Skip to main content
SpringerLink
Log in

Comparison of custom to standard TKA instrumentation with computed tomography

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

There is conflicting evidence whether custom instrumentation for total knee arthroplasty (TKA) improves component position compared to standard instrumentation. Studies have relied on long-limb radiographs limited to two-dimensional (2D) analysis and subjected to rotational inaccuracy. We used postoperative computed tomography (CT) to evaluate preoperative three-dimensional templating and CI to facilitate accurate and efficient implantation of TKA femoral and tibial components.

Methods

We prospectively evaluated a single-surgeon cohort of 78 TKA patients (51 custom, 27 standard) with postoperative CT scans using 3D reconstruction and contour-matching technology to preoperative imaging. Component alignment was measured in coronal, sagittal and axial planes.

Results

Preoperative templating for custom instrumentation was 87 and 79 % accurate for femoral and tibial component size. All custom components were within 1 size except for the tibial component in one patient (2 sizes). Tourniquet time was 5 min longer for custom (30 min) than standard (25 min). In no case was custom instrumentation aborted in favour of standard instrumentation nor was original alignment of custom instrumentation required to be adjusted intraoperatively. There were more outliers greater than 2° from intended alignment with standard instrumentation than custom for both components in all three planes. Custom instrumentation was more accurate in component position for tibial coronal alignment (custom: 1.5° ± 1.2°; standard: 3° ± 1.9°; p = 0.0001) and both tibial (custom: 1.4° ± 1.1°; standard: 16.9° ± 6.8°; p < 0.0001) and femoral (custom: 1.2° ± 0.9°; standard: 3.1° ± 2.1°; p < 0.0001) rotational alignment, and was similar to standard instrumentation in other measurements.

Conclusions

When evaluated with CT, custom instrumentation performs similar or better to standard instrumentation in component alignment and accurately templates component size. Tourniquet time was mildly increased for custom compared to standard.

Level of evidence

Level I, prospective diagnostic.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Aglietti P, Sensi L, Cuorno P, Ciardullo A (2008) Rotational position of femoral and tibial components in TKA using the femoral transepicondylar axis. Clin Orthop Relat Res 466:2751–2755

    Article  PubMed Central  PubMed  Google Scholar 

  2. Bellemans J (2011) Neutral mechanical alignment: a requirement for successful TKA (Opposes). Orthopedics 34:e507–e509

    Article  PubMed  Google Scholar 

  3. Berger RA, Crossett LS (1998) Determining rotation of the femoral and tibial components in total knee arthroplasty: a computer tomography technique. Oper Tech Orthop 8:128–133

    Article  Google Scholar 

  4. Chauhan S, Clark G, Lloyd S, Scott R, Breidahl W, Sikorski J (2004) Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT protocol). J Bone Joint Surg Br 86:818–823

    Article  CAS  PubMed  Google Scholar 

  5. Chung BJ, Kang YG, Chang CB, Kim SJ, Kim TK (2009) Differences between sagittal femoral mechanical and distal reference axes should be considered in navigated TKA. Clin Orthop Relat Res 467:2403–2413

    Article  PubMed Central  Google Scholar 

  6. Cobb JP, Dixon H, Dandachli W, Iranpour F (2008) The anatomical tibial axis: reliable rotational orientation in knee replacement. J Bone Joint Surg Br 90:1032–1038

    Article  CAS  PubMed  Google Scholar 

  7. 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 36:1589–1593

    Article  PubMed Central  PubMed  Google Scholar 

  8. 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 Athrosc. doi:10.1007/s00167-012-2098-z

    Google Scholar 

  9. Dennis DA (2008) Measured resection: an outdated technique in total knee arthroplasty. Orthopedics 31(940):943–944

    Google Scholar 

  10. Engh GA, Peterson TL (1990) Comparative experience with intramedullary and extramedullary alignment in total knee arthroplasty. J Arthroplasty 5:1–8

    Article  CAS  PubMed  Google Scholar 

  11. Gujarathi N, Putti AB, Abboud RJ, MacLean JG, Espley AJ, Kellett CF (2009) Risk of periprosthetic fracture after anterior femoral notching. Acta Orthop 80:553–556

