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A computer-assisted, tibia-first technique for improved femoral component rotation in total knee arthroplasty.

ABSTRACT: Background:The use of navigation for total knee arthroplasty (TKA) improves limb alignment in the coronal and sagittal planes. However, similar improvements in femoral and tibial component rotation have not yet been realized using currently available systems. Methods:We developed a modified navigated TKA technique in which femoral rotation was set using the resected tibial plane as the reference with the aim of achieving a rectangular flexion gap. Limb alignment was assessed in a cohort of 30 knees using the navigation system. Post-operative limb alignment was measured using long-leg standing radiographs. Computed tomography was used to determine post-operative component orientation. Results:Sagittal alignment data improved from a mean of 7.8° varus (pre-operative) to 0.0° (post-operative), assessed by intra-operative navigation. Post-operative hip-knee-ankle axis alignment was 0.9° valgus (mean; standard deviation [SD] 1.7°). Mean femoral component rotation was 0.5° internally rotated (SD 2.6°), relative to the surgical transepicondylar axis. Mean tibial component rotation was 0.9° externally rotated (SD 5.5°). No soft tissue releases were performed. Conclusions:These results confirm that the desired femoral rotation, set using a tibia-first approach with the resected tibial plane as the reference, can be achieved without compromising overall limb alignment. Femoral component rotation was within a narrow range, with a moderate improvement in achieving more consistent tibial component rotation compared with other techniques. This technique may prove to be useful for surgeons wishing to employ a tibia-first philosophy for TKA while maximizing the benefits associated with computer-assisted navigation.

SUBMITTER: Lee CM

PROVIDER: S-EPMC5859675 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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A computer-assisted, tibia-first technique for improved femoral component rotation in total knee arthroplasty.

Lee Chong Meng CM Dhillon Malkit K MK Sulaiman Mohd Amin MA

Arthroplasty today 20170818 1

<h4>Background</h4>The use of navigation for total knee arthroplasty (TKA) improves limb alignment in the coronal and sagittal planes. However, similar improvements in femoral and tibial component rotation have not yet been realized using currently available systems.<h4>Methods</h4>We developed a modified navigated TKA technique in which femoral rotation was set using the resected tibial plane as the reference with the aim of achieving a rectangular flexion gap. Limb alignment was assessed in a ...[more]

PMID: 29560400

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Project description:Computer assisted surgery was pioneered in early 1990s. The first computer assisted surgery (CAS) total knee replacement with an imageless system was carried out in 1997. In the past 25 years, CAS has progressed from experimental in vitro studies to established in vivo surgical procedures.A comprehensive body of evidence establishing the advantages of computer assisted surgery in knee and hip arthroplasty is available. Established benefits have been demonstrated including its role as an excellent research tool. Its advantages include dynamic pre-operative and per-operative assessment, increased accuracy in correction of deformities, kinematics and mechanical axis, a better alignment of components, better survival rates of prostheses and a better functional outcome. Adoption of computer navigation in the hip arthroplasty is still at an early stage compared to knee arthroplasty, though the results are well documented. Evidence suggests improved accuracy in acetabular orientation, positioning, hip offset and leg length correction.Among the orthopaedic surgeons, navigated knee arthroplasty is gaining popularity though slowly. The uptake rates vary from country to country. The Australian joint registry data shows increased navigated knee arthroplasty from 2.4% in 2003 to 28.6% in 2015 and decreased revision rates with navigated knee arthroplasty in comparison with traditional instrumented knee arthroplasty in patient cohort under the age of 55 years.Any new technology has a learning curve and with practice the navigation assisted knee and hip arthroplasty becomes easy. We have actively followed the evidence of CAS in orthopaedics and have successfully adopted it in our routine practice over the last decades. Despite the cautious inertia of orthopaedic surgeons to embrace CAS more readily; we are certain that computer technology has a pivotal role in lower limb arthroplasty. It will evolve to become a standard practice in the future in various forms like navigation or robotics.

