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Clinical Orthopaedics and Related Research®

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01-01-2012 | Symposium: Papers Presented at the Annual Meetings of The Knee Society

Improved Accuracy of Alignment With Patient-specific Positioning Guides Compared With Manual Instrumentation in TKA

Authors: Vincent Y. Ng, MD, Jeffrey H. DeClaire, MD, Keith R. Berend, MD, Bethany C. Gulick, RT (R), Adolph V. Lombardi Jr, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 1/2012

Abstract

Background

Coronal malalignment occurs frequently in TKA and may affect implant durability and knee function. Designed to improve alignment accuracy and precision, the patient-specific positioning guide is predicated on restoration of the overall mechanical axis and is a multifaceted new tool in achieving traditional goals of TKA.

Questions/purposes

We compared the effectiveness of patient-specific positioning guides to manual instrumentation with intramedullary femoral and extramedullary tibial guides in restoring the mechanical axis of the extremity and achieving neutral coronal alignment of the femoral and tibial components.

Methods

We retrospectively reviewed 569 TKAs performed with patient-specific positioning guides and 155 with manual instrumentation by two surgeons using postoperative long-leg radiographs. For all patients, we assessed the zone in which the overall mechanical axis passed through the knee, and for one surgeon’s cases (105 patient-specific positioning guide, 55 manual instrumentation), we also measured the hip-knee-ankle angle and the individual component angles with respect to their mechanical axes.

Results

The overall mechanical axis passed through the central third of the knee more often with patient-specific positioning guides (88%) than with manual instrumentation (78%). The overall mean hip-knee-ankle angle for patient-specific positioning guides (180.6°) was similar to manual instrumentation (181.1°), but there were fewer ± 3° hip-knee-ankle angle outliers with patient-specific positioning guides (9%) than with manual instrumentation (22%). The overall mean tibial (89.9° versus 90.4°) and femoral (90.7° versus 91.3°) component angles were closer to neutral with patient-specific positioning guides than with manual instrumentation, but the rate of ± 2° outliers was similar for both the tibia (10% versus 7%) and femur (22% versus 18%).

Conclusions

Patient-specific positioning guides can assist in achieving a neutral mechanical axis with reduction in outliers.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty. 2005;20:132–138.PubMedCrossRef

Bartel DL, Burstein AH, Santavicca EA, Insall JN. Performance of the tibial component in total knee replacement. J Bone Joint Surg Am. 1982;64:1026–1033.PubMed

Bathis H, Perlick L, Tingart M, Luring C, Grifka J. CT-free computer-assisted total knee arthroplasty versus the conventional technique: radiographic results of 100 cases. Orthopedics. 2004;27:476–480.PubMed

Bathis H, Perlick L, Tingart M, Luring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty: a comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br. 2004;86:682–687.PubMedCrossRef

Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R, Faris GW, Davis KE. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res. 2004;428:26–34.PubMedCrossRef

Berger RA, Crossett LS. Determining rotation of the femoral and tibial components in total knee arthroplasty: a computer tomography technique. Operative Tech Orthop. 1998;8:128–133.CrossRef

Bertsch C, Holz U, Konrad G, Vakili A, Oberst M. Early clinical outcome after navigated total knee arthroplasty. Comparison with conventional implantation in TKA: a controlled and prospective analysis. Orthopade. 2007;36:739–745.PubMedCrossRef

Biasca N, Wirth S, Bungartz M. Mechanical accuracy of navigated minimally invasive total knee arthroplasty (MIS TKA). Knee. 2009;16:22–29.PubMedCrossRef

Bohling U, Schamberger H, Grittner U, Scholz J. Computerised and technical navigation in total knee-arthroplasty. J Orthop Traumatol. 2005;6:69–75.CrossRef

10.

Bonutti P, Dethmers D, Stiehl JB. Case report: femoral shaft fracture resulting from femoral tracker placement in navigated TKA. Clin Orthop Relat Res. 2008;466:1499–1502.PubMedCrossRef

11.

Bonutti PM, Dethmers D, Ulrich SD, Seyler TM, Mont MA. Computer navigation-assisted versus minimally invasive TKA: benefits and drawbacks. Clin Orthop Relat Res. 2008;466:2756–2762.PubMedCrossRef

12.

