In-Vivo Alignment Comparing Patient Specific Instrumentation with both Conventional and Computer Assisted Surgery (CAS) Instrumentation in Total Knee Arthroplasty

Barrett, William P.; Hoeffel, Daniel; Dalury, David F.; Mason, J. Bohannon; Murphy, Jeff; Himden, Sam

doi:10.1016/j.arth.2013.06.029

Cited by 61 publications

(60 citation statements)

References 16 publications

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“…Three of five Level II studies demonstrated no benefit with PSI [2,3,25] and one study demonstrated improved tibial component rotation [30]. The final Level II study demonstrated a greater number of alignment outliers when PSI was used [8].…”

Section: Domentioning

confidence: 97%

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Systematic Review of Patient-specific Instrumentation in Total Knee Arthroplasty: New but Not Improved

Sassoon

Nam

Nunley

et al. 2015

Clinical Orthopaedics &Amp; Related Research

179

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Background Patient-specific cutting blocks have been touted as a more efficient and reliable means of achieving neutral mechanical alignment during TKA with the proposed downstream effect of improved clinical outcomes. However, it is not clear to what degree published studies support these assumptions. Questions/purposes We asked: (1) Do patient-specific cutting blocks achieve neutral mechanical alignment more reliably during TKA when compared with conventional methods? (2) Does patient-specific instrumentation (PSI) provide financial benefit through improved surgical efficiency? (3) Does the use of patient-specific cutting blocks translate to improved clinical results after TKA when compared with conventional instrumentation? Methods We performed a systematic review in accordance with Cochrane guidelines of controlled studies (prospective and retrospective) in MEDLINE 1 and EM-BASE 1 with respect to patient-specific cutting blocks and their effect on alignment, cost, operative time, clinical outcome scores, complications, and survivorship. Sixteen studies (Level I-III on the levels of evidence rubric) were identified and used in addressing the first question, 13 (Level I-III) for the second question, and two (Level III) for the third question. Qualitative assessment of the selected Level I studies was performed using the modified Jadad score; Level II and III studies were rated based on the Newcastle-Ottawa scoring system. Results The majority of studies did not show an improvement in overall limb alignment when PSI was compared with standard instrumentation. Mixed results were seen across studies with regard to the prevalence of alignment outliers when PSI was compared with conventional cutting blocks with some studies demonstrating no difference, some showing an improvement with PSI, and a single study showing worse results with PSI. The studies demonstrated mixed results regarding the influence of PSI on operative times. Decreased operative times were not uniformly observed, and when noted, they were found to be of minimal clinical or financial significance. PSI did reliably reduce the number of instrument trays required for processing perioperatively. The accuracy of the preoperative plan, generated by the PSI manufacturers, was found lacking, often leading to multiple intraoperative changes, thereby disrupting the flow of the operation and negatively impacting efficiency. Limited data exist with regard to the effect of PSI on postoperative function, improvement in pain, and patient

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Section: Domentioning

confidence: 97%

“…Among the studies providing a lower level of evidence, the results were again split. A Level II study [3] and two Level III studies [5,21] demonstrated faster operative times with PSI, whereas another Level II [8] and a Level III study failed to demonstrate quicker surgery with PSI [1].…”

Section: Domentioning

confidence: 99%

Systematic Review of Patient-specific Instrumentation in Total Knee Arthroplasty: New but Not Improved

Sassoon

Nam

Nunley

et al. 2015

Clinical Orthopaedics &Amp; Related Research

179

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“…Koch et al [18] assessed the radiological results of 301 TKAs performed with CT-based McKnee© PSI and found significant accuracy of implant position in all planes, with 14.4 % of outliers for HKA angle. Barrett et al [20] compared postoperative mechanical alignment achieved using CT-based TruMatch™ PSI with conventional and CAS instruments; postoperative mechanical alignment was comparable across groups. Lastly, Ensini et al [19] analysed and compared the accuracy of CT-based MyKnee® PSI and MRI/X-ray-based Visionaire® PSI.…”

Section: Discussionmentioning

confidence: 99%

“…In the case of CT-based PSI instrumentation, this need is particularly evident, as there is very limited experience with these devices in the world literature. To our knowledge, this is the fifth study to assess radiographic outcomes of TKA performed with CTbased PSI [14,[18][19][20]. The aim of this study was to compare radiological results of TKAs performed with CT-based PSI and conventional technique.…”

Section: Introductionmentioning

confidence: 99%

Patient-specific computed tomography based instrumentation in total knee arthroplasty: a prospective randomized controlled study

Kotela

2014

International Orthopaedics (SICOT)

