Skip to main content

Advertisement

SpringerLink
Log in

Patient-specific Guides Do Not Improve Accuracy in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

  • Symposium: 2013 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Recently, patient-specific guides (PSGs) have been introduced, claiming a significant improvement in accuracy and reproducibility of component positioning in TKA. Despite intensive marketing by the manufacturers, this claim has not yet been confirmed in a controlled prospective trial.

Questions/purposes

We (1) compared three-planar component alignment and overall coronal mechanical alignment between PSG and conventional instrumentation and (2) logged the need for applying changes in the suggested position of the PSG.

Methods

In this randomized controlled trial, we enrolled 128 patients. In the PSG cohort, surgical navigation was used as an intraoperative control. When the suggested cut deviated more than 3° from target, the use of PSG was abandoned and marked as an outlier. When cranial-caudal position or size was adapted, the PSG was marked as modified. All patients underwent long-leg standing radiography and CT scan. Deviation of more than 3° from the target in any plane was defined as an outlier.

Results

The PSG and conventional cohorts showed similar numbers of outliers in overall coronal alignment (25% versus 28%; p = 0.69), femoral coronal alignment (7% versus 14%) (p = 0.24), and femoral axial alignment (23% versus 17%; p = 0.50). There were more outliers in tibial coronal (15% versus 3%; p = 0.03) and sagittal 21% versus 3%; p = 0.002) alignment in the PSG group than in the conventional group. PSGs were abandoned in 14 patients (22%) and modified in 18 (28%).

Conclusions

PSGs do not improve accuracy in TKA and, in our experience, were somewhat impractical in that the procedure needed to be either modified or abandoned with some frequency.

Level of Evidence

Level I, therapeutic study. See instructions for authors for a complete description of levels of evidence.

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

Similar content being viewed by others

References

  1. Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H, Nakamura T. Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res. 1999;366:155–163.

    Article  PubMed  Google Scholar 

  2. Anouchi YS, Whiteside LA, Kaiser AD, Milliano MT. The effects of axial rotational alignment of the femoral component on knee stability and patellar tracking in total knee arthroplasty demonstrated on autopsy specimens. Clin Orthop Relat Res. 1993;287:170–177.

    PubMed  Google Scholar 

  3. Bargren JH, Blaha JD, Freeman MA. Alignment in total knee arthroplasty: correlated biomechanical and clinical observations. Clin Orthop Relat Res. 1983;173:178–183.

    PubMed  Google Scholar 

  4. Bauwens K, Matthes G, Wich M, Gebhard F, Hanson B, Ekkernkamp A, Stengel D. Navigated total knee replacement: a meta-analysis. J Bone Joint Surg Am. 2007;89:261–269.

    Article  PubMed  Google Scholar 

  5. Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat Award. Is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res. 2012;470:45–53.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Bellemans J, Robijns F, Duerinckx J, Banks S, Vandenneucker H. The influence of tibial slope on maximal flexion after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2005;13:193–196.

    Article  CAS  PubMed  Google Scholar 

  7. Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R, Faris GW, Davis KE. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res. 2004;428:26–34.

    Article  PubMed  Google Scholar 

  8. Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res. 1998;356:144–153.

    Article  PubMed  Google Scholar 

  9. Choong PF, Dowsey MM, Stoney JD. Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplasty. 2009;24:560–569.

    Article  PubMed  Google Scholar 

  10. Conteduca F, Iorio R, Mazza D, Caperna L, Bolle G, Argento G, Ferretti A. Evaluation of the accuracy of a patient-specific instrumentation by navigation. Knee Surg Sports Traumatol Arthrosc. 2012 June 27 [Epub ahead of print].

  11. Dennis DA. Measured resection: an outdated technique in total knee arthroplasty. Orthopedics. 2008;31:940, 943–944.

    Google Scholar 

  12. Dennis DA, Komistek RD, Kim RH, Sharma A. Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res. 2010;468:102–107.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24:39–43.

    Article  PubMed  Google Scholar 

  14. Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A. Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res. 2005;433:152–159.

    Article  PubMed  Google Scholar 

  15. Hanada H, Whiteside LA, Steiger J, Dyer P, Naito M. Bone landmarks are more reliable than tensioned gaps in TKA component alignment. Clin Orthop Relat Res. 2007;462:137–142.

    Article  PubMed  Google Scholar 

  16. Harrysson OL, Hosni YA, Nayfeh JF. Custom-designed orthopedic implants evaluated using finite element analysis of patient-specific computed tomography data: femoral-component case study. BMC Musculoskelet Disord. 2007;8:91.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Klatt BA, Goyal N, Austin MS, Hozack WJ. Custom-fit total knee arthroplasty (OtisKnee) results in malalignment. J Arthroplasty. 2008;23:26–29.

    Article  PubMed  Google Scholar 

  18. Lal K, White GS, Morea DN, Wright RF. Use of stereolithographic templates for surgical and prosthodontic implant planning and placement. Part I. The concept. J Prosthodontics. 2006;15:51–58.

    Article  Google Scholar 

  19. Lal K, White GS, Morea DN, Wright RF. Use of stereolithographic templates for surgical and prosthodontic implant planning and placement. Part II. A clinical report. J Prosthodontics. 2006;15:117–122.

    Google Scholar 

  20. Lombardi AV Jr, Berend KR, Adams JB. Patient-specific approach in total knee arthroplasty. Orthopedics. 2008;31:927–930.

    Article  PubMed  Google Scholar 

  21. Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2009;24:570–578.