    Article  PubMed Central  PubMed  Google Scholar 

  12. Henckel J, Richards R, Lozhkin K, Harris S, Rodriguez y Baena F, Barrett A, Cobb J (2006) Very low-dose computed tomography for planning and outcome measurement in knee replacement. J Bone Joint Surg Br 88:1513–1518

    Article  CAS  PubMed  Google Scholar 

  13. Howell SM, Chen J, Hull ML (2012) Variability of the location of the tibial tubercle affects the rotational alignment of the tibial component in kinematically aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-012-1987-5

    Google Scholar 

  14. Jerosch J, Peuker E, Phillipps B, Filler T (2002) Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis. Knee Surg Sports Traumatol Arthrosc 10:194–197

    Article  CAS  PubMed  Google Scholar 

  15. Kannan A, Hawdon G, McMahon SJ (2012) Effect of flexion and rotation on measures of coronal alignment after TKA. J Knee Surg 25:407–410

    Article  PubMed  Google Scholar 

  16. Konigsberg B, Hess R, Hartman C, Smith L, Garvin KL (2013) Inter- and intra-observer reliability of two-dimensional CT scan for total knee arthroplasty component malrotation. Clin Orthop Relat Res. doi:10.1007/s11999-013-3111-7

    PubMed  Google Scholar 

  17. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89:780–785

    Article  PubMed  Google Scholar 

  18. Lesh ML, Schneider DJ, Deol G, Davis B, Jacobs CR, Pellegrini VDJ (2000) The consequences of anterior femoral notching in total knee arthroplasty: a biomechanical study. J Bone Joint Surg 82-A:1096–1101

    CAS  PubMed  Google Scholar 

  19. Lombardi AVJ, Berend KR, Ng VY (2011) Neutral mechanical alignment: a requirement for successful TKA: affirms. Orthopedics 34:e504–e506

    PubMed  Google Scholar 

  20. Lonner JH, Laird MT, Stuchin SA (1996) Effect of rotation and knee flexion on radiographic alignment in total knee arthroplasties. Clin Orthop Relat Res 331:102–106

    Article  PubMed  Google Scholar 

  21. Lutzner J, Krummenauer F, Gunther KP, Kirschner S (2010) Rotational alignment of the tibial component in total knee arthroplasty is better at the medial third of the tibial tuberosity than at the medial border. BMC Musculoskel Disord 11:57

    Google Scholar 

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

    Article  PubMed  Google Scholar 

  23. 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 22:1097–1106

    Article  PubMed  Google Scholar 

  24. Matziolis G, Adam J, Perka C (2010) Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement. Arch Orthop Trauma Surg 130:1487–1491

    Article  PubMed  Google Scholar 

  25. Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C (2007) A prospective, randomized study of computer-assisted and conventional total knee arthroplasty. Three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am 89:236–243

    Article  PubMed  Google Scholar 

  26. Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 69:745–749

    CAS  PubMed  Google Scholar 

  27. Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AVJ (2012) Improved accuracy of alignment with patient specific positioning guides compared with manual instrumentation in total knee arthroplasty. Clin Orthop Relat Res 470:99–107

    Article  PubMed Central  PubMed  Google Scholar 

  28. Ng VY, McShane MA (2012) MRI-based pin guide patient specific instruments. In: Thienpont E (ed) Improving accuracy in knee arthroplasty. Jaypee Publishers, New Delhi, pp 233–252

    Chapter  Google Scholar 

  29. 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 470:889–894

    Article  PubMed Central  PubMed  Google Scholar 

  30. 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 470:895–902

    Article  PubMed Central  PubMed  Google Scholar 

  31. Olcott CW, Scott RD (2000) A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplasty. J Arthroplasty 15:22–26

    Article  CAS  PubMed  Google Scholar 

  32. Parratte S, Pagnano MW, Trousdale RT, Berry DJ (2010) Effect of postoperative mechanical axis alignment on the 15-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am 92:2143–2149

