Three-Dimensional Component Alignment and Functional Outcome in Computer-Navigated Total Knee Arthroplasty: A Prospective, Randomized Study Comparing Two Navigation Systems

doi:10.1016/j.arth.2010.12.022

The Journal of Arthroplasty

Volume 26, Issue 8, December 2011, Pages 1285-1290

https://doi.org/10.1016/j.arth.2010.12.022 Get rights and content

Abstract

Computer navigation in total knee arthroplasty produces better component alignment than conventional techniques. Different navigation systems exist. We undertook a prospective, randomized study comparing 2 navigations systems (Stryker Full Navigation and Stryker Articular Surface Mounted [ASM] navigation systems). Three-dimensional component alignment (Perth computed tomographic knee protocol) and function at 1 year (Knee Society Scores) were assessed. Forty patients participated (20 fully navigated and 20 ASM-navigated total knee arthroplasties). Cohorts were well matched according to sex, age, and body mass index. No statistically significant difference was seen in any parameter of 3-dimensional component alignment or function between cohorts. Operative time for the ASM cohort was significantly less than the fully navigated cohort (P = .001). Both systems performed equally well, and therefore, surgeon preference should determine which system is used.

Section snippets

Full Navigation System

This is an imageless system that uses anatomic mapping of the knee and kinematic analysis of the limb to build up a working model of the patient's knee. It uses an infrared camera array to track 2 fixed infrared trackers that are fixed to the distal femur and proximal tibia by bicortical screws (Fig. 1). The camera can also track the position of a pointer or attachment and relate their positions to the mapped anatomy. A process of registration is required, whereby the anatomic landmarks of the

Articular Surface Mounted Navigation System

The ASM navigation system is also an imageless system and avoids the use of bicortical femoral and tibial screws by using mini jigs attached directly to the respective femoral/tibial articular surfaces, that is, bone that will be resected (Fig. 2). Infrared trackers are attached directly to the ASM mini jigs. A similar anatomic mapping process as to the full navigation system is performed. The ASM system facilitates solely the planning of the distal femoral and tibial cuts in the coronal and

Methods

Formal approval of the study protocol by the local institutional ethics committee was obtained. Patients were recruited to the trial when attending for outpatient review and were provided with a detailed information sheet. Those agreeing to participate were randomized to either full or ASM navigation and consented to have surgery (both patients and paramedical staff being blinded as to the randomization process). Patients with active infection or malignancy or those deemed to be medically unfit

Results

Forty patients were included in the study. Of these, 20 underwent fully navigated TKA (13 female, 7 male; mean age, 67.5 years; mean BMI, 29.9 kg/m²), and 20, ASM-navigated TKA (12 female, 8 male; mean age, 70.3 years; mean BMI, 29.5 kg/m²). Cohorts were well matched in terms of sex, age, and BMI (P = .77, .38, and .81, respectively). Operative time for the ASM cohort was significantly less than the fully navigated cohort (122 minutes compared with 132 minutes; P = .001).

No statistically

Discussion

Computer navigation technology is “designed to improve the surgical performance and clinical outcome of knee replacement surgery” [27], and with this in mind, its use has increased in recent years. In parallel, the volume of literature relating to computer navigation technology in this field has expanded greatly, most published work relating to component alignment, whereas very few studies have addressed functional outcome.

It is now generally accepted that computer navigation produces better

Acknowledgment

The authors would like to acknowledge the significant contribution to this work performed by Mr Matthew Utting, FRCS (Tr & Orth), who tragically died while on fellowship under the supervision of the senior author.

