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Kaptein BL, Pijls B, Koster L, Kärrholm J, Hull M, Niesen A, Heesterbeek P, Callary S, Teeter M, Gascoyne T, Röhrl SM, Flivik G, Bragonzoni L, Laende E, Sandberg O, Solomon LB, Nelissen R, Stilling M. Guideline for RSA and CT-RSA implant migration measurements: an update of standardizations and recommendations. Acta Orthop 2024; 95:256-267. [PMID: 38819193 DOI: 10.2340/17453674.2024.40709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Indexed: 06/01/2024] Open
Abstract
Opening remarks: These guidelines are the result of discussions within a diverse group of RSA researchers. They were approved in December 2023 by the board and selected members of the International Radiostereometry Society to update the guidelines by Valstar et al. [1]. By adhering to these guidelines, RSA studies will become more transparent and consistent in execution, presentation, reporting, and interpretation. Both authors and reviewers of scientific papers using RSA may use these guidelines, summarized in the Checklist, as a reference. Deviations from these guidelines should have the underlying rationale stated.
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Affiliation(s)
- Bart L Kaptein
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Bart Pijls
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lennard Koster
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan Kärrholm
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maury Hull
- Orthopedic Surgery Department, University of California, Davis, United States
| | - Abby Niesen
- Orthopedic Surgery Department, University of California, Davis, United States
| | - Petra Heesterbeek
- Orthopedic Research Department, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Stuart Callary
- Department of Orthopedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Matthew Teeter
- Department of Medical Biophysics, Western University, London, Canada
| | | | - Stephan M Röhrl
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Gunnar Flivik
- Department of Orthopedics, Skane University Hospital, Lund, Sweden
| | | | - Elise Laende
- Department of Surgery, Dalhousie University, Halifax, Canada
| | | | - L Bogdan Solomon
- Department of Orthopedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Rob Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maiken Stilling
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
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Sheridan GA, Abdelmalek M, Howard LC, Neufeld ME, Masri BA, Garbuz DS. Navigated Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Prospective Randomized Controlled Trials. J Orthop 2024; 50:99-110. [PMID: 38187368 PMCID: PMC10770435 DOI: 10.1016/j.jor.2023.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024] Open
Abstract
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.
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He L, Wu C, Lang J, Chen L, Wu P. The main cause of tibial prosthesis malalignment after total knee arthroplasty in Southern Chinese population. Heliyon 2024; 10:e25447. [PMID: 38322978 PMCID: PMC10844569 DOI: 10.1016/j.heliyon.2024.e25447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives This study aimed to determine the occurrence rate of malalignment of tibial prosthesis and explore the influencing factors. Methods 296 patients from Southern China who underwent total knee arthroplasty (TKA) were selected as the research objects. Their general demographic data were recorded. The tibial bowing angle (TBA), tibial length, medial proximal tibial angle (MPTA), tibial plateau shift angle (TPSA), tibial bone loss, lateral distal tibial angle, and overall width of tibial plateau and widths of medial and lateral tibial plateau were measured before TKA. The tibial component coronal alignment angle (TCCA) was measured after the operation. Malalignment of the tibial prosthesis was defined as TCCA <87° or TCCA >93°. Tibial bowing was indicated by TBA >2°, and lateral bowing was recorded as +. The correlations of TCCA with demographic data and pre-operation imaging measurement parameters were statistically analyzed. Results Bivariate correlation analysis revealed negative correlations between TCCA and TBA (r = -0.602, P < 0.001) and TPSA (r = -0.304, P < 0.001), and a positive correlation with MPTA (r = -0.318, P < 0.001). Multivariate linear regression analysis demonstrated a significant negative correlation between TCCA and TBA (P < 0.001). The occurrence rate of malalignment of tibial prosthesis was 12.37 %. The occurrence rates of malalignment were 22.54 % in the tibial bowing group and 6.87 % in the non-tibial bowing group, showing statistical differences (P < 0.001). Conclusion The malalignment rate of tibial prosthesis among Southern Chinese patients is relatively high, possibly attributed to the tibial anatomy anomalies, particularly the tibial bowing. The entry point should be determined based on tibial morphology.
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Affiliation(s)
- Lili He
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Congcong Wu
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Junzhe Lang
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Lei Chen
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Peng Wu
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
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Perelli S, Costa GG, Russo A, Hinarejos P, Torres-Claramunt R, Sanchez-Soler J, Morales-Avalos R, Monllau JC. The distal tibiofibular syndesmosis is a reliable landmark for 3° varus tibial resection in total knee arthroplasty: a radiological evaluation on 1296 cases. Arch Orthop Trauma Surg 2024; 144:879-885. [PMID: 37864591 DOI: 10.1007/s00402-023-05099-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/30/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the reproducibility and the accuracy of distal tibiofibular syndesmosis (DTFS) as landmark to perform controlled varus tibial resections during total knee arthroplasty (TKA). The hypothesis was that DTFS can be used to perform an accurate 3° varus tibial cut. METHODS A retrospective analysis on a consecutive series of standard weightbearing full-length anteroposterior views of the lower limbs radiographic images was conducted. For each radiograph, the hip-knee-ankle (HKA) angle, the angle between the tibial mechanical axis and the line connecting the centre of the tibial spines and the DTFS (tibiofibular angle, TFA) and the medial proximal tibial angle (MPTA) were calculated. Each measurement was carried out twice by three independent observers, and intra- and inter-observer measurement reliability were assessed using the intraclass correlation coefficient (ICC) analysis. RESULTS A total of 1296 lower limbs were analysed from a series of 648 weightbearing full-length anteroposterior radiographs. The ICC were > 90% for all measurements. The mean TFA value was 2.94 ± 0.68 (range 2.38-3.51). No differences were detected comparing the mean TFA value on the right and left limb (p = 0.795) as well as comparing the values in male and female patients (p = 0.691). Linear regression analysis did not find statistically significant correlation between TFA and MPTA, or TFA and HKA angles, respectively. CONCLUSION The distal tibiofibular syndesmosis is a reliable and easy reproducible radiographic landmark that can be used when planning a 3° varus tibial cut. Future studies are needed to confirm the validity of this method also in clinical settings. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Simone Perelli
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Giuseppe Gianluca Costa
- Orthopaedic and Traumatologic Unit, Umberto I Hospital, Azienda Sanitaria Provinciale di Enna, C.da Ferrante, 94100, Enna, Italy.
| | - Arcangelo Russo
- Orthopaedic and Traumatologic Unit, Umberto I Hospital, Azienda Sanitaria Provinciale di Enna, C.da Ferrante, 94100, Enna, Italy
| | - Pedro Hinarejos
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Raul Torres-Claramunt
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Juan Sanchez-Soler
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Rodolfo Morales-Avalos
- Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autonoma de Nuevo León, Monterrey, Mexico
| | - Juan Carlos Monllau
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
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Wautier D, Thienpont E. Tibial implant design in primary TKA: retrospective comparison of two designs for the occurrence of radiolucent lines and aseptic loosening. Arch Orthop Trauma Surg 2024; 144:323-332. [PMID: 37733127 DOI: 10.1007/s00402-023-05030-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION The purpose of this retrospective study was to study the effect of tibial implant design on the occurrence of radiolucent lines (RLLs) and aseptic loosening (AL) by comparing two different total knee arthroplasty (TKA) designs. MATERIALS AND METHODS Two types of total knee arthroplasty, different for tibial shape, size and keel design were compared, 255 for the first and 774 for the second. The occurrence of RLLs and radiological signs of micro- and macro-mobility and aseptic loosening was analyzed. Demographic data were compared, as well as the type and rate of RLLs, occurrence of aseptic loosening and the presence of potential risk factors. RESULTS The first implant design is morphometric and has a squarer keel than the second implant TKA. The overall rate of RLLs was similar (21% vs 23%), despite of a significantly lower rates of radiological signs of macro-mobility of the tibial component with the first implant (2% vs 17%). Survivorship of both designs was overall comparable (99.6% vs 98.8 %) the first implant group had more potential risk factors for poor bone quality than the second group (p < 0.05). CONCLUSION A morphometric design is more anatomic and offers better bone coverage of the epiphyseal tibial surface. RLLs, as a sign of implant micro-mobility, were equally present in both designs. Radiological signs of macro-mobility at the metaphysis were less frequently observed in squared keel design. The morphometric implant did not show improved survivorship compared with a symmetric implant. LEVEL OF EVIDENCE III.
