Patient-specific instrumentation for total knee arthroplasty does not match the pre-operative plan as assessed by intra-operative computer-assisted navigation

  • Corey Scholes
  • Varun Sahni
  • Sebastien Lustig
  • David A. Parker
  • Myles R. J. Coolican



The introduction of patient-specific instruments (PSI) for guiding bone cuts could increase the incidence of malalignment in primary total knee arthroplasty. The purpose of this study was to assess the agreement between one type of patient-specific instrumentation (Zimmer PSI) and the pre-operative plan with respect to bone cuts and component alignment during TKR using imageless computer navigation.


A consecutive series of 30 femoral and tibial guides were assessed in-theatre by the same surgeon using computer navigation. Following surgical exposure, the PSI cutting guides were placed on the joint surface and alignment assessed using the navigation tracker. The difference between in-theatre data and the pre-operative plan was recorded and analysed.


The error between in-theatre measurements and pre-operative plan for the femoral and tibial components exceeded 3° for 3 and 17 % of the sample, respectively, while the error for total coronal alignment exceeded 3° for 27 % of the sample.


The present results indicate that alignment with Zimmer PSI cutting blocks, assessed by imageless navigation, does not match the pre-operative plan in a proportion of cases. To prevent unnecessary increases in the incidence of malalignment in primary TKR, it is recommended that these devices should not be used without objective verification of alignment, either in real-time or with post-operative imaging. Further work is required to identify the source of discrepancies and validate these devices prior to routine use.

Level of evidence



Patient specific Alignment Accuracy Total knee arthroplasty 



This study was supported financially by Zimmer Inc. and the Sydney Orthopaedic Research Institute. The authors would like to acknowledge Dr Joe Costa and Dr Jean Christian Balestro for their help with data collection. They would also like to acknowledge Mrs Amy Brierley and Mr Joe Lynch for their help with patient recruitment and data management.


  1. 1.
    Bali K, Walker P, Bruce W (2012) Custom-fit total knee arthroplasty: our initial experience in 32 knees. J Arthroplasty 27(6):1149–1154PubMedCrossRefGoogle Scholar
  2. 2.
    Barrack RL, Ruh EL, Williams BM, Ford AD, Foreman K, Nunley RM (2012) Patient specific cutting blocks are currently of no proven value. J Bone Joint Surg Br 94 (11 suppl A):95–99Google Scholar
  3. 3.
    Boonen B, Schotanus MG, Kort NP (2012) Preliminary experience with the patient-specific templating total knee arthroplasty. Acta Orthop 83(4):387–393PubMedCrossRefGoogle Scholar
  4. 4.
    Conteduca F, Iorio R, Mazza D, Caperna L, Bolle G, Argento G, Ferretti A (2012) Are MRI-based, patient matched cutting jigs as accurate as the tibial guides? Int Orthop 36(8):1589–1593PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Conteduca F, Iorio R, Mazza D, Caperna L, Bolle G, Argento G, Ferretti A (2012) Evaluation of the accuracy of a patient-specific instrumentation by navigation. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-012-2098-z Google Scholar
  6. 6.
    Daniilidis K, Tibesku CO (2013) Frontal plane alignment after total knee arthroplasty using patient-specific instruments. Int Orthop 37(1):45–50PubMedCentralPubMedGoogle Scholar
  7. 7.
    Fang D, Ritter MA (2009) Malalignment: forewarned is forearmed. Orthopedics 32(9):681–682CrossRefGoogle Scholar
  8. 8.
    Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK (2012) Meta-analysis of navigation vs conventional total knee arthroplasty. J Arthroplasty 27(6):1177–1182PubMedCrossRefGoogle Scholar
  9. 9.
    Heyse TJ, Tibesku CO (2012) Improved femoral component rotation in TKA using patient-specific instrumentation. Knee. doi: 10.1016/j.knee.2012.10.009 Google Scholar
  10. 10.
    Klatt BA, Goyal N, Austin MS, Hozack WJ (2008) Custom-fit total knee arthroplasty (OtisKnee) results in malalignment. J Arthroplasty 23(1):26–29PubMedGoogle Scholar
  11. 11.
    Lustig S, Fleury C, Goy D, Neyret P, Donell ST (2011) The accuracy of acquisition of an imageless computer-assisted system and its implication for knee arthroplasty. Knee 18(1):15–20PubMedCrossRefGoogle Scholar
  12. 12.
    Lustig S, Fleury C, Servien E, Demey G, Neyret P, Donell ST (2011) The effect of pelvic movement on the accuracy of hip centre location acquired using an imageless navigation system. Int Orthop 35(11):1605–1610PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Lustig S, Scholes CJ, Oussedik SI, Kinzel V, Coolican MR, Parker DA (2013) Unsatisfactory accuracy as determined by computer navigation of VISIONAIRE patient-specific instrumentation for total knee arthroplasty. J Arthroplasty 28(3):469–473PubMedCrossRefGoogle Scholar
  14. 14.
    Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K (2007) Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty 22(8):1097–1106PubMedCrossRefGoogle Scholar
  15. 15.
    Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AV Jr (2012) Improved accuracy of alignment with patient-specific positioning guides compared with manual instrumentation in TKA. Clin Orthop Relat Res 470:99–107PubMedCrossRefGoogle Scholar
  16. 16.
    Noble JW Jr, Moore CA, Liu N (2012) The value of patient-matched instrumentation in total knee arthroplasty. J Arthroplasty 27(1):153–155PubMedGoogle Scholar
  17. 17.
    Nunley RM, Ellison BS, Ruh EL, Williams BM, Foreman K, Ford AD, Barrack RL (2012) Are patient-specific cutting blocks cost-effective for total knee arthroplasty? Clin Orthop Relat Res 470:889–894PubMedCrossRefGoogle Scholar
  18. 18.
    Nunley RM, Ellison BS, Zhu J, Ruh EL, Howell SM, Barrack RL (2012) Do patient-specific guides improve coronal alignment in total knee arthroplasty? Clin Orthop Relat Res 470:895–902PubMedCrossRefGoogle Scholar
  19. 19.
    Slover JD, Rubash HE, Malchau H, Bosco JA (2012) Cost-effectiveness analysis of custom total knee cutting blocks. J Arthroplasty 27(2):180–185PubMedCrossRefGoogle Scholar
  20. 20.
    Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF (2009) Initial experience with custom-fit total knee replacement: intra-operative events and long-leg coronal alignment. Int Orthop 33(6):1571–1575PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Stronach BM, Pelt CE, Erickson J, Peters CL (2013) Patient-specific total knee arthroplasty required frequent surgeon-directed changes. Clin Orthop Relat Res 471:169–174PubMedCrossRefGoogle Scholar
  22. 22.
    Victor J, Van Doninck D, Labey L, Innocenti B, Parizel PM, Bellemans J (2009) How precise can bony landmarks be determined on a CT scan of the knee? Knee 16(5):358–365PubMedCrossRefGoogle Scholar
  23. 23.
    Widmer BJ, Scholes CJ, Lustig S, Conrad L, Oussedik SI, Parker DA (2013) Intraoperative computer navigation parameters are poor predictors of function 1 year after total knee arthroplasty. J Arthroplasty 28(1):56–61PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Corey Scholes
    • 1
  • Varun Sahni
    • 1
  • Sebastien Lustig
    • 1
    • 2
  • David A. Parker
    • 1
  • Myles R. J. Coolican
    • 1
  1. 1.Sydney Orthopaedic Research InstituteChatswoodAustralia
  2. 2.Albert Trillat CenterLyon University HospitalLyonFrance

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