Bonutti PM, Dethmers DA, McGrath MS, Ulrich SD, Mont MA. Navigation did not improve the precision of minimally invasive knee arthroplasty. Clin Orthop Relat Res. 2008;466:2730–2735.PubMedCrossRef

13.

Chang CW, Yang CY. Kinematic navigation in total knee replacement-experience from the first 50 cases. J Formos Med Assoc. 2006;105:468–474.PubMedCrossRef

14.

Chauhan S, Clark G, Lloyd S, Scott R, Breidahl W, Sikorski J. Computer-assisted total knee replacement: a controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT protocol). J Bone Joint Surg Br. 2004;86:818–823.PubMedCrossRef

15.

Cheung KW, Chiu KH. Imageless computer navigation in total knee arthroplasty. Hong Kong Med J. 2009;15:353–358.PubMed

16.

Chin PL, Yang KY, Yeo SJ, Lo NN. Randomized control trial comparing radiographic total knee arthroplasty implant placement using computer navigation versus conventional technique. J Arthroplasty. 2005;20:618–626.PubMedCrossRef

17.

Choong PF, Dowsey MM, Stoney JD. Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplasty. 2009;24:560–569.PubMedCrossRef

18.

Chotanaphuti T, Ongnamthip P, Teeraleekul K, Kraturerk C. Comparative study between computer assisted-navigation and conventional technique in minimally invasive surgery total knee arthroplasty, prospective control study. J Med Assoc Thai. 2008;91:1382–1388.PubMed

19.

Chung BJ, Kang YG, Chang CB, Kim SJ, Kim TK. Differences between sagittal femoral mechanical and distal reference axes should be considered in navigated TKA. Clin Orthop Relat Res. 2009;467:2403–2413.PubMedCrossRef

20.

Confalonieri N, Manzotti A, Pullen C, Ragone V. Computer-assisted technique versus intramedullary and extramedullary alignment systems in total knee replacement: a radiological comparison. Acta Orthop Belg. 2005;71:703–709.PubMed

21.

Daubresse F, Vajeu C, Loquet J. Total knee arthroplasty with conventional or navigated technique: comparison of the learning curves in a community hospital. Acta Orthop Belg. 2005;71:710–713.PubMed

22.

Dennis DA, Channer M, Susman MH, Stringer EA. Intramedullary versus extramedullary tibial alignment systems in total knee arthroplasty. J Arthroplasty. 1993;8:43–47.PubMedCrossRef

23.

Dutton AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong HC. Computer-assisted minimally invasive total knee arthroplasty compared with standard total knee arthroplasty: a prospective, randomized study. J Bone Joint Surg Am. 2008;90:2–9.PubMedCrossRef

24.

Ek ET, Dowsey MM, Tse LF, Riazi A, Love BR, Stoney JD, Choong PF. Comparison of functional and radiological outcomes after computer-assisted versus conventional total knee arthroplasty: a matched-control retrospective study. J Orthop Surg (Hong Kong). 2008;16:192–196.

25.

Engh GA, Peterson TL. Comparative experience with intramedullary and extramedullary alignment in total knee arthroplasty. J Arthroplasty. 1990;5:1–8.PubMedCrossRef

26.

Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S. Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res. 2007;457:156–162.PubMed

27.

Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24:39–43.PubMedCrossRef

28.

Green GV, Berend KR, Berend ME, Glisson RR, Vail TP. The effects of varus tibial alignment on proximal tibial surface strain in total knee arthroplasty: the posteromedial hot spot. J Arthroplasty. 2002;17:1033–1039.PubMedCrossRef

29.

Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A. Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res. 2005;433:152–159.PubMedCrossRef

30.

Han HS, Seong SC, Lee S, Lee MC. Rotational alignment of femoral components in total knee arthroplasty: nonimage-based navigation system versus conventional technique. Available at: https://www.orthosupersite.com/print.aspx?rid=18743. Accessed July 5, 2011.

31.

Hasegawa M, Yoshida K, Wakabayashi H, Sudo A. Minimally invasive total knee arthroplasty: comparison of jig-based technique versus computer navigation for clinical and alignment outcome. Knee Surg Sports Traumatol Arthrosc. 2011;19:904–910.PubMedCrossRef

32.