    Article  PubMed  Google Scholar 

  33. Petersen TL, Engh GA (1988) Radiographic assessment of knee alignment after total knee arthroplasty. J Arthroplasty 3:67–72

    Article  CAS  PubMed  Google Scholar 

  34. Radtke K, Becher C, Noll Y, Ostermeier S (2010) Effect of limb rotation on radiographic alignment in total knee arthroplasties. Arch Orthop Trauma Surg 130:451–457

    Article  PubMed  Google Scholar 

  35. Ritter M, Thong A, Keating E, Faris P, Meding J, Berend M, Pierson J, Davis K (2005) The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome. J Bone Joint Surg Am 87:2411–2414

    Article  PubMed  Google Scholar 

  36. Seo JG, Kim BK, Moon YW, Kim JH, Yoon BH, Ahn TK, Lee DH (2009) Bony landmarks for determining the mechanical axis of the femur in the sagittal plane during total knee arthroplasty. Clinics Orthop Surg 1:128–131

    Article  Google Scholar 

  37. Siston RA, Goodman SB, Patel JJ, Delp SL, Giori NJ (2006) The high variability of tibial rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 452:65–69

    Article  PubMed  Google Scholar 

  38. Stoeckl B, Nogler M, Krismer M, Belmel C, de la Barrera JL, Kessler O (2006) Reliability of the transepicondylar axis as an anatomical landmark in total knee arthroplasty. J Arthroplasty 21:878–882

    Article  PubMed  Google Scholar 

  39. Stronach B, Pelt C, Erickson J, Peters CL (2013) Patient-specific instrumentation in TKA required frequent surgeon directed intraoperative changes. Clin Orthop Relat Res 471:169–174

    Article  PubMed Central  PubMed  Google Scholar 

  40. Stronach B, Pelt C, Erickson J, Peters CL (2012) Patient-specific instrumentation in total knee arthroplasty provides no improvement in component alignment. J Knee Surg 25:213–219

    Article  Google Scholar 

  41. Tang WM, Chiu KY, Kwan MF, Ng TP, Yau WP (2005) Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty. J Orthop Res 23:41–45

    Article  CAS  PubMed  Google Scholar 

  42. Walensky NA (1965) A study of anterior femoral curvature in man. Anat Rec 151:559–570

    Article  CAS  PubMed  Google Scholar 

  43. Yehyawi TM, Callaghan JJ, Pedersen DR, O’Rourke MR, Liu SS (2007) Variances in sagittal femoral shaft bowing in patients undergoing TKA. Clin Orthop Relat Res 464:99–104

    PubMed  Google Scholar 

  44. Zalzal P, Backstein D, Gross AE, Papini M (2006) Notching of the anterior femoral cortex during total knee arthroplasty. J Arthroplasty 21:737–743

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Study funding provided by Zimmer Inc. (Warsaw, IN, USA).

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, The Wexner Medical Center, The Ohio State University, 725 Prior Hall, 376 West 10th Avenue, Columbus, OH, 43210, USA

    Vincent Y. Ng

  2. The Ohio Orthopaedic Center of Excellence, Columbus, OH, USA

    Lindsay Arnott, Ronald Hopkins, Jamie Lewis & Michael A. McShane

  3. School of Public Health, The University of Illinois Chicago, Chicago, IL, USA

    Lisa Nicholson

  4. Riverside Radiology and Interventional Associates, Columbus, OH, USA

    Douglas Reader

  5. Zimmer Inc, Warsaw, IN, USA

    Jia Li

  6. Doctor’s Hospital, Columbus, OH, USA

    Sean Sutphen

Authors
  1. Vincent Y. Ng
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lindsay Arnott
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jia Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ronald Hopkins
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jamie Lewis
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sean Sutphen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lisa Nicholson
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Douglas Reader
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Michael A. McShane
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vincent Y. Ng.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ng, V.Y., Arnott, L., Li, J. et al. Comparison of custom to standard TKA instrumentation with computed tomography. Knee Surg Sports Traumatol Arthrosc 22, 1833–1842 (2014). https://doi.org/10.1007/s00167-013-2632-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-013-2632-7

Keywords

Search

Navigation