Usefulness of an accelerometer-based portable navigation system in total knee arthroplasty

Navigated Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Prospective Randomized Controlled Trials

Background

Recent evidence on the cost-effectiveness of technology in total knee arthroplasty (TKA) demonstrated that navigated computer-assisted methods (N-TKA) is likely to be most cost-effective in the clinical setting. The aim of the current meta-analysis is to compare radiographic, clinical and functional outcomes between conventional TKA (C-TKA) and N-TKA methods.

Methods

All prospective randomized controlled trials (pRCTs) comparing primary TKA performed using C-TKA and N-TKA techniques were eligible for inclusion. Radiographic outcomes included postoperative coronal, sagittal and axial component alignment. Clinical outcomes included all-cause revision and aseptic revision. Functional outcomes were analyzed when reported. A random-effects meta-analysis of all available cases was performed. This allowed for all missing data.

Results

Normal coronal mechanical alignment of the tibial (p < 0.001) and femoral (p = 0.001) components was achieved more frequently with N-TKA. Normal sagittal mechanical alignment of the tibial component was achieved significantly more with N-TKA (p < 0.010). There was no difference in short-term clinical survivorship (all-cause, p = 0.649; aseptic, p = 0.79) or in functional outcomes reported between groups. There was a clinically significant reduction in the mean C-TKA operative time (87 min, σ = 16.6, 95% CI 76.4-98.8) compared N-TKA (97.6 min, σ = 16.9, 95% CI 86.2-109.1) (p = 0.17).

Conclusion

Navigated TKA achieves superior radiographic alignment for femoral and tibial components in both the coronal and sagittal plane. Operative times are 10 min longer in the N-TKA group. Functional outcomes are similar between navigated and conventional groups. Clinical outcomes reported in Level I studies are limited to short-term follow-up so future prospective studies are required.

The Accuracy of a Portable Accelerometer-Based Navigation System for Tibial Alignment Can be Reliable during Total Knee Arthroplasty for Obese Patients

A portable accelerometer-based navigation system can be useful for achieving the target alignment. Tibial registration is based on the medial and lateral malleoli; however, the identification of landmarks may be difficult in obese (body mass index [BMI] >30 kg/m2) patients whose bones are not easily palpable from the body surface. This study compared tibial component alignment achieved using a portable accelerometer-based navigation system (Knee Align 2 [KA2]) in obese and control groups and aimed to validate the accuracy of bone cutting in obese patients. A total of 210 knees that underwent primary total knee arthroplasty using the KA2 system were included. After 1:3 propensity score matching, there were 32 and 96 knees in the BMI >30 group (group O) and BMI ≤30 group (group C), respectively. The absolute deviations of the tibial implant from the intended alignment were evaluated in the coronal plane (hip-knee-ankle [HKA] angle and medial proximal tibial angle) and sagittal plane (posterior tibial slope [PTS]). The inlier rate of each cohort, which was defined as tibial component alignment within 2 degrees of the intended alignment, was investigated. In the coronal plane, the absolute deviations of the HKA and MPTA from the intended alignment were 2.2 ± 1.8 degrees and 1.8 ± 1.5 degrees in group C and 1.7 ± 1.5 degrees and 1.7 ± 1.0 degrees in group O (p = 1.26, and p = 0.532). In the sagittal plane, the absolute deviations of the tibial implant were 1.6 ± 1.2 degrees in group C and 1.5 ± 1.1 degrees in group O (p = 0.570). The inlier rate was not significantly different between group C and group O (HKA: 64.6 vs. 71.9%, p = 0.521; MPTA: 67.7 vs. 78.1%, p = 0.372; PTS: 82.2 vs. 77.8%, p = 0.667). The accuracy of tibial bone cutting for the obese group was comparable to that of the control group. An accelerometer-based portable navigation system can be useful when attempting to achieve the target tibial alignment in obese patients. LEVEL OF EVIDENCE:  Level IV.

Robotic-assisted total knee arthroplasty improved component alignment in the coronal plane compared with navigation-assisted total knee arthroplasty: a comparative study

The purpose of this study was to directly compare implant placement accuracy and postoperative limb alignment between robotic-assisted total knee arthroplasty and navigation-assisted total knee arthroplasty. This retrospective case-control study included a consecutive series of 182 knees (robotic-assisted group, n = 103 knees; navigation-assisted group, n = 79). An image-free handheld robotic system (NAVIO) or an image-free navigation system (Precision N) was used. Component and limb alignment were evaluated on three-dimensional computed tomography scans and full-length standing anterior-posterior radiographs. We compared the errors between the final intraoperative plan and the postoperative coronal and sagittal alignment of the components and the hip-knee-ankle angle between the two groups. The orientation of the femoral and tibial components in the coronal plane were more accurate in the robotic-assisted group than in the navigation-assisted group (p < 0.05). There was no significant difference in the orientation of the femoral and tibial component in the sagittal plane between the two groups. There were fewer outliers in the tibial coronal plane in the robotic-assisted group (p < 0.05). There was also no significant difference in the frequency of outlying values for coronal or sagittal alignment of the femoral component or sagittal alignment of the tibial component or the hip-knee-ankle angle between the two groups. Robotic-assisted total knee arthroplasty using a handheld image-free system improved component alignment in the coronal plane compared with total knee arthroplasty using an image-free navigation system. Robotic surgery helps surgeons to achieve personalised alignment that may result in better clinical outcomes.

An updated meta-analysis comparing complications, functional, clinically relevant and radiological outcomes of accelerometer based portable navigation and conventional technique of total knee arthroplasty

Introduction

Since previous studies, including small-scale meta-analyses comparing accelerometer-based portable navigation (APN-TKA) and conventional techniqueof total knee arthroplasty (CONV-TKA), have reported divergent results, there is a need for an updated meta-analysis to compare complications, functional outcomes, clinically relevant outcomes and radiographic alignment of components.

Methods

This meta-analysis was conducted as per PRISMA guidelines. Randomised controlled trials, and non-randomised comparative cohort studies in English language on primary TKA were included. The complications compared were Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), infection, manipulation under anaesthesia (MUA) for postoperative knee stiffness, re-operation and mortality. The functional outcomes compared were the Knee Society Knee Score, Knee Society Score function, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Arthritis Index. The evaluated clinically relevant outcomes were surgical time, blood loss, drop in haematocrit, tourniquet time, postoperative knee flexion and complications). The number of radiological outliers; as well as the absolute values of the alignment of the overall prosthesis, femoral and tibial components in both coronal and sagittal planes, was assessed.

