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Liu L, Lei K, Du D, Lin Y, Pan Z, Guo L. Functional knee phenotypes appear to be more suitable for the Chinese OA population compared with CPAK classification: A study based on 3D CT reconstruction models. Knee Surg Sports Traumatol Arthrosc 2024; 32:1264-1274. [PMID: 38488258 DOI: 10.1002/ksa.12130] [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: 11/10/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE The aim of this study was to investigate the distribution of coronal plane alignment of the knee (CPAK) classification and functional knee phenotypes in a Chinese osteoarthritis (OA) population and to compare different lower limb alignment targets according to the distribution characteristics to find suitable total knee arthroplasty (TKA) bone cut strategies for the Chinese OA patients. METHODS The computed tomography (CT) images were retrospectively collected and the three-dimensional (3D) models were reconstructed from 434 Chinese OA patients, including 93 males and 341 females, with a mean age of 66.4 ± 9.3 years. Femoral mechanical angle (FMA), tibial mechanical angle (TMA) and mechanical hip-knee-ankle angle (mHKA) were measured on the 3D models. Arithmetic hip-knee-ankle angle (aHKA) was calculated using FMA plus TMA, and joint line obliquity was calculated as 180 + TMA-FMA. The CPAK according to MacDessi and the functional knee phenotypes according to Hirschmann were performed. In addition, the suitable TKA bone cut strategies were explored according to the phenotypes and based on the characteristics of different alignment targets, such as mechanical alignment, anatomic alignment (AA), kinematic alignment, restricted KA (rKA) and adjusted MA (aMA). Statistical differences were determined using the independent-samples t-test or the two independent-samples Wilcoxon test, with p < 0.05 considered statistically significant. RESULTS The Chinese OA population showed a varus alignment tendency (mHKA = 172.1° ± 7.2°), to which the TMA was a major contributor (TMA = 84.7° ± 4.4° vs. FMA = 91.3° ± 3.2°). The mHKA was on average 3.9° more varus than the aHKA. A total of 140 functional knee phenotypes were found and 45.6% were concentrated in VARFMA3°-NEUFMA0° to VARTMA3°-NEUTMA0°. More than 70% of patients had different FMA and TMA phenotypes. There were 92.9% of CPAK distributed in types I to IV, with type I accounting for 53.9%. The FMA phenotypes were less changed if the aMA and rKA were chosen, and the TMA phenotypes were less changed if the AA and rKA were chosen. CONCLUSION Compared with the CPAK, the functional knee phenotypes were more suitable for the Chinese OA population with a wide distribution and a varus tendency, and it seemed more appropriate to choose aMA and rKA as TKA alignment targets for resection. LEVEL OF EVIDENCE Level Ⅲ.
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Affiliation(s)
- LiMing Liu
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Kai Lei
- Sports Medicine Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dekai Du
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Yong Lin
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Zhaoxun Pan
- Department of Joint Surgery, PLA Army 80th Group Military Hospital, Weifang City, Shandong Province, China
| | - Lin Guo
- Sports Medicine Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Qin S, Li M, Jia Y, Gao W, Xu J, Zhang B, Guo H, Feng A, Sun R. How Do the Morphological Abnormalities of Femoral Head and Neck, Femoral Shaft and Femoral Condyle Affect the Occurrence and Development of Medial Knee Osteoarthritis. Orthop Surg 2023; 15:3174-3181. [PMID: 37873579 PMCID: PMC10694027 DOI: 10.1111/os.13910] [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: 02/14/2023] [Revised: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVE At present, the main viewpoint is that tibial varus is the main reason of medial knee osteoarthritis (OA), and high tibial osteotomy (HTO) is also the main alignment correction method to correct medial knee OA. In contrast, the impact of the anatomical alignment of the femur on medial knee OA is often overlooked. We evaluated the increased risk for medial knee OA because a varus alignment could be attributed to the anatomical reasons that include hip anatomy, femoral shaft bowing (FSB) and femoral condylar dysplasia. METHODS The present research adopted a cross-sectional study method. We selected 62 patients with HTO in the Third Hospital of Hebei Medical University from June 2021 to March 2022 as the HTO group and 55 healthy volunteers as the control group. Femoral neck-shaft angle (NSA), lateral FSB, mechanical lateral distal femoral angle (mLDFA) and hip-knee-ankle (HKA) was radiographically examined within the two groups. The femoral neck length and offset were also measured, and the ratio is represented by the ratio of the femoral neck length to off-set (N/O). The 2-tailed Student t-test was used to compare the differences between groups when the data were in accordance with a normal distribution. Otherwise, the Mann-Whitney U tests was used to compare the differences between groups. RESULT Compared to the control group, the HTO group had a higher offset (p < 0.05), greater femoral neck length (p < 0.05), and decreased (more varus) NSA (p < 0.05). The HKA in the HTO group was 172.20 ° (3.50°), which was significantly lower than that of the control group 177.00° (3.05°), (p < 0.001), while the medial OA was associated with more varus HKA. The mean mLDFA was 89.10 ° (2.35°) and 87.50° (2.85°) in the HTO and control groups (p < 0.005), respectively. The mean lateral FSB values of the full-length radiographs were larger (p < 0.001) in the HTO group (4.24° ± 3.25°) than that in control group (1.16° ± 2.32°). CONCLUSION The reduction of NSA (coxa vara) and the increase of the mLDFA can lead to medial knee OA, while the lateral FSB also affects medial OA. We believe that femoral deformity is also one of the cause of the medial knee OA. Therefore, it is necessary to evaluate the joint deformity of the femur and tibia before surgery in order to determine whether to use HTO alone to correct the lower limb alignment.
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Affiliation(s)
- Shiqi Qin
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Ming Li
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Yanfeng Jia
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Wei Gao
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Juncai Xu
- Third Military Medical University Southwest HospitalChongqingChina
| | | | - Hailong Guo
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Ao Feng
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
| | - Ran Sun
- Hebei Medical University Third Affiliated HospitalShijiazhuangChina
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Wallace SJ, Greenstein MD, Fragomen AT, Reif TJ, Rozbruch SR. Staged Extra-Articular Deformity Correction in the Setting of Total Knee Arthroplasty. Arthroplast Today 2023; 24:101247. [PMID: 38023645 PMCID: PMC10663752 DOI: 10.1016/j.artd.2023.101247] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Extra-articular lower-leg deformities mandate unique considerations when planning total knee arthroplasty (TKA). Poor limb alignment may increase perioperative complications and cause early implant failure. This study reports on the safety and efficacy of staged, extra-articular deformity correction about the knee in the setting of osteoarthritis and TKA. Methods A retrospective review was conducted from December 2007 to December 2019 identifying 30 deformities in 27 patients (average age: 52.7 years; range 31-74) who underwent staged surgical correction of extra-articular deformity in preparation for TKA. Patient demographics, surgical details, clinical and radiographic measurements, severity of knee arthritis, and complications were collected. Results There were 17 femur and 12 tibia deformities. There was an average improvement of 14.7° of deformity measured in the coronal plane and 12.7° of deformity in the sagittal plane in the femur and 13.5° in the coronal plane and 10.3° in the sagittal plane in the tibia. Leg length discrepancies improved by 26 mm on average (1-100 mm). After an average 3.1-year follow-up, 12 out of 27 patients proceeded with primary or revision TKA. There were no cases of blood transfusion, nerve palsy, or compartment syndrome, and all patients achieved bony union. Conclusions Staged, extra-articular deformity correction is a safe and effective approach to improve limb alignment in the setting of knee osteoarthritis and TKA.
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Affiliation(s)
- Stephen J. Wallace
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
- Summit Orthopaedics, Lake Oswego, OR, USA
| | - Michael D. Greenstein
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - Austin T. Fragomen
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - Taylor J. Reif
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - S. Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
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Demirtas Y, Emet A, Ayik G, Cakmak G, Aksahin E, Celebi L. A novel robot-assisted knee arthroplasty system (ROSA) and 1-year outcome: A single center experience. Medicine (Baltimore) 2023; 102:e35710. [PMID: 37861507 PMCID: PMC10589563 DOI: 10.1097/md.0000000000035710] [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: 06/29/2023] [Accepted: 09/28/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Total knee arthroplasty is a successful procedure in the treatment of knee osteoarthritis. Searches in surgical technique have focused surgeons in particular on implant alignment. For this purpose, the use of robot-assisted total knee arthroplasty has become increasingly common in the last 10 years. METHODS A total of 46 patients (66 knees) who were operated for knee osteoarthritis with Robotic Surgical Assistant (ROSA, Zimmer-Biomet, Warshaw, Indiana, USA) between 2021 and 2023 were included in the study. Preoperative planning and intraoperative incision time, total surgical time, range of motion and follow-up time recorded. Oxford knee scores and knee society scores (KSS) of the patients were compared before and after surgery. At the last follow-up Forgotten Joint Score and the sagittal and coronal plane alignments were evaluated. RESULTS Preoperative mean Oxford score of the right knee of the patients was 18.5 ± 3.2, post-surgery mean Oxford score progressed to 43.5 ± 2.2. While the preoperative left knee Oxford score of the patients was 16.9 ± 2.3, the mean left knee Oxford score improved to 43.4 ± 2.2 postoperatively. The mean KSS score of the patients' right knee preoperatively was 49.7 ± 3.5, and progressed to 89.2 ± 4.7 postoperatively. While the preoperative mean left knee KSS score of the patients was 46.5 ± 4.3, the mean KSS score improved to 89.8 ± 3.2 postoperatively. The mean Forgotten Joint Score of the left knee at the last follow-up of the patients was 77.4 ± 3.8, while the mean Forgotten Joint Score of the right knee was 75.4 ± 5.9. CONCLUSION The results of ROSA-supported knee arthroplasty found to be functionally successful.
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Affiliation(s)
- Yunus Demirtas
- Yuksek İhtisas University Medical School Orthopedics and Traumatology Department, Ankara, Turkey
| | - Abdulsamet Emet
- Department of Orthopedics and Traumatology, Etlik City Hospital, Ankara, Turkey
| | | | - Gokhan Cakmak
- Yuksek İhtisas University Medical School Orthopedics and Traumatology Department, Ankara, Turkey
| | - Ertugrul Aksahin
- Yuksek İhtisas University Medical School Orthopedics and Traumatology Department, Ankara, Turkey
| | - Levent Celebi
- Yuksek İhtisas University Medical School Orthopedics and Traumatology Department, Ankara, Turkey
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Flury A, Hoch A, Cirigliano G, Hodel S, Kühne N, Zimmermann SM, Vlachopoulos L, Fucentese SF. Excessive femoral torsion is not associated with patellofemoral pain or instability if TKA is functionally aligned and the patella denervated. Knee Surg Sports Traumatol Arthrosc 2023; 31:3665-3671. [PMID: 36114342 PMCID: PMC10435632 DOI: 10.1007/s00167-022-07162-5] [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: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Recent data suggest that individual morphologic factors should be respected to restore preoperative patellofemoral alignment and thus reduce the likelihood of anterior knee pain. The goal of this study was to investigate the effect of excessive femoral torsion (FT) on clinical outcome of TKA. METHODS Patients who underwent TKA and complete preoperative radiographic evaluation including a long-leg radiograph and CT scan were included. 51 patients showed increased FT of > 20° and were matched for age/sex to 51 controls (FT < 20°). Thirteen patients were lost to follow-up. Thirty-eight matched pairs were compared after a 2 year follow-up clinically (Kujala and patellofemoral score for TKA) and radiographically (FT, frontal leg axis, TT-TG, patellar thickness, patellar tilt, and lateral displacement of patella). Functional alignment of TKA was performed (hybrid-technique). All patellae were denervated but no patella was resurfaced. RESULTS There was no significant difference between clinical scores two years after surgery between patients with normal and excessive FT (n.s.). Kujala score was 64.3 ± 16.7 versus 64.8 ± 14.4 (n.s.), and patellofemoral score for TKA was 74.3 ± 21 versus 78.5 ± 20.7 (n.s.) for increased FT group and control group, respectively. There was no correlation between preoperative FT and clinical scores. Other radiographic parameters were similar between both groups. No correlations between clinical outcomes and preoperative/postoperative frontal leg axis or total leg axis correction were found (n.s.). CONCLUSION If the leg axis deformity is corrected to a roughly neutral alignment during cemented TKA, including patellar denervation, then excessive FT was not associated with patellofemoral pain or instability. LEVEL OF EVIDENCE Prospective comparative study, level II.
