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Computer-assisted surgery and patient-specific instrumentation improve the accuracy of tibial baseplate rotation in total knee arthroplasty compared to conventional instrumentation: a systematic review and meta-analysis

Knee Surgery, Sports Traumatology, Arthroscopy volume 30, pages 2654–2665 (2022)Cite this article

Abstract

Purpose

To determine whether patient-specific instrumentation (PSI), computer-assisted surgery (CAS) or robot-assisted surgery (RAS) enable more accurate rotational alignment of the tibial baseplate in primary total knee arthroplasty (TKA) compared to conventional instrumentation, in terms of deviation from the planned target and the proportion of outliers from the target zone.

Methods

The authors independently conducted three structured electronic literature searches using the PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases from 2007 to 2020. Studies were included if they compared rotational alignment of the tibial baseplate during TKA using conventional instrumentation versus PSI, CAS, and/or RAS, and reported deviation from preoperatively planned rotational alignment of the tibial baseplate in terms of absolute angles and/or number of outliers. Methodological quality of eligible studies was assessed by two researchers according to the Downs and Black Quality Checklist for Health Care Intervention Studies.

Results

Fifteen studies, that reported on 2925 knees, were eligible for this systematic review, of which 6 studies used PSI, and 9 used CAS. No studies were found for RAS. Of the studies that reported on angular deviation from preoperatively planned rotational alignment, most found smaller deviations using PSI (0.5° to 1.4°) compared to conventional instrumentation (1.0° to 1.6°). All studies that reported on proportions of outliers from a target zone (± 3°), found lower rates of outliers using PSI (0 to 22%) compared to conventional instrumentation (5 to 96%). Most studies reported smaller angular deviation from preoperatively planned rotational alignment using CAS (0.1° to 6.9°) compared to conventional instrumentation (1.1° to 7.8°). Of the studies that reported on proportions of outliers from a target zone (± 3°), most found fewer outliers using CAS (10 to 61%) compared to conventional instrumentation (17 to 78%).

Conclusion

This systematic review and meta-analysis revealed that both CAS and PSI can improve the accuracy of rotational alignment of the tibial baseplate by decreasing angular deviation from the preoperatively planned target and reducing the proportion of outliers from the target zone. The clinical relevance is that PSI and CAS can improve alignment, though the thresholds necessary to grant better outcomes and survival remain unclear.

Level of evidence

IV.

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Acknowledgements

Pier-Francesco Indelli: Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA. Nanne P. Kort: CortoClinics, Steeg 6E, 5482 WN, Schijndel, The Netherlands. Michael Liebensteiner: Department for Orthopaedic Surgery and Traumatology, Medical University Innsbruck, Innsbruck, Austria. Jacobus H. Muller: ReSurg SA, Rue Saint Jean 22, 1260 Nyon, Switzerland. Antonia Chen: Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. René Attal: Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, LKH Feldkirch, Carinagasse 47, 6807, Feldkirch, Austria. Markus P. Arnold: Practice LEONARDO - Physicians for Orthopaedic and Traumatologic Surgery, Hirslanden Clinic Birshof, 4142, Münchenstein, Basel, Switzerland. Alfredo Schiavone-Panni: Department of Medical and Surgical Specialties and Dentistry, University of Campania Luigi Vanvitelli, Naples 80138, Italy.

Funding

The authors are grateful to Ramsay Santé for funding the statistical analysis and manuscript preparation for this study.

Author information

Authors and Affiliations

  1. Ortoklinik and Cankaya Orthopedics, Ankara, Turkey

    Reha N. Tandogan

  2. CortoClinics, Schijndel, The Netherlands

    Nanne P. Kort

  3. Department of Orthopaedics and Traumatology, Istanbul Saglik Bilimleri University Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

    Ersin Ercin

  4. ReSurg SA, Rue Saint Jean 22, 1260, Nyon, Switzerland

    Floris van Rooij, Luca Nover & Mo Saffarini

  5. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland

    Michael T. Hirschmann

  6. Department of Orthopedics and Traumatology, Centre of Joint Replacement, Hospital Brandenburg, Medical School “Theodor Fontane”, Brandenburg/Havel, Germany

    Roland Becker

  7. Ramsay Santé, Lyon-Ortho-Clinic, Clinique de la Sauvegarde, Lyon, France

    David Dejour

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Consortia

European Knee Associates (EKA)

  • Pier-Francesco Indelli
  • , Nanne P. Kort
  • , Michael C. Liebensteiner
  • , Jacobus H. Muller
  • , Antonia F. Chen
  • , René Attal
  • , Markus P. Arnold
  •  & Alfredo Schiavone-Panni

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Correspondence to Floris van Rooij.

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MS, LN, FvR, EE, RB and MTH declare that they have no competing interests; RNT reports personal fees from Smith & Nephew, personal fees from Menerini Pharma, personal fees from Santa Farma Pharma; NPK reports other fees from BodyCad, Stryker, Zimmer-Biomet, bioventus; DD reports personal fees from SBM.

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Tandogan, R.N., Kort, N.P., Ercin, E. et al. Computer-assisted surgery and patient-specific instrumentation improve the accuracy of tibial baseplate rotation in total knee arthroplasty compared to conventional instrumentation: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30, 2654–2665 (2022). https://doi.org/10.1007/s00167-021-06495-x

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Keywords

  • Total knee arthroplasty
  • TKA
  • Tibial alignment
  • Transverse plane
  • Rotational alignment
  • Total knee replacement
  • Tibial component