Results

Twenty-five studies were included. Both the groups were comparable in terms of preoperative demographic features. There was no difference in complications and functional outcomes. Operation time was longer in APN-TKA (p < 0.00001) but there was no difference in rest of the clinically relevant outcomes. Restoration of the lower limb mechanical axis (p = 0.003) and coronal femoral alignment angle (p = 0.0002) was better with APN. APN also significantly reduced the risk of the odds of outliers of lower limb mechanical axis (p < 0.0001), coronal femoral alignment (p = 0.03), coronal tibial alignment (p < 0.0001) and sagittal tibial alignment (p = 0.0001).

Conclusion

The improvement in the accuracy of implantation by the use of APN-TKA, as determined by the overall alignments of prosthesis, or femoral and tibial components, does not necessarily translate into lesser complications and better functional and clinical outcomes.

Level of evidence

Therapeutic study, Level II.

Femoral prosthesis alignment of augmented reality-assisted versus accelerometer-based navigation in total knee arthroplasty: A noninferiority analysis

INTRODUCTION

The purpose of this study was to examine the comparative precision of the augmented reality (AR)-assisted navigation system and the accelerometer-based navigation system in total knee arthroplasty (TKA).

MATERIALS AND METHODS

We performed noninferiority analysis in a retrospective cohort. The coronal alignment of femoral prosthesis was compared between 109 TKAs performed using the AR-assisted navigation system and 118 TKAs performed using the accelerometer-based navigation system. All femoral prostheses were planned to be positioned perpendicular to the mechanical axis of the femur. The primary outcome was the success rate of coronal alignment of the femoral prosthesis defined as alignment error relative to neutral alignment <3°. We calculated the noninferiority margin as 7%-points using the 95%-95 % method and also confirmed the validity of the noninferiority margin using the fixed margin method. Noninferiority would be shown if the lower boundary of the 95 % confidence interval (CI) for the between-group difference in percentage of the success rate was not less than 0.93 (i.e., 1.00 - 0.07).

RESULTS

Treatment success was achieved in 104 of 109 patients (95.4 %) in the AR-assisted navigation group and 110 of 118 (93.2 %) in the accelerometer-based navigation group. The risk ratio of success between the AR-assisted navigation group versus accelerometer-based navigation group was 1.02 (95 % CI, 0.96 to 1.09): the CIs did not include the noninferiority margin of 0.93.

CONCLUSION

The AR-assisted navigation system was noninferior to the accelerometer-based navigation system in terms of coronal alignment of the femoral prosthesis in TKA.

Accelerometer-Based Navigation in Primary TKA Leads to Improved Alignment but No Change in PROs

INTRODUCTION

Computer and accelerometer-based navigation tools have demonstrated improved mechanical alignment in primary total knee arthroplasty (TKA). Accelerometer-based navigation (ABN), in particular, is attractive due to avoidance of pins and trackers. Prior literature has yet to demonstrate an associated improvement in functional outcomes using ABN compared to conventional instrumentation (CONV). The purpose of this study was to compare alignment and functional outcomes between CONV and ABN in primary TKA in a large patient series.

METHODS

A retrospective study of 1,925 TKAs performed by a single surgeon sequentially was performed. There were 1,223 TKAs performed with CONV and measured resection technique. There were 702 TKAs performed with distal femoral ABN and restricted kinematic alignment goals. We compared radiographic alignment, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, rates of manipulation under anesthesia (MUA), and needs for aseptic revisions between cohorts. Chi-squared, Fisher's exact, and t-tests were used to compare demographics and outcomes.

RESULTS

The ABN cohort had higher rates of neutral alignment postoperatively than the CONV cohort (ABN 74 vs CONV 56%, P<0.001). Rates of MUA (ABN 2.8 vs CONV 3.4%, P=0.382) and aseptic revision (ABN 0.9 vs CONV 1.6%, P=0.189) were similar. The PROMIS physical function (ABN 42.6 vs CONV 42.9, P=0.4554), physical health (ABN 63.4 vs CONV 63.3, P=0.944), mental health (ABN 51.4 vs CONV 52.7, P=0.4349), and pain (ABN 32.7 vs CONV 30.9, P=0.256) scores were similar.

CONCLUSION

Accelerometer-based navigation is valuable in its ability to improve postoperative alignment, but does not improve complication rates or patient reported functional outcomes.

Accelerometer-based portable navigation, a faster guide compared to computer-assisted navigation in bilateral total knee arthroplasty-a randomized controlled study

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.

Accelerometer-Based Handheld Navigation Instrumentation in Total Knee Arthroplasty Decrease Blood Loss Compared to Conventional Instrumentation: A Prospective Comparative Study

Introduction Total Knee Arthroplasty (TKA) can be associated with significant peri- and post-operative blood loss necessitating blood transfusion. The blood loss may be relatively less when the accelerometer-based handheld navigation system (HHNS) is used, as there is neither a need for intramedullary breach nor additional pin insertions. The primary hypothesis was that HHNS instrumentation reduced perioperative blood loss when compared with conventional instrumentation, and to prove this, we compared the perioperative parameters like tourniquet time, hemoglobin loss, and estimated blood loss between patients undergoing total knee arthroplasty using conventional instrumentation with handheld navigation instrumentation. Methods This prospective comparative study involves 40 patients in the HHNS group and 40 patients in the conventional group based on the instrumentation used, respectively. Tourniquet was used in all the cases. Patient characteristics like age, sex, body mass index (BMI), American Society of Anaesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI) were recorded. The perioperative parameters like tourniquet time, the estimated blood loss, hemoglobin loss, blood transfusions, and the number of units transfused were recorded and compared between the groups. Results There was no significant difference in age, BMI, ASA grade, or CCI between the two groups. The tourniquet time was 83.7 ± 9.6 in the navigation and 73.9 ± 10.3 in the conventional group. The estimated Hb loss was lower at 2.5 ± 1.6 in the HHNS group compared to 3.0 ± 1.8 in the conventional group (p<0.001). Similarly, estimated blood loss was also lower at 830 ± 285ml for the HHNS group compared to 1088 ± 228 in the conventional group. Two patients in the navigation group had a total of four units transfused, whereas three patients in the conventional group had five units of blood transfusion. Conclusions The primary hypothesis that HHNS reduced perioperative blood loss was confirmed by the results of our study. We demonstrated that HHNS instrumentation significantly decreased the estimated blood loss, drain volume, and hemoglobin loss compared to conventional instrumentation with similar operating times. Though blood transfusions were seen in fewer patients, there was no significant reduction in blood transfusions by HHNS instrumentation.

