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An anatomo-functional implant positioning technique with robotic assistance for primary TKA allows the restoration of the native knee alignment and a natural functional ligament pattern, with a faster recovery at 6 months compared to an adjusted mechanical technique

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

An anatomo-functional implant positioning (AFIP) technique in total knee arthroplasty (TKA) could restore physiological ligament balance (symmetric gap in extension, asymmetric gap in flexion). The purposes were to compare (1) ligament balancing in extension and flexion after TKA in the AFIP group, (2) TKA alignment, implant positioning and patellar tracking between AFIP and adjusted mechanical alignment (aMA) techniques, (3) clinical outcomes between both groups at 12 months.

Methods

All robotic-assisted TKA with an AFIP technique were included (n = 40). Exclusion criteria were genu valgum (HKA angle > 183°), extra-articular deformity more than 10°, and patellar maltracking (high-grade J-sign). One control patient with a TKA implanted by an aMA technique was matched for each case, based on age, body mass index, sex, and knee alignment. Ligament balancing (medial and lateral gaps in millimeters) in full extension and at 90° of flexion after TKA in the AFIP group was assessed with the robotic system. TKA alignment (HKA angle), implants positioning (femoral and tibial coronal axis, tibial slope, joint-line orientation), patellar tracking (patellar tilt and translation) and the Knee Society Score (KSS) at 6 and 12 months were compared between both groups. The ligament balancing was compared using a t test for paired samples in the AFIP group. The radiographic measurements and KSS scores were compared between groups using a t test for independent samples.

Results

In the AFIP group, there was no significant difference between the medial and lateral gap laxity in extension (NS). A significant opening of the lateral gap was observed in flexion compared to extension (mean: + 2.9 mm; p < 0.0001). The mean postoperative HKA angle was comparable between both groups (177.3° ± 2.1 in the AFIP group vs 176.8° ± 3.2; NS). In the AFIP group, the femoral anatomy was restored (90.9° ± 1.6) and the tibial varus was partially corrected (87.4° ± 1.8). The improvement of Knee and Function KSS at 6 months was better in the AFIP group (59.3 ± 11.9 and 51.7 ± 20, respectively, versus 49.3 ± 9.7 and 20.8 ± 13; p < 0.001).

Conclusion

The AFIP concept allowed the restoration of the native knee alignment and a natural functional ligament pattern. With a more physiological target for ligament balancing, the AFIP technique had equivalent clinical outcomes at 12 months compared to aMA, with a faster recovery.

Level of evidence

III retrospective therapeutic case control series.

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Abbreviations

AFIP:

Anatomo-functional implant positioning

BMI:

Body mass index

HKA:

Hip–knee angle

JLCA:

Joint-line convergence angle

JLO:

Joint-line orientation

KA:

Kinematic alignment

KSS:

Knee Society Score

MA:

Mechanical alignment

MCL:

Medial collateral ligament

mMDFA:

Mechanical medial distal femoral angle

MPTA:

Medial proximal tibial angle

PA:

Personalized alignment

raTKA:

Robotic-assisted total knee arthroplasty

ROM:

Range of motion

TKA:

Total knee arthroplasty

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Funding

This research did not receive any specific grant from funding agencies from the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, International Knee and Joint Centre, Abu Dhabi, United Arab Emirates

    Sébastien Parratte & Burak Yagmur Ozturk

  2. Institute for Locomotion, Aix-Marseille University, Marseille, France

    Sébastien Parratte

  3. Department of Orthopaedic Surgery, AZ Maria Middelares, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium

    Philippe Van Overschelde

  4. Zimmer, GmbH, Winterthur, Switzerland

    Marc Bandi

  5. Department of Orthopaedic Surgery, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix Rousse, Lyon, France

    Cécile Batailler

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  1. Sébastien Parratte
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  4. Burak Yagmur Ozturk
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  5. Cécile Batailler
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Contributions

SP: Study design, operator, manuscript editing and supervisor. PVO: Literature review and manuscript editing. MB: Literature review and manuscript editing. BYO: Study design, data collection and manuscript editing. CB: Study design, data collection, statistical analysis, literature review and manuscript writing.

Corresponding author

Correspondence to Cécile Batailler.

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Conflict of interest

SP: Royalties from Zimmer Biomet and Newclip; Consultant for Zimmer Biomet; Treasurer for European Knee Society. PVO: Consultant for Microport; Shareholder for MoveUP. MB: Employee from Zimmer Biomet. BYO: Consultant for Smith and Nephew. CB: Grant from SoFCOT (Société francaise de chirurgie orthopédique et traumatologique).

Ethical approval

All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee, the 1964 Helsinki declaration, and its later amendments, or comparable ethical standards. The approval from the internal review board was obtained (study ID Number: MF3867, approval date: 20th December 2020).

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All patient participants provided informed consent for review of their medical records.

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Parratte, S., Van Overschelde, P., Bandi, M. et al. An anatomo-functional implant positioning technique with robotic assistance for primary TKA allows the restoration of the native knee alignment and a natural functional ligament pattern, with a faster recovery at 6 months compared to an adjusted mechanical technique. Knee Surg Sports Traumatol Arthrosc 31, 1334–1346 (2023). https://doi.org/10.1007/s00167-022-06995-4

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