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Purpose The aim of this study was to compare radiological results of total knee arthroplasties (TKAs) performed with patient-specific computed tomography (CT)-based instrumentation and conventional technique. The main study hypothesis was that CT-based patient-specific instrumentation (PSI) increases the accuracy of TKA. Methods A prospective, randomized controlled trial was carried out between January and December 2011. A group of 112 patients who met the inclusion and exclusion criteria were enrolled in this study and randomly assigned to an experimental or control group. The experimental group comprised 52 patients operated on with the aid of the Signature™ CT-based implant positioning system. The control group consisted of 60 patients operated on using conventional instrumentation. The radiographic evaluation of implant positioning and overall coronal alignment was performed 12 months after the surgery by using standing anteroposterior radiographs of the entire lower limb and standard lateral radiographs. Results Of the 112 patients initially enrolled for the study, 95 were included in the subsequent analyses. There were no statistically significant differences between groups in respect to coronal and sagittal component positioning and overall coronal alignment, except for frontal tibial component positioning. For this parameter, better results were obtained in the control group, with borderline statistical significance. Conclusions Our study did not reveal superiority of the CTbased PSI system over conventional instrumentation. Further high-quality investigations of patient-specific systems are absolutely indispensable to assess their utility for TKA. In our opinion, the surgeon applying PSI technology is required to have advanced knowledge and considerable experience with the conventional method.

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“…Again, higher accuracy and reproducibility in component placement with less outliers have been shown when using these techniques. However, there is no proof yet that either computer assisted surgery or patient-specific instrumentation improve clinical outcome [2,6].…”

mentioning

confidence: 99%

Does implant design and surgical technique improve the clinical outcome in total knee arthroplasty?

Becker

Hirschmann

Karlsson

2014

Knee Surg Sports Traumatol Arthrosc

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Recently, a new generation of prostheses for total knee arthroplasty (TKA) were introduced by different companies in order to improve the range of motion, clinical outcome and finally patient satisfaction. However, the basic principles in designing implants for total knee arthroplasty have not changed much over the last two decades. We still need to resect the anterior cruciate ligament (cruciate retaining, CR TKA) or remove both the anterior and posterior cruciate ligaments (posterior stabilised, PS TKA). The femoral component is designed to optimise patella tracking and to unload the patello-femoral compartment. Single and multiple radius designs are being used for the femoral condyles, both showing good reasons for preference. The multi-radius design of the femoral component respects the anatomical shape of the femoral condyles and the physiological change of flexion/extension axis during knee motion. However, CR mobile bearing TKA influence the flexion/extension axis as shown by Iacono et al. [10] in a study published in the current issue. The single-radius design presumes a fixed axis of flexion/ extension, which lies slightly posterior to the natural one. A slight posterior placed axis increases the quadriceps moment arm and improves the efficiency of quadriceps muscle function [16]. In clinical practise, better range of motion and less pain, in particular, when rising from a sitting position has been observed with the single-radius design [14]. These findings are in harmony with a biomechanical study by Ostermeier and Stukenborg-Colsman. However, other studies did not show any differences in range of motion or clinical outcome between the singleand multiple radius designs [7]. Both concepts raise the questions whether one should restore anatomy as exactly as possible or as the osteoarthritic knee's anatomy is altered by the disease process anyway and hence one should aim for the best knee function and modify the components accordingly?What about CR or PS designs in TKA? A Cochrane analysis showed a slightly better range of motion of 8°u sing the PS design in comparison to the CR design (105°v s. 113°) [11]. This finding is supported by a number of studies, but the clinical relevance of the differences in maximal degree of flexion of 8°remains questionable [5]. The prevalence of knee flexion of more than 90°was studied during a period of 35.7 h in 21 patients [9]. The patients flexed their knee more than 90°on average 10 min during this period only and eight oft them more than 120°f or 2.2 min only. Range of motion during daily activity depends on patient's activity, but it shows that small improvement in the degree of motion will not affect patients' outcome, but may instead increase the risk of aseptic loosening.Innovations in terms of the tibial component have been very limited. Increasing the number of component sizes and the re-introduction of asymmetric tibial component are considered to improve the knee function. Posterolateral impingement of the popliteus tendon is rather unlikely when using the a...

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In-Vivo Alignment Comparing Patient Specific Instrumentation with both Conventional and Computer Assisted Surgery (CAS) Instrumentation in Total Knee Arthroplasty

Cited by 61 publications

References 16 publications

Systematic Review of Patient-specific Instrumentation in Total Knee Arthroplasty: New but Not Improved

Systematic Review of Patient-specific Instrumentation in Total Knee Arthroplasty: New but Not Improved

Patient-specific computed tomography based instrumentation in total knee arthroplasty: a prospective randomized controlled study

Does implant design and surgical technique improve the clinical outcome in total knee arthroplasty?

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