    Article  PubMed  Google Scholar 

  22. Lotke PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg Am. 1977;59:77–79.

    CAS  PubMed  Google Scholar 

  23. Mahoney OM, Kinsey TL. 5- to 9-year survivorship of single-radius, posterior-stabilized TKA. Clin Orthop Relat Res. 2008;466:436–442.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Matsuda S, Miura H, Nagamine R, Urabe K, Hirata G, Iwamoto Y. Effect of femoral and tibial component position on patellar tracking following total knee arthroplasty: 10-year follow-up of Miller-Galante I knees. Am J Knee Surg. 2001;14:152–156.

    CAS  PubMed  Google Scholar 

  25. Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE. Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res. 2001;392:38–45.

    Article  PubMed  Google Scholar 

  26. Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AV Jr. Improved accuracy of alignment with patient-specific positioning guides compared with manual instrumentation in TKA. Clin Orthop Relat Res. 2012;470:99–107.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Nunley RM, Ellison BS, Zhu J, Ruh EL, Howell SM, Barrack RL. Do patient-specific guides improve coronal alignment in total knee arthroplasty? Clin Orthop Relat Res. 2012;470:895–902.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Nunley RM, Ellison BS, Zhu J, Ruh EL, Williams BM, Foreman K, Ford AD, Barrack RL. Are patient-specific cutting blocks cost-effective for total knee arthroplasty? Clin Orthop Relat Res. 2012;470:889–894.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Olcott CW, Scott RD. The Ranawat Award. Femoral component rotation during total knee arthroplasty. Clin Orthop Relat Res. 1999;367:39–42.

    PubMed  Google Scholar 

  30. Quack VM, Kathrein S, Rath B, Tingart M, Luring C. Computer-assisted navigation in total knee arthroplasty: a review of literature. Biomed Tech (Berl). 2012;57:269–275.

    PubMed  Google Scholar 

  31. Rhoads DD, Noble PC, Reuben JD, Mahoney OM, Tullos HS. The effect of femoral component position on patellar tracking after total knee arthroplasty. Clin Orthop Relat Res. 1990;260:43–51.

    PubMed  Google Scholar 

  32. Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement: its effect on survival. Clin Orthop Relat Res. 1994;299:153–156.

    PubMed  Google Scholar 

  33. Shah DA, Madden LV. Nonparametric analysis of ordinal data in designed factorial experiments. Phytopathology. 2004;94:33–43.

    Article  CAS  PubMed  Google Scholar 

  34. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;404:7–13.

    Article  PubMed  Google Scholar 

  35. Song EK, Seon JK, Park SJ, Jung WB, Park HW, Lee GW. Simultaneous bilateral total knee arthroplasty with robotic and conventional techniques: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2011;19:1069–1076.

    Article  PubMed  Google Scholar 

  36. Song EK, Seon JK, Yim JH, Netravali NA, Bargar WL. Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop Relat Res. 2013;471:118–126.

    Article  PubMed  Google Scholar 

  37. Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF. Initial experience with custom-fit total knee replacement: intra-operative events and long-leg coronal alignment. Int Orthop. 2009;33:1571–1575.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Tew M, Waugh W. Tibiofemoral alignment and the results of knee replacement. J Bone Joint Surg Br. 1985;67:551–556.

    CAS  PubMed  Google Scholar 

  39. Victor J. Rotational alignment of the distal femur: a literature review. Orthop Traumatol Surg Res. 2009;95:365–372.

    Article  CAS  PubMed  Google Scholar 

  40. Victor J, Hoste D. Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment. Clin Orthop Relat Res. 2004;428:131–139.

    Article  PubMed  Google Scholar 

  41. Victor J, Van Doninck D, Labey L, Innocenti B, Parizel PM, Bellemans J. How precise can bony landmarks be determined on a CT scan of the knee? Knee. 2009;16:358–365.

    Article  CAS  PubMed  Google Scholar 

  42. Wasielewski RC, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG. Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res. 1994;299:31–43.

    PubMed  Google Scholar 

  43. White D, Chelule KL, Seedhom BB. Accuracy of MRI vs CT imaging with particular reference to patient specific templates for total knee replacement surgery. Int J Met Robot. 2008;4:224–231.

    CAS  Google Scholar 

  44. Yoshii I, Whiteside LA, White SE, Milliano MT. Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty. 1991;6:169–177.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank BrainLAB AG (Munchen, Germany) for providing a free license for the generic Knee 2.1 Universal software used for surgical navigation in this study.

Author information

Authors and Affiliations

  1. Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium

    Jan Victor MD, PhD & Nele Arnout MD

  2. AZ St-Lucas, St-Lucaslaan 29, 8310, Brugge, Belgium

    Jan Victor MD, PhD

  3. Leuven University Hospitals, Leuven, Belgium

    Jan Dujardin MD, Hilde Vandenneucker MD & Johan Bellemans MD, PhD

Authors
  1. Jan Victor MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jan Dujardin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hilde Vandenneucker MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nele Arnout MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Johan Bellemans MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jan Victor MD, PhD.

Additional information

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at AZ St-Lucas (Brugge, Belgium) and UZ Leuven (Leuven, Belgium).

About this article

Cite this article

Victor, J., Dujardin, J., Vandenneucker, H. et al. Patient-specific Guides Do Not Improve Accuracy in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Clin Orthop Relat Res 472, 263–271 (2014). https://doi.org/10.1007/s11999-013-2997-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-2997-4

Keywords

Search

Navigation