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Patient-specific cruciate-retaining total knee replacement with individualized implants and instruments (iTotal™ CR G2)

Patientenspezifischer kreuzbanderhaltender totalendoprothetischer Kniegelenksersatz mit individualisierten Implantaten und Instrumenten (iTotalTM CR G2)

  • Surgical Techniques
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Abstract

Objective

Treatment of tricompartimental osteoarthritis (OA) using customized instruments and implants for cruciate-retaining total knee arthroplasty. Use of patient-specific instruments and implants (ConforMIS iTotalTM CR G2) together with a 3D-planning protocol (iView®). Retropatellar resurfacing is optional.

Indications

Symptomatic tricompartmental OA of the knee (Kellgren–Lawrence stage IV) with preserved posterior cruciate ligament (PCL) after unsuccessful conservative or joint-preserving surgical treatment.

Contraindications

Knee ligament instabilities of the posterior cruciate or collateral ligaments. Infection. Relative contraindication: knee deformities >15° (varus, valgus, flexion); prior partial knee replacement.

Surgical technique

Midline or parapatellar medial skin incision, medial arthrotomy; distal femoral resection with patient-specific cutting block; tibial resection using either a cutting jig for the anatomic slope or a fixed 5° slope. Balancing the knee in extension and flexion gap using patient-specific spacer. The final tibial preparation achieved with gap-balanced placement of the femoral cutting jigs. Kinematic testing using anatomic trial components. Final implant components are cemented in extension. Wound layers are sutured. Drainage is optional.

Postoperative management

Sterile wound dressing; compressive bandage. No limitation of the active and passive range of motion. Optional partial weight bearing during the first 2 weeks, then transition to full weight bearing. Follow-up directly after surgery, at 12 and 52 weeks, then every 1–2 years.

Results

Overall 60 patients with tricompartmental knee OA and preserved PCL were treated. Mean age was 66 (range 45–76) years. Minimum follow-up was 12 months. There was 1 septic revision after a low-grade infection, 1 reoperation to replace the patellar due to patellar osteoarthritis and 3 manipulations under anesthesia (MUAs) to increase range of motion. Radiographic analyses demonstrated an ideal implant fit with less than 2 mm subsidence or overhang. The WOMAC score improved from 154.8 points preoperatively to 83.5 points at 1 year and 59.3 points at 2 years postoperatively. The EuroQol-5D Score also improved from 11.1 points preoperatively to 7.7 points at 1 year postoperatively.

Zusammenfassung

Ziel

Kreuzbanderhaltende Knietotalendoprothese bei Patienten mit Pangonarthrose mittels medialer Arthrotomie. Verwendung patientenspezifischer Instrumente und Implantate (ConforMIS iTotalTM CR G2) mit 3‑D-Planungsprotokoll (iView®). Retropatellarersatz ist optional möglich.

Indikation

Symptomatische Pangonarthrose (nach Kellgren und Lawrence Stadium IV) mit erhaltenem hinterem Kreuzband (HKB) nach erfolgloser konservativer und/oder operativer gelenkerhaltender Therapie.

Kontraindikation

Kniebandinstabilitäten des hinteren Kreuzbands oder der Seitenbänder. Infektion. Relative Kontraindikation: Kniedeformitäten >15° (Varus, Valgus, Streckdefizit) und/oder vorangegangener Teilgelenkersatz.

Operationstechnik

Mittige oder medial parapatellare Hautinzision, mediale Arthrotomie. Distale femorale Resektion mit patientenspezifischem Schneideblock; Tibiaresektion mit einem Schneideblock, der einen anatomischen oder einen fixen tibialen Slope von 5° enthält. Balancierung des Kniegelenks in Streckung und Beugung mit individuell angepassten Balancierungshilfen. Finale balancierte Femurpräparation mit individuellen femoralen Schneideblöcken. Kinematische Prüfung mit anatomischen Probekomponenten. Die abschließende Tibiapräparation erfolgt mittels individueller Bohrschablone. Die finalen Implantatkomponenten werden in Streckstellung einzementiert. Schichtweiser Wundverschluss. Die Einlage einer Drainage ist optional.