Project description:OBJECTIVE:Total knee arthroplasty (TKA) is one of the most universal and effective means for treating terminal stage osteoarthritis (OA) of knee. Accurate intramedullary guide of femur is the basis for the distal femoral cuts. Determining the surgical transepicondylar axis (sTEA) is the key to reconstruction of the femoral rotational alignment, because the correct rotational alignment can place the femoral component in the right position, balance the flexion gap so that the inner and outer tension is equal, get stability during the flexion process of the knee, and enhance the quality of life of patients. With the development of three-dimensional printing (3DP) technology in the medical domain, the application of patient-specific instrumentation (PSI) in arthroplasty has become more common. The aim of this study was to evaluate the accuracy of a novel 3D-printed patient-specific intramedullary guide to control femoral component rotation in TKA. METHODS:Eighty patients (65 females and 15 males) with knee OA were included in this prospective randomized study. The patients were divided into two groups by random number table method, 40 in each group. TKA assisted by PSI (PSI group) and conventional TKA (conventional group) was performed respectively. Clinical outcomes [operation time, postoperative drainage volume, duration of drainage, Hospital for Special Surgery knee score (HSS), American Knee Society knee score (AKS)] and radiological outcomes [hip-knee-ankle angle (HKA), posterior condylar angle (PCA), patella transverse axis-femoral transepicondylar axis angle (PFA), depth of intramedullary guide] were compared between and within the two groups. RESULTS:PSI group had less postoperative drainage volume but longer operation time than the conventional group (P < 0.05). The AKS and HSS scores after surgery were improved compared with those before surgery in each group (P < 0.05). However, there was no significant difference in the duration of drainage and range of motion (ROM) after surgery between the two groups. For the radiological results, the HKA and PFA were improved after surgery in both groups (P < 0.05).The postoperative PFA and PCA of the PSI group were closer to 0°, which was better than that of the conventional group (P < 0.05). The depth of intramedullary guide in the PSI group was less than the conventional group (P < 0.05). But there was no significant difference in HKA before and after surgery between the two groups as well as the preoperative PFA. CONCLUSION:The short-term clinical efficacy of TKA assisted by PSI was similar to the conventional TKA. Although TKA assisted by PSI spent more time during operation, it could assist in intramedullary guide and align femoral rotation more accurately.

Project description:Despite the growing evidence in the literature there is still a lack of consensus regarding the use of minimally invasive surgical technique (MIS) in total knee arthroplasty (TKA).A prospective, randomized, international multicentre trial including 69 patients was performed to compare computer-assisted TKA (CAS-TKA) using either mini-midvastus (MIS group) or standard medial parapatellar approach (conventional group). Patients from 3 centers (Maastricht, Zwickau, Adelaide) with end-stage osteoarthritis of the knee were randomized to either an MIS group with dedicated instrumentation or a conventional group to receive cruciate retaining CAS-TKA without patella resurfacing. The primary outcome was to compare post operative pain and range of motion (ROM). The secondary outcome was to measure the duration of surgery, blood loss, chair rise test, quadriceps strength, anterior knee pain, Knee Society Score (KSS),WOMAC scores, mechanical leg axis and component alignment.Patients in the MIS group (3.97?±?2.16) had significant more pain at 2 weeks than patients in the conventional group (2.77?±?1.43) p?=?0.003. There was no significant difference in any of the other primary outcome parameters. Surgery time was significantly longer (p?<?0.001) and there were significantly higher blood loss (p?=?0.002) in the MIS group as compared to the conventional group. The difference of the mean mechanical leg alignment between the groups was not statistically significant (-0.43° (95% CI -1.50-0.64); p?=?0.43). There was no significant difference of component alignment between the two surgical groups with respect to flexion/extension (p?=?0.269), varus/valgus (p?=?0.653) or rotational alignment (p?=?0.485) of the femur component and varus valgus alignment (p?=?0.778) or posterior slope (p?=?0.164) of the tibial component.There was no advantage of the MIS approach compared to a conventional approach CAS-TKA in any of the primary outcome measurements assessed, however the MIS approach was associated with longer surgical time and greater blood loss. MIS-TKA in combination with computer navigation is safe in terms of implant positioning.ClinicalTrials.gov NCT02625311 8 December 2015.

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A computer-assisted, tibia-first technique for improved femoral component rotation in total knee arthroplasty.

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A computer-assisted, tibia-first technique for improved femoral component rotation in total knee arthroplasty.

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