Hernandez-Vaquero D, Suarez-Vazquez A, Sandoval-Garcia MA, Noriega-Fernandez A. Computer assistance increases precision of component placement in total knee arthroplasty with articular deformity. Clin Orthop Relat Res. 2010;468:1237–1241.PubMedCrossRef

33.

Howell SM, Kuznik K, Hull ML, Siston RA. Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48 patients. Orthopedics. 2008;31:857–863.PubMedCrossRef

34.

Ishida K, Matsumoto T, Tsumura N, Kubo S, Kitagawa A, Chin T, Iguchi T, Kurosaka M, Kuroda R. Mid-term outcomes of computer-assisted total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011;19:1107–1112.PubMedCrossRef

35.

Jeffery RS, Morris RW, Denham RA. Coronal alignment after total knee replacement. J Bone Joint Surg Br. 1991;73:709–714.PubMed

36.

Jenny JY, Boeri C. Computer-assisted implantation of total knee prostheses: a case-control comparative study with classical instrumentation. Comput Aided Surg. 2001;6:217–220.PubMedCrossRef

37.

Jenny JY, Clemens U, Kohler S, Kiefer H, Konermann W, Miehlke RK. Consistency of implantation of a total knee arthroplasty with a non-image-based navigation system: a case-control study of 235 cases compared with 235 conventionally implanted prostheses. J Arthroplasty. 2005;20:832–839.PubMedCrossRef

38.

Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004;86:1909–1916.PubMedCrossRef

39.

Kim SJ, MacDonald M, Hernandez J, Wixson RL. Computer assisted navigation in total knee arthroplasty: improved coronal alignment. J Arthroplasty. 2005;20:123–131.PubMedCrossRef

40.

Kim YH, Kim JS, Choi Y, Kwon OR. Computer-assisted surgical navigation does not improve the alignment and orientation of the components in total knee arthroplasty. J Bone Joint Surg Am. 2009;91:14–19.PubMedCrossRef

41.

Kim YH, Kim JS, Yoon SH. Alignment and orientation of the components in total knee replacement with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2007;89:471–476.PubMedCrossRef

42.

Klatt BA, Goyal N, Austin MS, Hozack WJ. Custom-fit total knee arthroplasty (OtisKnee) results in malalignment. J Arthroplasty. 2008;23:26–29.PubMedCrossRef

43.

Lee DH, Park JH, Song DI, Padhy D, Jeong WK, Han SB. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection. Knee Surg Sports Traumatol Arthrosc. 2010;18:381–387.PubMedCrossRef

44.

Liau JJ, Cheng CK, Huang CH, Lo WH. The effect of malalignment on stresses in polyethylene component of total knee prostheses—a finite element analysis. Clin Biomech (Bristol, Avon). 2002;17:140–146.CrossRef

45.

Lombardi AV Jr, Berend KR, Adams JB. Patient-specific approach in total knee arthroplasty. Orthopedics. 2008;31:927–930.PubMedCrossRef

46.

Lombardi AV Jr, Emerson RH Jr, Pietrzak WS. Signature Personalized Patient Care for total knee arthroplasty: a mechanical alignment cadaveric study. Internal Study. 2008:1–3.

47.

Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2009;24:570–578.PubMedCrossRef

48.

Lotke PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg Am. 1977;59:77–79.PubMed

49.

Luring C, Beckmann J, Haibock P, Perlick L, Grifka J, Tingart M. Minimal invasive and computer assisted total knee replacement compared with the conventional technique: a prospective, randomised trial. Knee Surg Sports Traumatol Arthrosc. 2008;16:928–934.PubMedCrossRef

50.

Lutzner J, Krummenauer F, Wolf C, Gunther KP, Kirschner S. Computer-assisted and conventional total knee replacement: a comparative, prospective, randomised study with radiological and CT evaluation. J Bone Joint Surg Br. 2008;90:1039–1044.PubMedCrossRef

51.