Accelerometer-based navigation vs. conventional techniques for total knee arthroplasty (TKA): a systematic review and meta-analysis of randomized controlled trials

Background

The aim of the study was to determine whether accelerometer-based navigation (ABN) can improve radiological and functional outcomes during total knee arthroplasty (TKA) compared with conventional techniques (CONV).

Method

We comprehensively searched the PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials databases. Only randomized controlled trials were selected for meta-analysis and, ultimately, 10 studies were included.

Results

The 10 studies involved 1,125 knees, of which 573 were in the ABN group and 552 in the CONV group. The results demonstrated that ABN significantly reduced the number of outliers for mechanical alignment (MA) (RR: 0.38, 95% CI: 0.27 to 0.54, P < 0.00001, I² = 45%), achieving more accurate MA (RR: –0.78, 95% CI: –0.93 to –0.62, P < 0.00001, I² = 76%). The results revealed that there was no significant difference in duration of surgery between the ABN and CONV groups (MD: –0.2, 95% CI: –1.45 to 1.05, P = 0.75, I² = 48%). There was less blood loss through the use of ABN (SMD: –0.49, 95% CI: –0.93 to –0.06, P = 0.03, I² = 75%). However, ABN group didn’t show better knee function (SMD: 0.13, 95% CI: –0.07 to 0.33, P = 0.20, I² = 0%), though the incidence of overall complications was significantly lower (RR: 0.69, 95% CI: 0.50 to 0.95, P = 0.02, I² = 0%).

Conclusions

The present meta-analysis demonstrated that ABN was superior to CONV in restoring MA of the lower limb. In addition, ABN reduced the loss of blood and the duration of surgery was not prolonged. However, patient-reported outcome measurements (PROMs) were not improved.

Revision Total Knee Arthroplasty Using Robotic Arm Technology

Total knee arthroplasty (TKA) is a highly successful operation for the treatment of end-stage osteoarthritis of the knee. Increasing use of computer-assisted and robotic-assisted total joint arthroplasty has been shown to improve component position, with short-term studies demonstrating improved survivability in unicompartmental knee arthroplasty. Robotic-assisted technology has been shown to be helpful in revising unicompartmental knee arthroplasty to TKA, as well as hip fusion to total hip arthroplasty, but few have described revision of a primary TKA. This case report describes the use of robotic-assisted technology in revision TKA. Robotic assistance during revision TKA may improve component alignment and increase prosthesis longevity. Future research is needed to investigate the effects on survivorship and cost.

[Research progress of anterior femoral notching in total knee arthroplasty]

Objective

To summarize the research progress of the causes and prevention methods of anterior femoral notching in total knee arthroplasty (TKA).

Methods

The related literature at home and abroad about the causes and prevention methods of the anterior femoral notching in TKA was extensively reviewed and summarized.

Results

The reasons for the occurrence of anterior femoral notching can be summarized as follows: the application of the posterior reference technique, the increase of the posterior condylar angle, the variant anatomical shape of anterior femoral cortex, the selective reduction of the femoral prosthesis size, backward movement of the entrance point, and the application of computer-assisted navigation technology or patient-specific instrumentation. To prevent the occurrence of anterior femoral notching, programs such as flex the femoral prosthesis, robot-assisted technology, and anterior and posterior reference techniques combination can be used.

Conclusion

Anterior femoral notching is a common surgical complication of TKA. A complete preoperative plan, assessment of the patient's knee joint condition, and development of a reasonable surgical plan can effectively reduce the occurrence of anterior femoral notching.

Accelerometer-based, hand-held navigation for improved knee alignment in total knee arthroplasty: An observational study

BACKGROUND

Malalignment in total knee arthroplasty has been associated with poor implant longevity and clinical outcomes. The aim of this study was to investigate the accuracy of accelerometer-based navigation in restoring the mechanical axis.

METHODS

106 primary total knee arthroplasties performed during February 2016 to September 2017 at a tertiary care centre in India were enrolled in this observational study. We noted the intra-op tourniquet time. Two separate blinded observers measured the preoperative mechanical axis and the post operative radiological results (mechanical axis, coronal and sagittal alignment of femoral and tibial components) and the mean value was taken as final data. Interclass correlation was done to look for variability between the two observers.

RESULTS

The mean pre operative mechanical axis was 13.74 ± 10.44. The mean tourniquet time was 53.14 ± 7.42 min 91.5% (96/106) knees were within ±3° of neutral mechanical axis with a mean of 1.00° ± 2.68°. The femoral and tibial components with coronal alignment within ±3° perpendicular to the mechanical axis were 93.39% (99/106) and 89.62% (95/106) respectively. In the sagittal plane 89.62% of the femoral components and 87.73% of the tibial components were within ±3° perpendicular to the axis of tibia.

CONCLUSION

The Accelerometer based portable navigation system effectively reduces the coronal and sagittal alignment outliers in total knee arthroplasty and has no role in rotational alignment of components.

[Early effectiveness of computer navigation-assisted total knee arthroplasty]

Objective

To estimate the early effectivenss of computer navigation-assisted total knee arthroplasty (TKA) by comparing with traditional TKA.

Methods

The clinical data of 89 patients (100 knees) underwent primary TKA between October 2017 and July 2018 were analyzed retrospectively, including 44 patients (50 knees) who completed the TKA under the computer-assisted navigation system as the navigation group and 45 patients (50 knees) treated with traditional TKA as the control group. There was no significant difference between the two groups ( P>0.05) in gender, age, body mass index, diagnosis, side, disease duration, Kellgren-Lawrence classification of osteoarthritis, and preoperative American Hospital for Special Surgery (HSS) score, range of motion (ROM), hip-knee-ankle angle (HKA) deviation. The operation time, incision length, difference in hemoglobin before and after operation, postoperative hospital stay, and the complications were recorded and compared between the two groups. The HSS score, ROM, and joint forgetting score (FJS-12) were used to evaluate knee joint function in all patients. Unilateral patients also underwent postoperative time of up and go test and short physical performance battery (SPPB) test. At 1 day after operation, the HKA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), sagittal femoral component angle (sFCA), and sagittal tibial component angle (sTCA) were measured and calculated the difference between the above index and the target value (deviation); and the joint line convergence angle (JLCA) was also measured.

