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Improved accuracy of component alignment with the implementation of image-free navigation in total knee arthroplasty

  • Ralf E. RosenbergerEmail author
  • Christian Hoser
  • Sebastian Quirbach
  • Rene Attal
  • Alfred Hennerbichler
  • Christian Fink
Knee

Abstract

Accuracy of implant positioning and reconstruction of the mechanical leg axis are major requirements for achieving good long-term results in total knee arthroplasty (TKA). The purpose of the present study was to determine whether image-free computer navigation technology has the potential to improve the accuracy of component alignment in TKA cohorts of experienced surgeons immediately and constantly. One hundred patients with primary arthritis of the knee underwent the unilateral total knee arthroplasty. The cohort of 50 TKAs implanted with conventional instrumentation was directly followed by the cohort of the very first 50 computer-assisted TKAs. All surgeries were performed by two senior surgeons. All patients received the Zimmer NexGen™ total knee prosthesis (Zimmer Inc., Warsaw, IN, USA). There was no variability regarding surgeons or surgical technique, except for the use of the navigation system (StealthStation® Treon plus®, Medtronic Inc., Minnesota, MI, USA). Accuracy of implant positioning was measured on postoperative long-leg standing radiographs and standard lateral X-rays with regard to the valgus angle and the coronal and sagittal component angles. In addition, preoperative deformities of the mechanical leg axis, tourniquet time, age, and gender were correlated. Statistical analyses were performed using the SPSS 15.0 (SPSS Inc., Chicago, IL, USA) software package. Independent t-tests were used, with significance set at P < 0.05 (two-tailed) to compare differences in mean angular values and frontal mechanical alignment between the two cohorts. To compute the rate of optimally implanted prostheses between the two groups we used the χ2 test. The average postoperative radiological frontal mechanical alignment was 1.88° of varus (range 6.1° of valgus–10.1° of varus; SD 3.68°) in the conventional cohort and 0.28° of varus (range 3.7°–6.0° of varus; SD 1.97°) in the navigated cohort. Including all criteria for optimal implant alignment, 16 cases (32%) in the conventional cohort and 31 cases (62%) in the navigated cohort have been implanted optimally. The average difference in tourniquet time was modest with additional 12.9 min in the navigated cohort compared to the conventional cohort. Our findings suggest that the experienced knee surgeons can improve immediately and constantly the accuracy of component orientation using an image-free computer-assisted navigation system in TKA. The computer-assisted technology has shown to be easy to use, safe, and efficient in routine knee replacement surgery. We believe that navigation is a key technology for various current and future surgical alignment topics and minimal-invasive lower limb surgery.

Keywords

Knee Osteoarthritis Total knee arthroplasty Navigation Minimal-invasive surgery 

Notes

Acknowledgment

We thank Gudrun Rosenberger, MD from the Psychiatry Neuroimaging Lab, Harvard Medical School, Boston, MA, USA, for her assistance in statistical analysis.

