The Mark Coventry Award: Custom Cutting Guides Do Not Improve Total Knee Arthroplasty Clinical Outcomes at 2 Years Followup

Nam, Denis; Park, Andrew; Stambough, Jeffrey B.; Johnson, Staci R.; Nunley, Ryan M.; Barrack, Robert L.

doi:10.1007/s11999-015-4216-y

Cited by 48 publications

(24 citation statements)

References 40 publications

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“…In their study of VISIONAIRE TKAs, Pfitzner et al reported no difference in Knee Society pain and function scores and Western Ontario and McMaster Universities Arthritis Index (WOMAC) for the PSI and conventional TKA groups at 3 months postoperatively [34]. Similarly, Nam et al report no benefit in range of motion or patient-reported outcomes for PSI compared to conventional TKAs, as well as no difference in the number of outliers (±3°from neutral) for long-leg alignment, at a mean follow-up of greater than 2 years [29]. Other studies have noted similar findings [43,44].…”

Section: Discussionmentioning

confidence: 98%

Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: A Retrospective Matched Cohort Study

Steinhaus

McLawhorn

Richardson

et al. 2016

HSS Journal®: The Musculoskeletal Journal of Hospital for Speci

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Background: Proper alignment of total knee arthroplasty (TKA) is essential for TKA function and may reduce the risk of aseptic failure. Technologies that prevent malalignment may reduce the risk of revision surgery. Questions/Purposes: The purpose of this study was to compare two competing TKA systems that purport improved alignment: patient-specific instrumentation (PSI), and a handheld portable navigation device (NAV). Methods: After IRB approval, 49 consecutive PSI TKAs (40 patients) were matched based on preoperative characteristics to 49 NAV TKAs (40 patients) performed by a single surgeon. A blinded observer measured alignment on digital radiographs. Operating room records were reviewed for procedure times. Two-tailed paired sample t tests and McNemar's test were used as appropriate. Alpha level was 0.05 for all tests. Results: Preoperative cohort characteristics were not different. Mean postoperative long-leg mechanical alignment was within ±1°of neutral for both groups, although statistically different (p = 0.026). There were no other significant differences in coronal alignment. PSI exhibited significantly greater posterior tibial slope (4.4°) compared to NAV (2.7°) (p = 0.004); PSI resulted in significantly more outliers (>6°; p = 0.004). Procedure time for unilateral TKAs was lower for PSI (74.4 min) compared to that for NAV (80.6 min; p = 0.023). Conclusion: NAV and PSI technologies provided excellent coronal plane alignment. NAV was better for sagittal tibial slope, while PSI procedure times were shorter for unilateral TKA. The impact of these technologies on patientreported outcomes and TKA survivorship is controversial and should be the focus of future research.

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Section: Discussionmentioning

confidence: 98%

Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: A Retrospective Matched Cohort Study

Steinhaus

McLawhorn

Richardson

et al. 2016

HSS Journal®: The Musculoskeletal Journal of Hospital for Speci

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“…As a result of the link between implant alignment outliers and early implant failure, efforts have been made to optimize alignment with the use of robotic navigation and patient-specific instrumentation [19][20][21][22][23][24][25][26][27][28][29][30][31][32] . However, little work has been conducted to identify the primary surgeon-specific factors that drive these outliers in order to understand the optimal patient populations in which to utilize this expensive technology.…”