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Affiliation(s)
- D Wautier
- Department of Orthopedic Surgery, CHU UCL Namur, Godinne, Avenue Docteur Gaston Therasse 1, 5530, Yvoir, Belgium.
| | - E Thienpont
- Department of Orthopedic Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Lee BS, Bin SI, Kim JM, Kim TH, Oh SM. Twenty-year survivorship cohort study of total knee arthroplasty in Asian patient using a single posterior-stabilized implant performed by a single surgeon. Orthop Traumatol Surg Res 2023; 109:103644. [PMID: 37331652 DOI: 10.1016/j.otsr.2023.103644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 05/05/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION As life expectancy has improved, the potential number of revision candidates is also expected to increase among patients who have undergone a total knee arthroplasty (TKA). The longevity of modern posterior stabilized knee prostheses after 20 years of use has not been well documented, especially in Asian populations that require a deeper flexion range due to a floor-based lifestyle. HYPOTHESIS Firstly, the implant longevity regarding mechanical failures such as aseptic loosening and polyethylene (PE) wear would vary over a longer follow-up depending on the age groups; and secondly there would be unique risk factors for revision surgery in an Asian TKA cohort. MATERIAL AND METHODS We conducted this age-stratified survival analysis in a consecutive series of 368 NexGen Legacy Posterior Stabilized (LPS) TKAs performed by a single surgeon. These cases were divided into four age groups (< 60 years, early 60s, late 60s, and ≥ 70 years). The implant longevity against aseptic mechanical failures was calculated using the Kaplan-Meier method. The revision surgery risk was evaluated using postoperative factors including a deep flexion capability (> 135̊), and postoperative mechanical alignments. RESULTS Overall survivorship was significantly lower in the youngest groups than other groups (Log-rank test, p=0.001). The cumulative 20-year implant longevity was more than 95% in the two oldest groups, but less than 60% in the youngest group. It was notable that the post-TKA implant longevity was not apparent up to 10 years between the age groups (p=0.073∼0.458). Aseptic loosening was observed with an earlier onset (3.1 to 18.9 years) trend than PE wear (9.8∼17.9 years), with most cases arising in the youngest groups. Flexion limitation and varus alignment were significant risks to aseptic loosening and PE wear (Cox proportional hazard regression: p=0.001 and 0.045, respectively). DISCUSSION A younger age (< 60 years), inability of postoperative deep flexion, and varus alignment were significant risk factors for aseptic loosening and PE wear after modern PS design in this Asian cohort. The difference in postoperative longevity affected by these factors was not obvious during the first 10 years but emerged over a second decade. LEVEL OF PROOF III; retrospective cohort study.
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Affiliation(s)
- Bum-Sik Lee
- College of Medicine, University of Ulsan, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, Unjeong Inbone Hospital, 31, Cheongam-ro 17-gil, Paju-si, 10892 Gyeonggi-do, Republic of Korea.
| | - Jong-Min Kim
- College of Medicine, University of Ulsan, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Tae-Hyuk Kim
- Gimpo Woori Hospital, 11, Gamam-ro, Gimpo-si, Gyeonggi-do, Republic of Korea
| | - Sung-Mok Oh
- Department of Orthopedic Surgery, Barun Hospital, 145, Yeouidaebang-ro, Yeongdeungpo-gu, 07392 Seoul, Republic of Korea
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Niesen AE, Hull ML. State of the Art in Radiostereometric Analysis for Tibial Baseplate Migration and Future Research Directions. J Biomech Eng 2023; 145:120801. [PMID: 37792485 DOI: 10.1115/1.4063626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/25/2023] [Indexed: 10/06/2023]
Abstract
Radiostereometric analysis (RSA) measures movement (migration) of a baseplate relative to the underlying tibia after total knee arthroplasty (TKA) and has been used extensively to evaluate safety of new implant designs and/or surgical techniques regarding baseplate loosening. Because RSA is a complex methodology which involves various choices that researchers make, including whether to use marker-based or model-based methods, which migration metric to report, how to relate short-term migrations to long-term risk, and how these choices impact error, the objectives of this review were to: (1) lay out a comprehensive structure illustrating the multiple components/considerations for RSA and their interrelations, (2) review components of the structure using the latest RSA literature, and (3) use the preceding review as a context for identifying future areas of study. The components to be reviewed were structured using the following topics: type of RSA, migration metrics, sources of error, studies/reports of error, stability limits, and studies of error in stability limits. Based on the current RSA literature and knowledge gaps which exist, the following future research directions were identified: (1) revising the ISO standard to require reporting of clinical measurement error (bias) and recommending use of a local baseplate coordinate system, (2) identifying the migration metric and associated threshold most predictive of baseplate loosening for individual patients, (3) creating a method for data sharing to improve individual patient diagnostics, and (4) determining an appropriate stability limit for model-based RSA for group stability and individual patient diagnostics.
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Affiliation(s)
- Abigail E Niesen
- Department of Biomedical Engineering, University of California, Davis, One Shields Avenue, Davis, CA 95616
| | - Maury L Hull
- Department of Biomedical Engineering, University of California, Davis, One Shields Avenue, Davis, CA 95616; Department of Mechanical Engineering, University of California, Davis, One Shields Avenue, Davis, CA 95616; Department of Orthopaedic Surgery, University of California Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA 95817
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Desai SS, Kunes JA, Held MB, Ren M, deMeireles AJ, Geller JA, Shah RP, Cooper HJ. A comparison of pin site complications between large and small pin diameters in robotic-assisted total knee arthroplasty. J Exp Orthop 2023; 10:22. [PMID: 36897468 PMCID: PMC10006377 DOI: 10.1186/s40634-023-00584-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/04/2023] [Indexed: 03/11/2023] Open
Abstract
PURPOSE Robotic-assisted total knee arthroplasty typically necessitates use of tracking pins, which can vary in diameter. Complications such as infections and fractures at the pin-site have been observed, but clarification of the effect of pin diameter on complication is needed. The aim of this study is to compare the pin-related complication rates following robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm diameter pins. METHODS In this retrospective cohort study, 90-day pin-site complication rates after robotic-assisted total knee arthroplasty were compared between 4.5 mm diameter and 3.2 mm diameter groups. In total, 367 patients were included: 177 with large pin diameter and 190 with small pin diameter. All four pin sites were evaluated using postoperative radiographs. Cases without orthogonal views or visualization of all four pin tracts were noted. Multivariate logistic regression was used to control for age, which differed between the two cohorts. RESULTS The rate of pin-site complications was 5.6% in the large pin diameter cohort and 2.6% in the small pin diameter cohort, with no statistically significant difference between the groups. The adjusted odds ratio for complications in small compared to large diameter group was 0.48, with a p-value of 0.18. The most common pin-site complication was infection/persistent drainage, found in 1.9% of patients, followed by intraoperative fracture of the second cortex in 1.4%. Intraoperative fracture could not be ruled out in 96 cases due to inadequate radiographic visualization of all pin sites. There was one postoperative pin-site fracture in the large diameter cohort, which required operative fixation. CONCLUSION This study demonstrates no statistically significant difference in pin-site complication rates after robotic-assisted total knee arthroplasty between 4.5 mm and 3.2 mm pin diameter cohorts, although there was a trend towards increased intraoperative and postoperative pin-site fractures in the 4.5 mm group.
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Affiliation(s)
- Sohil S Desai
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA.
| | - Jennifer A Kunes
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - Michael B Held
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - Mark Ren
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - Alirio J deMeireles
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
| | - H John Cooper
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 W 168th St, PH 11, NY, 10032, New York, USA
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Effect of total knee arthroplasty for valgus knee correction on clinical outcome and patellar position. INTERNATIONAL ORTHOPAEDICS 2023; 47:735-743. [PMID: 36645475 PMCID: PMC9931837 DOI: 10.1007/s00264-023-05689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/01/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose was to investigate the effect of different degrees of valgus deformity correction on patellar position and clinical outcome in patients with valgus knees after total knee arthroplasty (TKA). METHODS We retrospectively analyzed and followed 118 patients with valgus knees. Based on the post-operative hip-knee-ankle (HKA), patients were divided into three groups: neutral (±3°), mild (3-6°), and severe (> 6°). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), and Knee Society Score (KSS) were used to evaluate post-operative clinical efficacy. Also, the patellar tilt angle (ε-angle), congruence angle (θ-angle), and Insall-Salvati index (ISI) were used to represent the patellar position. Post-operative observation indicators included HKA, angle of the femur (α-angle), tibial angle (β-angle), femoral component flexion angle (γ-angle), and tibial component posterior slope angle (δ-angle). RESULTS All patients showed significant improvements in HKA, ROM, WOMAC, and KSS after operation (P < 0.001). Regarding patellar position, the ISI values decreased to varying degrees (P < 0.05). The patellar tilt angle was significantly increased in the severe valgus group compared to that in the mild valgus and neutral groups (P < 0.001). Univariate analysis showed that the degree of post-operative residual valgus was significantly affected by WOMAC, KSS, α-, ε-, and θ-angles. CONCLUSION Minor valgus undercorrection did not affect the short-term outcome after TKA; however, when the residual valgus angle was > 6°, the post-operative scores were significantly reduced. Inadequate valgus correction does not result in significant changes in patellar height but may increase the risk of poor patellar tracking.