References

  1. 1.
    Bach CM, Steingruber IE, Peer S, Nogler M, Wimmer C, Ogon M (2001) Radiographic assessment in total knee arthroplasty. Clin Orthop Relat Res 385:144–50PubMedCrossRefGoogle Scholar
  2. 2.
    Bathis H, Perlick L, Luring C, Kalteis T, Grifka J (2003) CT-based and CT-free navigation in knee prosthesis implantation. Results of a prospective study. Unfallchirurg 106(11):935–40PubMedGoogle Scholar
  3. 3.
    Berry DJ (2004) Computerassisted knee arthroplasty is better than a conventional jig-based technique in terms of component alignment. J Bone Joint Surg Am 86:2573PubMedGoogle Scholar
  4. 4.
    Brown GA, Firoozbakhsh K, DeCoster TA, Reyna JR Jr, Moneim M (2003) Rapid prototyping: the future of trauma surgery? J Bone Joint Surg 85(Suppl 4):49–55PubMedGoogle Scholar
  5. 5.
    Bolognesi M, Hofmann A (2005) Computer navigation versus standard instrumentation for TKA: a single-surgeon experience. Clin Orthop Relat Res 440:162–9PubMedCrossRefGoogle Scholar
  6. 6.
    Caillouette JT, Anzel SH (1990) Fat embolism syndrome following the intramedullary alignment guide in total knee arthroplasty. Clin Orthop Relat Res 251:198–9PubMedGoogle Scholar
  7. 7.
    Chauhan SK, Scott RG, Breidahl W, Beaver RJ (2004) Computerassisted knee arthroplasty versus a conventional jig-based technique. A randomised, prospective trial. J Bone Joint Surg Br 86:372–7PubMedCrossRefGoogle Scholar
  8. 8.
    Decking R, Markmann Y, Fuchs J, Puhl W, Scharf HP (2005) Leg axis after computer-navigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation. J Arthroplasty 20(3):282–8PubMedCrossRefGoogle Scholar
  9. 9.
    Delp SL, Stulberg SD, Davies B, Picard F, Leitner F (1998) Computer assisted knee replacement. Clin Orthop Relat Res 345:49–56CrossRefGoogle Scholar
  10. 10.
    Dennis DA, Channer M, Susmann MH, Stringer EA (1993) Intramedullary versus extramedullary tibial alignment systems in total knee arthroplasty. J Arthroplasty 8:43PubMedCrossRefGoogle Scholar
  11. 11.
    Ecker ML, Lotke PA, Windsor RE, Cella JP (1988) Long-term results after total condylar knee arthroplasty. Significance of radiolucent lines. Clin Orthop Rel Res 216:151–8Google Scholar
  12. 12.
    Fortheine F, Ohnsorge JAK, Schkommodau E, Radermacher K (2004) CT-based planning and individual template navigation in TKA. In: Stiehl JB, Konermann WH, Haaker RG Navigation and robotics in total joint and spine surgery. Springer, Berlin, pp 336–42Google Scholar
  13. 13.
    Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A (2005) Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res (433):152–9PubMedCrossRefGoogle Scholar
  14. 14.
    Hafez MA, Chelule KL, Seedhom BB, Sherman KP (2006) Computer-assisted total knee arthroplasty using patient-specific templating. Clin Orthop Relat Res 444:184–92PubMedCrossRefGoogle Scholar
  15. 15.
    Ischii Y, Ohmori G, Bechthold J, Gustilo RB (1995) Extramedullary versus intramedullary alignment guides in total knee arthroplasty. Clin Orthop Relat Res 318:167–75Google Scholar
  16. 16.
    Jeffery RS, Morris RW, Denham RA (1991) Coronal alignment after total knee replacement. J Bone Joint Surg Br 73:709–14PubMedGoogle Scholar
  17. 17.
    Jenny JY, Clemens U, Kohler S, Kiefer H, Konermann W, Miehlke RK (2005) 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 20(7):832–9PubMedCrossRefGoogle Scholar
  18. 18.
    Kalairajah Y, Cossey AJ, Verrall GM, Ludbrook GG, Spriggins AJ (2006) Are systemic emboli reduced in computerassisted knee surgery? A prospective, randomised, clinical trial. J Bone Joint Surg Br 88-B:198–202CrossRefGoogle Scholar
  19. 19.
    Kolettis GT, Wixson RL, Peruzzi WT, Blake MJ, Wardell S, Stuhlberg SD (1994) Safety of 1-stage bilateral total knee arthroplasty. Clin Orthop Relat Res 309:102–9PubMedGoogle Scholar
  20. 20.
    Laskin RS (2001) The genesis total knee prosthesis: a 10-year follow-up study. Clin Orthop Relat Res (388):95–102PubMedCrossRefGoogle Scholar
  21. 21.
    Loer I, Plitz W (2003) Tibial malalignment of mobile-bearing prostheses: a simulator study. Orthopade 32:296–304PubMedCrossRefGoogle Scholar
  22. 22.
    Maestro A, Harwin SF, Sandoval MG, Vaquero DH, Murcia A (1998) Influence of intramedullary versus extramedullary alignment guides on final total knee arthroplasty component position: a radiographic analysis. J Arthroplasty 13:552–8PubMedCrossRefGoogle Scholar
  23. 23.
