Three years of experience with computer navigation-assisted positioning of drilling tunnels in anterior cruciate ligament replacement (SS-67)

MakoTM robotic-arm-assisted total hip and total knee arthroplasty outcomes in an orthopedic oncology setting: A case series

Background

The MAKO Robotic-Arm system is a cutting-edge technology which combines both computed tomography (CT) scanning and three-dimensional planning to determine the ideal size and orientation of implants prior to bone resection. It is typically utilized within a general orthopedic setting for joint replacement procedures, such as total joint arthroplasties. However, its use within orthopedic oncology, which contains a much more compromised patient population and more complex surgical treatment, is not well documented within the literature.

Question/purposes

To determine the patient outcomes of those who underwent a total hip arthroplasty (THA) or total knee arthroplasty (TKA) at Morristown Medical Center using the MAKO Robotic-Arm System. Particularly, we aspired to delve into the use of the MAKO in an orthopedic oncology setting for patients with a degenerative hip or knee and a history of cancer or other orthopedic tumor, impending pathological fracture, PVNS, chondromatosis, radiation therapy, or other oncological related conditions.

Patients and methods

Our institution monitored twenty-five individuals with unique orthopedic oncology conditions that underwent MAKO robotic-assisted total hip and knee arthroplasty. This was performed between 2020 and 2022 at Morristown Medical Center in New Jersey. During this time period, 52% (13/25) of the operations were performed on knees and 48% (12/25) were performed on hips. Data regarding patient demographics, body mass index (BMI), medications, hemoglobin, hematocrit, comorbidities, American Society of Anesthesiologists (ASA) Class, operative data, the length of stay (LOS), readmission rates due to infection or periprosthetic fractures, and complications were collected retrospectively. All confidence intervals were calculated at the 95% confidence level.

Results

Postoperatively, the average LOS was 3.2 days, and there were no complications after any of the MAKO-assisted joint arthroplasty procedures. Additionally, there were no readmissions at any of our recorded intervals - 1-30, 1-60, 1-90, and 1 year - however one patient presented to the emergency department after falling 4 days post-operatively. X-ray imaging ultimately revealed no periprosthetic fracture or malalignment of the prosthesis.

Conclusions

The utilization of the MAKO Robotic-Arm System for joint arthroplasty procedures (THAs and TKAs) on orthopedic oncology patients yielded exceptional outcomes, with no complications or readmissions directly attributed to the use of this innovative robotic technology. Thus, this newly emerging surgical system holds great promise, potentially revolutionizing the approach for selected orthopedic oncology patients undergoing total joint arthroplasty compared to the traditional manual techniques. It further demonstrates that its use in an orthopedic oncology setting - where the cohort of patients are often compromised, leading to more intricate surgeries with heightened risks - elicits safety and provides optimal outcomes for patients. Nevertheless, its role within the field is evolving, and in the coming years, as it gains further popularity and sees broader application by orthopedic oncology surgeons, its potential will become clearer. To solidify its position, future clinical investigations and prospective research should be conducted to support the preference of the MAKO system over traditional manual techniques. This will help provide the necessary evidence to advocate for its widespread adoption and continued advancements in orthopedic oncology procedures.

An ACL reconstruction robotic positioning system based on anatomical characteristics

To improve the positioning accuracy of tunnels for anterior cruciate ligament (ACL) reconstruction, we proposed an ACL reconstruction robotic positioning system based on anatomical characteristics. The system includes a preoperative path planning system, an intraoperative path planning system, and a navigation and positioning system. Brahmet line, anterior, and posterior cortical lines are used for registration of preoperative computed tomography (CT) images and intraoperative X-ray images. A new calibrator of C-arm is applied to establish the mapping between medical images and surgical space. Tunnels for ACL reconstruction can be built anatomically by the robot. The accuracy of the path planning system is 1.73 mm in the four dry bones experiments and 2.17 mm in the two cadaver experiments. The accuracy meets the accuracy requirement of ACL construction surgery.