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Cao H, Sesselmann S, Xu J, Seehaus F, Forst R. How Do Classic (Static) RSA and Patient Motion Artifacts Affect the Assessment of Migration of a TKA Tibial Component? An In Vitro Study. Clin Orthop Relat Res 2023; 481:400-412. [PMID: 36398327 PMCID: PMC9831201 DOI: 10.1097/corr.0000000000002453] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Classic (static) Roentgen stereophotogrammetric analysis (RSA) is the current gold standard to assess, in vivo, the migration of total joint arthroplasty components. To prevent potential patient motion artifacts during the acquisition of paired radiostereometric images, images must be taken by simultaneously firing both X-ray tubes. However, the influence of nonsynchronized RSA paired images or patient motion artifacts on the precision of RSA and the assessment of implant migration is not well understood. QUESTIONS/PURPOSES We assessed (1) the effect of possible patient motion on the precision of RSA and (2) apparent differences in implant migration among axes (in-plane and out-of-plane translations and in-plane and out-of-plane rotations) of possible motion artifacts. METHODS Radiographs of two tibial knee arthroplasty components, each fixed in two bone-implant models as a customized phantom, were taken in a uniplanar measurement setup. We evaluated both model-based (implant models from reversed engineering) and marker-based (additional attached implant markers) RSA approaches. Between the simulated reference and follow-up examinations, we used one of the bone-implant models to simulate patient motion and the other to simulate no patient motion in parallel. Two defined protocols were followed for each of the bone-implant models: no-motion and simulated motion protocols. RSA image pairs were analyzed using a model-based RSA software package (MBRSA 4.1, RSA core ). Precision was calculated through repeat examinations, and migration of the two components was assessed for comparison of the components with each other. Measurements were taken along the medial-lateral and posterior-anterior axes for translations and around the cranial-caudal axis for rotations. The maximum total point motion was measured for comparison between the two components. RESULTS The effect of simulated patient motion was generally small, except in the cranial-caudal axis, but the induced imprecision associated with motion was larger in model-based RSA than it was in marker-based RSA. The mean ± standard deviation values of precision in model-based RSA were 0.035 ± 0.015 mm, 0.045 ± 0.014 mm, and 0.049 ± 0.036 mm greater than those in marker-based RSA, in accordance with the simulated motion protocol in translations along the medial-lateral axis (0.018 ± 0.004 mm; p = 0.01), along the posterior-anterior axis (0.018 ± 0.007 mm; p = 0.003), and rotations around the cranial-caudal axis (0.017 ± 0.006 mm; p = 0.02). Apparent differences in implant migration were the greatest for the maximum total point motion. The maximum total point motion increased from 0.038 ± 0.007 mm for the no-motion protocol to 1.684 ± 0.038 mm (p < 0.001) for the simulated motion protocol in marker-based RSA, and from 0.101 ± 0.027 mm for the no-motion protocol to 1.973 ± 0.442 mm (p < 0.001) for the simulated motion protocol in model-based RSA, and was the worst-case scenario regarding patient motion artifacts. CONCLUSION Patient motion exceeding 1 mm or 1° on nonsynchronized RSA images affects measurement errors regarding the detection of migration of a tibial component. In clinical RSA studies, the effect of patient motion on the assessment of implant migration should be of particular concern, even if clinical RSA systems have acceptable precision. Specially trained radiographers are crucial for correctly acquiring radiographs, especially when simultaneous radiography exposures are not electronically automated. In general, RSA requires synchronized image acquisition, and this should be the state-of-the-art. CLINICAL RELEVANCE In clinical RSA studies, precision assessed by repeat examinations may not be reliable using the current standards that are widely used in radiology departments. When assessing implant migration for reliability, comparison of the maximum total point motion between the tested (simulated motion) implant and baseline (no-motion) implant, as in this study, is advocated because of the accurate detection of patient motion artifacts.
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Affiliation(s)
- Han Cao
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Orthopaedic Surgery, Taizhou Second People’s Hospital, Taizhou, PR China
| | - Stefan Sesselmann
- Institute for Medical Technology, Ostbayerische Technische Hochschule Amberg-Weiden, Weiden, Germany
| | - Jing Xu
- Department of Orthopaedic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, PR China
| | - Frank Seehaus
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Orthopaedic and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Raimund Forst
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Femoral bowing affects varus femoral alignment but not patient satisfaction in mechanically aligned total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:89-96. [PMID: 34779926 DOI: 10.1007/s00590-021-03164-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/04/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE This study evaluated whether patients with particular lower limb morphological factors have femoral and tibial component malpositioning during mechanically aligned total knee arthroplasty (TKA) and lower postoperative satisfaction. METHODS This study included 146 knees in 117 Asian patients undergoing TKA for medial osteoarthritis. Preoperative bony morphological factors such as the angle between the femoral mechanical and anatomical axes (MA-AA angle), angle between the anatomical axes of the proximal and distal femur (lateral bowing femoral angle, LBFA), mechanical lateral distal femoral angle, medial proximal tibial angle, and % anatomical axis of the tibia were evaluated, as well as preoperative and 1-year postoperative 2011 Knee Society scores (KSSs). RESULTS MA-AA angle and LBFA were significantly larger in knees with varus femoral component alignment versus neutral alignment. Preoperative MA-AA angle was underestimated in patients with larger MA-AA angle or LBFA, especially by inexperienced surgeons. Tibial morphological factors did not affect tibial component alignment. Changes in 2011 KSSs were similar among groups by lower limb alignment or femoral and tibial component alignment. CONCLUSION Femoral bowing affects varus femoral component alignment by obscuring preoperative planning, but it had little impact on patient satisfaction when mechanical alignment is targeted during TKA.
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12
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Jang SJ, Kunze KN, Brilliant ZR, Henson M, Mayman DJ, Jerabek SA, Vigdorchik JM, Sculco PK. Comparison of tibial alignment parameters based on clinically relevant anatomical landmarks : a deep learning radiological analysis. Bone Jt Open 2022; 3:767-776. [PMID: 36196596 PMCID: PMC9626868 DOI: 10.1302/2633-1462.310.bjo-2022-0082.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AIMS Accurate identification of the ankle joint centre is critical for estimating tibial coronal alignment in total knee arthroplasty (TKA). The purpose of the current study was to leverage artificial intelligence (AI) to determine the accuracy and effect of using different radiological anatomical landmarks to quantify mechanical alignment in relation to a traditionally defined radiological ankle centre. METHODS Patients with full-limb radiographs from the Osteoarthritis Initiative were included. A sub-cohort of 250 radiographs were annotated for landmarks relevant to knee alignment and used to train a deep learning (U-Net) workflow for angle calculation on the entire database. The radiological ankle centre was defined as the midpoint of the superior talus edge/tibial plafond. Knee alignment (hip-knee-ankle angle) was compared against 1) midpoint of the most prominent malleoli points, 2) midpoint of the soft-tissue overlying malleoli, and 3) midpoint of the soft-tissue sulcus above the malleoli. RESULTS A total of 932 bilateral full-limb radiographs (1,864 knees) were measured at a rate of 20.63 seconds/image. The knee alignment using the radiological ankle centre was accurate against ground truth radiologist measurements (inter-class correlation coefficient (ICC) = 0.99 (0.98 to 0.99)). Compared to the radiological ankle centre, the mean midpoint of the malleoli was 2.3 mm (SD 1.3) lateral and 5.2 mm (SD 2.4) distal, shifting alignment by 0.34o (SD 2.4o) valgus, whereas the midpoint of the soft-tissue sulcus was 4.69 mm (SD 3.55) lateral and 32.4 mm (SD 12.4) proximal, shifting alignment by 0.65o (SD 0.55o) valgus. On the intermalleolar line, measuring a point at 46% (SD 2%) of the intermalleolar width from the medial malleoli (2.38 mm medial adjustment from midpoint) resulted in knee alignment identical to using the radiological ankle centre. CONCLUSION The current study leveraged AI to create a consistent and objective model that can estimate patient-specific adjustments necessary for optimal landmark usage in extramedullary and computer-guided navigation for tibial coronal alignment to match radiological planning.Cite this article: Bone Jt Open 2022;3(10):767-776.
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Affiliation(s)
- Seong J. Jang
- Weill Cornell Medical College, New York, New York, USA,Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA,Correspondence should be sent to Seong Jun Jang. E-mail:
| | - Kyle N. Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Zachary R. Brilliant
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA,University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Melissa Henson
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - David J. Mayman
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA,Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Seth A. Jerabek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA,Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Jonathan M. Vigdorchik
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA,Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Peter K. Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA,Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
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13
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Low tibial baseplate migration 1 year after unrestricted kinematically aligned total knee arthroplasty using a medial conforming implant design. Knee Surg Sports Traumatol Arthrosc 2022; 31:1433-1442. [PMID: 36201009 DOI: 10.1007/s00167-022-07171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Varus alignment of the tibial baseplate and limb > 3° might adversely affect baseplate fixation after total knee arthroplasty (TKA), especially for unrestricted kinematically aligned (KA) TKA which aligns a majority of baseplates in varus. The purposes of this study were to determine whether baseplate migration at 1 year (1) was significantly less than a stability limit of 0.5 mm, (2) increased over time, and (3) was related to varus alignment of the baseplate and limb after unrestricted KA TKA. METHODS Thirty-five patients underwent unrestricted KA TKA using a fixed-bearing, cemented, medial conforming tibial insert with posterior cruciate ligament retention. Using model-based radiostereometric analysis, maximum total point motion (MTPM) (i.e., largest displacement on the baseplate) was computed at 6 weeks, 3 months, 6 months, and 1 year postoperatively relative to the day of surgery. Baseplate and limb alignment were measured postoperatively on long-leg CT scanograms. RESULTS At 1 year, mean MTPM of 0.35 mm was significantly less than the 0.5 mm stability limit (p = 0.0002). Mean MTPM did not increase from 6 weeks to 1 year (p = 0.3047). Notably, 89% (31/35) of tibial baseplates and 46% (16/35) of limbs were > 3° varus. Baseplate and limb alignment had no relationship to MTPM at 1 year (|r|≤ 0.173, p ≥ 0.3276). CONCLUSION Low and non-progressive tibial baseplate migration 1 year after unrestricted KA TKA with a medial conforming design should allay any concern that unrestricted KA TKA increases risk of baseplate loosening due to varus alignment of the baseplate and limb. LEVEL OF EVIDENCE Level II, therapeutic prospective cohort study.