Results

The operations of the two groups were successfully completed, and the incisions healed by first intention. The operation time and incision length of the navigation group were longer than those of the control group ( P<0.05); the difference in difference of hemoglobin before and after the operation and the postoperative hospital stay between groups was not significant ( P>0.05). Patients in the two groups were followed up 27-40 months, with an average of 33.6 months. Posterior tibial vein thrombosis occurred in 1 case in each of the two groups, and 1 case in the control group experienced repeated knee joint swelling. The HSS scores of the two groups gradually increased after operation ( P<0.05); HSS scores in the navigation group at 1 and 2 years after operation, and knee ROM and FJS-12 scores at 2 years were significantly higher than those in the control group ( P<0.05). There was no significant difference in the postoperative time of up and go test and SPPB results between the two groups at 7 days after operation ( P>0.05); the postoperative time of up and go test of the navigation group was shorter than that of the control group at 2 years ( t=-2.226, P=0.029), but there was no significant difference in SPPB ( t=0.429, P=0.669). X-ray film measurement at 1 day after operation showed that the deviation of HKA after TKA in the navigation group was smaller than that of the control group ( t=-7.392, P=0.000); among them, the HKA deviations of 50 knees (100%) in the navigation group and 36 knees (72%) in the control group were less than 3°, showing significant difference between the two groups ( χ ²=16.279, P=0.000). The JLCA and the deviations of mLDFA, mMPTA, sFCA, and sTCA in the navigation group were smaller than those in the control group ( P<0.05).

Conclusion

Compared with traditional TKA, computer navigation-assisted TKA can obtain more accurate prosthesis implantation position and lower limb force line and better early effectiveness. But there is a certain learning curve, and the operation time and incision length would be extended in the early stage of technology application.

Can accuracy with the iASSIST navigation be confirmed by assessment? A multi-center prospective randomized controlled trial with independent three-dimensional image assessment

BACKGROUND

iASSIST is one of the novel accelerometer-based navigation systems for total knee arthroplasty (TKA). Although the accuracy of iASSIST compared with conventional instruments has been reported, such evaluations were performed on two-dimensional (2D) images (X-rays). This multi-center prospective randomized controlled trial aimed to assess component positioning between TKA with and without iASSIST by 3D image assessment, and to clarify whether the iASSIST provides any benefit with regard to alignment accuracy.

METHODS

Eighty-three knees with primary knee osteoarthritis were enrolled in this study. iASSIST was used for distal femoral and proximal tibial resection in 42 knees (iA group) and a conventional guide was used in 41 knees (CONV group). At 6 months postoperatively, component alignment was evaluated with 3D images by the independent orthopaedic surgeons, and surgical parameters, range of motion and clinical outcomes were examined.

RESULTS

The rate of knees who have the alignment within 3° of neutral compared with the iA group and CONV group were 92.9% (39/42) vs. 87.8% (36/41) for femur and 76.2% (32/42) vs. 56.1% (23/41) for tibia in the coronal plane, respectively, whereas in the sagittal plane, the rate was 85.7% (36/42) vs. 58.5% (24/41) for femur and 83.3% (35/42) vs. 78.0% (32/41) for tibia, respectively. Compared with the CONV group, the iA group had a significantly improved femoral alignment in the sagittal plane (P = 0.006). There were no clinical or patient-reported differences at 6 months postoperatively.

CONCLUSIONS

The iASSIST provides technically high accuracy in femoral resection at TKA compared with a conventional procedure.

The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty

BACKGROUND

The Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs.

METHODS

A systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher's exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant.

RESULTS

A total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result.

CONCLUSION

Hip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA.

LEVEL OF EVIDENCE

Level I.

The Use of Computer Navigation and Robotic Technology in Complex Total Knee Arthroplasty

»

The potential benefits of computer-assisted surgical (CAS) navigation and robotic total knee arthroplasty (TKA) systems, such as increased reliability of restoring the mechanical axis, fewer outliers, more rapid hospital discharge, less physical therapy requirements, decreased blood loss, and decreased revision rates, have led to their application not only in primary cases but also in complex cases such as preoperative deformity and revision.

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Early evidence demonstrates that CAS navigation may help to improve alignment in complex cases of femoral and tibial deformity and in cases of femoral bowing.

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Data regarding deformity correction with robotic systems are similar to CAS navigation with regard to alignment, but are more limited. There are also scant data regarding revision cases and cases of previous intramedullary canal instrumentation.

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Concerns remain regarding cost, learning curves, and operative times. There are potential long-term cost savings associated with a decrease in revisions and readmissions that require additional investigation.

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Early evidence for the use of these emerging technologies for deformity correction and revision cases is promising, but their impact on long-term functional outcomes remains to be demonstrated. Additional well-designed comparative studies are warranted.

Usefulness of an accelerometer-based navigation system in bilateral one-stage total knee arthroplasty

Background

Bilateral one-stage total knee arthroplasty (BTKA) have increased because it provides a number of advantages. Recently, Accelerometer-based navigation (ABN) system which guide the cutting plane without intramedullary disturbance might result in less endothelial and microvascular damage. Therefore, we hypothesized that the ABN may reduce blood loss, reduce postoperative pain, and better restore BTKA alignment compared to conventional instruments.

Methods

We retrospectively compared 44 consecutive patients receiving ABN assisted BTKA (iBTKA) to 57 patients with conventional instruments (cBTKA). Identical pre- and post-operative care was utilized to all patients. The outcome measures assessed were hemoglobin (Hb), calculated blood loss (CBL), blood transfusion, VAS score for pain, morphine consumption, knee flexion angle, and length of stay (LOS). Radiographic assessment included mechanical axis (MA) and component positioning at 3–6 months of follow up.

Results

Both iBTKA and cTKA groups had equivalent demographic data. Postoperative Hb of the cBTKA group was significantly lower than those in the iBTKA group at 24 h (p = 0.02), but there was no significant difference in drain volume, CBL, and blood transfusion rate. For radiographic measures, the iBTKA group had more accurate MA and component orientation, and had a lower number of outliers than those in the cBTKA group (p ≤ 0.01), except for the sagittal femoral component angle.