Stability Outcomes following Computer-Assisted ACL Reconstruction

Purpose. The purpose of this study was to determine whether intraoperative prereconstruction stability measurements and/or patient characteristics were associated with final knee stability after computer-assisted ACL reconstruction. Methods. This was a retrospective review of all patients who underwent computer-assisted single-bundle ACL reconstruction by a single surgeon. Prereconstruction intraoperative stability measurements were correlated with patient characteristics and postreconstruction stability measurements. 143 patients were included (87 male and 56 female). Average age was 29.8 years (SD ± 11.8). Results. Females were found to have significantly more pre- and postreconstruction internal rotation than males (P < 0.001 and P = 0.001, resp.). Patients with additional intra-articular injuries demonstrated more prereconstruction anterior instability than patients with isolated ACL tears (P < 0.001). After reconstruction, these patients also had higher residual anterior translation (P = 0.01). Among all patients with ACL reconstructions, the percent of correction of anterior translation was found to be significantly higher than the percent of correction for internal or external rotation (P < 0.001). Conclusion. Anterior translation was corrected the most using a single-bundle ACL reconstruction. Females had higher pre- and postoperative internal rotation. Patients with additional injuries had greater original anterior translation and less operative correction of anterior translation compared to patients with isolated ACL tears.

Accuracy of a computer-assisted planning and placement system for anatomical femoral tunnel positioning in anterior cruciate ligament reconstruction

BACKGROUND

Femoral tunnel positioning is a difficult, but important factor in successful anterior cruciate ligament (ACL) reconstruction. Computer navigation can improve the anatomical planning procedure besides the tunnel placement procedure.

METHODS

The accuracy of the computer-assisted femoral tunnel positioning method for anatomical double bundle ACL-reconstruction with a three-dimensional template was determined with respect to both aspects for AM and PL bundles in 12 cadaveric knees.

RESULTS

The accuracy of the total tunnel positioning procedure was 2.7 mm (AM) and 3.2 mm (PL). These values consisted of the accuracies for planning (AM:2.9 mm; PL:3.2 mm) and for placement (about 0.4 mm). The template showed a systematic bias for the PL-position.

CONCLUSIONS

The computer-assisted templating method showed high accuracy for tunnel placement and has promising capacity for application in anatomical tunnel planning. Improvement of the template will result in an accurate and robust navigation system for femoral tunnel positioning in ACL-reconstruction.

Evaluation of a computer-assisted navigation system for anterior cruciate ligament reconstruction: prospective non-randomized cohort study versus conventional surgery

BACKGROUND

Conventional reconstruction of the anterior cruciate ligament (ACL) is associated with a 15% failure rate. Computer-assisted navigation systems (CANS) have been developed to improve the accuracy of tunnel positioning.

HYPOTHESIS

The use of a CANS for ACL reconstruction decreases the rate of failure, defined as IKDC grade C or D, compared to conventional ACL reconstruction.

MATERIALS AND METHODS

This prospective multicentre observational non-randomised open study compared two groups of patients requiring arthroscopic ACL reconstruction: one group was managed with a CANS and the other (control group) without a CANS. The primary evaluation criterion was based on the subjective and objective IKDC scores. Inclusion criteria were age older than 18 years and first ACL reconstruction procedure using autologous semitendinosus and gracilis tendons or an autologous bone-patellar tendon-bone graft. Of the 272 included patients, 214 were analysed; 100 were in the control group and 114 in the CANS group.

RESULTS

No significant between-group differences were found for the fraction of patients having an IKDC grade A or B (P=0.953), the subjective IKDC score (P=0.77), differential knee laxity at 150 N (1.38 ± 1.79 mm in the control group and 1.77 ± 2.06 mmin the CANS group, P=0.384), graft-type, or graft positioning.

DISCUSSION

Our results establish the large-scale feasibility of computer-assisted navigation for ACL reconstruction. However, the main outcomes at 1 year showed no significant differences between patients managed with and without computer-assisted navigation.