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Klasan A, Rainbird S, Peng Y, Holder C, Parkinson B, Young SW, Lewis PL. No Difference in Revision Rate Between Low Viscosity and High Viscosity Cement Used in Primary Total Knee Arthroplasty. J Arthroplasty 2022; 37:2025-2034. [PMID: 35525417 DOI: 10.1016/j.arth.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/08/2022] [Accepted: 04/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Loosening remains one of the most common reasons for revision total knee arthroplasty (TKA). Cement viscosity has a potential role in reducing revision rates for loosening. The aim of this study was to assess the outcome for loosening of the 5 most used cemented knee prostheses by constraint type, based on the cement viscosity type used. METHODS There were 214,708 TKA procedures performed between 1999 and 2020 for a diagnosis of osteoarthritis using the 5 most commonly used minimally stabilized, posterior stabilized, and medial pivot design cemented tibial components. Only procedures with a cemented tibial component were included. Outcomes for two different cement viscosities, 140,060 high viscosity and 74,648 low viscosity cement, were compared for each fixation type within each of the three stability groups. RESULTS There was no difference in a risk of all-cause revision when high viscosity cement was used compared to low viscosity cement for minimally stabilized prostheses (hazards ratio [HR] 1.07 [95% CI 0.99-1.15], P = .09), posterior stabilized prostheses (HR 1.03 [95% CI 0.95-1.11], P = .53), and medial pivot design prostheses (HR 1.06 [95% CI 0.80-1.41], P = .67). No difference was observed between cement viscosity types for any of the prosthesis constraint types when aseptic loosening was assessed. CONCLUSIONS We found no difference in the risk of revision for any reason, or for loosening, with cement viscosity for the most commonly used minimally stabilized, posterior stabilized, and medial pivot TKA. The role of cement viscosity in the risk of TKA revision remains unclear and further research is required. LEVEL OF EVIDENCE Level III Retrospective comparative study.
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Affiliation(s)
- Antonio Klasan
- Kepler University Hospital, Linz, Austria; Johannes Kepler University, Linz, Austria
| | - Sophia Rainbird
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Yi Peng
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Carl Holder
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | | | | | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
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15
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Jenny JY, Baldairon F. The coronal alignment technique impacts deviation from native knee anatomy after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 31:1427-1432. [PMID: 36125511 DOI: 10.1007/s00167-022-07157-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to analyze and quantify the changes in native coronal alignment of a population of TKA patients according to different alignment goals. METHODS Five hundred and twenty TKAs were analyzed. The following angles were measured using an image-free navigation system prior to prosthetic implantation: medial femorotibial mechanical angle without stress and with maximum manual stress to reduce the deformity, medial distal femoral mechanical angle, medial proximal tibial mechanical angle. The native angles were derived from the osteoarthritic knee angles using a validated correction technique, and the overall, femoral and tibial coronal phenotypes were defined. Five different coronal alignment techniques were simulated: mechanical (MA), restricted mechanical (RMA), anatomical (AA), kinematic (KA) and restricted kinematic (RKA). The overall, femoral and tibial coronal phenotypes were compared before and after TKA. The primary endpoint was the binary criterion of whether or not TKA restored the natural overall phenotype. Secondary endpoints were the binary criteria of whether or not the natural femoral and tibial phenotypes were restored by TKA. The rates of restored and non restored phenotypes were compared with a Chi-square test at a 0.05 level of significance, with post hoc tests between all pairs of techniques at a 0.01 level of significance. RESULTS The overall phenotype was restored significantly differently by the five alignment techniques: 15% for MA, 23% for RMA, 2% for AA, 100% for KA and 79% for RKA (p < 0.001). There was a significant difference between each of the technique pairs (p < 0.01 to p < 0.001), except for the mechanical alignment-restricted mechanical alignment pair. The femoral phenotype was restored significantly differently by the five alignment techniques: 37% for MA, 58% for RMA, 19% for AA, 100% for KA and 85% for RKA (p < 0.001). The tibial phenotype was restored significantly differently by the five alignment techniques: 36% for MA, 36% for RMA, 17% for AA, 100% for KA and 88% for RKA (p < 0.001). There was a significant difference between each pair of techniques for both femoral and tibial phenotypes (p < 0.01 to p < 0.001). CONCLUSION Except for the kinematic alignment technique, the various alignment techniques induce significant changes in the pre-arthritic anatomy of the TKA patient. The surgeon must be aware of these modifications. The clinical relevance of this alteration still needs to be defined. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jean-Yves Jenny
- Locomax Unit, University Hospital, 1 avenue Molière, 67200, Strasbourg, France.
| | - Florent Baldairon
- Locomax Unit, University Hospital, 1 avenue Molière, 67200, Strasbourg, France
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Li J, Zhang Y, Gao X, Dou T, Li X. Accelerometer-based navigation vs. conventional techniques for total knee arthroplasty (TKA): a systematic review and meta-analysis of randomized controlled trials. ARTHROPLASTY 2022; 4:35. [PMID: 36050798 PMCID: PMC9438290 DOI: 10.1186/s42836-022-00135-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Seven phenotypes of varus osteoarthritic knees can be identified in the coronal plane. Knee Surg Sports Traumatol Arthrosc 2022; 30:2793-2805. [PMID: 34286347 DOI: 10.1007/s00167-021-06676-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/14/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Recommendations for resecting distal femur and proximal tibia in mechanical and anatomical alignment techniques are standardized. Kinematic alignment propagates individualizing resection planes. Whether significant variation exists, to warrant departure from standardized resection planes, has not been shown thus far in a large cohort of knees and with a wide range of varus deformity. The null hypothesis of this study was that there was no phenotypic variation in varus osteoarthritic knees. The aim of this paper was to determine whether distinct phenotypes could be identified, based on variations in coronal femoral and tibial morphology, which could aid in surgical planning and categorizing varus knees for future studies. METHODS 2129 full-leg weightbearing radiographs were analyzed (1704 preoperative; 425 of contralateral arthritic knee). Measurements made were of HKA (hip-knee-ankle angle), VCA (valgus correction angle), mLDFA (lateral mechanical distal femoral angle), aLDFA (lateral anatomical distal femoral angle), MPTA (medial proximal tibial angle), MNSA (medial neck shaft angle), TAMA (angle between tibial mechanical and anatomical axes), and TPDR (percentage length of tibia proximal to extra-articular deformity). RESULTS Seven distinct types were identified covering 2021 knees, reducible to 4 broad phenotypes: 11% were Type 1 'Neutral' knees showing values close to reported normal knees (mean VCA 5.5°, mLDFA 87°, aLDFA 81°). 38% were Type 2 'Intra-articular varus' with medial intra-articular bone loss (mean mLDFA 90.9°, MPTA 85.4°, VCA of 5.7°). 41% were Type 3 'Extra-articular varus' with extra-articular deformity (EAD). Type 3a had proximal tibial EAD; Type 3b had tibial diaphyseal EAD; Type 3c had femoral EAD (mean VCA 8.7°, HKA 166°), and severe medial bone loss (mean mLDFA 92°, MPTA 83°). 9% were Type 4 'Valgoid type' with features of valgus knees: Type 4a had medial femoral bowing (mean VCA 2.9°); Type 4b had significant distal femoral valgus (mean mLDFA 85.3°, aLDFA 78.6°). CONCLUSIONS The null hypothesis that there was no phenotypic variation in varus osteoarthritic knees was rejected as considerable variation was found in coronal morphology of femur and tibia. Four broad phenotypic groups could be identified. Plane of the knee joint articular surface was quite variable. This has relevance to planning and performance of corrective osteotomies, unicompartmental and total knee arthroplasty. LEVEL OF EVIDENCE III, retrospective cohort study.
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Miralles-Muñoz FA, Rubio-Morales M, Bello-Tejada L, González-Parreño S, Lizaur-Utrilla A, Alonso-Montero C. Varus alignment of the tibial component up to seven degrees is not associated with poor long-term outcomes in a neutrally aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:2768-2775. [PMID: 34175990 DOI: 10.1007/s00167-021-06627-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this retrospective study was to evaluate the effect of varus alignment of the tibial component on the outcomes with a minimum follow-up of 10 years. The hypothesis was that varus alignment of the tibial component might not affect the outcomes and survival of a neutrally aligned primary TKA. METHODS A matched case-control study was designed between 66 patients with varus alignment of the tibial component and 66 with neutral alignment with a minimum follow-up of 10 years. Functional outcome was assessed with the knee surgery scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Patient satisfaction was evaluated by a 0-10 visual analog scale. Radiological evaluation was performed at early postoperative and at final follow-up. RESULTS The mean follow-up was 11.9 (SD 2.6) years for both groups. The mean postoperative proximal tibial angle in the varus group was 85.0° (SD 0.9) and 88.8° (SD 0.9) in control group. At the final follow-up, there were no significant differences in KSS, WOMAC, range of motion or patient satisfaction. There were no differences in the coronal anatomical alignment of the TKA between groups. Revision of TKA was performed in four knees in the varus group, and one in control group, due to aseptic loosening of the tibial component in all cases. TKA survival at 10 years was not significantly different between groups. CONCLUSION The alignment of the tibial component up to 7° varus did not negatively affect implant survival, patient satisfaction, and function of a well-aligned TKA, with a minimum postoperative follow-up of 10 years. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Marta Rubio-Morales
- Department of Orthopaedic Surgery, University Hospital of Elda, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Laiz Bello-Tejada
- Department of Orthopaedic Surgery, University Hospital of Elda, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Santiago González-Parreño
- Department of Orthopaedic Surgery, University Hospital of Elda, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Alejandro Lizaur-Utrilla
- Department of Orthopaedic Surgery, University Hospital of Elda, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
- Faculty of Medicine, Department of Traumatology and Orthopaedics, Miguel Hernandez University, Elche, Alicante, Spain
| | - Carolina Alonso-Montero
- Faculty of Medicine, Department of Traumatology and Orthopaedics, Miguel Hernandez University, Elche, Alicante, Spain
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Sappey-Marinier E, Shatrov J, Batailler C, Schmidt A, Servien E, Marchetti E, Lustig S. Restricted kinematic alignment may be associated with increased risk of aseptic loosening for posterior-stabilized TKA: a case-control study. Knee Surg Sports Traumatol Arthrosc 2022; 30:2838-2845. [PMID: 34424356 DOI: 10.1007/s00167-021-06714-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of the study was to compare clinical and radiological results between kinematic alignment (KA) and mechanical alignment (MA) with a posterior-stabilized (PS) total knee arthroplasty (TKA) with a post-cam mechanism at a minimum follow-up of 3 years. The authors hypothesized a higher risk of aseptic loosening when performing KA using PS TKA. METHODS A retrospective monocentric single surgeon case control study was performed comparing 100 matched patients who had TKA performed using a MA philosophy to 50 patients receiving TKA with a KA technique between January 2016 and October 2017. All patients had the same knee prosthesis (GMK primary posterior-stabilized, Medacta®, Switzerland). Patient specific cutting blocks were used in both groups and a restricted KA (rKA) was aimed in the KA group. A hybrid cementation technique was performed. The new Knee Society Score (KSS) and radiological assessment were collected preoperatively and at the final follow-up. Comparisons between groups were done with the T test or Fisher exact test. Global survival curves were estimated with Kaplan-Meier model. Significance was set at p < 0.05. RESULTS Mean follow-up was 42.9 months ± 3.6 (range 37.6-46.7) and 53.3 months ± 4.1 (range 45.5-59.8) for rKA and MA groups. Postoperatively, no significant differences were found for clinical scores between both groups. Radiological assessment found similar postoperative Hip-Knee-Ankle angle for rKA and MA groups (178° versus 179° respectively, NS). At last follow-up, a significant higher survivorship was found for the MA group compared to the rKA group (97 versus 84%; p < 0.001) for aseptic loosening revision as the endpoint. CONCLUSION An increased risk of tibial implant loosening was found with rKA compared to MA using a posterior-stabilized TKA with a post-cam system at short-term follow-up. Caution should be taken when choosing the TKA design while performing rKA. LEVEL OF EVIDENCE Retrospective case-control study, Level IV.