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Affiliation(s)
- Andreas Flury
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland.
| | - Armando Hoch
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Gabriele Cirigliano
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro Hodel
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Nathalie Kühne
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Stefan M Zimmermann
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
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Seki K, Seki T, Siigi E, Imagama T, Yamabe T, Sakai T. Comparing inter- and intraobserver reliability between two-dimensional and three-dimensional measurements in the tibial component position of unicompartmental knee arthroplasty. Acta Orthop Belg 2023; 89:316-325. [PMID: 37924549 DOI: 10.52628/89.2.10553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023]
Abstract
In unicompartmental knee arthroplasty (UKA), the tibial component has a small coronal plane width, the tibia and tibial component rotations are mismatched, and the large tibial component posterior tilt may make accurate measurements of component positions difficult in radiography. The study aimed to assess the intra- and interobserver reliabilities of radiographic (2D) and 3D computed tomography (3D-CT) measurements and to determine the minimum detectable change (95% confidence level, MDC95) in the tibial component position measurements in UKA. The study included 23 females and 7 males. Two surgeons measured the tibial component position. Intraclass and interclass correlation coefficients (ICC) were calculated to obtain reliability, and Bland-Altman analysis was performed to assess systematic errors. The MDC95 was calculated according to MDC95 = standard error of measurement × 1.96 × √2. In the 2D and 3D- CT measurements, intraobserver reliability for coronal and sagittal positions of the tibial component were sufficiently reliable, where ICCs were >0.8. In the coronal plane, the ICCs for interobserver reliability were lower in 2D (ICC, 0.5-0.7) than in 3D-CT (ICC > 0.9). Bland-Altman plots showed systematic bias in sagittal alignment in the 2D assessment. In the 3D assessment of intra- and interobserver reliability, the MDC95 of the coronal, sagittal, and axial planes was <2°. In the 2D intra- and interobserver reliability, the MDC95 of the coronal and sagittal planes was >2°. The 2D measurement had a risk of misidentifying the tibial component position in UKA.
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Effect of total knee arthroplasty for valgus knee correction on clinical outcome and patellar position. INTERNATIONAL ORTHOPAEDICS 2023; 47:735-743. [PMID: 36645475 PMCID: PMC9931837 DOI: 10.1007/s00264-023-05689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/01/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose was to investigate the effect of different degrees of valgus deformity correction on patellar position and clinical outcome in patients with valgus knees after total knee arthroplasty (TKA). METHODS We retrospectively analyzed and followed 118 patients with valgus knees. Based on the post-operative hip-knee-ankle (HKA), patients were divided into three groups: neutral (±3°), mild (3-6°), and severe (> 6°). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), and Knee Society Score (KSS) were used to evaluate post-operative clinical efficacy. Also, the patellar tilt angle (ε-angle), congruence angle (θ-angle), and Insall-Salvati index (ISI) were used to represent the patellar position. Post-operative observation indicators included HKA, angle of the femur (α-angle), tibial angle (β-angle), femoral component flexion angle (γ-angle), and tibial component posterior slope angle (δ-angle). RESULTS All patients showed significant improvements in HKA, ROM, WOMAC, and KSS after operation (P < 0.001). Regarding patellar position, the ISI values decreased to varying degrees (P < 0.05). The patellar tilt angle was significantly increased in the severe valgus group compared to that in the mild valgus and neutral groups (P < 0.001). Univariate analysis showed that the degree of post-operative residual valgus was significantly affected by WOMAC, KSS, α-, ε-, and θ-angles. CONCLUSION Minor valgus undercorrection did not affect the short-term outcome after TKA; however, when the residual valgus angle was > 6°, the post-operative scores were significantly reduced. Inadequate valgus correction does not result in significant changes in patellar height but may increase the risk of poor patellar tracking.
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Accelerometer-based portable navigation, a faster guide compared to computer-assisted navigation in bilateral total knee arthroplasty-a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2023; 31:786-792. [PMID: 34997248 DOI: 10.1007/s00167-021-06842-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE There are limited studies in the literature comparing the alignment accuracy of the large console, imageless, computer-assisted navigation (CAN) and portable, hand-held, accelerometer-based navigation (ABN) in total knee arthroplasty (TKA). This study was aimed to compare the operative time, blood loss, radiological, clinical and functional outcomes between CAN- and ABN-guided bilateral TKA. METHODS From Jan 2016 to Dec 2017, 50 patients who underwent bilateral TKA were randomized to undergo either CAN-guided or ABN-guided TKA. Tourniquet time and blood loss were recorded, and intra-op complications were noted. Post-op radiological outcomes at 2 weeks were compared between the groups. The clinical and functional outcomes using the American Knee Society Scores (KSS) and Oxford Knee Score (OKS) were recorded pre-operatively and post-operatively at 3, 6, 12 months and at the end of the study with a minimum follow-up of 48 months. RESULTS Both groups were well-matched in terms of patient demographic parameters. The mean surgical time per knee was significantly lower in the ABN group (54.5 ± 5.6 min) compared to the CAN group (61.7 ± 13.7 min; p < 0.01). Mean blood loss per knee in the ABN group was 592.1 ± 245.3 mL compared to 682.8 ± 322.0 in the CAN group (p = 0.11). In the ABN group, the mean post-op mechanical axis was 1.2 ± 3.2° (vs 1.5 ± 2.2° in the CAN group, p 0.6), the frontal femoral angle was 88.8 ± 2.3° (vs 88.8 ± 1.8° in the CAN group, p 1.0) and frontal tibial angle was 90.1 ± 1.6° (vs 89.7 ± 1.1° in the CAN group, p 0.14). At 48 month follow-up, the mean functional KSS in the ABN group was 89.0 ± 5.7 (vs 88.1 ± 4.5 in the CAN group, p 0.37) and the mean OKS was 40.5 ± 2.8 (vs 39.6 ± 3.2 in the CAN group, p 0.12). CONCLUSION Portable, hand-held ABN offers alignment accuracy and functional outcomes in TKA similar to that with CAN, with a reduced duration of surgery. There was no advantage of either of the techniques in terms of clinical or functional outcomes at 48 month follow-up. LEVEL OF EVIDENCE 1.
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Verasense sensor-assisted total knee arthroplasty showed no difference in range of motion, reoperation rate or functional outcomes when compared to manually balanced total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:1851-1858. [PMID: 36854996 PMCID: PMC10090011 DOI: 10.1007/s00167-023-07352-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/10/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The aim of this systematic review was to investigate the clinical and functional knee outcomes after Verasense sensor-assisted total knee arthroplasty (VA TKA), and to compare these outcomes, where possible, with those from manually balanced total knee arthroplasty (MB TKA). METHODS A systematic literature search following PRISMA guidelines was conducted on PubMed, Embase, Medline and Scopus from the beginning of January 2012 until the end of June 2022, to identify potentially relevant articles for this review. Selection was based on the following inclusion criteria: full text English- or German-language clinical studies, published in peer-reviewed journals, which assessed clinical and functional outcomes following VA TKA. Not original research, preprints, abstract-only papers, protocols, reviews, expert opinion papers, book chapters, surgical technique papers, and studies pertaining only to unicondylar knee arthroplasty (UKA) or patellofemoral arthroplasty (PFA) were excluded. Several scores (Knee Society Score [KSS], Oxford Knee Score [OKS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Knee injury and Osteoarthritis Outcome Score-4 subscales [KOOS4] and Physical Function-Computerised Adaptive Testing [PF-CAT]), alongside postoperative measurements of range of motion [ROM], reoperation rates and the rate of manipulation under anaesthesia [MUA]) were used to evaluate clinical and functional outcomes. The quality of included papers, except randomised control trials (RCTs), was evaluated using the Methodological Index for Non-Randomised Studies (MINORS). For the assessment of included RCTs, the Jadad Scale was used. RESULTS The literature search identified 243 articles. After removing duplicates, 184 papers were included in the initial screening process. Fourteen of them met all the inclusion criteria following the selection process. Mean MINORS for non-comparative studies value was 11.5 (11-12), and for comparative studies 18.2 (13-21). Mean Jadad Scale score was 3.6 (2-5). Outcomes from a total number of 3633 patients were evaluated (mean age at surgery 68.5 years [32-88 years]). In terms of clinical outcomes, the overwhelming majority of studies observed an improvement after VA TKA, but no statistically significant difference in ROM and reoperation rate when compared to MB TKA. On the other hand, lower rates of MUA have been described in the VA TKA group. An increase in postoperative clinical and functional scores values, when compared to the preoperative ones, has been reported in both groups, although no statistically significant difference between them has been observed. CONCLUSION The use of Verasense pressure sensors in TKA leads to no significant improvement in ROM, reoperation rate or functional outcomes, when compared to the standard manually balancing technique. However, lower rates of MUA have been described in the VA TKA group. These findings highlight the importance of tools being able to measure ligament stresses or joint pressure for achieving an optimally balanced knee. LEVEL OF EVIDENCE III.
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The impact of different alignment strategies on bone cuts in total knee arthroplasty for varus knee phenotypes. Knee Surg Sports Traumatol Arthrosc 2023; 31:1840-1850. [PMID: 36811657 PMCID: PMC10089997 DOI: 10.1007/s00167-023-07351-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The purpose of this study was to visualise the influence of alignment strategy on bone resection in varus knee phenotypes. The hypothesis was that different amounts of bone resection would be required depending on the alignment strategy chosen. Through visualisation of the corresponding bone sections, it was hypothesised, it would be possible to assess which of the different alignment strategies would require the least amount of change to the soft tissues for the chosen phenotype, whilst still ensuring acceptable alignment of the components, and thus could be considered the most ideal alignment strategy. METHODS Simulations of the different alignment strategies (mechanical, anatomical, constrained kinematic and unconstrained kinematic) in relation to their bone resections were performed on five common exemplary varus knee phenotypes. VARHKA174° VARFMA87° VARTMA84°, VARHKA174° VARFMA90° NEUTMA87°, VARHKA174° NEUFMA93° VARTMA84°, VARHKA177° NEUFMA93° NEUTMA87° and VARHKA177° VALFMA96° VARTMA81°. The phenotype system used categorises knees based on overall limb alignment (i.e. hip knee angle) but also takes into account joint line obliquity (i.e. TKA and FMA) and has been applied in the global orthopaedic community since its introduction in 2019. The simulations are based on long-leg radiographs under load. It is assumed that a change of 1° in the alignment of the joint line corresponds to a displacement of the distal condyle by 1 mm. RESULTS In the most common phenotype VARHKA174° NEUFMA93° VARTMA84°, a mechanical alignment would result in an asymmetric elevation of the tibial medial joint line by 6 mm and a lateral distalisation of the femoral condyle by 3 mm, an anatomical alignment only by 0 and 3 mm, a restricted by 3 and 3 mm, respectively, whilst a kinematic alignment would result in no change in joint line obliquity. In the similarly common phenotype 2 VARHKA174° VARFMA90° NEUTMA87° with the same HKA, the changes are considerably less with only 3 mm asymmetric height change on one joint side, respectively, and no change in restricted or kinematic alignment. CONCLUSION This study shows that significantly different amounts of bone resection are required depending on the varus phenotype and the alignment strategy chosen. Based on the simulations performed, it can, therefore, be assumed that an individual decision for the respective phenotype is more important than the dogmatically correct alignment strategy. By including such simulations, the modern orthopaedic surgeon can now avoid biomechanically inferior alignments and still obtain the most natural possible knee alignment for the patient.
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Effects of Severe Varus Deformity on Soft Tissue Balancing in Total Knee Arthroplasty. J Clin Med 2022; 12:jcm12010263. [PMID: 36615063 PMCID: PMC9821530 DOI: 10.3390/jcm12010263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/06/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
This study aimed to establish the effect of severe varus deformity on soft tissue balance in total knee arthroplasty (TKA), which is not yet well established. We retrospectively enrolled 205 patients (270 knees) who underwent primary TKA using the measured resection technique. Four intraoperatively measured TKA gaps and gap differences were compared between the severe varus deformity group (Hip-knee-ankle [HKA] varus angle ≥ 10°) and the mild varus deformity group (HKA varus angle < 10°). Pearson’s correlation analysis and multiple linear regression analysis were used to investigate the factors affecting flexion and extension gap differences (FGD and EGD). A receiver operating characteristic curve was applied to assess the cut-off value of the HKA varus angle to discriminate the rectangular gap. The FGD (1.42 ± 1.35 mm vs. 1.05 ± 1.16 mm, p = 0.019) and the EGD (1.45 ± 1.32 mm vs. 0.97 ± 1.53 mm, p = 0.006) were significantly larger in severe varus deformity group than in mild varus deformity group. The HKA varus angle was positively correlated with both FGD (r = 0.264, p < 0.001) and EGD (r = 0.319, p < 0.001) and was an influencing factor for FGD (β = 0.232, p = 0.040) and EGD (β = 0.229, p = 0.037). A preoperative HKA angle of 12.4° was selected as the cutoff value to discriminate between rectangular and trapezoidal gaps. Thus, the severity of varus deformity (HKA varus angle) was found to be a significant factor affecting the mediolateral gap difference in TKA. When performing TKA in a knee with an HKA varus angle ≥ 12.4°, a trapezoidal gap is more likely to be expected. Level of evidence III, case−control study.