Does computer navigation system really improve early clinical outcomes after anterior cruciate ligament reconstruction? A meta-analysis and systematic review of randomized controlled trials

Inaccurate tunnel placement is an important cause of failure in conventional anterior cruciate ligament (ACL) reconstruction. Controversy currently exists over the usefulness of computer-assisted navigation systems in addressing this problem. Five randomized or quasi-randomized, controlled trials comparing computer-navigated versus conventional technique in ACL reconstructions until December 1, 2009 were identified through a systematical database search. The clinical outcomes of the trials were analyzed by Lachman test, pivot-shift test, International Knee Documentation Committee knee score, Lysholm score, and Tegner score. Mean difference or risk ratio with 95% confidence interval was calculated using a fixed-effects or random-effects model. Heterogeneity across the studies was also assessed. We found that the use of computer-assisted navigation systems led to additional operative time (8-17min). No significant differences between computer-navigated and conventional groups were found in terms of knee stability and functional assessment during short-term follow-up. The role of computer-assisted navigation systems on clinical performance and longevity needs further investigation in large sample, long-term randomized trials.

Intraoperative comparison of knee laxity between anterior cruciate ligament-reconstructed knee and contralateral stable knee using navigation system

PURPOSE

The objective of this study was to compare knee laxity between anterior cruciate ligament (ACL)-reconstructed knees and contralateral stable knees by use of intraoperative navigation.

METHODS

Five patients with ipsilateral ACL-deficient knees with contralateral stable knees without any ligament injuries were included in this study. Anteroposterior (AP) knee laxity during anterior drawer force applied manually and range of tibial rotation and AP knee laxity during internal and external rotational torque applied manually in both the ACL-deficient knee and the contralateral stable knee were measured by use of a navigation system from 15 degrees to 90 degrees of knee flexion. After the temporary fixation of the posterolateral bundle, anteromedial bundle (AMB), or double-bundle (DB) reconstruction, knee laxity was measured again and compared with that of the stable knee.

RESULTS

The mean laxities for PLB reconstruction were significantly greater than those of the contralateral stable knee at more than 75 degrees of knee flexion (P < .05). The mean laxities for AMB or DB reconstruction were not significantly different from those of the contralateral stable knee at all knee flexion angles. Those for AMB reconstruction were within +1.6 mm and those for DB reconstruction were within -2.0 mm of those of the contralateral stable knee. The mean rotations for all reconstructions were significantly less than those of the contralateral stable knee at less than 30 degrees of knee flexion (P < .05).

CONCLUSIONS

DB and AMB reconstructions could restore knee laxity closer to the level of the contralateral stable knee. Because normal knee laxity is different in each individual, evaluation of contralateral stable knee laxity during ACL reconstruction surgery would be helpful for restoration to the level of the specific preinjury knee laxity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Double-bundle anterior cruciate ligament reconstruction: a comprehensive kinematic study using navigation

BACKGROUND

Single-bundle anterior cruciate ligament reconstruction seems to be insufficient to control a combined rotatory load of internal and valgus torque, whereas anatomical double-bundle reconstruction might produce a better biomechanical outcome, especially during rotatory loads.

HYPOTHESIS

The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce the internal rotation of the tibia at different degrees of flexion.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten consecutive anterior cruciate ligament reconstruction procedures were performed in male patients using double-bundle gracilis and semitendinosus tendon graft with the 2.0 OrthoPilot anterior cruciate ligament navigation system. Anteroposterior displacement at 30 degrees , 60 degrees , and 90 degrees as well as internal and external rotation at 0 degrees , 15 degrees , 30 degrees , 45 degrees , 60 degrees , and 90 degrees of knee flexion were evaluated before reconstruction, after fixation of the anteromedial bundle, and then after fixation of the posterolateral bundle.

RESULTS

Fixation of the anteromedial bundle significantly (P < .05) reduced the anteroposterior displacement at 30 degrees , 60 degrees , and 90 degrees of knee flexion; the internal rotation at 15 degrees , 30 degrees , 45 degrees , and 60 degrees ; and the external rotation at 0 degrees , 30 degrees , 60 degrees , and 90 degrees . The addition of the posterolateral bundle to the anteromedial bundle did not significantly reduce internal and external rotation of the tibia at degrees of flexion measured (P > .05).

CONCLUSION

The hypothesis that the addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia, minimizing the pivot-shift phenomenon, was not confirmed.

CLINICAL RELEVANCE

The effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model of anterior cruciate ligament reconstruction using doubled semitendinosus and gracilis graft.

