. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Prashant V Rajan
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Koh IJ, Kang BM, Kim MS, Choi KY, Sohn S, In Y. How Does Preoperative Central Sensitization Affect Quality of Life Following Total Knee Arthroplasty? J Arthroplasty 2020; 35:2044-2049. [PMID: 32362478 DOI: 10.1016/j.arth.2020.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/25/2020] [Accepted: 04/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Central sensitization (CS) has been recently identified as a significant risk factor for persistent pain and patient dissatisfaction following total knee arthroplasty (TKA). However, it remains unclear as to whether the preoperative CS persists after the elimination of a nociceptive pain source by TKA, or how CS affects the quality of life after TKA. METHODS A total of 222 consecutive patients undergoing primary TKA were enrolled in the study. All patients were preoperatively screened for CS using the Central Sensitization Inventory (CSI) and categorized into either a CS (n = 55; CSI ≥ 40) or non-CS group (n = 167; CSI < 40). CSI, pain visual analog scale (VAS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score, and satisfaction were recorded at postoperative 2 years. RESULTS Two years after TKA, preoperative CS remained unchanged; there was no difference between preoperative and postoperative CSI scores, and both preoperative and postoperative CSI severity levels were similar (P > .1). The CS group showed worse pain VAS, KSS, and Western Ontario and McMaster Universities Osteoarthritis Index scores than did the non-CS group (P < .01) and more patients in the CS group were dissatisfied with all activities (P < .01). However, a similar percentage of the CS group achieved the previously documented minimal clinically important difference in pain VAS and KSS, compared with the non-CS group. Multivariate regression analysis revealed that preoperative CSI scores were associated with dissatisfaction at postoperative 2 years. CONCLUSION Preoperative CS was persistent at 2 years after TKA. Although CS patients achieved comparable clinical improvement following TKA, CS patients had worse quality of life, functional disability, and dissatisfaction than non-CS patients.
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Affiliation(s)
- In Jun Koh
- Joint Replacement Center, Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea; Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Min Kang
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Man Soo Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Keun Young Choi
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Sueen Sohn
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
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Jin QH, Lee WG, Song EK, Kim WJ, Jin C, Seon JK. No difference in the anteroposterior stability between the GRADIUS and multi-radius designs in total knee arthroplasty. Knee 2020; 27:1197-1204. [PMID: 32711882 DOI: 10.1016/j.knee.2020.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 04/22/2020] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This retrospective study aimed to compare stability and clinical and radiological outcomes of total knee arthroplasty (TKA) for the GRADIUS and multi-radius femoral designs after minimum of two-year follow-up. METHODS A total of 142 patients who underwent TKA using ATTUNE posterior stabilized (PS) implants (68 patients, GRADIUS group) or Persona PS implants (74 patients, multi-radius group) for degenerative osteoarthritis were included. After an average of 2-year follow-up, the anteroposterior (AP) stability at 30°, 60°, and 90° was measured using KT 2000 device and compared between the two groups. The clinical outcome measurements included range of motion (ROM) of the knee, patient-reported outcomes and anterior knee pain (AKP). For the clinical evaluation of mid-flexion instability, pain was evaluated using the visual analog scale (VAS) score recorded during climbing up or going down stairs. The radiolucent lines on knee radiographs obtained at final follow-up were evaluated and compared between two groups. RESULTS The average AP stability at 30° knee flexion was 5.7 mm in the GRADIUS group and 5.9 mm in the multi-radius group; however, the difference was not significant. The AP stability at 60° and 90° knee flexion was also similar in both groups. There were no significant differences in the ROM, patient-reported outcomes at follow-up, incidence of AKP and VAS scores between the two groups. There were no differences in the incidence of radiolucency around the components between the two groups. CONCLUSION The GRADIUS design did not show any advantage with respect to the stability or clinical outcomes compared with the multi-radius design in TKA.
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Affiliation(s)
- Quan He Jin
- Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Won-Gyun Lee
- Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Eun-Kyoo Song
- Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Woo-Jong Kim
- Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea
| | - Cheng Jin
- Department of Orthopaedic Surgery, Zhoushan Hospital, Zhoushan, Zhejiang, China
| | - Jong-Keun Seon
- Chonnam National University Hwasun Hospital, Jeollanam-do, Republic of Korea.
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Current evidence base for kinematic alignment. DER ORTHOPADE 2020; 49:584-592. [PMID: 32507940 DOI: 10.1007/s00132-020-03932-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Kinematic alignment recently became an alternative alignment option for total knee arthroplasty (TKA). Beside previous studies assessing mechanical alignment in comparison to unintentional malalignment of TKA in terms of implant survival and clinical outcome, more and more studies have focused on the direct comparison of intentional kinematic alignment with mechanical alignment of the prosthesis. In the past 5 years the number of studies with respect to kinematic alignment has risen from 11 to 91 studies. AIM The aim of this review article is to give a narrative overview of the current literature in the debate concerning kinematic and mechanical alignment in TKA.