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12
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Zheng K, Sun H, Zhang W, Zhu F, Zhou J, Li R, Geng D, Xu Y. Mid-Term Outcomes of Navigation-Assisted Primary Total Knee Arthroplasty Using Adjusted Mechanical Alignment. Orthop Surg 2022; 15:230-238. [PMID: 36440506 PMCID: PMC9837234 DOI: 10.1111/os.13595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The adjusted mechanical alignment (aMA) technique is an extension of conventional mechanical alignment (MA), which has rarely been reported. The purpose of this study was to evaluate mid-term outcomes of navigation-assisted total knee arthroplasty (TKA) using aMA. METHODS This retrospective cohort study enrolled 63 consecutive patients (77 knees) who underwent navigation-assisted TKA using aMA between September 2017 and October 2019. Fifty-two consecutive patients (61 knees) who underwent TKA using MA during the same period were assessed as the controlled group. The demographic data and perioperative data were recorded. The parameters of resection and soft tissue balance including tibia resection angle, frontal femoral angle, axial femoral angle, joint line translation, medial and lateral gap in extension and flexion position were recorded. Radiographic parameters and functional scores including the Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Forgotten Joint Score-12 (FJS-12) were evaluated. Surgery-related complications were recorded. The average follow-up was 3.5 years, with a minimum of 2.4 years. RESULTS The frontal femoral angle was 2.55° ± 1.08° in aMA group versus 0.26° ± 0.60° in MA group (p < 0.001). The axial femoral angle was 3.07° ± 2.23° external in aMA group versus 2.30° ± 1.70° in MA group (p = 0.027). The lateral flexion gap was wider in the aMA group, with a mean of 0.71 mm more laxity (p = 0.001). Postoperative coronal alignment was 177.03° ± 1.82° in aMA group versus 178.14° ± 1.69° in MA group (p < 0.001). The coronal femoral component angle was 92.62° ± 2.78° in aMA group versus 90.85° ± 2.01° in MA group (p < 0.001). Both aMA-TKA and MA-TKA achieved satisfactory mid-term clinical outcomes. However, the HSS scores at 1 month postoperatively were significantly higher using aMA than using MA (p < 0.001). CONCLUSION Navigation-assisted TKA using aMA technique obtained satisfactory mid-term clinical outcomes. The aMA technique aims to produce a biomimetic wider lateral flexion-extension gap and minimize releases of soft tissues, which might be associated with better early clinical outcomes than MA technique.
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Affiliation(s)
- Kai Zheng
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Houyi Sun
- Department of OrthopaedicsQilu Hospital of Shandong UniversityJinanChina
| | - Weicheng Zhang
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Feng Zhu
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Jun Zhou
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Rongqun Li
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Dechun Geng
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Yaozeng Xu
- Department of OrthopaedicsThe First Affiliated Hospital of Soochow UniversitySuzhouChina
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13
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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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14
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Luan Y, Zhang M, Ran T, Wang H, Fang C, Nie M, Wang M, Cheng CK. Correlation between component alignment and short-term clinical outcomes after total knee arthroplasty. Front Surg 2022; 9:991476. [PMID: 36311927 PMCID: PMC9606652 DOI: 10.3389/fsurg.2022.991476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/26/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between component alignment and short-term clinical outcomes after total knee arthroplasty (TKA). METHODS 50 TKA patients from a regional hospital were enrolled in the study. The following component alignments were measured from radiological data acquired within 1 week after surgery: hip-knee-ankle angle (HKA), medial distal femoral angle (MDFA), medial proximal tibial angle (MPTA), femoral flexion-extension angle (FEA), tibial slope angle (TSA), femoral rotational angle (FRA) and tibial rotational angle (TRA). The Hospital for Special Surgery (HSS) knee scoring system was used to assess clinical outcomes after 1 year, with patients being divided into three groups (excellent, good and not good) according to the HSS scores. Difference analysis and linear correlation analysis were used for the statistical analysis. RESULTS The results showed significant differences in MDFA (p = 0.050) and FEA (p = 0.001) among the three patient groups. It was also found that the total HSS had only a moderate correlation with FEA (r = 0.572, p < 0.001), but FEA had a positive linear correlation with pain scores (r = 0.347, p = 0.013), function scores (r = 0.535, p = 0.000), ROM scores (r = 0.368, p = 0.009), muscle scores (r = 0.354, p = 0.012) and stability scores (r = 0.312, p = 0.028). A larger MDFA was associated with lower FE deformity scores (r = -0.289, p = 0.042) and the TSA had a positive influence on the ROM (r = 0.436, p = 0.002). Also, changes in FRA produced a consequent change in the FE deformity score (r = 0.312, p = 0.027), and the muscle strength scores increased as TRA increased (r = 0.402, p = 0.004). CONCLUSION The results show that the FEA plays a significant role in clinical outcomes after TKA. Surgical techniques and tools may need to be improved to accurately adjust the FEA to improve joint functionality and patient satisfaction.
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Affiliation(s)
- Yichao Luan
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Min Zhang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Tianfei Ran
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Huizhi Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Chaohua Fang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,Department of Joint Surgery, Ningbo No.6 Hospital, Ningbo, China
| | - Maodan Nie
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Min Wang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China,Correspondence: Min Wang Cheng-Kung Cheng
| | - Cheng-Kung Cheng
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,Correspondence: Min Wang Cheng-Kung Cheng
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15
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Larrainzar-Garijo R, Molanes-Lopez EM, Murillo-Vizuete D, Garcia-Bogalo R, Escobar-Anton D, Lopez-Rodriguez J, Diez-Fernandez A, Corella-Montoya F. Mechanical Alignment in Knee Replacement Homogenizes Postoperative Coronal Hip-Knee-Ankle Angle in Varus Knees: A Navigation-Based Study. J Knee Surg 2022; 35:1285-1294. [PMID: 33472260 DOI: 10.1055/s-0040-1722694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
After knee replacement, postoperative lower limb alignment is influenced by the geometry of the prosthesis position and surrounding soft tissue that contributes to the hip-knee-ankle (HKA) angle. The purpose of this study is to determine the dynamic coronal HKA angle after mechanical alignment in total knee replacement using computer navigation. We conducted a pre-post design study of 71 patients with varus osteoarthritic knees on which total knee arthroplasty was performed. The HKA was measured before and at the end of the surgical procedure with the patient in the supine position using a navigation system at 30, 60, and 90 degrees of knee flexion. Postoperative implant position and flexion and extension gaps were assessed. HKA was clustered in three preoperative dynamic patterns (PDPs; Varus-Neutral, Varus-Valgus, and Varus-Varus). There were statistically significant differences in the dynamic coronal HKA between the preoperative and postoperative statuses after mechanically aligned knee replacement (with p < 0.0001) Before the surgical procedure, statistically significant differences were found between patterns at any angle of flexion confirming a well-differentiated preoperative dynamic behavior between the three groups. Postoperatively, 98.6% (71 out of 72) of the knees were within ± 3 degrees of the HKA at full extension. Fifty-eight knees (80.6%) were assessed to a "within-range" postoperative dynamic alignment at any grade of flexion considered. There are differences between the preoperative and postoperative status of the dynamic coronal HKA angle after mechanically aligned knee replacement. We proposed that an excellent dynamic HKA alignment is achieved not only at full extension within the range of 0 ± 3 degrees but also when this alignment is maintained at 30, 60, and 90 degrees.
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Affiliation(s)
- Ricardo Larrainzar-Garijo
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain.,Departamento Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Elisa M Molanes-Lopez
- Departamento de Estadística e Investigación Operativa, Unidad Departamental de Bioestadística, Facultad de Medicina, Universidad Complutense, Madrid Spain
| | - David Murillo-Vizuete
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Raul Garcia-Bogalo
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - David Escobar-Anton
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Jesus Lopez-Rodriguez
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Angel Diez-Fernandez
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Fernando Corella-Montoya
- Department of Orthopadic and Trauma, Hospital Universitario Infanta Leonor, Madrid, Spain.,Departamento Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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16
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Hörlesberger N, Zinggl C, Smolle MA, Leitner L, Lohberger B, Leithner A, Sadoghi P. Mechanically aligned total knee arthroplasty with the extension-first technique does not equally restore neutral knee alignment in all preoperative knee phenotypes. Knee Surg Sports Traumatol Arthrosc 2022; 31:1405-1411. [PMID: 36087129 PMCID: PMC10049937 DOI: 10.1007/s00167-022-07147-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of this study was to determine the change in the long leg axis according to the preoperative knee phenotype using the mechanically aligned extension-first technique in total knee arthroplasty. The hypothesis of this study was that the knee phenotype would have an impact on the postoperative leg axis. METHODS This was a retrospective comparative study comprising 224 whole-leg radiographs of 112 patients. The leg axes of the pre- and postoperative radiographs were measured and categorized into three preoperative limb phenotypes (based on the hip-knee-ankle angle [HKA]) according to Hirschmann et al. (varus-HKA < 178.5°, neutral-HKA 178.5°-181.5°, and valgus-HKA > 181.5°). Additionally, femoral phenotypes (based on the femoral mechanical angle [FMA], i.e., the mechanical medial distal femoral angle [mMDFA], as well as the tibial phenotypes [based on the tibial mechanical angle, i.e., the medial proximal tibial angle (MPTA)] was calculated. The change in the long leg axis was analyzed and compared with the preoperative limb phenotype. RESULTS Significantly more patients with preoperative varus alignment shifted to neutral alignment (46.3%, n = 31) than did patients with preoperative valgus alignment (38.9%; n = 14). Moreover, 43.3% of patients (n = 29) with the varus phenotype remained in a varus alignment, compared with the 58.3% of patients with preoperative valgus phenotype (n = 21) remaining in valgus alignment. These findings were similar for both females (p < 0.001) and males (p = 0.015). CONCLUSION Using an extension-first mechanically aligned surgical technique, varus phenotypes predominantly result in neutral leg axes or remain varus, neutral phenotypes remain neutral, and valgus phenotypes remain valgus or change to neutral phenotypes. This study showed that preoperative knee phenotypes in valgus knees influence this technique more strongly than estimated in previous investigations, which is in line with modern alignment philosophies for TKA. LEVEL OF EVIDENCE Level IV, retrospective comparative study.
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Affiliation(s)
- Nina Hörlesberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Carina Zinggl
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Birgit Lohberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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17
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Robot-assisted knee arthroplasty improves component positioning and alignment, but results are inconclusive on whether it improves clinical scores or reduces complications and revisions: a systematic overview of meta-analyses. Knee Surg Sports Traumatol Arthrosc 2022; 30:2639-2653. [PMID: 33666686 DOI: 10.1007/s00167-021-06472-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this systematic overview was to identify, synthesise and critically appraise findings of meta-analyses on robot-assisted versus conventional unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The hypothesis was that robotic assistance would reduce complications and revision rates, yield better clinical scores, and improve component positioning and alignment. METHODS Two researchers independently conducted a literature search using Embase®, MEDLINE®, Web of Science, Allied and Complementary Medicine™ and Cochrane Database of Systematic Reviews on 2 November 2020 for meta-analyses (Level I-IV) on robotic assistance in UKA and/or TKA. Outcomes were tabulated and reported as weighted mean difference (WMD), risk ratio (RR) or weighted odds ratio (WOR), and were considered statistically significant when p < 0.05. RESULTS A total of ten meta-analyses were identified; four on robot-assisted UKA (n, 1880 robot-assisted vs. 2352 conventional UKA; follow-up, 0 to 60 months), seven on robot-assisted TKA (n, 4567 robot-assisted vs. 5966 conventional TKA; follow-up, 0 to 132 months). Of the meta-analyses on UKA, one found that robotic assistance reduced complication rates (relative risk (RR), 0.62), one found that it improved clinical scores (weighted mean difference (WMD), 19.67), three found that it extended operation times (WMD, 15.7 to 17.1 min), and three found that it improved component positioning and alignment (WMD, - 1.30 to - 3.02 degrees). Of the meta-analyses on TKA, two found that robotic assistance improved clinical scores (WMD, 1.62-1.71), two found that that it extended surgery times (WMD, 21.5-24.26 min), and five found that it improved component positioning and alignment (WMD, - 0.50 to - 10.07 degrees). None of the meta-analyses reported differences in survivorship between robot-assisted versus conventional knee arthroplasty. CONCLUSION Robot-assisted knee arthroplasty enabled more accurate component positioning and placement within target zones, but extended operation time considerably. Although robotic assistance improved component positioning, its benefits regarding clinical scores, patient satisfaction and implant survivorship remains to be confirmed. Finally, this overview revealed that six of the ten meta-analyses were of 'critically low quality', calling for caution when interpreting results. LEVEL OF EVIDENCE IV.
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18
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Lei K, Liu L, Yang P, Xiong R, Yang L, He R, Guo L. Robotics versus personalized 3D preoperative planning in total knee arthroplasty: a propensity score-matched analysis. J Orthop Surg Res 2022; 17:227. [PMID: 35410239 PMCID: PMC8996413 DOI: 10.1186/s13018-022-03115-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
Lower limb alignment is crucial in total knee arthroplasty (TKA). Previous studies have shown that robotics and personalized three-dimensional (3D) preoperative planning could improve postoperative alignment accuracy compared with conventional TKA, but comparison between the above two techniques has never been reported. The authors hypothesized that robotics may be superior to personalized 3D preoperative planning in terms of postoperative alignment in primary TKA, with similar patient-reported outcome measures (PROMs) but higher cost and longer operative time.