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Affiliation(s)
- Elliot Sappey-Marinier
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France. .,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France.
| | - Jobe Shatrov
- Sydney Orthopaedic Research Institute, Chatswood, Sydney, Australia.,University of Notre Dame Australia, Sydney, Australia.,Hornsby and Ku-Ring Hospital, Sydney, Australia
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
| | - Axel Schmidt
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.,LIBM - EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
| | - Emmanuel Marchetti
- Centre Orthopédique Fleming, 30 Avenue Alexandre Fleming, 38300, Bourgoin-Jallieu, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
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20
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Doan GW, Courtis RP, Wyss JG, Green EW, Clary CW. Image-Free Robotic-Assisted Total Knee Arthroplasty Improves Implant Alignment Accuracy: A Cadaveric Study. J Arthroplasty 2022; 37:795-801. [PMID: 34979253 DOI: 10.1016/j.arth.2021.12.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Improving resection accuracy and eliminating outliers in total knee arthroplasty (TKA) is important to improving patient outcomes regardless of alignment philosophy. Robotic-assisted surgical systems improve resection accuracy and reproducibility compared to conventional instrumentation. Some systems require preoperative imaging while others rely on intraoperative anatomic landmarks. We hypothesized that the alignment accuracy of a novel image-free robotic-assisted surgical system would be equivalent or better than conventional instrumentation with fewer outliers. METHODS Forty cadaveric specimens were used in this study. Five orthopedic surgeons performed 8 bilateral TKAs each, using the VELYS Robotic-Assisted System (DePuy Synthes) and conventional instrumentation on contralateral knees. Pre-resection and postresection computed tomography scans, along with optical scans of the implant positions were performed to quantify resection accuracies relative to the alignment targets recorded intraoperatively. RESULTS The robotic-assisted cohort demonstrated smaller resection errors compared to conventional instrumentation in femoral coronal alignment (0.63° ± 0.50° vs 1.39° ± 0.95°, P < .001), femoral sagittal alignment (1.21° ± 0.90° vs 3.27° ± 2.51°, P < .001), and tibial coronal alignment (0.93° ± 0.72° vs 1.65° ± 1.29°, P = .001). All other resection angle accuracies were equivalent. Similar improvements were found in the femoral implant coronal alignment (0.89° ± 0.82° vs 1.42° ± 1.15°, P = .011), femoral implant sagittal alignment (1.51° ± 1.08° vs 2.49° ± 2.10°, P = .006), and tibial implant coronal alignment (1.31° ± 0.84° vs 2.03° ± 1.44°, P = .004). The robotic-assisted cohort had fewer outliers (errors >3°) for all angular resection alignments. CONCLUSION This in vitro study demonstrated that image-free robotic-assisted TKA can improve alignment accuracy compared to conventional instrumentation and reduce the incidence of outliers.
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Affiliation(s)
- Gary W Doan
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
| | | | | | | | - Chadd W Clary
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
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21
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Zimmermann M, Moser L, Moret C, Iordache E, Amsler F, Rasch H, Hügli R, Hirschmann MT. Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment. Knee 2022; 34:259-269. [PMID: 35077945 DOI: 10.1016/j.knee.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/15/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment. METHODS Consecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05). RESULTS In the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA. CONCLUSION Preoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.
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Affiliation(s)
- M Zimmermann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - L Moser
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - C Moret
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - E Iordache
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - F Amsler
- Amsler Consulting, Basel, Switzerland
| | - H Rasch
- Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - R Hügli
- Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
| | - M T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland; University of Basel, Basel, Switzerland.
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22
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What is the "safe zone" for transition of coronal alignment from systematic to a more personalised one in total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:419-427. [PMID: 34973095 PMCID: PMC8866271 DOI: 10.1007/s00167-021-06811-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE In total knee arthroplasty (TKA), implants are increasingly aligned based on emerging patient-specific alignment strategies, such as unrestricted kinematic alignment (KA), according to their constitutional limb alignment (phenotype alignment), which results in a large proportion of patients having a hip-knee angle (HKA) outside the safe range of ± 3° to 180° traditionally considered in the mechanical alignment strategy. The aim of this systematic review is to investigate whether alignment outside the safe zone of ± 3° is associated with a higher revision rate and worse clinical outcome than alignment within this range. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane and World of Science, with search terms including synonyms and plurals for "total knee arthroplasty", "alignment", "outlier", "malalignment", "implant survival" and "outcome". Five studies were identified with a total number of 927 patients and 952 implants. The Oxford Knee Score (OKS) and the WOMAC were used to evaluate the clinical outcome. The follow-up period was between 6 months and 10 years. RESULTS According to HKA 533 knees were aligned within ± 3°, 47 (8.8%) were varus outliers and 121 (22.7%) were valgus outliers. No significant differences in clinical outcomes were found between implants positioned within ± 3° and varus and valgus outliers. Likewise, no significant differences were found regarding revision rates and implant survival. CONCLUSION The universal use of the "safe zone" of ± 3° derived from the mechanical alignment strategy is hardly applicable to modern personalised alignment strategies in the light of current literature. However, given the conflicting evidence in the literature on the risks of higher revision rates and poorer clinical outcomes especially with greater tibial component deviation, the lack of data on the outcomes of more extreme alignments, and regarding the use of implants for KA TKA that are actually designed for mechanical alignment, there is an urgent need for research to define eventual evidence-based thresholds for new patient-specific alignment strategies, not only for HKA but also for FMA and TMA, also taking into account the preoperative phenotype and implant design. It is of utmost clinical relevance for the application of modern alignment strategies to know which native phenotypes may be reproduced with a TKA. LEVEL OF EVIDENCE IV.