Conclusion

The ABN assisted BTKA could not reduce blood loss or postoperative pain more than cBTKA, nor improve functional recovery. However, the ABN significantly improved the accuracy of MA and prostheses positioning.

Trial registration

The protocol of this study was registered in the Thai Clinical Trials Registry database No. TCTR20180731001# on 25 July 2018.

New Technologies in Knee Arthroplasty: Current Concepts

Total knee arthroplasty (TKA) is an effective treatment for severe osteoarthritis. Despite good survival rates, up to 20% of TKA patients remain dissatisfied. Recently, promising new technologies have been developed in knee arthroplasty, and could improve the functional outcomes. The aim of this paper was to present some new technologies in TKA, their current concepts, their advantages, and limitations. The patient-specific instrumentations can allow an improvement of implant positioning and limb alignment, but no difference is found for functional outcomes. The customized implants are conceived to reproduce the native knee anatomy and to reproduce its biomechanics. The sensors have to aim to give objective data on ligaments balancing during TKA. Few studies are published on the results at mid-term of these two devices currently. The accelerometers are smart tools developed to improve the TKA alignment. Their benefits remain yet controversial. The robotic-assisted systems allow an accurate and reproducible bone preparation due to a robotic interface, with a 3D surgical planning, based on preoperative 3D imaging or not. This promising system, nevertheless, has some limits. The new technologies in TKA are very attractive and have constantly evolved. Nevertheless, some limitations persist and could be improved by artificial intelligence and predictive modeling.

Accuracy of tibial component placement in unicompartmental knee arthroplasty performed using an accelerometer-based portable navigation system

PURPOSE

There is a need for new devices to improve the accuracy of implantation in unicompartmental knee arthroplasties (UKAs). The accelerometer-based portable navigation system is expected to improve this accuracy. This study aimed to compare the accuracy of UKAs performed by the portable navigation system with that of the conventional method, and to investigate whether the portable navigation system can complement the surgeon's experience.

METHODS

The study comprised of 80 Oxford UKAs. Knees were divided into two groups based on the method of tibial osteotomy: the conventional group (37 UKAs performed by an experienced surgeon using the extra-medullary guide) and the portable navigation group (43 UKAs performed by 2 unaccustomed surgeons using the navigation system). The absolute error from the target angle on the coronal and sagittal plane was measured on whole lower leg X-ray. The incidence of outliers (> 3°) was compared between the groups using Fisher's exact probability test.

RESULTS

The incidences of outliers on the coronal plane were 41.0% (15 of 37 knees) in the conventional group and 9.3% (4 of 43 knees) in the portable navigation group (p < 0.0001). The incidences of outliers on the sagittal plane were 13.5% (5 of 37 knees) in the conventional group and 14.0% (6 of 43 knees) in the portable navigation group (p = 0.3772).

CONCLUSION

This is the first report on the usefulness of an accelerometer-based portable navigation system in UKA. The use of this system improves the accuracy of implantation of the tibial component beyond the experience of the surgeon.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Usefulness of an Accelerometer-Based Portable Navigation System for Total Knee Arthroplasty: A Multicenter Prospective Randomized Controlled Trial

BACKGROUND

An accelerometer-based portable navigation system was recently introduced to improve prosthetic alignment during total knee arthroplasty (TKA). The purpose of this multicenter prospective randomized controlled trial (RCT) was to evaluate the effects of this accelerometer-based portable navigation system for achieving more accurate alignment during TKA in the clinical setting.

METHODS

One hundred patients with primary varus osteoarthritis of the knee were enrolled in this prospective RCT conducted in 5 hospitals. A navigation system was utilized in 50 patients (navigation group), and a conventional intramedullary femoral guide and an extramedullary tibial guide were utilized in 50 patients (conventional group). At 6 months postoperatively, weight-bearing radiographs were obtained of the whole operative leg. An experienced surgeon who was blinded to the treatment assignments then measured the alignment to 1 decimal place with use of computer software. Power analysis showed that 41 knees were required in each group.

RESULTS

There were no complications as a result of the use of the accelerometer-based portable navigation system. Postoperative radiographs were obtained in 45 patients from each group. There were no significant differences in sex, age, height, body weight, body mass index, preoperative femorotibial angle, and operative time between groups. The absolute differences of the femoral prosthesis (p = 0.01), tibial prosthesis (p < 0.01), and hip-knee-ankle angle (p < 0.01) from a neutral mechanical axis were less in the navigation group compared with those in the conventional group. Alignment outliers (>2° away from the neutral mechanical axis) of the tibial prosthesis and hip-knee-ankle angle were less in the navigation group (9% and 27%, respectively) compared with those in the conventional group (31% and 49%; p = 0.01 and p = 0.04, respectively).

CONCLUSIONS

To our knowledge, this is the first multicenter prospective RCT to evaluate an accelerometer-based portable navigation system. An accelerometer-based portable navigation system provides more accurate prosthetic and limb alignment in the coronal plane than conventional techniques, without extended operative time or an increased rate of complications. The results of this study may help orthopaedic surgeons decide whether or not to use an accelerometer-based portable navigation system.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Are There Differences in Accuracy or Outcomes Scores Among Navigated, Robotic, Patient-specific Instruments or Standard Cutting Guides in TKA? A Network Meta-analysis

BACKGROUND

Several kinds of cutting guides, including patient-specific instrumentation, navigation, standard cutting guides, accelerometer-based navigation, and robotic guidance, are available to restore a planned alignment during TKA. No previous study has simultaneously compared all of these devices; a network meta-analysis is an especially appealing method because it allows comparisons across approaches that were not compared head-to-head in individual randomized controlled trials.

QUESTIONS/PURPOSES

We performed a network meta-analysis to determine whether novel approaches to achieving implant alignment, such as patient-specific instrumentation, navigation, accelerometer-based navigation, and robotic guidance, provide any advantage over standard cutting guides in terms of: (1) hip-knee-ankle (HKA) alignment outliers greater than ± 3°, (2) outcome scores (1989 - Knee Society Score and WOMAC score) measured 6 months after surgery, or (3) femoral and tibial implant malalignment (greater than ± 3°), taken separately, in the frontal and sagittal plane, as well as other secondary outcomes including validated outcome scores 1 and 2 years after surgery.