Methods
A consecutive series of patients who received TKA in our center from September 2020 to January 2021 were enrolled retrospectively. After 1:2 matching, 52 and 104 patients were included and divided into study group for robotics and control group for personalized 3D preoperative planning, respectively. Multiple postoperative alignment angles were measured, and clinical features such as operation and tourniquet time, length of hospital stay and hemoglobin (Hb) were recorded. Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate clinical results.
Results
Compared with control group, robotics group had significantly lower frontal femoral component angle (FFC) and frontal tibial component angle (FTC) absolute deviation (P < 0.05). It also had less outliers in hip–knee–ankle angle (HKA), FTC, lateral femoral component angle (LFC) and lateral tibial component angle (LTC) (P < 0.05). Hb loss of robotics group was significantly lower than control group (P < 0.001), while the operation and tourniquet time were longer (P < 0.001). There was no significant difference in KSS and WOMAC scores between two groups.
Conclusion
Compared with control group, patients in robotics group had significantly less malalignment, malposition, Hb loss, but similar PROMs. The operations in robotics group spent longer operation time and cost more compared with control group.
Trial registration: The Chinese Clinical Trial Registry, ChiCTR2000036235. Registered 22 August 2020, http://www.chictr.org.cn/showproj.aspx?proj=59300.
Level of evidence
III.
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19
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Liu B, Feng C, Tu C. Kinematic alignment versus mechanical alignment in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:201. [PMID: 35379289 PMCID: PMC8981671 DOI: 10.1186/s13018-022-03097-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/23/2022] [Indexed: 01/02/2023] Open
Abstract
Background The purpose of this study was to perform an updated meta-analysis to compare the outcomes of kinematic alignment (KA) and mechanical alignment (MA) in patients undergoing total knee arthroplasty. Methods PubMed, EMBASE, Web of Science, Google Scholar, and the Cochrane Library were systematically searched. Eligible randomized controlled trials regarding the clinical outcomes of patients undergoing total knee arthroplasty with KA and MA were included for the analysis. Results A total of 1112 participants were included in this study, including 559 participants with KA and 553 patients with MA. This study revealed that the Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score (knee and combined), and knee flexion range were better in the patients with kinematic alignment than in the mechanical alignment. In terms of radiological results, the femoral knee angle, mechanical medial proximal tibial angle, and joint line orientation angle were significantly different between the two techniques. Perioperatively, the walk distance before discharge was longer in the KA group than in the MA group. In contrast, other functional outcomes, radiological results, perioperative outcomes, and postoperative complication rates were similar in both the kinematic and mechanical alignment groups. Conclusions The KA technique achieved better functional outcomes than the mechanical technique in terms of KSS (knee and combined), WOMAC scores, and knee flexion range. PROSPERO trial registration number CRD42021264519. Date registration: July 28, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03097-2.
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Affiliation(s)
- Binfeng Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.,Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan, Zhengzhou, 450003, China.,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Chengyao Feng
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Chao Tu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China. .,Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
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20
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Shin KH, Jang KM, Han SB. Residual varus alignment can reduce joint awareness, restore joint parallelism, and preserve the soft tissue envelope during total knee arthroplasty for varus osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2022; 30:507-516. [PMID: 32743784 DOI: 10.1007/s00167-020-06201-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The objectives were to compare the coronal joint configuration of the knee joints, coronal gap imbalances requiring substantial medial release, and patient-reported outcomes, including the forgotten joint score, between knees in which residual varus alignment was intentionally allowed according to an individualised lower limb analysis and those with mechanical alignment in total knee arthroplasty for varus osteoarthritis. METHODS Consecutive primary navigated total knee arthroplasty procedures for varus osteoarthritis were retrospectively reviewed. The study cohort was stratified based on whether residual varus alignment was intentionally allowed. Propensity-score matching was performed based on the baseline characteristics, including demographic characteristics, preoperative radiological measurements, and the Western Ontario and McMaster University Osteoarthritis Index (mechanical alignment group vs residual varus group). The patient-reported outcomes and coronal joint line orientation of the knee (relative to the ground) and ankle were evaluated. Coronal gap differences and coronal gap imbalances were analysed using intraoperative gap measurements. RESULTS Relative to the ground and ankle, the postoperative knee joint line orientation slanted down laterally in the mechanical alignment group (- 3.05˚ ± 1.62, relative to the ground; - 2.65˚ ± 1.56, relative to the ankle joint), but was parallel in the residual varus group (- 0.75˚ ± 1.59, relative to the ground; - 0.95˚ ± 1.71, relative to the ankle joint). Coronal gap differences at extension and the proportion of coronal gap imbalances requiring substantial medial release were 1.27 ± 1.53 and 6% in the residual varus group and 2.32 ± 1.24 and 15% in the mechanical alignment group. Postoperatively, the residual varus group showed higher Western Ontario and McMaster University Osteoarthritis Index scores and total forgotten joint scores than the mechanical alignment group (6.97 ± 4.75 vs. 10.31 ± 5.74 and 56.42 ± 12.85 vs. 45.69 ± 14.49, respectively). CONCLUSION Intentionally allowed residual varus alignment with individualised analysis of lower limb alignment restored the parallel joint line of the knees, preserved the soft tissue envelope, and reduced joint awareness after total knee arthroplasty for varus osteoarthritis. LEVEL OF EVIDENCE Therapeutic, Level III retrospective case-control study.
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Affiliation(s)
- Kyun-Ho Shin
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea.
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Satisfactory mid- to long-term outcomes of TKA aligned using conventional instrumentation for flexion gap balancing with minimal soft tissue release. Knee Surg Sports Traumatol Arthrosc 2022; 30:627-637. [PMID: 33175282 DOI: 10.1007/s00167-020-06360-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe a technique for flexion gap management in total knee arthroplasty (TKA) using conventional instrumentation with minimal soft tissue release, by aligning the femoral component to restore close-to-native posterior condylar angle (PCA). The hypothesis was that this technique renders consistent outcomes, regardless the preoperative deformity or intraoperative parameters. METHODS In a consecutive series of 152 TKAs, the femoral component was rotated to restore anatomic PCA of 2° ± 2° and the flexion gap was balanced with a final lateral flexion laxity of 1-3 mm. Patients were assessed using the Knee Society Score (KSS), the Oxford Knee Score (OKS) and University of California Los Angeles (UCLA) activity score at a minimum follow-up of 4 years. Uni- and multivariable analyses were performed to determine associations between clinical scores and patient demographics, PCA, laxity, pre- and postoperative hip-knee-ankle (HKA) angle, and preoperative femoral mechanical angle (FMA) and tibial mechanical angle (TMA). RESULTS Intraoperative measurements indicated a target PCA of 2.9° ± 1.0° (range 0°-6°) with a final lateral flexion laxity of 1.5 ± 0.6 mm (range 0-3). The target PCA was achieved in 145 knees (95%) and the desired final lateral flexion laxity was achieved in 151 knees (99.3%). There were no significant differences in postoperative clinical outcomes between knees within the target PCA range and outliers. KSS function decreased with age and preoperative HKA angle, and was lower for women, while KSS satisfaction improved with follow-up. OKS increased with target PCA and follow-up, decreased with preoperative TMA, was lower for women and better for knees with resurfaced patellae. UCLA activity decreased with age, preoperative HKA angle and BMI, and was lower for women. CONCLUSIONS In this consecutive series of 152 TKAs performed with minimal ligament release, the target PCA and final lateral flexion laxity were simultaneously achieved in 95% of knees. At a minimum follow-up of 4 years, adequate clinical scores and patient satisfaction were achieved, even in knees outside the target PCA range. LEVEL OF EVIDENCE IV.
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22
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Relevant changes of leg alignment after customised individually made bicompartmental knee arthroplasty due to overstuffing. Knee Surg Sports Traumatol Arthrosc 2022; 30:567-573. [PMID: 32915259 DOI: 10.1007/s00167-020-06271-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of this study is to analyse the change in knee alignment after customised individually made (CIM) bicompartmental knee arthroplasty (BKA) and the subsequent consequences for patellar tracking. METHODS Medical records of 23 patients who received 26 CIM BKA (ConforMIS iDuo G2) at our clinic between November 2015 and July 2018 were reviewed. The objective part of the Knee Society Score (KSS), the hip-knee-ankle angle (HKA), the tibial mechanical angle (TMA) and femoral mechanical angle (FMA) were recorded preoperative and four months postoperative. Leg alignment was classified as neutral (HKA = 180° ± 3°), varus (HKA < 177°) or valgus (HKA > 183°). Furthermore, patellar tracking was determined on skyline view radiographs and adverse events were recorded. Implant survival rate was determined with the Kaplan-Meier method. Patient-reported outcome measures (PROMs) were pain, satisfaction, overall improvement and if the patient would undergo the surgery again. RESULTS The mean KSS improved from 61 points preoperative [standard deviation (SD) 14] to 90 points postoperative (SD 7, p < 0.001). The mean change for HKA was 6.3° (SD 3.5), for TMA 1.5° (SD 1.2) and for FMA 3.8° (SD 2.3). Postoperative leg alignment was neutral in 13 CIM BKA (50%), varus in two (8%) and valgus in 11 (42%) and patella tracking was central in 19 CIM BKA (73%) and lateral in seven (27%), respectively. Adverse events occurred in five CIM BKA: three patients required a patella resurfacing and one patient with bilateral CIM BKA needed a revision to a total knee arthroplasty. Implant survival rate was 92.3% at a follow-up of 3.2 years (SD 0.8). PROMs for CIM BKA without revision surgery were available at a mean follow-up of 3.2 years (SD 0.8). Mean pain with level walking decreased to 0.8 points (SD 1.4, p < 0.001) and mean pain with stairs or inclines to 1.6 points (SD 1.3, p < 0.001). Patient satisfaction was very satisfied or satisfied (78%), neutral (17%) or unsatisfied (4%). Overall improvement was much better or considerably better for 91% of all patients; 87% would undergo the surgery again. CONCLUSION A relevant change of the leg axis away from the treated femorotibial compartment due to overstuffing was observed. Although, neutral leg alignment was not restored in every case, clinical and patient-reported outcomes improved significantly. Further studies with long-term clinical and patient-reported outcomes are required to evaluate whether patients with bicompartmental knee osteoarthritis benefit from CIM BKA. LEVEL OF EVIDENCE IV, case series.
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Navigation and robotics improved alignment compared with PSI and conventional instrument, while clinical outcomes were similar in TKA: a network meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:721-733. [PMID: 33492410 DOI: 10.1007/s00167-021-06436-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/05/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To achieve the desired alignment more accurately and improve postoperative outcomes, new techniques such as computer navigation (Navigation), patient-specific instruments (PSI) and surgical robots (Robot) are applied in Total Knee Arthroplasty (TKA). This network meta-analysis aims to compare the radiological and clinical outcomes among the above-mentioned techniques and conventional instruments (CON). METHODS A PRISMA network meta-analysis was conducted and study protocol was published online at INPLASY (INPLASY202060018). Three databases (PubMed, EMBASE and Cochrane) were searched up to June 1, 2020. Randomised controlled trials (RCTs) comparing any two of the four techniques were included. A Bayesian network meta-analysis was performed focusing on radiological and clinical outcomes. The odds ratio (OR) or mean difference (MD) in various outcomes were calculated, and the interventions were ranked by the surface under the cumulative ranking area (SUCRA) value. RESULTS Seventy-three RCTs were included, with a total of 4209 TKAs. Navigation and Robot could significantly reduce the occurrence of malalignment and malposition compared with PSI and CON, and Navigation could obtain higher medium-and-long-term KSS knee scores than CON. Robot had the greatest advantage in achieving the desired alignment accurately, followed by Navigation; Navigation had the greatest advantage in the KSS score. CONCLUSION Navigation and Robot did improve the accuracy of alignment compared with PSI and conventional instrument in TKA, but the above four techniques showed no clinical significance in postoperative outcomes. LEVEL OF EVIDENCE I.
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Hothi H, Cerquiglini A, Büel L, Henckel J, Moser LB, Hirschmann MT, Hart A. SPECT/CT Assessment of In-Vivo Loading of the Knee Correlates with Polyethylene Deformation in Retrieved Total Knee Arthroplasty. Tomography 2022; 8:180-188. [PMID: 35076625 PMCID: PMC8788541 DOI: 10.3390/tomography8010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/18/2021] [Accepted: 01/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background: SPECT/CT distribution patterns in patients with total knee replacements have previously been correlated with factors such as time of implantation, implant type and alignment. It is unknown, however, if an increased and more extended bone tracer uptake (BTU) in SPECT/CT, representing loading of the joint, correlates with findings from retrieval studies. The aim of this study was to further understand this subject. Materials and Methods: 62 retrieved TKA were included. SPECT/CT was performed prior to revision. Quantitative and qualitative medio-lateral comparisons of BTU intensity and distribution in the tibia were performed. Retrieval analysis was performed with a micro-CT method to assess the thickness differences between medial and lateral sides of polyethylene inserts with symmetrical designs. Results: In the subgroup of TKA with asymmetrical SPECT/CT distribution, there was a significant correlation between retrieval and medical imaging data (p = 0.0355): patients showing a more extended BTU in the medial compartment also had a significantly thinner insert in the medial compartment, and vice versa in the lateral side. Conclusion: This is the first study comparing BTU distribution patterns and retrieval findings. Our results support the hypothesis that SPECT/CT is able to identify bone activity due to implant position and loading.