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23
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Hasan S, Kaptein BL, Nelissen RGHH, van Hamersveld KT, Toksvig-Larsen S, Marang-van de Mheen PJ. The Influence of Postoperative Coronal Alignment on Tibial Migration After Total Knee Arthroplasty in Preoperative Varus and Valgus Knees: A Secondary Analysis of 10 Randomized Controlled Trials Using Radiostereometric Analysis. J Bone Joint Surg Am 2021; 103:2281-2290. [PMID: 34648477 DOI: 10.2106/jbjs.20.01659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons aim for mechanical alignment when performing total knee arthroplasty (TKA) as malalignment is associated with loosening. Loosening may be predicted by migration as measured with radiostereometric analysis (RSA), but previous RSA studies on postoperative alignment have shown contradictory results and have been limited to cemented implants and small numbers of patients. Therefore, we performed a secondary analysis of 10 previously published randomized controlled trials (RCTs) to compare migration between postoperative in-range and out-of-range cemented and uncemented TKA implants among patients with a preoperative varus or valgus knee. METHODS All RCTs involving the use of RSA that had been conducted at 2 centers were included. Alignment was classified, with use of the hip-knee-ankle angle (HKA), as in-range (0° ± 3°) or out-of-range (<-3° or >3°). The fixation methods included cemented, uncemented-coated, and uncemented-uncoated. Migration was measured at 3, 12, and 24 months. A linear mixed model was used, with adjustment for fixation method and clustering of patients within centers. RESULTS Of 476 TKA implants that had been out-of-range preoperatively, 290 were in-range postoperatively and 186 were out-of-range in either varus (n = 143) or valgus (n = 43) postoperatively. The mean migration at 3, 12, and 24 months was 0.73 mm (95% confidence interval [CI], 0.66 to 0.79 mm), 0.92 mm (95% CI, 0.85 to 1.00 mm), and 0.97 mm (95% CI, 0.90 to 1.05 mm), respectively, for the in-range group and 0.80 mm (95% CI, 0.72 to 0.87 mm), 0.98 (95% CI, 0.90 to 1.07 mm), and 1.04 mm (95% CI, 0.95 to 1.13 mm), respectively, for the out-of-range group (p = 0.07). The fixation method significantly influenced migration, with uncemented-uncoated implants migrating more than cemented and uncemented-coated implants (p < 0.001). CONCLUSIONS Postoperative alignment did not influence migration of TKAs in the first 2 postoperative years in patients with preoperative varus or valgus alignment of the knee. However, the fixation method significantly influenced migration, with uncemented-uncoated implants showing the greatest migration. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shaho Hasan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart L Kaptein
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen T van Hamersveld
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Sören Toksvig-Larsen
- Department of Orthopaedics, Hässleholm Hospital, Hässleholm, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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24
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Feng Z, Ma M, Wang Y, Yang C, Liu Z, Xia Y. Clinical and Radiological Changes of Ankle in Knee Osteoarthritis With Varus After Total Knee Arthroplasty: A Systematic Review. Front Surg 2021; 8:713055. [PMID: 34527697 PMCID: PMC8435772 DOI: 10.3389/fsurg.2021.713055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Arthritis with severe varus deformity remains a challenge in total knee arthroplasty (TKA). Until recently, surgeons aimed at a neutral lower limb alignment when performing a TKA. However, the impact of TKA on the ankle joint has been ignored. Therefore, we conducted a systematic review to assess the clinical and radiological changes in the ankle joint after TKA on knees with severe varus deformity. Methods: A systematic search was conducted in four English (PubMed, Embase, Cochrane Library, and Web of Science) and four Chinese (CBM, VIP, CNKI, and Wan Fang Database) databases. Screening of literature and extraction of data were independently performed by two researchers. The modified methodological index for non-randomized studies (MINORS) was used to assess the quality. Results: A total of eight studies were eligible, namely, four prospective and four retrospective studies. TKA resulted in a negative clinical effect in the ankle joint in patients with ankle osteoarthritis. Seven studies reported changes in the mechanical tibiofemoral angle, and four studies reported radiological changes in the hindfoot. The mean score of the MINORS was 9.8 out of eight (9-11). Conclusion: As a result of the correction of the knee osteoarthritis with severe varus deformity following mechanically aligned TKA, the radiological malalignment of the ankle joint was improved. However, some patients experience increased ankle pain after undergoing TKA, especially, if there was a residual knee varus deformity, a stiff hindfoot with varus deformity, or ankle arthritis.
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Affiliation(s)
- Zhiwei Feng
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China.,Department of Orthopaedics, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College, Nanchong, China
| | - Ming Ma
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Yaobin Wang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | | | - Zhongcheng Liu
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, China
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25
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Hernández-Vaquero D. The alignment of the knee replacement. Old myths and new controversies. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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26
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Hernández-Vaquero D. La alineación de la artroplastia de rodilla. Antiguos mitos y nuevas controversias. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recot.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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27
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van Hamersveld KT, Marang-van de Mheen PJ, Tsonaka R, Nilsson KG, Toksvig-Larsen S, Nelissen RGHH. Risk Factors for Tibial Component Loosening: A Meta-Analysis of Long-Term Follow-up Radiostereometric Analysis Data. J Bone Joint Surg Am 2021; 103:1115-1124. [PMID: 33886528 DOI: 10.2106/jbjs.20.01454] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radiostereometric analysis (RSA) is a highly accurate tool to detect implant migration and predict loosening following total knee arthroplasty (TKA). However, little is known about the predisposing risk factors for implant migration, nor which migration profile should be considered physiological (i.e., merely part of an implant-settling phase) and which should be considered pathological (i.e., having a high probability for implant loosening). By pooling individual participant data from long-term follow-up RSA studies, we aimed to identify predisposing risk factors for tibial component loosening. METHODS Individual data were collected for 630 patients from 11 RSA studies. The repeated measurements were analyzed with use of a linear mixed-effects model, determining the effect of age, sex, body mass index, diagnosis, preoperative and postoperative limb alignment, and prosthesis characteristics on tibial component migration over time, taking into account the clustering of patients within studies. RESULTS High initial migration was found to result in early mechanical loosening in 18 cases (2.9%) and septic loosening in 2 cases (0.3%), whereas stabilization of high initial migration occurred in 17 cases (2.7%). Late loosening occurred in 13 cases (2.1%). All other 580 cases (92.1%) showed early stabilization and remained stable over time. Mixed-effects model analyses showed that for cemented prostheses, sex, diagnosis, and posterior cruciate ligament type had an effect on migration, but these differences were nonsignificant when analyzing migration from 3 months onwards. Uncemented prostheses aligned in varus showed more migration than neutrally and valgus-aligned TKAs (p = 0.031), and this difference increased over time (p < 0.001). Significantly higher migration was observed following uncemented TKA without an osseointegration-promoting surface (p < 0.001). CONCLUSIONS For cemented prostheses, increased migration during the first 3 postoperative months was observed for female patients, patients with rheumatoid arthritis, and patients who underwent a posterior-stabilized TKA. For uncemented prostheses, both postoperative varus alignment of the lower limb and the absence of an osseointegration-promoting surface significantly increased postoperative tibial component migration. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Koen T van Hamersveld
- Departments of Orthopaedics (K.T.v.H. and R.G.H.H.N.) and Biomedical Data Sciences (P.J.M.-v.d.M. and R.T.), Leiden University Medical Center, Leiden, the Netherlands
| | - Perla J Marang-van de Mheen
- Departments of Orthopaedics (K.T.v.H. and R.G.H.H.N.) and Biomedical Data Sciences (P.J.M.-v.d.M. and R.T.), Leiden University Medical Center, Leiden, the Netherlands
| | - Roula Tsonaka
- Departments of Orthopaedics (K.T.v.H. and R.G.H.H.N.) and Biomedical Data Sciences (P.J.M.-v.d.M. and R.T.), Leiden University Medical Center, Leiden, the Netherlands
| | - Kjell G Nilsson
- Department of Surgical and Perioperative Sciences and Department of Orthopaedics, Umeå University, Umeå, Sweden
| | - Sören Toksvig-Larsen
- Department of Orthopaedics, Hässleholm Hospital, Hässleholm, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Rob G H H Nelissen
- Departments of Orthopaedics (K.T.v.H. and R.G.H.H.N.) and Biomedical Data Sciences (P.J.M.-v.d.M. and R.T.), Leiden University Medical Center, Leiden, the Netherlands
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28
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Abhari S, Hsing TM, Malkani MM, Smith AF, Smith LS, Mont MA, Malkani AL. Patient satisfaction following total knee arthroplasty using restricted kinematic alignment. Bone Joint J 2021; 103-B:59-66. [PMID: 34053299 DOI: 10.1302/0301-620x.103b6.bjj-2020-2357.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment. METHODS A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019. RESULTS Mean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group. CONCLUSION With the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59-66.
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Affiliation(s)
- Sarag Abhari
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Thomas M Hsing
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA.,Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Columbia, Missouri, USA
| | | | - Austin F Smith
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Langan S Smith
- Department of Orthopaedic Surgery, UofL Physicians - Orthopedics, Louisville, Kentucky, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Arthur L Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA
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29
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Ishii Y, Noguchi H, Sato J, Takahashi I, Ishii H, Ishii R, Ishii K, Toyabe SI. Alignment evaluation using different distal reference points after total knee arthroplasty. J Orthop 2021; 25:186-190. [PMID: 34045821 DOI: 10.1016/j.jor.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022] Open
Abstract
Background To assess alignment for total knee arthroplasty, the center of the ankle has been used as the main reference point for the distal tibia; however, the true load-bearing mechanical axis should be determined as a line from the center of the femoral head to the lowest point of calcaneus. Thus, the purpose of this study was to compare the differences in alignment. Methods Patients with medial osteoarthritis who underwent primary total knee arthroplasty (Group A, center of ankle reference, or Group C, calcaneal contact reference) were recruited. We determined (1) the total number with calcaneal contact point lateral to the center of ankle and compared (2) percentage of displacement of the load-bearing axis at the level of the knee, (3) anatomical axis angle, (4) mechanical axis angle, and (5) tibial component angle. Results The study included 94 patients (128 knees), with the calcaneal contact reference point located lateral relative to the center of the ankle in 88.3% (113/128 knees). Using calcaneal contact point references, displacement of the load-bearing axis at the knee was greater (p < 0.0001, 38.7% vs 34.0%), and angles demonstrated significantly valgus alignment (p < 0.0001, 5.6° vs. 4.8° for anatomical axis angle, -3.0° vs. -4.2° for mechanical axis angle, and 89.9° vs. 88.6°for tibial component angle). Conclusions Varus alignment measured by the ankle reference method might correspond to the neutral alignment by the amount of valgus alignment indicated by the calcaneal reference. Surgeons should take this into account when preoperative planning, performing intraoperative procedures, and during postoperative evaluation.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Hideo Noguchi
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Junko Sato
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Ikuko Takahashi
- Ishii Orthopaedic & Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Hana Ishii
- Kanazawa Medical University, School of Plastic Surgery, 1-1 Daigaku, Uchinada, Ishikawa, 920-0253, Japan
| | - Ryo Ishii
- Sado General Hospital, 161 Chikusa Sado, Niigata, 952-1209, Japan
| | - Kei Ishii
- Iwate Prefectural Ninohe Hospital, 38 Horino, Ninohe, Iwate, 028-6193, Japan
| | - Shin-Ichi Toyabe
- Niigata University Crisis Management Office, Niigata University Hospital, Niigata University Graduate School of Medical and Dental Sciences, 1 Asahimachi Dori Niigata, Niigata, 951-8520, Japan
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30
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Koster LA, Meinardi JE, Kaptein BL, Van der Linden-Van der Zwaag E, Nelissen RGHH. Two-year RSA migration results of symmetrical and asymmetrical tibial components in total knee arthroplasty: a randomized controlled trial. Bone Joint J 2021; 103-B:855-863. [PMID: 33934647 DOI: 10.1302/0301-620x.103b5.bjj-2020-1575.r2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The objective of this study was to compare the two-year migration pattern and clinical outcomes of a total knee arthroplasty (TKA) with an asymmetrical tibial design (Persona PS) and a well-proven TKA with a symmetrical tibial design (NexGen LPS). METHODS A randomized controlled radiostereometric analysis (RSA) trial was conducted including 75 cemented posterior-stabilized TKAs. Implant migration was measured with RSA. Maximum total point motion (MTPM), translations, rotations, clinical outcomes, and patient-reported outcome measures (PROMs) were assessed at one week postoperatively and at three, six, 12, and 24 months postoperatively. RESULTS A linear mixed-effect model using RSA data of 31 asymmetrical and 38 symmetrical TKAs did not show a difference in mean MTPM migration pattern of the tibial or femoral components. Mean tibial component MTPM at two years postoperative of the asymmetrical TKA design was 0.93 mm and 1.00 mm for the symmetrical design. For the femoral component these values were 1.04 mm and 1.14 mm, respectively. No significant differences were observed in other migration parameters or in clinical and PROM measurements. CONCLUSION The TKA design with an asymmetrical tibial component has comparable component migration with the proven TKA with a symmetrical tibial component. This suggests the risk of long-term aseptic loosening of the two designs is comparable. Cite this article: Bone Joint J 2021;103-B(5):855-863.