METHODS

In our network meta-analysis, we included randomized controlled trials comparing the different cutting guides by using at least one of the previously specified criteria, without limitation on language or date of publication. We searched electronic databases, major orthopaedic journals, proceedings of major orthopaedic meetings, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform until October 1, 2018. This led to the inclusion of 90 randomized controlled trials involving 9389 patients (mean age 68.8 years) with 10,336 TKAs. Two reviewers independently selected trials and extracted data. The primary outcomes were the proportion patients with malalignment of the HKA angle (defined as HKA > 3° from neutral) and the Knee Society Score and WOMAC scores at 6 months postoperatively. We combined direct and indirect comparisons using a Bayesian network meta-analysis framework to assess and compare the effect of different cutting guides on outcomes. Bayesian estimates are based on the posterior distribution of an endpoint and are called credible intervals. Usually the 95% credible interval, corresponding to a posterior probability of 0.95 that the endpoint lies in the interval, is computed. Unlike the frequentist approach, the Bayesian approach does not allow the calculation of the p value.

RESULTS

The proportion of HKA outliers was lower with navigation than with patient-specific instrumentation (risk ratio 0.46 [95% credible interval (CI) 0.34 to 0.63]) and standard cutting guides (risk ratio 0.45 [95% CI 0.37 to 0.53]); however, this corresponded to an actual difference of only 12% of patients for navigation versus 21% of patients for patient-specific instrumentation, and 12% of patients for navigation versus 25% for standard cutting guides. We found no differences for other comparisons between different cutting guides, including robotics and the accelerometer. We found no differences in the Knee Society Score or WOMAC score between the different cutting guides at 6 months. Regarding secondary outcomes, navigation reduced the risk of frontal and sagittal malalignments for femoral and tibial components compared with the standard cutting guides, but none of the other cutting guides showed superiority for the other secondary outcomes.

CONCLUSIONS

Navigation resulted in approximately 10% fewer patients having HKA outliers of more than 3°, without any corresponding improvement in validated outcomes scores. It is unknown whether this incremental reduction in the proportion of patients who have alignment outside a window that itself has been called into question will justify the increased costs and surgical time associated with the approach. We believe that until or unless these new approaches either (1) convincingly demonstrate superior survivorship, or (2) convincingly demonstrate superior outcomes, surgeons and hospitals should not use these approaches since they add cost, have a learning curve (during which some patients may be harmed), and have the risks associated with uncertainty of novel surgical approaches.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Improved implant alignment accuracy with an accelerometer-based portable navigation system in medial unicompartmental knee arthroplasty

PURPOSE

This study aimed to examine the accuracy of tibial implant alignment using an accelerometer-based portable navigation system in unicompartmental knee arthroplasty (UKA).

METHODS

This retrospective matched case-control study reviewed 51 UKAs performed using an accelerometer-based portable navigation system, matched with 51 UKAs performed using conventional extramedullary rods. Coronal alignment and posterior slope of the tibial implant were measured on postoperative radiographs, and differences from preoperative planning were examined. Outliers and accuracy of tibial implant alignment were compared between the portable navigation and conventional groups using Fisher's exact test and Mann-Whitney U test, respectively.

RESULTS

In the portable navigation group, 100% of the implants were aligned within 3.0° of both target coronal and sagittal implant alignment. In the conventional group, 76.5% and 88.2% of the implants were within 3.0° of both target coronal and sagittal implant alignment. Statistical analysis revealed that outliers of coronal and sagittal alignment were significantly less in the portable navigation group than in the conventional group (P < 0.05). In addition, the absolute value difference between postoperative measurement and preoperative planning of both coronal and sagittal alignment was significantly smaller in the portable navigation group than in the conventional group (P < 0.05).

CONCLUSION

The portable navigation system improved the accuracy of tibial implant alignment in UKA. We found that 100% of the implants were aligned within 3.0° of both target coronal and sagittal implant alignment. The portable navigation system decreased the outliers of tibial coronal and sagittal alignment.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

The use of accelerometer-based navigation for coronal TKA alignment: a prospective, single surgeon comparative study

INTRODUCTION

There is the need for a device that can be used to accurately position components during total knee arthroplasty (TKA) with minimal impact on procedure time, workflow and cost. This study aimed to investigate the accuracy and time efficiency of a novel, accelerometer-based navigation system (ABN).

METHODS

This prospective, single surgeon study of patients undergoing TKA for osteoarthritis over a 5 year period involved a total of 138 patients: 110 using the ABN system and 28 without. The ABN system consists of two coupled inertial pods that are secured to resection guides, providing a body-fixed 3D coordinate system for limb segments. Post-operative coronal alignment was measured from standardised long-leg AP radiographs. Deviation of the femur and tibia from the neutral coronal mechanical axis was recorded. Intra-observer repeatability was performed on three independent blinded data sets. The BMI and the surgical time (skin to skin) were recorded for all patients.

RESULTS

The mean BMI was 34 in the ABN group and 33 in the control group (p = 0.92). The skin-to-skin time was also similar between the groups; 105 min in the navigation group and 100 min in the control group (p = 0.297). The use of navigation resulted in significantly fewer outliers as defined by < 3º deviation from the target angle. 3 of 110 navigated patients recorded an AP femur angle of more than 3º from the target of 90º, where 5 of 28 control patients fell outside of the ± 3º window (p = 0.009, Fig. 1).

CONCLUSION

The use of the ABN system significantly improved accuracy of implant position and alignment without increasing surgical time.

Handheld, accelerometer-based navigation versus conventional instrumentation in total knee arthroplasty: a meta-analysis

BACKGROUND

Precise and accurate alignments in total knee arthroplasty are important predictors for survivorship and functional outcomes. We aim to compare accelerometer-based navigation (ABN) to conventional instrumentation (CONV), patient-specific instrumentation (PSI) and computer-assisted surgery (CAS) in published literature.

METHODS

A systematic search of publications from databases (MEDLINE, EMBASE and Cochrane) was obtained from inception to 15 August 2018. A random-effects meta-analysis was used to pool odd ratios for outliers greater than 3° for the hip-knee-ankle, coronal and sagittal femoral and tibial angles (CFA, CTA, SFA, STA). Secondary outcomes included procedural characteristics and functional outcomes.

