Patient-specific Total Knee Arthroplasty Required Frequent Surgeon-directed Changes

Stronach, Benjamin M.; Pelt, Christopher E.; Erickson, Jill; Peters, Christopher L.

doi:10.1007/s11999-012-2573-3

Cited by 119 publications

(127 citation statements)

References 15 publications

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“…The accuracy of the preoperative plan accompanying the PSI was also called into question by our literature review. This represents a significant aspect in procedural efficiency, because four studies demonstrated inaccuracies in anticipated alignment or a need to change the preoperative plan with respect to the planned resections or component sizes [10,27,29,31]. This apparent need for secondary checks would seem to diminish the value of PSI considerably as it relates to operative efficiency.…”

Section: Discussionmentioning

confidence: 99%

“…One Level II study concluded that the bony cuts achieved using the patient-specific cutting blocks did not always match the preoperative plan generated [29]. An additional Level II study [31] and a Level III study [27] noted a high frequency of intraoperative changes to the preoperative plan and component sizing required to achieve an optimal surgical result. Finally, another Level II study demonstrated that cuts achieved with PSI did not correspond to the preoperative plan when checked intraoperatively with computer-assisted navigation tools [10].…”

Section: Domentioning

confidence: 99%

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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

177

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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: Discussionmentioning

confidence: 99%

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

177

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“…In general, results of studies on PSI are equivocal [8,15,[25][26][27][28]. We believe that results obtained with one particular PSI system are not automatically applicable to other systems and should not be generalised [14,23]. At the moment, several companies offer various PSI systems for TKA.…”

Section: Discussionmentioning

confidence: 99%

“…Less optimistic results were observed in a multicentre, randomised control trial performed by Boonen et al [31], who found a statistically significant difference in outliers for the LFC angle, with a higher percentage of outliers in the MRIbased Signature™ PSI group than in the conventional group (65 % vs. 49 %, respectively). Stronach et al [23] reported inadequate fit of MRI-based Signature™ PSI. In their study, the femoral guide did not fit the bone structures precisely in 12 % and tibial guide in 5 % of PSI patients,.…”

Section: Discussionmentioning

confidence: 99%

“…In all cases, the same type of uncemented cruciate-retaining prostheses were implanted (Vanguard™ Complete Knee System; Biomet Inc. Warsaw, IN, USA), without resurfacing the patella. The process by which Signature™ instrumentation is produced and used has been described precisely in previous studies [3,13,14,[21][22][23]. Briefly, each patient in group 1 obtained a preoperative CT scan of the knee joint, along with …”

Section: Methodsmentioning

confidence: 99%

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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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Three‐dimensional implant position and orientation after total knee replacement performed with patient‐specific instrumentation systems

Cenni

Timoncini

Tamarri

et al. 2013

Journal Orthopaedic Research

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Patient-specific instrumentation systems are entering into clinical practice in total knee replacement, but validation tests have yet to determine the accuracy of replicating computer-based plans during surgery. We performed a fluoroscopic analysis to assess the final implant location with respect to the corresponding preoperative plan. Forty-four patients were analyzed after using a patientspecific system based on CT and MRI. Computer aided design implant models and models of the femur and tibia bone portions, as for the preoperative plans, were provided by the manufacturers. Two orthogonal fluoroscopic images of each knee were taken after surgery for pseudo-biplane imaging; 3D component locations with respect to the corresponding bones were estimated by a shape-matching technique. Assuming that the corresponding values at the preoperative plan were equal to zero, discrepancies were taken as an indication of accuracy for the systems. A repeatability test revealed that the technique was reliable within 1 mm and 1˚. The maximum discrepancies for all the patients for the femoral component were 5.9 mm in a proximo-distal direction and 4.2˚in flexion. Good matching was found between final implantations and preoperative plans with mean discrepancies smaller than 3.1 mm and 1.9˚.

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Patient-specific Total Knee Arthroplasty Required Frequent Surgeon-directed Changes

Abstract: We caution surgeons against blind acceptance of patient-specific instrumentation technology without supportive data.

Cited by 119 publications

References 15 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

Three‐dimensional implant position and orientation after total knee replacement performed with patient‐specific instrumentation systems

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