Navigation evaluation of the pivot-shift phenomenon during double-bundle anterior cruciate ligament reconstruction: is the posterolateral bundle more important?

PURPOSE

The purpose of this study was to assess the pivot-shift phenomenon during double-bundle anterior cruciate ligament (ACL) reconstruction using a navigation system.

METHODS

Ninety patients who received navigated double-bundle ACL reconstruction were included in this study. The mean age of the patients was 21.9 years. During reconstruction, pivot-shift tests were performed 4 times: before reconstruction, after the posterolateral bundle fixation, after the anteromedial bundle fixation, and after the double-bundle reconstruction. Both tibial internal rotation and anterior translation under the pivot-shift test were measured at each phase by the additional functions of the navigation. The navigation system used in this study was the image-free, which does not require preoperative or intraoperative images, OrthoPilot ACL (version 2.0; B. Braun Aesculap, Tuttlingen, Germany).

RESULTS

Before ACL reconstruction, average (+/- standard deviation) tibial internal rotation and anterior translation under the pivot-shift test were 23.7 degrees +/- 6.1 degrees and 5.2 +/- 2.4 mm. They were significantly decreased to 20.9 degrees +/- 6.4 degrees and 2.3 +/- 1.1 mm after the posterolateral bundle fixation, and also decreased to 22.2 degrees +/- 5.7 degrees and 2.4 +/- 1.1 mm after the anteromedial bundle fixation. There was no significant difference between the groups. After double-bundle reconstruction, they improved to 20.3 degrees +/- 6.3 degrees and 2.0 +/- 1.0 mm.

CONCLUSIONS

Our results indicate that both the posterolateral and the anteromedial bundle similarly control both anterior translation and internal rotation during pivot-shift testing. Double-bundle reconstruction may further improve knee stability.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria on basis of consecutive patients with universally applied reference gold standard.

Double-bundle anterior cruciate ligament reconstruction: a computer-assisted orthopaedic surgery study

BACKGROUND

The biomechanical function of single-bundle anterior cruciate ligament reconstruction, in cadaveric studies, is successful in limiting anterior tibial translation in response to an anterior tibial load but seems to be insufficient to control a combined rotator load of internal and valgus torque. Anatomical double-bundle anterior cruciate ligament reconstruction might produce a better biomechanical outcome.

HYPOTHESIS

The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce internal rotation of the tibia at 30 degrees of knee flexion, compared with a standard single-bundle reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty consecutive anterior cruciate ligament reconstructions were performed in male patients in April and May 2006 with double-bundle gracilis and semitendinosus tendon grafts using the 2.0 OrthoPilot navigation system. Group A (10 patients) underwent standard single-bundle anterior cruciate ligament reconstruction with doubled gracilis and semitendinosus tendon graft; group B (10 patients) underwent double-bundle reconstruction with doubled gracilis and semitendinosus tendon graft. Anteroposterior displacement and internal and external rotation at 30 degrees of knee flexion were evaluated before and after reconstruction, using manual maximum force.

RESULTS

Both techniques significantly reduced anteroposterior displacement and internal and external rotation of the tibia with respect to preoperative anterior cruciate ligament-deficient condition (P < .05). Comparing groups, no differences in anteroposterior tibial displacement and internal and external rotation of the tibia were found (anteroposterior, 3.7 mm and 5.2 mm; internal rotation, 16.3 degrees and 16.6 degrees; external rotation, 15.7 degrees and 15.1 degrees, respectively) in group A and B (P = .06, .90, and .72, respectively).

CONCLUSION

The hypothesis that addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia at 30 degrees of knee flexion is not confirmed.

CLINICAL RELEVANCE

The effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model.

Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study

Anatomic reconstructions of anterior cruciate ligament (ACL) with double bundle gracilis and semitendonosus tendons graft, reproducing AM and PL bundles, have been introduced to offer a better biomechanical outcome, especially during rotatory loads. On the other hand, many methods of tenodesing the lateral aspect of the tibia to the femur to reduce internal rotation (IR) of the tibia and minimize anterior translation of the tibia relative to the femur as a backup for intra-articular reconstruction, have been also suggested. The goal of this study is to evaluate the effect, on the IR of the tibia, of a lateral reconstruction in addition to a standard single bundle ACL reconstruction as compared with an anatomic double bundle ACL reconstruction. Computer assisted ACL reconstruction has been used because it could be very effective in evaluating the global kinematic performance of the reconstructed knee. We selected 20 consecutive ACL reconstruction procedures to be performed in males in our hospital. Patients were alternately assigned to one of the two groups--group A: standard single bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique and a lateral extraarticular reconstruction; group B: double bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique. In all ACL reconstruction procedures navigation process was performed. Both surgical techniques reduced significantly AP displacement, IR and external rotation (ER) of the tibia respect to pre-operative ACL deficient condition (p<0.05). Comparing the group A after the single bundle reconstruction and the group B after the AM bundle fixation, non differences were found in AP displacement, IR and ER of the tibia (p=0.75, p=0.07 and p=0.07 respectively; power: 0.94). Comparing the group A after the addition of the lateral tenodesis and group B after the PL bundle fixation (AM+PL) no differences in AP tibial displacement and in ER of tibia were found (p=0.9 and 0.15, respectively; power: 0.99); however a significant reduction in IR of the tibia was found in group A after the addition of the lateral tenodesis respect to the group B after the addition of the PL bundle (p=0.0001; power: 0.26). On the basis of our study, the addition of a lateral extraarticular reconstruction to a standard single bundle ACL reconstruction with hamstrings tendons graft in an "in vivo" reconstruction, is more effective in reducing the IR of the tibia at 30 degrees of knee flexion, as compared with a standard single bundle ACL reconstruction and with an anatomic double bundle reconstruction is confirmed.

Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction

BACKGROUND

Recommended techniques for transtibial drilling in anterior cruciate ligament reconstruction are based on strategies to prevent graft impingement and preserve tibial tunnel length. The limitations of this drilling technique may restrict the ability to centralize tunnels in the anterior cruciate ligament footprints.

HYPOTHESIS

A transtibial drilling starting point to centralize the tibial and femoral tunnels in their respective footprints can be identified, but it will result in a short tibial tunnel.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The femoral and tibial attachments of the anterior cruciate ligament were characterized in 12 fresh-frozen cadaveric knees. Knees were secured in 70 degrees and 90 degrees of flexion. A guide pin was drilled antegrade through the central femoral and proximal anterior cruciate ligament attachment sites through the central tibial anterior cruciate ligament attachment site to exit on the anterior tibia.

RESULTS

In 90 degrees of flexion using the central femoral and tibial attachment sites, the exit point of the pin on the anterior tibia was 14.1 mm from the tibial joint line and 20.9 mm anterior to the superficial medial collateral ligament. The length of the pin in the tibia was 30.6 mm. Extending the knee to 70 degrees or directing the pin through the proximal femoral anterior cruciate ligament attachment moved the starting point less than 4 mm from this point.

CONCLUSION

The transtibial technique can produce tunnels centered in the anterior cruciate ligament footprints, but a starting point close to the tibial joint line is required. This will result in a relatively short tibial tunnel.

CLINICAL RELEVANCE

If tunnels centered in the anterior cruciate ligament attachment sites are desired with the transtibial drilling technique, then a short tibial tunnel is necessary. A short tibial tunnel may compromise graft fixation and graft incorporation, or it may result in a tunnel length-graft length mismatch. An alternative drilling strategy might be employed.

Computer-assisted navigation and anterior cruciate ligament reconstruction: accuracy and outcomes

As many as 175,000 anterior cruciate ligament (ACL) reconstructions are performed annually in the United States at a cost >1 billion dollars. Estimates of the rate of revision surgery are as high as 10%-20%, potentially resulting in as many as 35,000 revisions a year. In addition, errors that are not obvious at short-term or mid-term follow-up may have significant long--term effects in young patients. Studies have demonstrated that the majoriity of visions are related to technical errors, primarily tunnel placement. Computer-aided navigation systems provide enhanced precision in tunnel placement and may reduce the rate of revision surgery. Computer-aided systems can provide valuable data on rotational and translational laxity of the knee.