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Affiliation(s)
- Lennard A Koster
- Biomechanics and Imaging Group, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris E Meinardi
- Biomechanics and Imaging Group, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart L Kaptein
- Biomechanics and Imaging Group, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Rob G H H Nelissen
- Biomechanics and Imaging Group, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Robotic total knee arthroplasty (TKA) has demonstrated improved component positioning and a reduction of alignment outliers with regard to pre-operative planning. Early robotic TKA technologies were mainly active systems associated with significant technical and surgical complications. Current robotic TKA systems are predominantly semi-active with additional haptic feedback which minimizes iatrogenic soft tissue injury compared to conventional arthroplasty and older systems. Semi-active systems demonstrate advantages in terms of early functional recovery and hospital discharge compared to conventional arthroplasty. Limitations with current robotic technology include high upfront costs, learning curves and lack of long-term outcomes. The short-term gains and greater technical reliability associated with current systems may justify the ongoing investment in robotic technology. Further long-term data are required to fully ascertain the cost-effectiveness of newer robotic systems.
Cite this article: EFORT Open Rev 2021;6:270-279. DOI: 10.1302/2058-5241.6.200052
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Affiliation(s)
| | - En Lin Goh
- Oxford University Clinical Academic Graduate School, Medical Sciences Division, University of Oxford, Oxford, UK
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Liu C, Zhao G, Chen K, Lyu J, Chen J, Shi J, Huang G, Chen F, Wei Y, Wang S, Xia J. Tibial component coverage affects tibial bone resorption and patient-reported outcome measures for patients following total knee arthroplasty. J Orthop Surg Res 2021; 16:134. [PMID: 33579313 PMCID: PMC7881541 DOI: 10.1186/s13018-021-02250-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/20/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose The aim of this study is to investigate the prognostic value of tibial component coverage (over-hang and under-hang) and the alignment of total knee arthroplasty (TKA) components 1 week after surgery. We select patient-reported outcome measures (PROMS) (the Knee Society score (KSS score) and the Western Ontario and McMaster Universities Osteoarthritis Index-pain score (WOMAC pain score)) and tibial bone resorption (TBR) 2 years after surgery as the end points. Methods The study retrospectively analyzed 109 patients undergoing TKA (fixed-bearing prosthesis with asymmetrical tibial tray) from January 2014 to December 2017 in Huashan Hospital. By using standard long-leg X-rays, anteroposterior (AP) and lateral X-rays of the knee, tibial component coverage (under-hang or over-hang), AP tibial-femoral anatomical angle (AP-TFA), AP femoral angle (AP-FA), AP tibial angle (AP-TA), and lateral tibial angle (L-TA) were measured at 1 week after surgery, while TBR was measured through postoperative 1-week and 2-year AP and lateral radiographs of the knee on three sides (medial side, lateral side on AP radiograph, and anterior side on lateral radiograph). The Pearson correlation analysis, simple linear regression, multiple linear regression, the Student’s t test, and one-way ANOVA together with Tukey’s post hoc test (or Games-Howell post hoc test) were used in the analyses. Results Tibial under-hang was more likely to appear in our patients following TKA (42%, medially, 39%, laterally, and 25%, anteriorly). In multivariate linear regression analysis of TBR, tibial under-hang (negative value) 1 week after surgery was positively correlated with TBR 2 years later on the medial (p = 0.003) and lateral (p = 0.026) side. Tibial over-hang (positive value) 1 week after surgery on the medial side was found negatively related with KSS score (p = 0.004) and positively related with WOMAC pain score (p = 0.036) 2 years later in multivariate linear regression analysis of PROMS. Both scores were better in the anatomically sized group than in the mild over-hang group (or severe over-hang) (p < 0.001). However, no significant relationship was found between the alignment of TKA components at 1 week after surgery and the end points (TBR and PROMS) 2 years later. Conclusion Under-hang of the tibial component on both the medial and lateral sides can increase the risk of TBR 2 years later. Over-hang of tibial component on the medial side decreases the PROMS (KSS score and WOMAC pain score) 2 years later. An appropriate size of tibial component during TKA is extremely important for patient’s prognosis, while the alignment of components might not be as important. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02250-7.
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Affiliation(s)
- Changquan Liu
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Guanglei Zhao
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Kangming Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jinyang Lyu
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jie Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jingsheng Shi
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Gangyong Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Feiyan Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Yibing Wei
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Siqun Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China
| | - Jun Xia
- Department of Orthopedics, Huashan Hospital, Fudan University, 12, Wulumuqi Rd., Jing'an District, Shanghai, China.
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Budhiparama NC, Lumban-Gaol I, Ifran NN, de Groot PCJ, Utomo DN, Nelissen RGHH. Mismatched knee implants in Indonesian and Dutch patients: a need for increasing the size. Knee Surg Sports Traumatol Arthrosc 2021; 29:358-369. [PMID: 32162046 DOI: 10.1007/s00167-020-05914-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the anthropometric differences between knees of Indonesian Asians and Dutch Caucasians and the fit of nine different knee implant systems. METHODS A total of 268 anteroposterior (AP) and lateral knee preoperative radiographs from 134 consecutive patients scheduled for total knee arthroplasty at two different centres in Jakarta and Leiden were included. Both patient groups were matched according to age and sex and included 67 Asians and 67 Caucasians. We assessed the radiographic differences between the Asian and Caucasian anthropometric data. The dimensions of the nine knee implant designs (Vanguard, Genesis II, Persona Standard, Persona Narrow, GK Sphere, Gemini, Attune Standard, Attune Narrow, and Sigma PFC) were compared with the patients' anthropometric (distal femur and proximal tibia) measurements. RESULTS The Dutch Caucasian patients had larger mediolateral (ML) and AP femoral and tibial dimensions than the Indonesian Asians. The aspect ratios of the distal femur and tibia were larger in Asians than in Caucasians. The AP and ML dimensions were mismatched between the tibial components of the nine knee systems and the Asian anthropometric data. Both groups had larger ML distal femoral dimensions than the knee systems. CONCLUSION Absolute and relative differences in knee dimensions exist not only between Asian and Caucasian knees but also within both groups. Not all TKA systems had a good fit with the Asian and Caucasian knee phenotypes. An increase in the range of available knee component sizes would be beneficial, although TKA remains an adequate compromise. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicolaas C Budhiparama
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jl. Jend. Gatot Subroto Kav. 59, Jakarta, 12950, Indonesia. .,Department of Orthopaedics and Traumatology, School of Medicine, University of Airlangga, Jl. Mayjend. Prof. Dr. Moestopo 6-8, Surabaya, 60286, Indonesia. .,Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Imelda Lumban-Gaol
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jl. Jend. Gatot Subroto Kav. 59, Jakarta, 12950, Indonesia
| | - Nadia Nastassia Ifran
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jl. Jend. Gatot Subroto Kav. 59, Jakarta, 12950, Indonesia
| | - Pieter C J de Groot
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Dwikora Novembri Utomo
- Department of Orthopaedics and Traumatology, School of Medicine, University of Airlangga, Jl. Mayjend. Prof. Dr. Moestopo 6-8, Surabaya, 60286, Indonesia
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Burssens A, De Roos D, Barg A, Welck MJ, Krähenbühl N, Saltzman CL, Victor J. Alignment of the hindfoot in total knee arthroplasty: a systematic review of clinical and radiological outcomes. Bone Joint J 2021; 103-B:87-97. [PMID: 33380206 DOI: 10.1302/0301-620x.103b1.bjj-2020-0143.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity. METHODS A systematic literature search was performed in the databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of "total knee arthroplasty/replacement" combined with "hindfoot/ankle alignment". Inclusion criteria were all English language studies analyzing the association between TKA and the alignment of the hindfoot, including the clinical or radiological outcomes. Exclusion criteria consisted of TKA performed with a concomitant extra-articular osteotomy and case reports or expert opinions. An assessment of quality was conducted using the modified Methodological Index for Non-Randomized Studies (MINORS). The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42019106980). RESULTS A total of 17 studies were found to be eligible for review. They included six prospective and ten retrospective studies, and one case-control study. The effects of TKA showed a clinical improvement in the hindfoot deformity in three studies, but did not if there was osteoarthritis (OA) of the ankle (one study) or a persistent deformity of the knee (one study). The radiological alignment of the hindfoot corrected in 11 studies, but did not in the presence of a rigid hindfoot varus deformity (in two studies). The effects of a hindfoot deformity on TKA included a clinical association with instability of the knee in one study, and a shift in the radiological weightbearing axis in two studies. The mean MINORS score was 9.4 out of 16 (7 to 12). CONCLUSION TKA improves both the function and alignment of the hindfoot in patients with a preoperative deformity of the hindfoot. This may not apply if there is a persistent deformity of the knee, a rigid hindfoot varus deformity, or OA of the ankle. Moreover, a persistent deformity of the hindfoot may adversely affect the stability and longevity of a TKA. These findings should be interpreted with caution due to the moderate methodological quality of the studies which were included. Therefore, further prospective studies are needed in order to determine at which stage correction of a hindfoot deformity is required to optimize the outcome of a TKA. Cite this article: Bone Joint J 2021;103-B(1):87-97.