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Affiliation(s)
- Harry Hothi
- The Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK; (A.C.); (J.H.); (A.H.)
- Correspondence:
| | - Arianna Cerquiglini
- The Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK; (A.C.); (J.H.); (A.H.)
| | - Lukas Büel
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101 Bruderholz, Switzerland; (L.B.); (L.B.M.); (M.T.H.)
- Department of Orthopaedics, University of Basel, 4001 Basel, Switzerland
| | - Johann Henckel
- The Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK; (A.C.); (J.H.); (A.H.)
| | - Lukas B. Moser
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101 Bruderholz, Switzerland; (L.B.); (L.B.M.); (M.T.H.)
| | - Michael T. Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101 Bruderholz, Switzerland; (L.B.); (L.B.M.); (M.T.H.)
| | - Alister Hart
- The Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK; (A.C.); (J.H.); (A.H.)
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Zimmermann M, Moser L, Moret C, Iordache E, Amsler F, Rasch H, Hügli R, Hirschmann MT. Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment. Knee 2022; 34:259-269. [PMID: 35077945 DOI: 10.1016/j.knee.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/15/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment. METHODS Consecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05). RESULTS In the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA. CONCLUSION Preoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.
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Affiliation(s)
- M Zimmermann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - L Moser
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - C Moret
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - E Iordache
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - F Amsler
- Amsler Consulting, Basel, Switzerland
| | - H Rasch
- Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - R Hügli
- Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - M T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland.
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CT-based patient-specific instrumentation for total knee arthroplasty in over 700 cases: single-use instruments are as accurate as standard instruments. Knee Surg Sports Traumatol Arthrosc 2022; 30:447-455. [PMID: 32676744 PMCID: PMC8866287 DOI: 10.1007/s00167-020-06150-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Efforts in total knee arthroplasty are made to improve accuracy for a correct leg axis and reduce component malpositioning using patient-specific instruments. It was hypothesized that use of patient-specific instruments (vs. computer-navigated and conventional techniques) will reduce the number of outliers. Our second hypothesis was that single-use instrumentation will lead to the same accuracy compared to patient-specific instruments made of metal. METHODS 708 primary total knee arthroplasties between 2014 and 2018 using computer tomography (CT)-based patient-specific cutting block technique and a preoperative planning protocol were retrospectively reviewed. Preoperative data [hip-knee-angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), tibial slope, femoral component flexion] was compared to postoperative performed standard radiological follow-up X-rays. Differences of > 3° between measurements were defined as outliers. RESULTS Overall 500 prostheses using standard instrumentation and 208 prostheses using single-use instruments were implanted. Preoperative HKA axes (- 1.2°; p < 0.001), femoral component flexion (Δ 0.8°, p < 0.001), LDFA (Δ - 1.5°, p < 0.001), MPTA (Δ - 0.5°, p < 0.001) and tibial posterior slopes (Δ 0.5°, p < 0.001), respectively, were different from postoperative axes. More outliers occurred using standard (vs. single-use) instruments (p < 0.001) regarding postoperative HKA (ranges of standard- vs. single-use: instruments: HKA 178.0°-180.5° vs. 178.0°-180.5°, femoral component flexion 0.0°-6.0° vs. 0.0°-4.5°, LDFA 90.0°-91.0° vs. 90.0°-90.0°, MPTA 90.0°-90.0° vs. 90.0°-90.0°, tibial posterior slope - 10° to 10° vs. - 1° to 10°). No differences were seen for other angles measured. Comparing both systems, total number of outliers was higher using standard (8%) vs. single-use instruments (4.3%). CONCLUSION This study shows a high accuracy of CT-based patient-specific instrumentation concerning postoperative achieved knee angles and mechanical leg axes. Single-use instruments showed a similar accuracy. LEVEL OF EVIDENCE III.
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Graef F, Hommel H, Falk R, Tsitsilonis S, Zahn RK, Perka C. Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms. Knee Surg Sports Traumatol Arthrosc 2022; 30:527-535. [PMID: 32839848 PMCID: PMC8866357 DOI: 10.1007/s00167-020-06246-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/14/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. METHODS In this case-control study, n = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). RESULTS The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI (R = 0.95, p < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85-0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10-127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI (R = 0.74, p < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. CONCLUSIONS In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Frank Graef
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Hagen Hommel
- Department of Orthopedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
| | - Roman Falk
- Department of Orthopedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
| | - Serafeim Tsitsilonis
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Robert Karl Zahn
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Wan XF, Yang Y, Wang D, Xu H, Huang C, Zhou ZK, Xu J. Comparison of Outcomes After Total Knee Arthroplasty Involving Postoperative Neutral or Residual Mild Varus Alignment: A Systematic Review and Meta-analysis. Orthop Surg 2021; 14:177-189. [PMID: 34898039 PMCID: PMC8867439 DOI: 10.1111/os.13155] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 09/08/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Comparing mainly clinical and functional outcomes as well as prosthesis survival with neutral and residual mild varus alignment, we searched PubMed, Embase, Cochrane Library and Web of Science databases from 1 January 1974 to 18 December 2020 to identify studies comparing clinical and functional outcomes as well as prosthesis survival in the presence of different alignments after total knee arthroplasty (TKA) for varus knees. The included studies were assessed by two researchers according to the Newcastle–Ottawa Scale (NOS). Postoperative neutral alignment (0° ± 3°) was compared to residual mild varus (3°–6°) and residual severe varus (>6°). Meta‐analysis was performed using Review Manager 5.3. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables. The fixed‐effect model and random‐effect model were used to meta‐analyze the data. Nine studies were included in the meta‐analysis with 1410 cases of postoperative neutral alignment, 564 of residual mild varus alignment and 175 of residual severe varus alignment following TKA, all of which were published after 2013. Three studies scored 7 points on the NOS, while the remaining studies scored 8 points, suggesting high quality. The pooled mean differences (MDs) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were 1.07 [95% confidence interval (CI) −1.06 to 3.20; P = 0.32; I2 = 79%]. The meta‐analysis showed that neutral alignment and mild varus alignment were associated with similar the Oxford Knee Score (OKS), Knee Society Knee Score (KS‐KS), and Knee Society Function Score (KS‐FS), while neutral alignment was associated with lower Forgotten Joint Score (FJS) [mean difference −6.0, 95% confidence interval (CI) −9.37 to −2.64, P = 0.0005]. Neutral alignment was associated with higher KS‐KS than severe alignment (M 2.98, 95% CI 1.42 to 4.55, P = 0.0002; I2 = 0%) as well as higher KS‐FS (M 8.20, 95% CI 4.58 to 11.82, P < 0.00001; I2 = 0%). Neutral alignment was associated with similar rate of survival as mild varus alignment (95% CI 0.36 to 9.10; P = 0.48; I2 = 65%) or severe varus alignment (95% CI 0.94 to 37.90; P = 0.06; I2 = 61%). There was no statistical difference in others. Residual mild varus alignment after TKA may lead to similar or superior outcomes than neutral alignment in patients with preoperative varus knees, yet the available evidence appears to be insufficient to replace the current gold standard of neutral alignment. Severe varus alignment should be avoided.
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Affiliation(s)
- Xu-Feng Wan
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Yang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Duan Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Chao Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Xu
- Tianjin Hospital, Tianjin, China
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Restoration of pre-operative joint line orientation and alignment does not affect KSS and KOOS 1 year after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2021; 29:3170-3177. [PMID: 32556430 DOI: 10.1007/s00167-020-06097-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The objectives of this study were to examine the relation between clinical outcomes 1 year postoperatively, in a cohort of mechanically aligned total knee arthroplasties (TKA), and (1) the degrees of alignment change of the tibial, femoral and the hip-knee-ankle (HKA) angle; (2) the change of phenotype; (3) the postoperative knee joint line orientation to the floor. METHODS Pre-operative and postoperative long-leg X-rays of 90 patients were used to determine the coronal alignment. The absolute difference between the pre-operative and postoperative measurements was determined and the outcomes were categorized in whether or not a change in phenotype had occurred. Finally, the orientation of the knee joint line relative to the floor (tibial joint line angle-TJLA) was measured. Clinical outcomes were determined with the KOOS and KSS at 1-year follow-up. RESULTS The clinical outcomes (1) did not correlate with the absolute difference of the alignment measured; (2) did not show a difference between patients with or without a change in phenotype; and (3) were higher (KOOS ADL, Sport and QoL) in patients with a medial open TJLA. CONCLUSION This study showed no correlation between clinical outcomes and joint line restoration of the femur, tibia or HKA in patients after TKA. Leaving the prosthesis with some degrees of under correction on the coronal plane maintaining the phenotype, was not associated to better clinical results compared to TKA overcorrection. Nevertheless, the results showed that patients with a medial open TJLA had better clinical outcomes than patients with a lateral open TJLA. LEVEL OF EVIDENCE III.
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Katsumi R, Sato T, Mochizuki T, Watanabe S, Tanifuji O, Kawashima H. Influence of posterior tibial slope on three-dimensional femorotibial alignment under weight-bearing conditions in healthy Japanese elderly people. Biomed Mater Eng 2021; 32:183-194. [PMID: 33967036 DOI: 10.3233/bme-201209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Assessment of three-dimensional (3D) femorotibial alignment is essential for successful knee osteoarthritis treatment in the elderly. The complex morphology of the posterior tibial slope (PTS) might have an influence on sagittal and rotational alignment and the positional relationship between the femur and tibia in the anterior-posterior (AP) direction under weight-bearing conditions. OBJECTIVE This study aimed to clarify the association between the PTS and 3D femorotibial alignment under weight-bearing conditions in healthy Japanese elderly individuals. METHODS We investigated the 3D femorotibial alignment of 110 lower extremities of 55 healthy individuals (26 women, 29 men, mean age: 70 ± 6 years). Using our previously reported 3D-to-2D image registration technique, we evaluated the 3D hip-knee-ankle angle (3DHKA) in the sagittal plane, rotational alignment, and the distance between the femoral and tibial origins in the AP direction (tibial AP position) as femorotibial alignment parameters under weight-bearing conditions. We assessed the medial and lateral PTS and their angular difference (PTS difference) as PTS parameters. Stepwise multiple linear regression analysis was performed using PTS parameters and other possible confounders (age, sex, height, and weight) as the independent variables and femorotibial alignment parameters as the dependent variable. RESULTS Weight (𝛽 = 0.393, p < 0.001) and lateral PTS (𝛽 = 0.298, p < 0.001) were the predictors associated with 3DHKA in the sagittal plane. Lateral PTS (𝛽 = 0.304, p = 0.001) was the only predictor associated with the tibial AP position. Sex (𝛽 = -0.282, p = 0.002) and PTS difference (𝛽 = -0.231, p = 0.012) were associated with rotational alignment. CONCLUSIONS We found that a steeper lateral PTS resulted in a more flexed knee and anterior tibia. The PTS difference was positively correlated with tibial external rotation. Our data could be used as the standard reference for realignment surgery to ensure PTS is appropriately maintained.
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Affiliation(s)
- Ryota Katsumi
- Department of Orthopaedic Surgery, Niigata Medical Center, Niigata, Japan
| | - Takashi Sato
- Department of Orthopaedic Surgery, Niigata Medical Center, Niigata, Japan
| | - Tomoharu Mochizuki
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Satoshi Watanabe
- Department of Orthopaedic Surgery, Niigata Medical Center, Niigata, Japan
| | - Osamu Tanifuji
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
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Kaneko T, Igarashi T, Takada K, Yoshizawa S, Ikegami H, Musha Y. Robotic-assisted total knee arthroplasty improves the outlier of rotational alignment of the tibial prosthesis using 3DCT measurements. Knee 2021; 31:64-76. [PMID: 34118583 DOI: 10.1016/j.knee.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 01/06/2021] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of the present study was to compare the accuracy of prosthetic alignment with three-dimensional computed tomography (3DCT) measurements following total knee arthroplasty (TKA) performed using a robotic-assisted surgical technique versus a conventional TKA. METHODS 41 TKAs were performed with a handheld robotic-assisted surgical procedure (Robot group) between 2019 and 2020. Another 41 patients underwent TKA with a conventional manual surgical procedure (Manual group) using the same prosthesis. The operation durations between both groups were investigated. 3DCT scans of the entire lower extremities were taken before and after the surgery and femoral and tibial alignments in the coronal, sagittal, and axial planes were measured using computer software. The differences in prosthetic alignment and translation between the preoperative 3DCT plan and postoperative 3DCT image were also measured. RESULTS There were no statistically significant differences in the post-operative outliers of the femorotibial angle between the groups. In the tibial-axial plane, the mean of prosthetic alignment in the anteroposterior plane was 4.0° in the Robot group and 6.7° in the Manual group (p < 0.01). The rate of outliers for tibial-axial alignment in the Robot group was significantly less than in the Manual group (p < 0.01). There were no statistically significant differences in prosthetic translation in the proximal-distal, anterior-posterior and medial-lateral orientations between the groups. CONCLUSIONS In a radiologic study using 3DCT, robotic-assisted TKA reduced the outliers for rotational alignment of the tibial prosthesis in comparison to conventional TKA, which can lead to improved tracking of the femoral-tibial bearing surfaces.