    Mahaluxmivala J, Bankes MJK, Nicolai P, Aldam CH, Allen PW (2001) The effect of surgeon experience on component positioning in 673 press fit condylar posterior cruciate—sacrificing total knee arthroplasties. J Arthroplasty 16:635–40PubMedCrossRefGoogle Scholar
  24. 24.
    McGrory JE, Trousdale RT, Pagnano MW, Nigbur M (2002) Preoperative hip to ankle radiographs in total knee arthroplasty. Clin Orthop Relat Res 404:196–202PubMedCrossRefGoogle Scholar
  25. 25.
    Mont MA, Urquhart MA, Hungerford DS, Krackow KA (1997) Intramedullary goniometer can improve alignment in knee arthroplasty surgery. J Arthroplasty 12(3):332–6PubMedCrossRefGoogle Scholar
  26. 26.
    Moreland JR (1988) Mechanics of failure of total knee arthroplasty. Clin Orthop Relat Res 226:49–64PubMedGoogle Scholar
  27. 27.
    Patel DV, Ferris BD, Aichroth PM (1991) Radiological study of alignment after total knee replacement. Short radiographs or long radiographs?. Int Orthop 15:209–10PubMedGoogle Scholar
  28. 28.
    Perlick L, Bathis H, Lerch K, Luring C, Tingart M, Grifka J (2005) Revision total knee arthroplasty: a comparison of postoperative leg alignment after computer-assisted implantation versus the conventional technique. Knee Surg Sports Traumatol Arthrosc 13(3):167–73PubMedCrossRefGoogle Scholar
  29. 29.
    Petersen TL, Engh GA (1988) Radiographic assessment of knee alignment after total knee arthroplasty. J Arthroplasty 3:67–72PubMedCrossRefGoogle Scholar
  30. 30.
    Ranawat CS, Boachie-Adjei O (1988) Survivorship analysis and results of total condylar knee arthroplasty. Clin Orthop Relat Res 226:6–13PubMedGoogle Scholar
  31. 31.
    Rand JA, Coventry MB (1988) Ten-year evaluation of geometric total knee arthroplasty. Clin Orthop Rel Res 232:168–73Google Scholar
  32. 32.
    Reed SC, Gollish J (1997) The accuracy of femoral intramedullary guides in total knee arthroplasty. J Arthroplasty 12:677–82PubMedCrossRefGoogle Scholar
  33. 33.
    Ritter MA, Faris PM, Keating EM, Meding JB (1994) Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop 153–6PubMedGoogle Scholar
  34. 34.
    Rodriguez JA, Bhende H, Ranawat CS (2001) Total condylar knee replacement: a 20-year follow-up study. Clin Orthop Relat Res (388):10–7PubMedCrossRefGoogle Scholar
  35. 35.
    Ryd L, Lindtsrand A, Stentstrom A, Selvik G (1990) Porous coated anatomic tricompartmental tibial components. The relationship between position and micromotion. Clin Orthop Relat Res 251:189–97PubMedGoogle Scholar
  36. 36.
    Siu D, Cooke TD, Broekhiven LD, Lam M, Fisher B, Saunders G, Challis TW (1991) A standardized technique for lower limb radiography. Practice, applications, and error analysis. Invest Radiol 26:71–7PubMedCrossRefGoogle Scholar
  37. 37.
    Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A (2003) Positioning of total knee arthroplasty with and without navigation support. J Bone Joint Surg Br 85-B:830–5Google Scholar
  38. 38.
    Stulberg SD, Loan P, Sarin V (2002) Computer-assisted navigation in total knee replacement: results of an initial experience in thirty-five patients. J Bone Joint Surg Am 90–8Google Scholar
  39. 39.
    Swanson KE, Stocks GW, Warren PD, Hazel MR, Janssen HF (2000) Does axial limb rotation affect the alignment measurements in deformed limbs?. Clin Orthop Relat Res 371:246–52PubMedCrossRefGoogle Scholar
  40. 40.
    Teter KE, Bregman D, Colwell CW Jr (1995) Accuracy of intramedullary versus extramedullary tibial alignment cutting systems in total knee arthroplasty. Clin Orthop Relat Res 5 321:106–10Google Scholar
  41. 41.
    Tew M, Waugh W (1985) Tibiofemoral alignment and the results of knee replacement. J Bone Joint Surg Am 67B:551–6Google Scholar
  42. 42.
    Vince KG, Insall JN, Kelly MA (1989) The total condylar prosthesis. Ten- to twelve-year results of a cemented knee replacement. J Bone Joint Surg Br 793–7Google Scholar
  43. 43.
    Wright JG, Treble N, Feinstein AR (1993) Measurement of lower limb alignment using long radiographs. J Bone Joint Surg Br 75:164–5Google Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Ralf E. Rosenberger
    • 1
    Email author
  • Christian Hoser
    • 1
  • Sebastian Quirbach
    • 1
  • Rene Attal
    • 1
  • Alfred Hennerbichler
    • 1
  • Christian Fink
    • 1
  1. 1.Department of Trauma Surgery and Sports MedicineInnsbruck Medical UniversityInnsbruckAustria

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