Macule-Beneyto F, Hernandez-Vaquero D, Segur-Vilalta JM, Colomina-Rodriguez R, Hinarejos-Gomez P, Garcia-Forcada I, Seral Garcia B. Navigation in total knee arthroplasty: a multicenter study. Int Orthop. 2006;30:536–540.PubMedCrossRef

52.

Mahoney OM. The role of alignment in TKR survivorship. Presented at Orthopedics Today Hawaii 2010. January 10–13, 2010. Kohala Coast, HI.

53.

Martin A, Wohlgenannt O, Prenn M, Oelsch C, von Strempel A. Imageless navigation for TKA increases implantation accuracy. Clin Orthop Relat Res. 2007;460:178–184.PubMed

54.

Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;22:1097–1106.PubMedCrossRef

55.

Massai F, Conteduca F, Vadala A, Iorio R, Basiglini L, Ferretti A. Tibial stress fracture after computer-navigated total knee arthroplasty. J Orthop Traumatol. 2010;11:123–127.PubMedCrossRef

56.

Matsumoto T, Tsumura N, Kurosaka M, Muratsu H, Kuroda R, Ishimoto K, Tsujimoto K, Shiba R, Yoshiya S. Prosthetic alignment and sizing in computer-assisted total knee arthroplasty. Int Orthop. 2004;28:282–285.PubMedCrossRef

57.

Matziolis G, Adam J, Perka C. Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement. Arch Orthop Trauma Surg. 2010;130:1487–1491.PubMedCrossRef

58.

Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C. A prospective, randomized study of computer-assisted and conventional total knee arthroplasty: three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am. 2007;89:236–243.PubMedCrossRef

59.

Mizu-uchi H, Matsuda S, Miura H, Okazaki K, Akasaki Y, Iwamoto Y. The evaluation of post-operative alignment in total knee replacement using a CT-based navigation system. J Bone Joint Surg Br. 2008;90:1025–1031.PubMedCrossRef

60.

Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am. 1987;69:745–749.PubMed

61.

Mullaji A, Kanna R, Marawar S, Kohli A, Sharma A. Comparison of limb and component alignment using computer-assisted navigation versus image intensifier-guided conventional total knee arthroplasty: a prospective, randomized, single-surgeon study of 467 knees. J Arthroplasty. 2007;22:953–959.PubMedCrossRef

62.

Novak EJ, Silverstein MD, Bozic KJ. The cost-effectiveness of computer-assisted navigation in total knee arthroplasty. J Bone Joint Surg Am. 2007;89:2389–2397.PubMedCrossRef

63.

Oberst M, Bertsch C, Konrad G, Lahm A, Holz U. CT analysis after navigated versus conventional implantation of TKA. Arch Orthop Trauma Surg. 2008;128:561–566.PubMedCrossRef

64.

Oberst M, Bertsch C, Wurstlin S, Holz U. [CT analysis of leg alignment after conventional vs. navigated knee prosthesis implantation: initial results of a controlled, prospective and randomized study] [in German]. Unfallchirurg. 2003;106:941–948.PubMed

65.

Pang CH, Chan WL, Yen CH, Cheng SC, Woo SB, Choi ST, Hui WK, Mak KH. Comparison of total knee arthroplasty using computer-assisted navigation versus conventional guiding systems: a prospective study. J Orthop Surg (Hong Kong). 2009;17:170–173.

66.

Park SE, Lee CT. Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty. 2007;22:1054–1059.PubMedCrossRef

67.

Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010;92:2143–2149.PubMedCrossRef

68.

Perlick L, Bathis H, Lerch K, Luring C, Tingart M, Grifka J. [Navigated implantation of total knee endoprostheses in secondary knee osteoarthritis of rheumatoid arthritis patients as compared to conventional technique] [in German]. Z Rheumatol. 2004;63:140–146.PubMedCrossRef

69.

Perlick L, Bathis H, Tingart M, Perlick C, Grifka J. Navigation in total-knee arthroplasty: CT-based implantation compared with the conventional technique. Acta Orthop Scand. 2004;75:464–470.PubMedCrossRef

70.

Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement. Clin Orthop Relat Res. 1994;299:153–156.PubMed

71.

Rosenberger R, Hoser C, Quirbach S, Attal R, Hennerbichler A, Fink C. Improved accuracy of component alignment with the implementation of image-free navigation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2008;16:249–257.PubMedCrossRef

72.