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Affiliation(s)
- Takao Kaneko
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
| | | | - Kazutaka Takada
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
| | - Shu Yoshizawa
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan.
| | - Hiroyasu Ikegami
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan.
| | - Yoshiro Musha
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan.
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Kinematic aligned femoral rotation leads to greater patella tilt but similar clinical outcomes when compared to traditional femoral component rotation in total knee arthroplasty. A propensity score matched study. Knee Surg Sports Traumatol Arthrosc 2021; 29:1059-1066. [PMID: 32488370 DOI: 10.1007/s00167-020-06081-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/22/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE External rotation of femoral component in total knee arthroplasty (TKA) with reference to the posterior condyles is recommended in mechanical alignment (MA) to ensure optimum patella tracking. In kinematic knee alignment (KA) technique, femoral component is more internally rotated as the femoral resection is based on flexion-extension axis. This study aims to investigate the clinical and radiological outcomes of the patellofemoral joint in patients who underwent TKA using KA versus mechanical alignment. METHODS A review of prospectively collected registry data of 378 consecutive cruciate retaining primary TKAs (P.F.C.® Total Knee System, DePuy Synthes, Massachusetts, United States) was performed. Propensity scoring was performed matching patients who received KA TKA (n = 93) to MA TKA (n = 93). Oxford Knee Score (OKS), Knee Society Score (KSS), Short-Form 36 (SF-36), range of motion as well as radiographs assessing patella tilt were compared at 6 months and 2 years after surgery. All patients received the same implant and had their patella resurfaced. RESULTS OKS, KSS, physical component of SF-36 and satisfaction rates were comparable at both 6 months and 2 years after surgery. There was moderate association between preoperative and postoperative patella tilt in KA TKA (Cramer's V = 0.260, p < 0.05). Postoperatively, KA group had a greater number of patients with lateral patella tilt compared to the mechanical group (12 [12.9%] vs 1 [1.1%], p < 0.001). Patella tilts, however, resolved two years after surgery. CONCLUSION The relative internal rotation of the femoral component in KA TKA results in greater incidence of lateral patella tilt postoperatively. Nevertheless, patella tilt resolution was noted at 2 years. LEVEL OF EVIDENCE Level III Evidence-Retrospective Cohort Study.
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Intra- and postoperative assessment of femoral component rotation in total knee arthroplasty: an EKA knee expert group clinical review. Knee Surg Sports Traumatol Arthrosc 2021; 29:772-782. [PMID: 32350578 DOI: 10.1007/s00167-020-06006-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/16/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Malrotation of the femoral component after primary total knee arthroplasty (TKA) is one of the most important problems leading to painful TKA requiring revision surgery. METHODS A comprehensive systematic review of the literature was performed to present current evidence on how to optimally place the femoral component in TKA. Several landmarks and techniques for intraoperative determination of femoral component placement and examination of their reliability were analyzed. RESULTS 2806 articles were identified and 21 met the inclusion criteria. As there is no unquestioned gold standard, numerous approaches are possible which come along with specific advantages and disadvantages. In addition, imaging modalities and measurements regarding postoperative femoral component rotation were also investigated. Femoral component rotation measurements on three-dimensional (3D) reconstructed computerised tomography (CT) images displayed intraclass correlation coefficients (ICC) above 0.85, significantly better than those performed in radiographics or two-dimensional (2D) CT images. Thus, 3D CT images to accurately evaluate the femoral prosthetic component rotation are recommended, especially in unsatisfied patients after TKA. CONCLUSION The EKA Femoral Rotation Focus Group has not identified a single best reference method to determine femoral component rotation, but surgeons mostly prefer the measured resection technique using at least two landmarks for cross-checking the rotation. LEVEL OF EVIDENCE III.
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Liu C, Zhao G, Chen K, Lyu J, Chen J, Shi J, Huang G, Chen F, Wei Y, Wang S, Xia J. Tibial component coverage affects tibial bone resorption and patient-reported outcome measures for patients following total knee arthroplasty. J Orthop Surg Res 2021; 16:134. [PMID: 33579313 PMCID: PMC7881541 DOI: 10.1186/s13018-021-02250-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/20/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose The aim of this study is to investigate the prognostic value of tibial component coverage (over-hang and under-hang) and the alignment of total knee arthroplasty (TKA) components 1 week after surgery. We select patient-reported outcome measures (PROMS) (the Knee Society score (KSS score) and the Western Ontario and McMaster Universities Osteoarthritis Index-pain score (WOMAC pain score)) and tibial bone resorption (TBR) 2 years after surgery as the end points. Methods The study retrospectively analyzed 109 patients undergoing TKA (fixed-bearing prosthesis with asymmetrical tibial tray) from January 2014 to December 2017 in Huashan Hospital. By using standard long-leg X-rays, anteroposterior (AP) and lateral X-rays of the knee, tibial component coverage (under-hang or over-hang), AP tibial-femoral anatomical angle (AP-TFA), AP femoral angle (AP-FA), AP tibial angle (AP-TA), and lateral tibial angle (L-TA) were measured at 1 week after surgery, while TBR was measured through postoperative 1-week and 2-year AP and lateral radiographs of the knee on three sides (medial side, lateral side on AP radiograph, and anterior side on lateral radiograph). The Pearson correlation analysis, simple linear regression, multiple linear regression, the Student’s t test, and one-way ANOVA together with Tukey’s post hoc test (or Games-Howell post hoc test) were used in the analyses. Results Tibial under-hang was more likely to appear in our patients following TKA (42%, medially, 39%, laterally, and 25%, anteriorly). In multivariate linear regression analysis of TBR, tibial under-hang (negative value) 1 week after surgery was positively correlated with TBR 2 years later on the medial (p = 0.003) and lateral (p = 0.026) side. Tibial over-hang (positive value) 1 week after surgery on the medial side was found negatively related with KSS score (p = 0.004) and positively related with WOMAC pain score (p = 0.036) 2 years later in multivariate linear regression analysis of PROMS. Both scores were better in the anatomically sized group than in the mild over-hang group (or severe over-hang) (p < 0.001). However, no significant relationship was found between the alignment of TKA components at 1 week after surgery and the end points (TBR and PROMS) 2 years later. Conclusion Under-hang of the tibial component on both the medial and lateral sides can increase the risk of TBR 2 years later. Over-hang of tibial component on the medial side decreases the PROMS (KSS score and WOMAC pain score) 2 years later. An appropriate size of tibial component during TKA is extremely important for patient’s prognosis, while the alignment of components might not be as important. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02250-7.
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Affiliation(s)
- Changquan Liu
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Guanglei Zhao
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Kangming Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jinyang Lyu
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jie Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jingsheng Shi
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Gangyong Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Feiyan Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Yibing Wei
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Siqun Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jun Xia
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China.
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Lee SS, Yeom J, Lee DH, Moon YW. Similar outcomes between ultracongruent and posterior-stabilized insert in total knee arthroplasty: A propensity score-matched analysis. J Orthop Surg (Hong Kong) 2020; 28:2309499019893515. [PMID: 31876242 DOI: 10.1177/2309499019893515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE (1) To compare postoperative range of motion (ROM), stability, and clinical outcomes between fixed-bearing posterior-stabilized (PS) and ultracongruent (UC). (2) The effect of postoperative stability on ROM and clinical outcomes was also evaluated in both designs. MATERIALS AND METHODS Propensity score matching was conducted for age, gender, body mass index, preoperative ROM, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Knee Society (KS) scores, hip-knee-ankle (HKA) alignment, and follow-up period. Two hundred patients (100 PS and 100 UC) were enrolled. Preoperative and final follow-up outcomes including postoperative ROM, anteroposterior (AP) stability (good, fair, and poor), WOMAC index, and KS scores were compared. Then, postoperative outcomes compared between the PS and UC. We also analyzed if AP stability was associated with the postoperative outcomes in both implant designs. RESULTS In both groups, ROM and clinical outcomes of final follow-up showed improvement than preoperation. Statistical significance was not determined between the PS and UC groups in terms of postoperative ROM (PS vs. UC, 134.6° vs. 133.4°, p = 0.13), stability (good/fair/poor, 91/9/0 vs. 84/14/0, p = 0.376), WOMAC index, KS scores, and outliers of HKA alignment (15% vs. 10%, p = 0.393). "Fair" stability showed inferior KS scores but greater ROM than "good" stability in both designs. CONCLUSION TKA with UC insert provided similar ROM, AP stability, and clinical outcomes when compared to PS insert. In both designs, greater postoperative ROM was found but inferior clinical outcomes were found when TKA resulted in fair stability instead of good stability. LEVEL OF EVIDENCE 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
| | - Jaewoo Yeom
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae-Hee Lee
- 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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Nayak M, Kumar V, Yadav R, Srivastava DN, Pandit H, Malhotra R. Lateral Coronal Bowing of Femur and/or Tibia Amplifies the Varus Malalignment of Lower Limb as well as Increases Functional Disability in Patients with Knee Osteoarthritis. Indian J Orthop 2020; 55:88-96. [PMID: 34122760 PMCID: PMC8149558 DOI: 10.1007/s43465-020-00303-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/24/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE In the present study, we aimed at assessing the effect of femoral and tibial coronal bowing on varus malalignment and Oxford knee score (OKS) at different grades of knee osteoarthritis (OA). MATERIALS AND METHODS This prospective observational study was conducted at a tertiary referral centre in New Delhi, India. Consecutive patients presenting to the "knee OA" outpatient clinics were invited to take part in the study conducted over a 12-month period. All consented patients underwent long-leg standing alignment radiographs using standardised technique and patient reported knee pain and function were recorded using Oxford knee score. The following radiological parameters were measured from weight-bearing long-leg radiographs of 824 varus aligned limbs via a morphometric software (Matlab R2009a) (1) hip-knee-ankle angle (HKAA), (2) femoral bowing, (3) tibial bowing. The knees were graded according to Kellegren and Lawrence grade (K&L) and OKS was recorded. 3 groups of HKAA were made based on the angle, A (0° to - 3°), B (- 3° to - 10°) and C (< - 10°). Both the femoral and tibial bow were also categorized into three groups depending upon the angle; in-range (- 2° to + 2°), varus (< - 2°), valgus (> + 2°). RESULTS The mean (± SD) of HKAA, femoral bow and tibial bow of the whole cohort was - 6.97° ± 5.64°, - 1.54° ± 4.31° and - 1.96° ± 3.5°, respectively. An increase in the lateral bow of both femur and tibia was seen with an increase in the severity of OA. A consequent increase in the varus malalignment was observed with an increase in the lateral bow of both femur as well as the tibia at all grades of OA, with significant correlation observed between HKAA with Femoral bowing and HKAA with tibial bowing. The mean OKS for femoral bow, in-range, varus and valgus was 30.6 ± 11.5, 21.3 ± 11.5 and 35.3 ± 11.4, respectively, and for tibial bow, in-range, varus and valgus was 27.6 ± 11.5, 26. ± 11.5 and 28 ± 11.4, respectively. The difference in the mean OKS was observed to be significant when the varus bow group was compared to in range as well as valgus group (p < 0.01) for both femur and tibia for all the grades of OA. CONCLUSION The present study shows a significant correlation between varus malalignment and the bowing of extremities. Varus coronal bowing of both femur and tibia were seen to have significantly lower mean OKS as compared to valgus bowing or in-range bowing at all grades of knee OA.
