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Surgeon-defined assessment is a poor predictor of knee balance in total knee arthroplasty: a prospective, multicenter study

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Background

The accuracy of surgeon-defined assessment (SDA) of soft tissue balance in total knee arthroplasty (TKA) is poorly understood despite balance being considered a significant determinant of surgical success. The study’s hypothesis was that intra-operative SDA is a poor predictor of coronal balance in TKA.

Methods

A prospective, multicenter study assessing accuracy of SDA of balance was conducted in 250 patients (285 TKAs). Eight surgeons and thirteen trainees participated, and all were blinded to sensor measurements. The primary outcome was test accuracy of SDA measured at 10°, 45° and 90° compared to sensor measures as the gold standard test. Cohen’s kappa coefficient was calculated to determine chance-corrected agreement. Secondary outcomes include the relationship of SDA to level of surgical experience, analysis of between-surgeon differences, and the influence of patient and operative factors on SDA accuracy.

Results

Average accuracy of SDA was 58.3%, 61.2% and 66.5% at 10°, 45° and 90° respectively. Cohen’s kappa coefficient was 0.18 at all angles and rated as “slight agreement”. SDA sensitivities to correctly identify a balanced knee (76.2% at 10°; 82.6% at 45°; 83.2% at 90°) were approximately twice specificities to correctly identify an unbalanced knee (42.6% at 10°; 34.1% at 45°; 41.4% at 90°). Surgical experience (surgeon versus trainee) had no effect on capacity to determine balance. Considerable between-surgeon variability was found (33–65% at 10°, 41–73% at 45°, 55–89% at 90°).

Conclusion

SDA was a poor predictor of balance, particularly when assessing the unbalanced TKA. Surgeon experience had no effect on test accuracy and considerable between-surgeon variability was recorded. These findings question the accuracy of SDA in TKA.

Trial Registration Number: ACTRN# 12618000817246.

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Acknowledgements

We wish to thank Mr Giovanni Porcella for his assistance with data collection and data entry. We also thank Mr Rick Moore and the Smith & Nephew team for their support of this project. We are appreciative of grants received from OrthoSensor, USA and Ramsay Hospital Research Foundation, Australia to support this research. Lastly, we are grateful to the Ingham Institute of Applied Medical Research, Australia for administering the funding for this study.

SENSOR BALANCE Study Group: Aziz Bhimani (Wollongong Private Hospital, Wollongong, NSW, Australia, Wollongong Hospital, Wollongong, NSW, Australia), Alexander W. R. Burns (Canberra Private Hospital, Deakin, ACT, Australia, Calvary John James Private Hospital, Deakin, ACT, Australia), Darren B. Chen (Sydney Knee Specialists, Kogarah NSW, Australia, St George Private Hospital, Kogarah, NSW, Australia, The Canterbury Hospital, Campsie, NSW, Australia), Ashish D. Diwan (St George and Sutherland Clinical School, University of NSW, Kogarah, NSW, Australia, St George Private Hospital, Kogarah, NSW, Australia), Ian A. Harris (Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia, South Western Sydney Clinical School, Faculty of Medicine, UNSW, Sydney, Australia), Anthony K. L. Leong (Wollongong Private Hospital, Wollongong, NSW, Australia, Wollongong Hospital, Wollongong, NSW, Australia, Kareena Private Hospital, Caringbah, NSW, Australia), Samuel J. MacDessi (Sydney Knee Specialists, Kogarah NSW, Australia, St George and Sutherland Clinical School, University of NSW, Kogarah, NSW, Australia, St George Private Hospital, Kogarah, NSW, Australia, The Canterbury Hospital, Campsie, NSW, Australia), Robert B Molnar (St George Private Hospital, Kogarah, NSW, Australia, Sutherland Hospital, Caringbah, NSW, Australia), Jonathan S. Mulford (Calvary St Luke’s Hospital, Launceston, TAS, Australia), Richard M Walker (Sydney Southwest Private Hospital, Liverpool, NSW, Australia, Fairfield Hospital, Prairiewood, NSW, Australia), Jil A Wood (Sydney Knee Specialists, Kogarah NSW, Australia)

Funding

This study was supported by grants from OrthoSensor (Dania Beach, FL, USA) and Ramsay Hospital Research Foundation (Sydney, Australia). Smith & Nephew provided the sensor inserts at no additional cost to patients. Grants were held in a dedicated research account and administered through the Ingham Institute of Applied Medical Research (Liverpool, NSW).

Author information

Authors and Affiliations

  1. Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hway, Kogarah, NSW, 2217, Australia

    Samuel J. MacDessi, Jil A. Wood, Samuel J. MacDessi & Jil A. Wood

  2. St George and Sutherland Clinical School, University of NSW, Kogarah, NSW, Australia

    Samuel J. MacDessi, Ashish D. Diwan, Ashish D. Diwan & Samuel J. MacDessi

  3. St George Private Hospital, Kogarah, NSW, Australia

    Samuel J. MacDessi, Ashish D. Diwan, Ashish D. Diwan & Samuel J. MacDessi

  4. The Canterbury Hospital, Campsie, NSW, Australia

    Samuel J. MacDessi & Samuel J. MacDessi

  5. Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia

    Ian A. Harris & Ian A. Harris

  6. South Western Sydney Clinical School, Faculty of Medicine, UNSW, Sydney, Australia

    Ian A. Harris & Ian A. Harris

Authors
  1. Samuel J. MacDessi
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Consortia

for the SENSOR BALANCE Study Group

  • Aziz Bhimani
  • , Alexander W. R. Burns
  • , Darren B. Chen
  • , Ashish D. Diwan
  • , Ian A. Harris
  • , Anthony K. L. Leong
  • , Samuel J. MacDessi
  • , Robert B. Molnar
  • , Jonathan S. Mulford
  • , Richard M. Walker
  •  & Jil A. Wood

Corresponding author

Correspondence to Samuel J. MacDessi.

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The authors declare that they have no competing interests.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The members of SENSOR BALANCE Study Group and their affiliations are listed in Acknowledgements section.

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MacDessi, S.J., Wood, J.A., Diwan, A.D. et al. Surgeon-defined assessment is a poor predictor of knee balance in total knee arthroplasty: a prospective, multicenter study. Knee Surg Sports Traumatol Arthrosc 29, 498–506 (2021). https://doi.org/10.1007/s00167-020-05925-6

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