Postoperatives Management

Sterile Wundauflagen und elastokompressive Wickelung. Keine Limitierung des aktiven und passiven Bewegungsausmaßes. Eine Teilbelastung für die ersten 2 Wochen postoperativ ist optional, bevor der Übergang zur Vollbelastung erfolgt. Verlaufskontrollen direkt postoperativ, nach 12 und 52 Wochen, danach alle 1 bis 2 Jahre.

Ergebnisse

Behandelt wurden 60 Patienten mit Pangonarthrose und erhaltenem HKB. Durchschnittsalter: 66 (45–76) Jahre. Nachuntersuchungszeit mindestens 12 Monate. Es gab eine Revision nach einer Low-grade-Infektion, eine Reoperation zur Behandlung einer Retropatellararthrose mit Retropatellarersatz und 3 Narkosemobilisationen zur Verbesserung der Beweglichkeit. Röntgenkontrollen zeigten durchweg eine ideale Implantatpassform mit weniger als 2 mm Implantatüber- oder -unterstand. Der WOMAC-Gesamtscore verbesserte sich von 154,8 Punkten präoperativ auf 83,5 Punkte nach einem Jahr und auf 59,3 Punkte nach 2 Jahren postoperativ. Auch der EuroQol-5D-Score verbesserte sich von 11,1 Punkten präoperativ auf 7,7 Punkte postoperativ.

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References

  1. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ (2010) Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop 468:57–63

    Article  Google Scholar 

  2. Parvizi J, Nunley RM, Berend KR et al (2014) High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop 472:133–137

    Article  Google Scholar 

  3. Leszko F, Hovinga KR, Lerner AL, Komistek RD, Mahfouz MR (2011) In vivo normal knee kinematics: is ethnicity or gender an influencing factor? Clin Orthop Relat Res 469:95–106. https://doi.org/10.1007/s11999-010-1517-z

    Article  PubMed  Google Scholar 

  4. Puthumanapully PK, Harris SJ, Leong A, Cobb JP, Amis AA, Jeffers J (2014) A morphometric study of normal and varus knees. Knee Surg Sports Traumatol Arthrosc 22:2891–2899. https://doi.org/10.1007/s00167-014-3337-2

    Article  PubMed  PubMed Central  Google Scholar 

  5. Thienpont E, Schwab PE, Fennema P (2017) Efficacy of patient-specific instruments in total knee arthroplasty: a systematic review and meta-analysis. J Bone Joint Surg Am 99:521–530. https://doi.org/10.2106/JBJS.16.00496

    Article  PubMed  Google Scholar 

  6. Steinert AF, Sefrin L, Hoberg M, Arnholdt J, Rudert M (2015) Individualized total knee arthroplasty. Orthopade 44:290–301. https://doi.org/10.1007/s00132-015-3104-1 (German)

    Article  CAS  PubMed  Google Scholar 

  7. Steinert AF, Holzapfel BM, Sefrin L, Arnholdt J, Hoberg M, Rudert M (2016) Total knee arthroplasty. Patient-specific instruments and implants. Orthopade 45:331–340. https://doi.org/10.1007/s00132-016-3246-9 (Review. German)

    Article  PubMed  Google Scholar 

  8. Patil S, Bunn A, Bugbee WD, Colwell CW Jr, D’Lima DD (2015) Patient-specific implants with custom cutting blocks better approximate natural knee kinematics than standard TKA without custom cutting blocks. Knee 22:624–629

    Article  Google Scholar 

  9. Vanlommel J, Luyckx JP, Labey L, Innocenti B, De Corte R, Bellemans J (2011) Cementing the tibial component in total knee arthroplasty. J Arthroplasty 26:492–496. https://doi.org/10.1016/j.arth.2010.01.107