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Affiliation(s)
- Mayur Nayak
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Vijay Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rahul Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Hemant Pandit
- Chapel Allerton Hospital, University of Leeds, Leeds, UK
| | - Rajesh Malhotra
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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Faschingbauer M, Hacker S, Seitz A, Dürselen L, Boettner F, Reichel H. The tibial cut influences the patellofemoral knee kinematics and pressure distribution in total knee arthroplasty with constitutional varus alignment. Knee Surg Sports Traumatol Arthrosc 2020; 28:3258-3269. [PMID: 31875233 DOI: 10.1007/s00167-019-05835-2] [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: 07/19/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The current literature suggests that kinematic total knee arthroplasty (kTKA) may be associated with better outcome scores in patients with constitutional varus alignment. The underlying patellofemoral kinematic changes (patella tilting and patella tracking) and patellofemoral pressure distribution have not yet been described. The present study compared the effects of different tibial cuts, as used in kTKA, on patellofemoral knee kinematics and the pressure distribution, in addition to comparisons with the natural constitutional varus knee. METHODS Seven cadaveric knee joints with constitutional varus alignment were examined in the native state and after 0°, 3°, or 6° tibial cut cruciate-retaining (CR)-TKA using an established knee joint simulator. The effects on patella rotation/patella tilting, patellofemoral pressure, and patellofemoral length ratios (= patella tracking) were determined. In addition, the natural knee joint and different tibial cuts in CR-TKA were compared (Student's t test). RESULTS In the patellofemoral joint, 6° CR-TKA was associated with the greatest similarity with the natural constitutional varus knee. By contrast, knees subjected to 0° CR-TKA exhibited the largest deviations of patellar kinematics. The smallest difference compared with the natural knee joint concerning patella tilting was found for 6° CR-TKA (mean 0.4°, p < 0.001), and the largest difference was noted for 0° CR-TKA (mean 1.7°, p < 0.001). Concerning patellofemoral pressure, 6° CR-TKA resulted in outcomes most similar to the natural knee joint, featuring a mean difference of 3 MPa. The largest difference from the natural knee joint was identified for 0° CR-TKA, with an average difference of 8.1 MPa (p < 0.001; total mean 17.7 MPa). Meanwhile, 3° and 6° CR-TKA induced medialization of the patella, with the latter inducing the largest medialization value of 4.5 mm at 90° flexion. CONCLUSIONS The improved outcome parameters in kTKA described in the literature could be attributable to the similar kinematics of the patellofemoral joint relative to the normal state. The current study confirmed the similar kinematics between the native constitutional varus knee joint and knee joints subjected to 3° or 6° CR-TKA (patellofemoral rotation/patella tilting and patella pressure). Conversely, there was pronounced medialization of the patella following 6° CR-TKA. Patella pressure and patella tilting are described in the literature as possible causes of anterior knee pain after TKA, whereas medialization of the patella, which is also influenced by other causes, might play a subordinate role. LEVEL OF EVIDENCE V, Biomechanical study.
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Affiliation(s)
- Martin Faschingbauer
- Department of Orthopedic Surgery, RKU, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - S Hacker
- Institute of Orthopaedic Research and Biomechanics, University of Ulm, Helmholtzstraße 14, 89081, Ulm, Germany
| | - A Seitz
- Institute of Orthopaedic Research and Biomechanics, University of Ulm, Helmholtzstraße 14, 89081, Ulm, Germany
| | - L Dürselen
- Institute of Orthopaedic Research and Biomechanics, University of Ulm, Helmholtzstraße 14, 89081, Ulm, Germany
| | - F Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - H Reichel
- Department of Orthopedic Surgery, RKU, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
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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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Chen Z, Deng Z, Li Q, Chen J, Ma Y, Zheng Q. How to predict early clinical outcomes and evaluate the quality of primary total knee arthroplasty: a new scoring system based on lower-extremity angles of alignment. BMC Musculoskelet Disord 2020; 21:518. [PMID: 32746812 PMCID: PMC7397679 DOI: 10.1186/s12891-020-03528-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/20/2020] [Indexed: 12/29/2022] Open
Abstract
Background A method that can accurately predict the outcome of surgery can give patients timely feedback. In addition, to some extent, an objective evaluation method can help the surgeon quickly summarize the patient’s surgical experience and lessen dependence on the long wait for follow-up results. However, there was still no precise tool to predict clinical outcomes of total knee arthroplasty (TKA). This study aimed to develop a scoring system to predict clinical results of TKA and then grade the quality of TKA. Methods We retrospectively reviewed 98 primary TKAs performed between April 2013 and March 2017 to determine predictors of clinical outcomes among lower-extremity angles of alignment. Applying multivariable linear-regression analysis, we built Models (i) and (ii) to predict detailed clinical outcomes which were evaluated using the Knee Society Score (KSS). Multivariable logistic-regression analysis was used to establish Model (iii) to predict probability of getting a good clinical outcome (PGGCO) which was evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) score. Finally, we designed a new scoring system consisting of 3 prediction models and presented a method of grading TKA quality. Thirty primary TKAs between April and December 2017 were enrolled for external validation. Results We set up a scoring system consisting of 3 models. The interpretations of Model (i) and (ii) were good (R2 = 0.756 and 0.764, respectively). Model (iii) displayed good discrimination, with an area under the curve (AUC) of 0.936, and good calibration according to the calibration curve. Quality of surgery was stratified as follows: “A” = PGGCO ≥0.8, “B” = PGGCO ≤0.6 but < 0.8, and “C” = PGGCO < 0.6. The scoring system performed well in external validation. Conclusions This study first developed a validated, evidence-based scoring system based on lower-extremity angles of alignment to predict early clinical outcomes and to objectively evaluate the quality of TKA.
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Affiliation(s)
- Ziming Chen
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China.,Centre for Orthopaedic Translational Research, Medical School, University of Western Australia, Nedlands, Australia
| | - Zhantao Deng
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China
| | - Qingtian Li
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China
| | - Junfeng Chen
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China
| | - Yuanchen Ma
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China.
| | - Qiujian Zheng
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou City, 510080, Guangdong Province, China.
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Varus alignment after total knee arthroplasty results in greater axial rotation during deep knee bend activity. Clin Biomech (Bristol, Avon) 2020; 77:105051. [PMID: 32464429 DOI: 10.1016/j.clinbiomech.2020.105051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/01/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS The correlation between in vivo knee kinematics and alignment has not been fully elucidated. Recently, similar or better clinical outcomes have been reported by restoration of mild varus alignment after total knee arthroplasty for preoperative varus knees. The aim of this study was to evaluate the effect of postoperative alignment on knee kinematics during a deep knee bend activity. METHODS In vivo knee kinematics of 36 knees (25 patients) implanted with tri-condylar total knee arthroplasty were analyzed with a three dimensional model fitting approach using fluoroscopy. Under fluoroscopic surveillance, individual video frames were digitized at 30° increments from full extension to maximum flexion. Postoperative coronal and sagittal alignments were assessed using radiographs, and rotational alignment was assessed with computed tomography. Pearson correlation coefficients were calculated to determine the correlations between the alignment data and kinematic factors. FINDINGS Correlation analysis showed that coronal alignment was significantly correlated with knee kinematics. The varus alignment of the limb and tibial component led to a greater axial rotation from full extension to maximum flexion and more rotated position in the mid to deep flexion range. Neither the rotational alignment of the femoral nor tibial components showed significant correlation with axial rotation from full extension to maximum flexion. INTERPRETATION Varus alignment resulted in greater axial rotation, which could represent near-normal knee kinematics. The current study can be a kinematic rationale reporting similar or better clinical and functional outcomes for the total knee arthroplasty with residual varus alignment.
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Similar results with kinematic and mechanical alignment applied in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:1720-1735. [PMID: 31250055 DOI: 10.1007/s00167-019-05584-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/18/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE This meta-analysis compared the results of kinematic alignment (KA) and mechanical alignment (MA) applied in total knee arthroplasty (TKA). METHODS Randomized controlled trials and cohort studies comparing functional, radiological, and perioperative results and complications in TKA with KA and MA were collected from databases and included in the analysis. RESULTS Nine trials were included. KA showed a better performance in terms of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (mean difference [MD] = - 9.06, 95% confidence interval [CI] - 14.69, - 3.42) and Oxford knee score (OKS) (MD = 4.72, 95% CI 0.24, 9.21); however, the Knee Society score (KSS), knee injury and osteoarthritis outcome score (KOOS), EuroQoL 5-dimension questionnaire (ED-5D), range of motion, and complications were similar for KA and MA (n.s.). KA resulted in slightly more varus alignment in the tibia [mechanical medial proximal tibial angle (mMPTA) MD = - 2.45, 95% CI - 2.89, - 2.01) and more valgus alignment in the femur (mLDFA MD = - 2.06, 95% CI - 2.48, - 1.65) than MA (P < 0.05), but showed similar results in terms of the joint line orientation angle (JLOA) (MD = 0.54, 95% CI - 2.59, 3.66), hip-knee-ankle angle (HKA), anatomical knee angle (AKA), femoral flexion-extension angle (FFA), and tibial slope (TS). The preoperative results, including the incision length, hospital stay, and changes in hemoglobin, were also similar. CONCLUSION KA achieved functional, radiological, and perioperative results similar to those of MA and did not increase the complication rate. KA is an acceptable and satisfactory method for application in TKA. LEVEL OF EVIDENCE III.
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Lee HJ, Lim JW, Lee DH, Kim DH, Park YB. Slight under-correction using individualized intentional varus femoral cutting leads to favorable outcomes in patients with lateral femoral bowing and varus knee. Knee Surg Sports Traumatol Arthrosc 2020; 28:1579-1586. [PMID: 31230123 DOI: 10.1007/s00167-019-05577-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/17/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Restoration of neutral alignment is considered key in total knee arthroplasty (TKA). However, this may be undesirable and can result in medial soft-tissue over-release in patients with varus knee and lateral femoral bowing. This study aimed to determine whether individualized intentional varus distal femoral cutting yielded satisfactory clinical and radiological outcomes. METHODS A total of 77 patients (91 knees) with varus knee (hip-knee-ankle axis ≥ 10°) and lateral femoral bowing > 5° underwent navigation-assisted primary TKA using individualized intentional varus distal femoral cutting. Knee Society scores, Western Ontario and McMaster Universities scores, and radiographs for limb alignment, implant alignment, and aseptic loosening were evaluated. Subgroup analyses were performed according to the limb alignment and coronal femoral component alignment (0° ± 3° vs. varus of > 3°). RESULTS All clinical outcomes significantly improved at the final follow-up (p < 0.05 in all). The mechanical axis angle changed from 13.1° ± 2.7° to 2.8° ± 1.5°. The coronal femoral component angle at the final follow-up was 2.8° ± 1.3°. Radiolucent lines were observed in 6 cases (6.6%) and were less than 2 mm in all cases without progression. In subgroup analyses, no significant differences were observed in clinical outcomes (n.s. in all) and in the incidence of radiolucent lines (n.s. in limb alignment, n.s. in coronal femoral component alignment). CONCLUSIONS Individualized intentional varus distal femoral cutting yielded favorable clinical outcomes without complications at 5-year follow-up. Slight under-correction using intentional varus distal femoral cutting could be a viable option in patients with varus knee and lateral femoral bowing during navigation-assisted TKA. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Jung-Won Lim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Dong-Hoon Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Dong-Hyun Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea.
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Zahn RK, Graef F, Conrad JL, Renner L, Perka C, Hommel H. Accuracy of tibial positioning in the frontal plane: a prospective study comparing conventional and innovative techniques in total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:793-800. [PMID: 32124032 PMCID: PMC7244465 DOI: 10.1007/s00402-020-03389-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 12/05/2022]
Abstract
BACKGROUND Coronal alignment of the tibial component determines functional outcome and survival in total knee arthroplasty (TKA). Innovative techniques for tibial instrumentation have been developed to improve accuracy and reduce the rate of outliers. METHODS In a prospective study, 300 patients were allocated to four different groups using a randomization process (two innovative and two conventional) techniques of tibial instrumentation (conventional: extramedullary, intramedullary; innovative: navigation and patient-specific instrumentation (PSI); n = 75 for each group). The aims were to reconstruct the medial proximal tibial angle (MPTA) to 90° and the mechanical tibio-femoral axis (mTFA) to 0°. Both angles were evaluated and compared between all groups three months after the surgery. Patients who presented with a postoperative mTFA > 3° were classified as outliers. RESULTS The navigation and intramedullary technique both demonstrated that they were significantly more precise in reconstructing a neutral mTFA and MPTA compared to the other two techniques. The odd's ratio (OR) for producing outliers was highest for the PSI method (PSI OR = 5.5, p < 0.05; extramedullary positioning OR = 3.7, p > 0.05; intramedullary positioning OR = 1.7, p > 0.05; navigation OR = 0.04, p < 0.05). We could only observe significant differences between pre- and postoperative MPTA in the navigation and intramedullary group. The MPTA showed a significant negative correlation with the mTFA in all groups preoperatively and in the extramedullary, intramedullary and PSI postoperatively. CONCLUSION The navigation and intramedullary instrumentation provided the precise positioning of the tibial component. Outliers were most common within the PSI and extramedullary technique. Optimal alignment is dependent on the technique of tibial instrumentation and tibial component positioning determines the accuracy in TKA since mTFA correlated with MPTA pre- and postoperatively.