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Koh IJ, Lin CC, Patel NA, Chalmers CE, Maniglio M, Han SB, McGarry MH, Lee TQ. Kinematically aligned total knee arthroplasty reproduces more native rollback and laxity than mechanically aligned total knee arthroplasty: A matched pair cadaveric study. Orthop Traumatol Surg Res 2019; 105:605-611. [PMID: 31006644 DOI: 10.1016/j.otsr.2019.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/17/2019] [Accepted: 03/22/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND A growing body of evidence supports that kinematically aligned (KA) total knee arthroplasty (TKA) provides superior clinical outcomes and satisfaction than mechanically aligned (MA) TKA. In theory, KA TKA would restore knee kinematics closer to the native condition than MA TKA, but the current biomechanical evidence is lacking. HYPOTHESIS KA TKA would restore knee biomechanics to the native condition better than MA TKA. METHODS Seven pairs of cadavers were tested. For each pair, one knee was randomly assigned to KA TKA and the other to MA TKA. During KA TKA, the sizes of femur and tibia resections were equivalent to implant thickness to align with the patient-specific joint line. MA TKA was performed using conventional measured resection techniques. All specimens were mounted on a customized knee-testing system and digitized. Knee motions measured during flexion included rollback, axial tibiofemoral rotation, and laxities, specifically varus-valgus laxity, anterior-posterior translation, and internal-external rotation. RESULTS The pattern of knee motion following KA TKA was similar to the native knee. However, following MA TKA, both medial and lateral rollback and tibiofemoral axial rotation were decreased relative to those of the native knee. Valgus laxity was restored only after KA TKA, whereas varus laxity was restored only after MA TKA. Anterior translation was increased regardless of the alignment strategy. In addition, rotational laxities were restored after KA TKA, but external rotation laxity increased after MA TKA. CONCLUSION KA TKA restores femoral rollback and laxity to the native condition better than MA TKA. KA TKA may enhance functional performance and provide a more normal knee sensation. LEVEL OF EVIDENCE II, Controlled laboratory study.
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Affiliation(s)
- In Jun Koh
- Joint Replacement Center, Eunpyeong St. Mary's Hospital, 03312 Seoul, Republic of Korea; Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, 06591 Seoul, Republic of Korea.
| | - Charles C Lin
- University of California, Irvine, School of Medicine, 92697 Irvine, CA, United States
| | - Nilay A Patel
- Department of Orthopaedic Surgery, University of California, Irvine, UCI Medical Center, route 81, 101 City Drive South, 92868 Orange, CA, United States
| | - Christen E Chalmers
- University of California, Irvine, School of Medicine, 92697 Irvine, CA, United States
| | - Mauro Maniglio
- Department of Orthopaedics and Traumatology; Inselspital Bern, University Hospital, Bern, Switzerland
| | - Sung Bin Han
- Joint Replacement Center, Eunpyeong St. Mary's Hospital, 03312 Seoul, Republic of Korea
| | - Michelle H McGarry
- Congress Medical Foundation, 800 South Raymond Pasadena, 91105 CA, United States
| | - Thay Q Lee
- Congress Medical Foundation, 800 South Raymond Pasadena, 91105 CA, United States
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Ro DH, Kim JK, Lee DW, Lee J, Han HS, Lee MC. Residual varus alignment after total knee arthroplasty increases knee adduction moment without improving patient function: A propensity score-matched cohort study. Knee 2019; 26:737-744. [PMID: 30902513 DOI: 10.1016/j.knee.2019.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/09/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Targeting residual varus alignment in total knee arthroplasty may be functionally beneficial to preoperative varus patients. METHODS Bilateral TKA patients were enrolled. According to the postoperative hip-knee-ankle axis, patients were allocated into residual varus (3° ± 1°) alignment group or neutral (0° ± 1°) alignment group. Then, 1:2 propensity score matching was used to match preoperative variables. Finally, matched neutral (n = 45) and varus groups (n = 32) were followed-up for two years and compared. The primary outcome was the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were range of motion (ROM), Knee Society knee score and function score, spatiotemporal gait parameters, dynamic alignment, knee flexion angle, knee adduction moment (KAM) and internal knee extension moment. RESULTS At two years after surgery, the mean difference of WOMAC score was 0.3 (95% CI, [-3.1, 3.7]) between the two groups. All secondary outcomes, except KAM and dynamic alignment, showed no significant difference between the two groups. Residual varus alignment group showed increased KAM and maximum KAM was 19% higher (P = 0.006). CONCLUSIONS Residual varus alignment showed no clinical benefits, and both groups of patients had a functionally identical knee gait biomechanics, except for increased KAM and varus alignment. The authors consider that even in patients with varus alignment, the first principle is still achieving neutral alignment, which is helpful for reducing the KAM. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Du Hyun Ro
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Keun Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Do Weon Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jangyun Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyuk-Soo Han
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea.
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