    Article  PubMed  Google Scholar 

  10. Mahoney OM, Kinsey T (2010) Overhang of the femoral component in knee arthroplasty: risk factors and clinical consequences. J Bone Joint Surg Am 92:1115–1121

    Article  Google Scholar 

  11. Ivie CB, Probst PJ, Bal AK, Stannard JT, Crist BD, Bal SB (2014) Improved radiographic outcomes with patient-specific total knee arthroplasty. J Arthroplasty 29:2100–2103. https://doi.org/10.1016/j.arth.2014.06.024

    Article  PubMed  Google Scholar 

  12. Schwarzkopf R, Brodsky M, Garcia GA, Gomoll AH (2015) Surgical and functional outcomes in patients undergoing total knee replacement with patient-specific implants compared with “off-the-shelf” implants. Orthop J Sports Med. https://doi.org/10.1177/2325967115590379

    Article  PubMed  PubMed Central  Google Scholar 

  13. Palmer J, Sloan K, Clark G (2014) Functional outcomes comparing Triathlon versus Duracon total knee arthroplasty: does the Triathlon outperform its predecessor? Int Orthop 38:1375–1378. https://doi.org/10.1007/s00264-014-2307-0

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ranawat CS, White PB, West S, Ranawat AS (2017) Clinical and radiographic results of attune and PFC sigma knee designs at 2‑year follow-up: a prospective matched-pair analysis. J Arthroplasty 32:431–436. https://doi.org/10.1016/j.arth.2016.07.021

    Article  PubMed  Google Scholar 

  15. Rajgopal A, Aggarwal K, Khurana A, Rao A, Vasdev A, Pandit H (2017) Gait parameters and functional outcomes after total knee arthroplasty using persona knee system with cruciate retaining and ultracongruent knee inserts. J Arthroplasty 32:87–91. https://doi.org/10.1016/j.arth.2016.06.012

    Article  PubMed  Google Scholar 

  16. Beyond.Compliance.iTotal G2 XE and iTotal G2.11/02/2018.19:20©2018 Northgate Public Services (UK) Limited

  17. Meier M, Zingde S, Steinert A, Kurtz W, Koeck F, Beckmann J (2019) What is the possible impact of high variability of distal femoral geometry on TKA? A CT data analysis of 24,042 knees. Clin Orthop Relat Res 477:561–570. https://doi.org/10.1097/CORR.0000000000000611

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University Würzburg, Brettreichstraße 11, Würzburg, Germany

    Andre F. Steinert MHBA, Björn Jansen, Lennart Schröder, Boris M. Holzapfel, Jörg Arnholdt & Maximilian Rudert

  2. Campus Bad Neustadt, Klinik für Orthopädie, Unfallchirurgie, Schulterchirurgie und Endoprothetik, Rhön Klinikum, Von-Guttenberg-Straße 11, 97616, Bad Neustadt a.d. Saale, Germany

    Andre F. Steinert MHBA

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  1. Andre F. Steinert MHBA
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  2. Lukas Sefrin
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  3. Björn Jansen
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  5. Boris M. Holzapfel
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  7. Maximilian Rudert
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Corresponding author

Correspondence to Andre F. Steinert MHBA.

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Conflict of interest

A.F. Steinert received support for consulting activities from ConforMIS Inc. M. Rudert states that he received institutional support from ConforMIS Europe GmbH for training activities. L. Sefrin, B. Jansen, L. Schröder, B.M. Holzapfel and J. Arnholdt declare that they have no competing interests.

All procedures performed in studies involving human participants or on human tissue were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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W. Petersen, Berlin

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H. Konopatzki, Heidelberg

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Steinert, A.F., Sefrin, L., Jansen, B. et al. Patient-specific cruciate-retaining total knee replacement with individualized implants and instruments (iTotal™ CR G2). Oper Orthop Traumatol 33, 170–180 (2021). https://doi.org/10.1007/s00064-020-00690-8

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  • DOI: https://doi.org/10.1007/s00064-020-00690-8

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