Saragaglia D, Picard F, Chaussard C, Montbarbon E, Leitner F, Cinquin P. [Computer-assisted knee arthroplasty: comparison with a conventional procedure: results of 50 cases in a prospective randomized study] [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2001;87:18–28.PubMed

73.

Schmitt J, Hauk C, Kienapfel H, Pfeiffer M, Efe T, Fuchs-Winkelmann S, Heyse TJ. Navigation of total knee arthroplasty: rotation of components and clinical results in a prospectively randomized study. BMC Musculoskelet Disord. 2011;12:16.PubMedCrossRef

74.

Seon JK, Park SJ, Lee KB, Li G, Kozanek M, Song EK. Functional comparison of total knee arthroplasty performed with and without a navigation system. Int Orthop. 2009;33:987–990.PubMedCrossRef

75.

Seon JK, Song EK. Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial. J Arthroplasty. 2006;21:777–782.PubMedCrossRef

76.

Seon JK, Song EK, Yoon TR, Park SJ, Bae BH, Cho SG. Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty. Comput Aided Surg. 2007;12:189–193.PubMed

77.

Sikorski JM. Alignment in total knee replacement. J Bone Joint Surg Br. 2008;90:1121–1127.PubMed

78.

Skowronski J, Bielecki M, Hermanowicz K, Skowronski R. The radiological outcomes of total knee arthroplasty using computer assisted navigation ORTHOPILOT. Chir Narzadow Ruchu Ortop Pol. 2005;70:5–8.PubMed

79.

SooHoo NF, Lieberman JR, Ko CY, Zingmond DS. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480–485.PubMedCrossRef

80.

Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A. Positioning of total knee arthroplasty with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2003;85:830–835.PubMed

81.

Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF. Initial experience with custom-fit total knee replacement: intra-operative events and long-leg coronal alignment. Int Orthop. 2009;33:1571–1575.PubMedCrossRef

82.

Stulberg SD, Picard F, Saragaglia D. Computer-assisted total knee replacement arthroplasty. Oper Tech Orthop. 2000;10:25–39.CrossRef

83.

Swank ML, Alkire M, Conditt M, Lonner JH. Technology and cost-effectiveness in knee arthroplasty: computer navigation and robotics. Am J Orthop. 2009;38:32–36.PubMed

84.

Tew M, Waugh W. Tibiofemoral alignment and the results of knee replacement. J Bone Joint Surg Br. 1985;67:551–556. PubMed

85.

Tingart M, Luring C, Bathis H, Beckmann J, Grifka J, Perlick L. Computer-assisted total knee arthroplasty versus the conventional technique: how precise is navigation in clinical routine? Knee Surg Sports Traumatol Arthrosc. 2008;16:44–50.PubMedCrossRef

86.

Victor J, Hoste D. Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment. Clin Orthop Relat Res. 2004;428:131–139.PubMedCrossRef

87.

Yau WP, Chiu KY, Zuo JL, Tang WM, Ng TP. Computer navigation did not improve alignment in a lower-volume total knee practice. Clin Orthop Relat Res. 2008;466:935–945.PubMedCrossRef

88.

Yehyawi TM, Callaghan JJ, Pedersen DR, O’Rourke MR, Liu SS. Variances in sagittal femoral shaft bowing in patients undergoing TKA. Clin Orthop Relat Res. 2007;464:99–104.PubMed

89.

Zorman D, Etuin P, Jennart H, Scipioni D, Devos S. Computer-assisted total knee arthroplasty: comparative results in a preliminary series of 72 cases. Acta Orthop Belg. 2005;71:696–602.

Title: Improved Accuracy of Alignment With Patient-specific Positioning Guides Compared With Manual Instrumentation in TKA
Authors: Vincent Y. Ng, MD
Jeffrey H. DeClaire, MD
Keith R. Berend, MD
Bethany C. Gulick, RT (R)
Adolph V. Lombardi Jr, MD
Publication date: 01-01-2012
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 1/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-011-1996-6

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Improved Accuracy of Alignment With Patient-specific Positioning Guides Compared With Manual Instrumentation in TKA

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

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