Accuracy of the Precision Saw versus the Sagittal Saw during total knee arthroplasty: A randomised clinical trial

Primary total knee arthroplasty assisted by computed tomography-free navigation for secondary knee osteoarthritis following massive calcium phosphate cement packing for distal femoral giant-cell bone tumor treatment: a case report

BACKGROUND

Giant cell tumor of bone (GCTB) is an intermediate tumor commonly arising from the epiphysis of the distal femur and proximal tibia. Standard GCTB treatment is joint-preserving surgery performed using thorough curettage and the filling of the cavity with allo-, auto-, polymethyl methacrylate (PMMA), or synthetic bone graft. Calcium phosphate cement (CPC) is an artificial bone substitute, which has the benefit of being able to adjust defects, consequently inducing immediate mechanical strength, and promoting biological healing. Secondary osteoarthritis may occur following GCTB treatment and may need additional surgery if severe. However, details regarding surgery for secondary osteoarthritis have not been fully elucidated. There are no reports on the use of total knee arthroplasty (TKA) for the treatment of secondary osteoarthritis following CPC packing. The insertion of an alignment rod is a standard procedure in TKA; however, it was difficult to perform in this case due to CPC. Therefore, we used a computed tomography (CT)-free navigation system to assist the distal femur cut. This study presents a knee joint secondary osteoarthritis case following CPC packing for GCTB curettage that was treated with standard TKA.

CASE PRESENTATION

A 67-year-old Japanese woman, who was previously diagnosed with left distal femur GCTB and was treated by curettage and CPC packing 7 years ago, complained of severe knee pain. Left knee joint plain radiography revealed Kellgren and Lawrence (K-L) grade 4 osteoarthritis without evidence of tumor recurrence. Therefore, she was scheduled for TKA. There are no reports on the cutting of a femoral condyle surface with massive CPC with accurate alignment. Because it is difficult to insert the alignment rod intramedullary and cut the femoral condyle with CPC, we planned CT-free navigation-guided surgery for accurate bone cutting using an oscillating tip saw system to prevent CPC cracks. We performed standard TKA without complications, as planned. Postoperative X-ray showed normal alignment. Knee Society Knee Score (KSKS) and Knee Society Function Score (KSFS) ameliorated from 27 and 29 to 64 and 68, respectively The patient can walk without a cane postoperatively.

CONCLUSION

There was no report about the surface TKA guided by CT-free navigation after primary GCT surgery with CPC. We believe that this case report will help in planning salvage surgery for secondary osteoarthritis after CPC packing.

[Is the unlimited use of surgical instruments safe? : Discussion using the example of endoprosthetics]

As medical devices surgical instruments are important components when performing surgery. They can significantly influence the course and outcome of the surgery. Instruments are mechanically stressed in daily use and resterilized multiple times. The majority of manufacturer documentation for endoprostheses lacks specific information regarding tolerable instrument wear and the maximum number of applications for surgical instruments. So far, there are no mandatory algorithms for the necessity of checking and replacing surgical instruments. The risk of mechanical failure, surface damage and ultimately incidents is illustrated using endoprosthesis instruments as examples.

Improving Tibial Component Coronal Alignment During Total Knee Arthroplasty with the Use of a Double-Check Technique

Objective

To compare the efficacy of the restoration of tibial component coronal alignment with a double‐check technique and the conventional surgical technique during total knee arthroplasty (TKA) in knee osteoarthritis patients, and to investigate the distribution of the medial proximal tibial angle (MPTA) after TKA.

Methods

A retrospective review was performed of 151 patients (179 knees) with knee osteoarthritis undergoing primary TKA in Beijing Chaoyang Hospital, Capital Medical University from February 2013 to January 2015 to evaluate the differences in MPTA in patients undergoing the conventional TKA and those undergoing a modified TKA with a double‐check technique after the surgery. All patients were evaluated by MPTA, range of motion (ROM), Knee Society Clinical Rating System (KSS) clinical scores, and KSS functional scores. An MPTA deviation of 3° or greater was considered malalignment.

Results

A total of 130 TKA procedures in 119 patients were included in the study: 64 knees treated with conventional TKA and 66 knees treated with the double‐check technique TKA. The mean postoperative MPTA was 88.6° ± 2.2° in the conventional TKA group and 89.1° ± 1.5° in the double‐check TKA group. The mean postoperative MPTA between the two groups was not significantly different. In the conventional TKA group, 79.7% (51 knees) had a postoperative MPTA deviation within 3° and 20.3% (13 knees) had a MPTA deviation greater than 3°. In the double‐check TKA group, 93.9% (62 knees) had a postoperative MPTA deviation within 3°and 6.1% (4 knees) had a MPTA deviation greater than 3°. The postoperative MPTA deviation within 3° showed a statistically significant difference between the two groups. In the double‐check TKA group, a 21.2% (14 knees) tibial malalignment was detected after the first check and a 9.1% (6 knees) tibial malalignment was detected after the second check. The mean postoperative ROM was 118.1° ± 9.2° in the conventional TKA group and 115.7° ± 10.1° in the double‐check TKA group. The mean postoperative KSS clinical score was 89.3 ± 3.5 in the conventional TKA group and 89.0 ± 3.7 in the double‐check TKA group. The mean postoperative KSS functional score was 84.8 ± 10.0 in the conventional TKA group and 84.9 ± 9.0 in the double‐check TKA group. The mean postoperative ROM, KSS clinical scores, and KSS functional scores between the two groups were not statistically significantly different.

Conclusion

Malalignment of the tibial component can occur after conventional TKA, and the double‐check technique is an effective method to improve tibial component coronal alignment.

No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty

PURPOSE

It was hypothesized that malrotation of femoral component in total knee arthroplasty (TKA) will significantly impact clinical outcome.

METHODS

Eighty-eight consecutive patients with primary osteoarthritis of the knee were prospectively evaluated. They received a cemented posterior stabilized TKA (NexGen, Zimmer/Biomet^® Inc., Warsaw, IN, USA). The femoral component was placed in 3° of external rotation referenced to the posterior condylar line. Postoperatively, a CT scan was performed to evaluate rotation of femoral component in the transverse plane. SF-36, KSS, and WOMAC, as well as their range of motion was assessed prior to surgery, after 6 and 24 months. Data are presented as mean and standard deviation (SD), as well as range if applicable. Correlation analysis was performed between the placement of the femoral component in the transverse plane and the clinical outcome.

RESULTS

Femoral component placement was on average 0.1° [SD 2.5°, range - 6.5° to + 6.5°] referenced to the surgical transepicondylar line showing a wide range between the two landmarks after surgery. After 6 months, WOMAC category 'physical function' correlated significantly with femoral component rotation (r = - 0.28, p = 0.007). After 24 months, WOMAC categories 'physical function' and 'pain' correlated significantly with femoral rotation (r = - 0.41, p < 0.001; and r = - 0.33, p = 0.001). No significant correlations were found between femoral component rotation and range of motion (r = 0.04), WOMAC category "stiffness", KSS, as well as SF-36 questionnaires. These reported formally significant correlations were without any clinical relevance.

DISCUSSION

The study showed that there is a significant patients specific femoral component placement in the transverse plane. Internal or external malrotation of the femoral component does not correlate automatically with poor knee function. The lack of correlation between femoral component position and clinical as well as functional outcome underlines complexity and significant individuality of each patient. The surgeon should be aware of the finding and attention should be paid during surgery when significant divergency is seen between the two landmarks. Soft tissue balancing might be very crucial in these specific patients, which needs to be studied in depth in the future.

LEVEL OF EVIDENCE

II.