RESULTS

Thirteen studies, involving 1566 patients, met inclusion that compared ABN (50.2%) to CONV (49.8%) and five comparing ABN to CAS/PSI. The pooled odds ratios for percent outliers of greater than 3° from the mechanical axis for the hip-knee-ankle (relative risk 0.58, P = <0.05) and CFA (relative risk 0.42, P = 0.02) was significantly lower for ABN compared to CONV. The pooled odds ratios for CTA, SFA and STA were not significantly different. No differences were identified in comparison to PSI/CAS. There was no statistically significant difference in procedural characteristics and functional outcomes.

CONCLUSIONS

The use ABN in total knee arthroplasty is a successful method of increased precision and accuracy for the restoration of the mechanical axis. In addition, there is no significant compromise in procedural or functional outcomes.

Comparison of a novel handheld accelerometer-based navigation system and conventional instrument for performing distal femoral resection in total knee arthroplasty: a randomized controlled trial

Background

This prospective study aimed to compare the efficacy of a novel, hand-held, accelerometer-based navigation system (i-JOIN knee navigation system) for distal femoral resection in total knee arthroplasty (TKA) with conventional instrument.

Methods

A multi-center, double-blinded, randomized controlled trial (RCT) was conducted. A total of 79 consecutive patients scheduled for primary TKA were enrolled and divided into navigation group (39 patients) and conventional group (40 patients). Post-operative mechanical and component position were evaluated through full-leg weight bearing X-ray. Pre-operatively and 1 week post-operatively, adverse events were recorded. Intraoperative surgical time and blood loss were also recorded.

Results

The mean outlier of 180° neutral mechanical axis was 1.60° (SD 1.11°) in navigation group and 2.30° (SD 2.06°) in conventional group (P=0.0917). Thirty-eight patients (97.4%) in navigation group and 35 patients (87.5%) in conventional group had an alignment which was ≤3°away from the neutral mechanical axis (P=0.2007). α angle between the navigation group and conventional group was not statistically different (89.81° vs. 89.76°, P>0.05), as well as adverse events rate post-operatively. The operative time of navigation group was significantly longer than that of control group (114.54±35.34 vs. 100.33±28.38 min, P=0.0493), whereas the intraoperative blood loss was not significantly different.

Conclusions

i-JOIN knee navigation system had equivalent results for distal femoral resection in TKA compared with the conventional technique.

Does Accelerometer-based Navigation Have Any Clinical Benefit Compared with Conventional TKA? A Systematic Review

BACKGROUND

Accelerometer-based navigation is a handheld navigation tool that was introduced to offer a simpler technique compared with more-cumbersome computer-assisted surgery (CAS). Considering the increasing number of adopters, it seems important to evaluate the potential clinical benefits of this technology compared with conventional TKA.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) Is accelerometer-based navigation more accurate than conventional TKA? (2) Does accelerometer-based navigation provide better functional outcome than conventional TKA? (3) Does accelerometer-based navigation increase surgical time or decrease the risk of complications or reoperations compared with conventional TKA?

METHODS

This systematic review included all comparative prospective and retrospective studies published in the MEDLINE/PubMed and Cochrane libraries over the last 10 years. Inclusion criteria were all studies in English that compared accelerometer-based navigation with conventional TKA. Eleven studies met these criteria with 621 knees in accelerometer-based navigation group and 677 knees in conventional TKA group. Results related to alignment, objective and subjective functional scores, duration of surgery, complications and reoperations were extracted and compared between accelerometer-based-navigation and conventional TKA. Methodological quality was assessed using Methodological Index for Non-Randomized Studies (MINORS) tool (for nonrandomized control trials) and Cochrane Risk of Bias (for randomized control trials (RCTs). All studies with fair or better quality were included. Four RCTs and six nonrandomized studies comparing accelerometer-based navigation to conventional TKA were found.

RESULTS

Inconsistent evidence on mechanical axis alignment was found, with five of nine studies slightly favoring the accelerometer-based navigation group, and the other four showing no differences between the groups. Only two of eight studies favored accelerometer-based navigation in terms of tibial component alignment in the coronal plane; the other six found no between-group differences. Similarly, mixed results were found regarding other metrics related to component alignment; a minority of studies favored accelerometer-based navigation by a small margin, and most studies found no between-group differences. Only three studies evaluated functional outcome and none of them showed a difference in range of motion or patient-reported outcomes. Most studies, six of seven, found no between-group differences concerning surgical time; one study demonstrated a slight increase in time with accelerometer-based navigation. There were no between-group differences in terms of the risk of complications, which generally were uncommon in both groups, and no reoperations or revisions were reported in either group.

CONCLUSIONS

We found conflicting evidence about whether accelerometer-based navigation reduces the number of coronal-plane outliers or improves alignment to a clinically important degree, and we found no evidence that it improves patient-reported outcomes or reduces the risk of complications or reoperations. Accelerometer-based navigation may increase surgical time. The overall quality of the evidence was low, which suggested that any observed benefits were overestimated. Given the absence of higher-quality evidence demonstrating compelling benefits of this accelerometer-based navigation technology, it should not be widely adopted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparison of the accelerometer-based navigation system with conventional instruments for total knee arthroplasty: a propensity score-matched analysis

Background

The accelerometer-based navigation (ABN) system is an emerging navigation system for total knee arthroplasty (TKA). This study aimed to determine whether the ABN system could improve the accuracy of mechanical alignment, component positioning, and short-term clinical outcomes for TKA when compared to conventional instruments (CON).

Methods

A total of 204 patients were selected and divided into two groups (CON: 135, ABN: 69) after applying the inclusion and exclusion criteria. Then, 1:1 propensity score matching was performed for age, gender, body mass index, hip-knee-ankle angle (HKA), Knee Society Score (KSS), Western Ontario and McMaster Universities (WOMAC) score, and follow-up times. A total of 82 consecutive patients (82 knees) underwent total knee arthroplasty using ABN (n = 41) or CON (n = 41) were enrolled in this study. The postoperative HKA, frontal femoral component (FFC) angle, frontal tibial component (FTC) angle, lateral femoral flexion (LFF) angle, and lateral tibial component (LTC) angle were compared between the two groups to evaluate mechanical alignment and component positioning. Additional clinical parameters, including haemoglobin reduction, the KSS, and the WOMAC score, were assessed at the final follow-up (the mean follow-up period was 20.9 months in the CON group and 21.2 months in the ABN group).