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Affiliation(s)
- Arne Burssens
- Department of Orthopaedics, Royal National Orthopaedic Hospital, UCL Institute of Orthopaedics and Musculoskelatal Science, Stanmore, UK.,Department of Orthopaedics, University Hospital of Ghent, Ghent, Belgium
| | - Dries De Roos
- Department of Orthopaedics, University Hospital of Ghent, Ghent, Belgium
| | - Alexej Barg
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Matt J Welck
- Department of Orthopaedics, Royal National Orthopaedic Hospital, UCL Institute of Orthopaedics and Musculoskelatal Science, Stanmore, UK
| | - Nicola Krähenbühl
- Deparment of Orthopaedics and Traumatology, Kantonsspital Baselland, Liestal, Switzerland.,Department of Orthopaedics and Traumatology, Universitätsklinik Balgrist, Zurich, Switzerland
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Jan Victor
- Department of Orthopaedics, University Hospital of Ghent, Ghent, Belgium
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Minoda Y, Hayakawa K, Hagio K, Konishi N, Tamaki T, Iwakiri K. Usefulness of an Accelerometer-Based Portable Navigation System for Total Knee Arthroplasty: A Multicenter Prospective Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:1993-2000. [PMID: 33208642 DOI: 10.2106/jbjs.20.00387] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazue Hayakawa
- Department of Orthopaedic Surgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Keisuke Hagio
- Department of Orthopaedic Surgery, Osaka Minami Medical Center, Kawachinagano, Osaka, Japan
| | - Natsuo Konishi
- Department of Orthopaedic Surgery, Akita Kousei Medical Center, Akita, Japan
| | - Tatsuya Tamaki
- Department of Orthopaedic Surgery, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Kentaro Iwakiri
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Ikoma, Nara, Japan
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36
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Kurmis AP. Considering the Value of Imageless, Accelerometer-Based, Intraoperative Mini-Navigation Systems in Contemporary Primary Total Knee Arthroplasty: Commentary on an article by Yukihide Minoda, MD, PhD, et al.: "Usefulness of an Accelerometer-Based Portable Navigation System for Total Knee Arthroplasty. A Multicenter Prospective Randomized Controlled Trial". J Bone Joint Surg Am 2020; 102:e129. [PMID: 33208649 DOI: 10.2106/jbjs.20.01534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Andrew P Kurmis
- Discipline of Medical Specialties, Division of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
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Hasan S, van Hamersveld KT, Marang-van de Mheen PJ, Kaptein BL, Nelissen RGHH, Toksvig-Larsen S. Migration of a novel 3D-printed cementless versus a cemented total knee arthroplasty: two-year results of a randomized controlled trial using radiostereometric analysis. Bone Joint J 2020; 102-B:1016-1024. [DOI: 10.1302/0301-620x.102b8.bjj-2020-0054.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims Although bone cement is the primary mode of fixation in total knee arthroplasty (TKA), cementless fixation is gaining interest as it has the potential of achieving lasting biological fixation. By 3D printing an implant, highly porous structures can be manufactured, promoting osseointegration into the implant to prevent aseptic loosening. This study compares the migration of cementless, 3D-printed TKA to cemented TKA of a similar design up to two years of follow-up using radiostereometric analysis (RSA) known for its ability to predict aseptic loosening. Methods A total of 72 patients were randomized to either cementless 3D-printed or a cemented cruciate retaining TKA. RSA and clinical scores were evaluated at baseline and postoperatively at three, 12, and 24 months. A mixed model was used to analyze the repeated measurements. Results The mean maximum total point motion (MTPM) at three, 12, and 24 months was 0.33 mm (95% confidence interval (CI) 0.25 to 0.42), 0.42 mm (95% CI 0.33 to 0.51), and 0.47 mm (95% CI 0.38 to 0.57) respectively in the cemented group, versus 0.52 mm (95% CI 0.43 to 0.63), 0.62 mm (95% CI 0.52 to 0.73), and 0.64 mm (95% CI 0.53 to 0.75) in the cementless group (p = 0.003). However, using three months as baseline, no difference in mean migration between groups was found (p = 0.497). Three implants in the cemented group showed a > 0.2 mm increase in MTPM between one and two years of follow-up. In the cementless group, one implant was revised due to pain and progressive migration, and one patient had a liner-exchange due to a deep infection. Conclusion The cementless TKA migrated more than the cemented TKA in the first two-year period. This difference was mainly due to a higher initial migration of the cementless TKA in the first three postoperative months after which stabilization was observed in all but one malaligned and early revised TKA. Whether the biological fixation of the cementless implants will result in an increased long-term survivorship requires a longer follow-up. Cite this article: Bone Joint J 2020;102-B(8):1016–1024.
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Affiliation(s)
- Shaho Hasan
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Koen T. van Hamersveld
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Bart L. Kaptein
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Sören Toksvig-Larsen
- Department of Orthopaedic Surgery, Hässleholm Hospital, Hässleholm, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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38
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Current evidence base for kinematic alignment. DER ORTHOPADE 2020; 49:584-592. [PMID: 32507940 DOI: 10.1007/s00132-020-03932-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Kinematic alignment recently became an alternative alignment option for total knee arthroplasty (TKA). Beside previous studies assessing mechanical alignment in comparison to unintentional malalignment of TKA in terms of implant survival and clinical outcome, more and more studies have focused on the direct comparison of intentional kinematic alignment with mechanical alignment of the prosthesis. In the past 5 years the number of studies with respect to kinematic alignment has risen from 11 to 91 studies. AIM The aim of this review article is to give a narrative overview of the current literature in the debate concerning kinematic and mechanical alignment in TKA.
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CORR Insights®: Does Robotic-assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial. Clin Orthop Relat Res 2020; 478:276-278. [PMID: 31567287 PMCID: PMC7438141 DOI: 10.1097/corr.0000000000000969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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40
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Slaven SE, Cody JP, Sershon RA, Ho H, Hopper RH, Fricka KB. The Impact of Coronal Alignment on Revision in Medial Fixed-Bearing Unicompartmental Knee Arthroplasty. J Arthroplasty 2020; 35:353-357. [PMID: 31668526 DOI: 10.1016/j.arth.2019.09.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/29/2019] [Accepted: 09/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To better define the optimal alignment target for medial fixed-bearing unicompartmental knee arthroplasty (UKA), this study compares the postoperative mechanical alignment of well-functioning UKAs against 2 groups of failed UKAs, including revisions for progression of lateral compartment osteoarthritis ("Progression") and revisions for aseptic loosening or subsidence ("Loosening"). METHODS From our prospective institutional database of 3351 medial fixed-bearing UKAs performed since 2000, we identified 37 UKAs revised for Progression and 61 UKAs revised for Loosening. Each of these revision cohorts was matched based on age at surgery, gender, body mass index, and postoperative range of motion with unrevised UKAs that had at least 10 years of follow-up and a Knee Society Score of 70 or greater without subtracting points for alignment ("Success" groups). Postoperative alignment was quantified by the hip-knee-ankle (HKA) angle measured on long-leg alignment radiographs. RESULTS The mean HKA angle at 4-month follow-up for the Progression group was 0.3° ± 3.6° of valgus compared to 4.4° ± 2.6° of varus for the matched Success group (P < 0.001). For the Loosening group, the mean HKA angle was 6.1° ± 3.1° of varus versus 4.0° ± 2.7° of varus for the matched Success group (P < 0.001). CONCLUSIONS Patients with well-functioning UKAs at 10 years exhibited mild varus mechanical alignment of approximately 4°, whereas patients revised for progression of osteoarthritis averaged more valgus and those revised for loosening or subsidence averaged more varus. The optimal mechanical alignment for medial fixed-bearing UKA survival with contemporary polyethylene is likely slight varus.
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Affiliation(s)
- Sean E Slaven
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - John P Cody
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, VA
| | | | - Kevin B Fricka
- Anderson Orthopaedic Research Institute, Alexandria, VA; Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, VA
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