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Affiliation(s)
- R. K. Zahn
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - F. Graef
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
| | - J. L. Conrad
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - L. Renner
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - C. Perka
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany
| | - H. Hommel
- Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Charitéplatz 1, 10115 Berlin, Germany ,Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
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Lu Y, Zheng Z, Chen W, Lv H, Lv J, Zhang Y. Dynamic deformation of femur during medial compartment knee osteoarthritis. PLoS One 2019; 14:e0226795. [PMID: 31860687 PMCID: PMC6924647 DOI: 10.1371/journal.pone.0226795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the morphological changes of the femur in the coronal plane in progressing varus gonarthrosis and to explore the interrelation of each component. PATIENTS AND METHODS From January to July 2017, radiographic images of 1538 knees of 883 consecutive patients were collected and analyzed. We drew the alignments and measured the orientation angles of the lower extremities and compared the results among age groups for each sex. Correlation and regression tests were used to analyze the measurements. RESULTS There were significant differences in the neck-shaft angle (NSA), femoral bowing angle (FBA) and anatomic medial distal femoral angle (aMDFA) by age group in females, whereas the differences were not significant in males. In females, a positive correlation was found between age and the FBA and aMDFA (r = 0.253, 0.141, p<0.01), and a negative correlation was found between age and the NSA while the FBA was controlled (r = -0.065, p<0.05). The FBA was positively correlated with the NSA (r = 0.312, p<0.01) and aMDFA (r = 0.233, p<0.01). The NSA, FBA, and aMDFA together affected 72.2% of the mechanical medial distal femoral angle (mMDFA) (β = 0.071, -0.528, 0.803, p<0.01). CONCLUSION As knee osteoarthritis (KOA) progressed, dynamic deformation of the femur was found in females, while no obvious changes were found in males. Femoral mechanical axis varus (mMDFA decrease) was the result of changes in the NSA, FBA and aMDFA. The deformation was throughout the femur rather than in a local area, as femur bowing can lead to corresponding changes in both ends of the femur. We provided a theoretical basis for TKA and knee-salvage treatment, and more attention should be paid to aging patients, especially females, in the preoperative protocol for orthomorphia.
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Affiliation(s)
- Yang Lu
- Department of Emergency Surgery, The First Hospital of Qinhuangdao Affiliated to Hebei Medical University, Haigang District, Qinhuangdao, Hebei Province, People’s Republic of China
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, People’s Republic of China
| | - Zhanle Zheng
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, People’s Republic of China
| | - Wei Chen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, People’s Republic of China
| | - Hongzhi Lv
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, People’s Republic of China
| | - Ji Lv
- Department of Emergency Surgery, The First Hospital of Qinhuangdao Affiliated to Hebei Medical University, Haigang District, Qinhuangdao, Hebei Province, People’s Republic of China
| | - Yingze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, People’s Republic of China
- * E-mail:
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Popescu R, Haritinian EG, Cristea S. Methods of intra- and post-operative determination of the position of the tibial component during total knee replacement. INTERNATIONAL ORTHOPAEDICS 2019; 44:119-128. [PMID: 31655885 DOI: 10.1007/s00264-019-04424-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022]
Abstract
AIM OF THE STUDY To identify the most reliable anatomical landmarks and imaging techniques for assessing the rotation of the tibial component in total knee arthroplasty (TKA). METHODS An extensive literature review (from January 2016 to March 2019) was performed. We included studies about primary TKA with details concerning the anatomical landmarks used for implanting the tibial component and also imaging studies assessing tibial component rotation. The final selection comprises only thirty-five articles consistent with the inclusion criteria. RESULTS Extra-articular landmarks are not always reliable (even though the tibial tubercle is one of the most popular extra-articular landmarks used to assess the rotation of the tibial component), mainly because they vary and can lead to malrotation of the tibial component. Akagi's line (an intra-articular landmark) is considered to be the most reliable and easy to find during surgery and likewise is not affected by articular deformities. The anterior tibial cortex (intra-articular landmark) also proved to be accurate and reliable with the main advantage being that is palpable after tibial resection. Radiography provides a good and inexpensive option for imaging, but it is insufficient. Magnetic resonance imaging (MRI) is used in some cases but not routinely for assessing TKA components or their orientation. Computed tomography (CT), used together with a well-defined protocol (Berger's method being the preferred choice), remains the "gold standard" for evaluating the rotation of the tibial component after TKA. CONCLUSION Currently, the most accurate and reliable anatomical landmarks are represented by Akagi's line and the anterior cortex of the tibia. Post-operatively, through CT and well-established protocols, the rotation of the tibial component can be accurately determined.
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Affiliation(s)
- Roman Popescu
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania
| | - Emil G Haritinian
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania. .,Clinical Hospital of Orthopedics and Traumatology and Osteoarticular TB "Foișor", Ferdinand Blvd, no. 35-37, District 2, 021382, Bucharest, Romania.
| | - Stefan Cristea
- Carol Davila University of Medicine and Pharmacy, Rectorate - Dionisie Lupu Street, no. 37, District 1, 020021, Bucharest, Romania. .,Department of Orthopaedics and Traumatology, Saint Pantelimon Emergency Hospital, Pantelimon Road, no. 340-342, District 2, 021659, Bucharest, Romania.
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Yoshino K, Hagiwara S, Nakamura J, Tsukeoka T, Tsuneizumi Y, Ohtori S. Intra- and interobserver reliability and agreement in three-dimensional computed tomography measurements of component positions after total knee arthroplasty. Knee 2019; 26:1102-1110. [PMID: 31340892 DOI: 10.1016/j.knee.2019.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/17/2019] [Accepted: 07/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Accurate evaluation of the postoperative position of total knee arthroplasty (TKA) components is crucial in the analysis of the association of alignments with clinical outcomes. The aim of this study was to investigate the reliability of measurements of component positions after TKA using three-dimensional computed tomography (3D-CT) reconstruction. METHODS Two independent orthopedic surgeons (an attending surgeon and a fellow) examined 30 knees after primary TKA. The coronal, sagittal, and rotational positions of the femoral and tibial components were measured twice at an interval of six weeks on 3D-CT images reconstructed using ZedKnee software. Mean intra- and interobserver differences of measured angles were calculated, and the intra- and interobserver reliability was determined using intraclass correlation coefficients (ICCs), with agreement assessed by Bland-Altman analysis. RESULTS The mean intraobserver difference between alignment measurements for femoral and tibial components was <2° (range 0.23-1.17°) and the mean interobserver difference was <1° (range 0.22-0.97°). The intra- and interobserver ICCs were >0.8 for all component positions. The only systematic bias found in the intra- and interobserver agreements occurred for the sagittal position of the femoral component. CONCLUSION Three-dimensional-CT measurements of component positions after TKA showed good intra- and interobserver reliability for the femoral and tibial components in coronal, sagittal and rotational positions. The intra- and interobserver agreements were favorable for all but the sagittal position of the femur. These results suggest that 3D-CT can be used to evaluate the alignment of all TKA components except for the sagittal position of the femur.
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Affiliation(s)
- Kensuke Yoshino
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan; Department of Orthopaedic Surgery, Chiba Rehabilitation Center, Chiba, Japan.
| | - Shigeo Hagiwara
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Junichi Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tadashi Tsukeoka
- Department of Orthopaedic Surgery, Chiba Rehabilitation Center, Chiba, Japan
| | | | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Johnston H, Abdelgaied A, Pandit H, Fisher J, Jennings LM. The effect of surgical alignment and soft tissue conditions on the kinematics and wear of a fixed bearing total knee replacement. J Mech Behav Biomed Mater 2019; 100:103386. [PMID: 31408775 DOI: 10.1016/j.jmbbm.2019.103386] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/18/2019] [Accepted: 08/02/2019] [Indexed: 11/19/2022]
Abstract
As life expectancy and activity levels of patients increase so does the demand on total knee replacements (TKRs). Abnormal mechanics and wear of TKRs can lead to implant loosening and revision. Component alignment after surgery varies due to the presurgical alignment, the accuracy of the surgical instrumentation and due to patient factors, such as the soft tissue balance. This study experimentally investigated the effect of variation in component alignment and the soft tissue conditions on the kinematics and wear of a fixed bearing TKR. DePuy Sigma fixed bearing TKRs with moderately cross-linked UHMWPE were used. Different alignment conditions were simulated in the coronal, sagittal and transverse planes in an ISO force-controlled simulation system. Three different soft tissue conditions were simulated using virtual springs to represent a stiff knee, a preserved PCL and a resected PCL. Four different alignment conditions were studied; ideal alignment, 4° tibial and femoral varus joint line, 14° rotational mismatch and 10° posterior tibial slope. The varus joint line alignment resulted in similar kinematics and lower wear rate compared to ideal alignment. The rotational mismatch alignment resulted in significantly higher tibial rotation and abduction-adduction as well as a significantly higher wear rate than ideal alignment. The posterior tibial slope alignment resulted in significantly higher wear than the ideal alignment and dislocated under the lower tension soft tissue conditions. Component alignment and the soft tissue conditions had a significant effect on the kinematics and wear of the TKR investigated in this study. The surgical alignment of the TKR is an important factor in the clinical outcome of the joint as factors such as increased tibial rotation can lead to anterior knee pain and instability and increased wear can lead to aseptic loosening and early failure resulting in revision.
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Affiliation(s)
- Helena Johnston
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | | | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - John Fisher
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | - Louise M Jennings
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK.
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Hirschmann MT, Becker R, Tandogan R, Vendittoli PA, Howell S. Alignment in TKA: what has been clear is not anymore! Knee Surg Sports Traumatol Arthrosc 2019; 27:2037-2039. [PMID: 31190246 DOI: 10.1007/s00167-019-05558-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/06/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Roland Becker
- Department of Orthopaedics and Traumatology, Brandenburg Medical School Theodore Fontane, 14770, Brandenburg, Germany
| | | | - Pascal-André Vendittoli
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal University, Montreal, QC, Canada
| | - Stephen Howell
- Professor of Biomedical Engineering, University of California at Davis, Davis, USA
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Lampart M, Behrend H, Moser LB, Hirschmann MT. Due to great variability fixed HKS angle for alignment of the distal cut leads to a significant error in coronal TKA orientation. Knee Surg Sports Traumatol Arthrosc 2019; 27:1434-1441. [PMID: 29961097 DOI: 10.1007/s00167-018-5041-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE For coronal alignment in total knee arthroplasty (TKA) most surgeons use the patient's individual hip-knee shaft (HKS) angle (angle between the anatomical axis and the mechanical axis of the femur). The major problem of the sole use of HKS angle is that the individual patient's distal femoral asymmetry is not considered. The purpose of this study was to determine the variability of the HKS angle, the mechanical femoral angle (FMA) and to evaluate whether or not one of the two angles is more important for TKA alignment strategy. It was the hypothesis that HKS and FMA are not directly related to each other and hence HKS should not be considered as guide for coronal alignment. METHODS Prospectively collected CT data of 1480 consecutive patients who underwent 3D reconstructed CT scans before TKA was used for this retrospective registry study [882 women and 598 men, mean age ± standard deviation 71 ± 9 years (34-99 years)]. The CT protocol was modified according to the Imperial Knee Protocol, which is a lowdose CT protocol that includes high-resolution 0.75-mm slices of the knee and 3-mm slices of the hip and ankle joints. All measurements were done using Symbios® 3D knee preoperative planning's software (Symbios, Yverdon les Bains, Switzerland). The HKS, FMA and hip-knee-ankle (HKA) angles were measured. Angles measured were displayed as mean, standard deviation (SD) and range. In addition, the angles were shown as percentages after categorization. The HKS was categorized between 3° and 9° in 1° increments. The FMA was categorized between 83.5° and 98.5° in 3° increments. The HKA was categorized between 12.5° varus 5.5° valgus in 3° increments. Pearson correlations were used to investigate correlation of HKS and FMA (p < 0.05). RESULTS The HKS angle was not constant at 7° but averaged 6°, and ranged from 2.5° to 9°. The FMA angle was on average 93° but varied more than 20°, ranging from 75° (varus) to 104° (valgus). The mean HKA ± SD was - 3.4° ± 5.7° (range - 23.0° to 15.0°). The mean HKSSD was 5.6° ± 0.9° (range 2.5°-8.8°). The mean FMASD was 92.6° ± 2.8° (range 75.2°-103.5°). The Pearson correlations of all measured angles are presented in Table 1. HKS significantly correlated negatively with HKA and FMA (p < 0.001). FMA and HKA were strongly correlated with each other (p < 0.0001). Considering the HKS angle as a constant angle can induce a deviation of up to 5° with respect to an orthogonal distal femoral cutting objective. The great variability of the FMA angle implies that the FMA seems more relevant than the HKS angle to define the strategy of realignment of the lower limb. However, then patient specific instrumentation has to be used to precisely transfer the planning to the surgical technique. Having the aim of a more personalized TKA alignment in mind the individual constitutional knee phenotype should be taken into account.
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Affiliation(s)
- Maurin Lampart
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland
- University of Basel, Basel, Switzerland
| | - Henrik Behrend
- Department of Orthopaedic Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Lukas B Moser
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland
- University of Basel, Basel, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.
- University of Basel, Basel, Switzerland.
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Hirschmann MT, Friederich NF, Becker R, Karlsson J. Personalised medicine in knee arthroplasty: we need more science! Knee Surg Sports Traumatol Arthrosc 2019; 27:1357-1358. [PMID: 30868188 DOI: 10.1007/s00167-019-05428-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Niklaus F Friederich
- University of Basel, Basel, Switzerland
- University Hospital Basel, Basel, Switzerland
| | - Roland Becker
- Department of Orthopaedic and Traumatology, Brandenburg Medical School Theodor Fontane, Hochstrasse 29, 14770, Brandenburg/Havel, Germany
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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