mentioning

confidence: 99%

The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty

Kazarian

Lawrie

Barrack

et al. 2019

The Journal of Bone and Joint Surgery

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Background: Implant malalignment may predispose patients to prosthetic failure following total knee arthroplasty (TKA). A more thorough understanding of the surgeon-specific factors that contribute to implant malalignment following TKA may uncover actionable strategies for improving implant survival. The purpose of this study was to determine the impact of surgeon volume and training status on malalignment. Methods: In this retrospective multicenter study, we performed a radiographic analysis of 1,570 primary TKAs performed at 4 private academic and state-funded centers in the U.S. and U.K. Surgeons were categorized as high-volume (‡50 TKAs/ year) or low-volume (<50 TKAs/year), and as a trainee (fellow/resident under the supervision of an attending surgeon) or a non-trainee (attending surgeon). On the basis of these designations, 3 groups were defined: high-volume non-trainee, lowvolume non-trainee, and trainee. The postoperative medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured. Outlier measurements were defined as follows: DFA, outside of 5°± 3°of valgus; PTA, >±3°deviation from the neutral axis; and PSA, <0°or >7°of flexion for cruciate-retaining or <0°or >5°of flexion for posterior-stabilized TKAs. "Far outliers" were defined as measurements falling >± 2°outside of these ranges. The proportions of outliers were compared between the groups using univariate and multivariate analyses. Results: When comparing the high and low-volume non-trainee groups using univariate analysis, the proportions of knees with outlier measurements for the PTA (5.3% versus 17.4%) and PSA (17.4% versus 28.3%) and the proportion of total outliers (11.8% versus 20.7%) were significantly lower in the high-volume group (all p < 0.001). The proportions of DFA (1.9% versus 6.5%), PTA (1.8% versus 5.7%), PSA (5.5% versus 12.6%), and total far outliers (3.1% versus 8.3%) were also significantly lower in the high-volume non-trainee group (all p < 0.001). Compared with the trainee group, the high-volume non-trainee group had significantly lower proportions of DFA (12.6% versus 21.6%), PTA (5.3% versus 12.0%), PSA (17.4% versus 33.3%), and total outliers (11.8% versus 22.3%) (all p < 0.001) as well as DFA (1.9% versus 3.9%; p = 0.027), PSA (5.5% versus 12.6%; p < 0.001), and total far outliers (3.1% versus 6.4%; p = 0.004). No significant differences were identified when comparing the low-volume non-trainee group and the trainee group, with the exception of PTA outliers (17.4% versus 12.0%; p = 0.041) and PTA far outliers (5.7% versus 2.6%; p = 0.033). Findings from multivariate analysis accounting for the effects of patient age, body mass index, and individual surgeon demonstrated similar results. Conclusions: Low surgical volume and trainee status were risk factors for outlier and far-outlier malalignment in primary TKA, even when accounting for differences in individual surgeon and patient characteristics. Trainee surgeons performed similarly, and certa...

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“…Additionally, manual instrumentation was used for the neutral MA group compared with this study that used computer navigation. Although previous studies report no difference in patient-reported outcomes between TKAs performed with PSI versus manual instrumentation [35,43], a meta-analysis of Level I studies did report a small functional advantage (mean 7-point increase in KSS score) for mechanically aligned TKAs performed with computer navigation versus manual instruments [38].…”

Section: Discussionmentioning

confidence: 94%

The Chitranjan S. Ranawat Award

Young

Walker

Bayan

et al. 2017

Clinical Orthopaedics &Amp; Related Research

198

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Background Neutral mechanical alignment (MA) in total knee arthroplasty (TKA) aims to position femoral and tibial components perpendicular to the mechanical axis of the limb. In contrast, kinematic alignment (KA) attempts to match implant position to the prearthritic anatomy of the individual patient with the aim of improving functional outcome. However, comparative data between the two techniques are lacking.Questions/purposes In this randomized trial, we asked: (1) Are 2-year patient-reported outcome scores enhanced in patients with KA compared with an MA technique? (2) How does postoperative component alignment differ between the techniques? (3) Is the proportion of patients undergoing reoperation at 2 years different between the techniques? Methods Ninety-nine primary TKAs in 95 patients were randomized to either MA (n = 50) or KA (n = 49) groups. A pilot study of 20 TKAs was performed before this trial using the same patient-specific guides positioning in kinematic alignment. In the KA group, patient-specific cutting blocks were manufactured using individual preoperative MRI data. In the MA group, computer navigation was used to ensure neutral mechanical alignment accuracy. Postoperative alignment was assessed with CT scan, and functional scores (including the Oxford Knee Score, WOMAC, and the Forgotten Joint Score) were assessed preoperatively and at 6 weeks, 6 months, and 1 and 2 years postoperatively. No patients were lost to followup. We set sample size at a minimum of 45 patients per treatment arm based on a 5-point improvement in the mean Oxford Knee Score (OKS; the previously reported minimum clinically significant difference for the OKS in TKA), a pooled SD of 8.3, 80% power, and a two-sided significance level of 5%. Results We observed no difference in 2-year change scores (postoperative minus preoperative score) in KA versus MA The institution of one or more of the authors (SWY, MLW, AB, BF) has received, during the study period, funding from Stryker (Kalamazoo, MI, USA) One or more of the authors (AB, MLW, BF) or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Stryker. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to 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 the Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand. Postoperative hipknee-ankle a...

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The Mark Coventry Award: Custom Cutting Guides Do Not Improve Total Knee Arthroplasty Clinical Outcomes at 2 Years Followup

Cited by 48 publications

References 40 publications

Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: A Retrospective Matched Cohort Study

Handheld Navigation Device and Patient-Specific Cutting Guides Result in Similar Coronal Alignment for Primary Total Knee Arthroplasty: A Retrospective Matched Cohort Study

The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty

The Chitranjan S. Ranawat Award

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