Results

The ABN group had a significantly improved mean absolute deviation of HKA (P = 0.033), FFC (P = 0.004), FTC (P = 0.017), LFF (P = 0.023), and LTC (P = 0.031) compared to those of the CON group. The numbers of FFCs and LTCs within 3° were significantly different (P = 0.021, P = 0.023, respectively) between the two groups. However, no differences in the numbers of FTCs within 3° (P = 0.166) and LFF within 3° (P = 0.556) were found. The ABN group had a significantly higher KS function score (P = 0.032), and the pain and stiffness scores were significantly different (P = 0.034, P = 0.020, respectively) between the two groups. Moreover, the ABN system could reduce hidden blood loss postoperatively. However, no difference was found in the KS knee score and the total WOMAC score between the two groups.

Conclusion

This study demonstrates that ABN system improved TKA mechanical alignment and component positioning and decreased the hidden blood loss postoperatively compared to conventional instruments. However, no significant differences were found in short-term clinical outcomes between ABN and conventional instruments at the final follow-up. However, whether this system contributes to revision rates and long-term clinical outcomes requires further study.

No definite advantage of a portable accelerometer-based navigation system over conventional technique in total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Precise implant alignment is a crucial prognostic factor in total knee arthroplasty (TKA). Portable navigation systems (PN-TKA) were reported to be better than the conventional technique (CON-TKA). We hypothesized that PN-TKA offered greater radiologic precision than CON-TKA in mechanically aligning components. We investigated whether (1) it improved global mechanical alignment, and (2) optimized component placement with respect to the tibial and femoral mechanical axes.

PATIENTS AND METHODS

A systematic literature review compared PN-TKA versus CON-TKA. PubMed, Web of Science and Cochrane Library search retrieved ten studies. Their data were pooled using RevMan 5.3. Odds ratios (OR) for dichotomous data were calculated with 95% confidence intervals (CIs) for each outcome. Statistical heterogeneity was assessed as I² using a standard χ² test. I²>50% denoted significant heterogeneity requiring a random effects model; otherwise, a fixed effects model was applied.

RESULTS

There were significantly fewer outliers for mechanical axis (I²=24%, OR=0.62, 95% CI=0.42-0.91, p=0.02) and coronal femoral component angle (I²=58%, OR=0.31, 95% CI=0.13-0.73, p=0.007) using PN-TKA; however, no significant difference was observed for coronal tibial component angle outliers (I²=0%, OR=0.66, 95% CI=0.38-1.15, p=0.14).

DISCUSSION

Although PN-TKA appeared to improve global alignment, it had no effect on coronal tibial alignment, which is a key factor in predicting the long-term success of component fixation. There thus appeared to be no definite advantage of PN-TKA over CON-TKA.

LEVEL OF EVIDENCE

III.

An accelerometer-based portable navigation system improved prosthetic alignment after total knee arthroplasty in 3D measurements

PURPOSE

This study aimed to compare prosthetic alignment using three-dimensional (3D) measurements following total knee arthroplasty (TKA) performed using an accelerometer-based portable navigation system (KneeAlign2) versus the conventional technique.

METHODS

A total of 159 patients who had primary osteoarthritis of the knee with varus deformity underwent TKA. The KneeAlign2 system was used for distal femoral resection and tibial resection in 78 knees, and the conventional instrumentation (intramedullary for the femur and extramedullary for the tibia) was used in 81 knees. 3D computed tomography (CT) scans of the whole leg were taken after TKA. Femoral and tibial prosthetic alignments in the coronal, sagittal, and axial planes were measured using computer software. The operation time and estimated blood loss were calculated. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were evaluated using the contrast-enhanced multi-detector row CT at 1 week after TKA.

RESULTS

In the femoral coronal plane, the mean and standard deviation of prosthetic alignment from neutral alignment were 1.2° [95% confidence interval (CI) 1.0°-1.4°) in the navigation group and 1.6° (95% CI 1.3°-2.0°) in the conventional group (p = 0.03). The femoral component outliers (> 3° away from the goal alignment) using the navigation system and the conventional technique were 3 and 15%, respectively, in the coronal plane (p < 0.01), and 15 and 43%, respectively, in the sagittal plane (p < 0.01). The outliers in tibial coronal and tibial sagittal planes were not statistically different between the two groups. There were no statistically significant differences between the two groups in operation time, blood loss, DVT, and PE.

CONCLUSION

Using an accelerometer-based portable navigation system decreased the outliers of prosthetic alignment in femoral coronal and sagittal planes, and did not increase the complications such as operation time, blood loss, DVT, and PE. To our knowledge, this study is the first to investigate the usefulness of an accelerometer-based portable navigation system using the validated 3D measurement.

LEVEL OF EVIDENCE

III.

Two-dimensional measurement misidentifies alignment outliers in total knee arthroplasty: a comparison of two- and three-dimensional measurements

PURPOSE

Two-dimensional (2D) and three-dimensional (3D) measurements of prosthetic alignment and "outliers" after total knee arthroplasty (TKA) might not necessarily be comparable. The aim of this study was to compare the use of 2D and 3D measurements in the identification of prosthetic alignment and outliers after TKA.

METHODS

This cross-sectional study included 159 consecutive TKAs. All patients underwent plain radiography, fluoroscopy-guided radiography, and computed tomography after TKA. The same baseline was used for 2D and 3D measurements. The reliability of prosthetic alignment and outlier identification (> 3° from neutral alignment) was compared between the 2D and 3D measurements.

RESULTS

The mean prosthetic alignment and rate of outliers were not significantly different the between 2D and 3D measurements. The inter- and intra-observer reliabilities were higher for the 3D measurements than for the 2D measurements. The agreement between 2D and 3D measurements in outlier identification was poor, except for femoral coronal alignment. Cohen's κ coefficients were 0.19 in femoral sagittal (poor), 0.02 in tibial coronal (poor), and 0.10 in tibial sagittal (poor) on plain radiography. The values were 0.23 in tibial coronal (poor) and 0.002 in tibial sagittal (poor) on fluoroscopy-guided radiography.

CONCLUSIONS

The agreement between 2D and 3D measurements in the identification of outliers was poor, even on fluoroscopy-guided radiography. Since 2D measurements have an inherent risk of misidentifying alignment outliers, this finding is clinically relevant. To properly analyze the correlation between outliers and clinical results, such as longevity, patient satisfaction, and patient-reported outcome, 3D measurements for prosthetic alignment are desirable.

LEVEL OF EVIDENCE

III.