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Cited by (27)

Trends in Operative Time and Short-Term Outcomes After Conventional and Navigated Total Knee Arthroplasty
2021, Arthroplasty Today
Citation Excerpt :
Arthroplasty navigation platforms vary in their means of guidance, with some using image-guidance, while others use imageless systems. Within Nav-TKA, specific types of navigation platforms have differing requirements for intraoperative setup and anatomic landmark registration, and thus, the specific type of navigation used may affect the impact on total operative time [28,29]. Nationwide trends show a slow but steady rise in utilization of Nav-TKA, necessitating a better understanding of the impacts on patient outcomes and resource utilization associated with the use of Nav-TKA [14,16].
Adoption of navigated total knee arthroplasty (Nav-TKA) is increasing. However, it has been suggested that a perceived decrease in surgical efficiency and a lack of proven superior functional outcomes associated with Nav-TKA have hindered its widespread adoption.
The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who had undergone TKA with or without navigation between 2012 and 2018. Patients were further subclassified based on the type of navigation used, image-guided or imageless. Multivariate logistic regression was used to compare operative time and 30-day complication rates between conventional TKA (Conv-TKA) and Nav-TKA with and without image guidance.
A total of 316,210 Conv-TKAs and 8554 Nav-TKAs (8270 imageless, 284 image-guided) were identified. Across the study period, the use of Nav-TKA was associated with a 1.5-minute increase in operative time. However, the overall time burden decreased over the study period, and by 2018, the mean operative time for Nav-TKA was 2.4 minutes less than that of Conv-TKA. Compared with Conv-TKA, Nav-TKA was associated with decreased rates of postoperative transfusion and surgical site complications but a similar incidence of systemic thromboembolism.
This is the first large-scale database study to examine the differences in operative time between Conv-TKA and Nav-TKA. The time burden associated with Nav-TKA decreased over the study period and even reversed by 2018. Nav-TKA was associated with lower rates of postoperative transfusion and surgical site complications. Further studies are needed to evaluate the long-term and functional outcomes between conventional and navigated knee arthroplasty techniques.
Navigation for lower limb alignment during internal fixation of complex tibial-plateau fractures
2018, Orthopaedics and Traumatology: Surgery and Research
In complex fractures of the proximal tibial metaphysis and epiphysis, possible adverse outcomes after internal fixation include not only joint surface incongruity, but also lower limb malalignment requiring revision surgery. Navigation has been proven effective for the intraoperative control of lower limb alignment during osteotomy and knee arthroplasty. In complex traumatic fractures, temporary fixation by a locking screw plate allows sensor positioning followed by navigation maneuvers to adjust lower limb alignment. If malalignment is found, the construct can be modified economically by altering the diaphyseal fixation without modifying the metaphyseal screws. The objective of this study was to describe the use of navigation in three patients who required internal fixation of tibial-plateau fractures.
Navigation for lower limb alignment during internal fixation of complex tibial plateau fractures
2018, Revue de Chirurgie Orthopedique et Traumatologique
Les fractures complexes métaphyso-épiphysaires de l’extrémité proximale du tibia peuvent conduire, outre le défaut de réduction articulaire, à un défaut d’axe du membre inférieur après ostéosynthèse, nécessitant une reprise chirurgicale. La navigation est un outil qui a fait ses preuves pour contrôler en peropératoire l’axe mécanique du membre inférieur dans les ostéotomies et les arthroplasties du genou. Elle est utilisable en chirurgie traumatologique, pour ces fractures complexes, en réalisant une ostéosynthèse temporaire par une plaque à vissage verrouillé, permettant la mise en place des capteurs et la réalisation des manœuvres de navigation pour contrôler l’axe du membre inférieur. Il est possible de reprendre le montage a minima en cas d’anomalie de l’axe, en modifiant la fixation diaphysaire sans toucher aux vis métaphysaires. L’objectif de ce travail était de présenter son utilisation au cours de 3 ostéosynthèses de fractures du plateau tibial.
A randomized controlled trial to compare component placement in navigated total knee arthroplasty using original and streamlined registration processes
2017, Arthroplasty Today
Citation Excerpt :
Computer-assisted knee arthroplasty is still not mainstream. Several reasons have been suggested to explain this, such as risk of infections and fractures related to tracker fixation and increasing time of surgery [17,18]. It is clear that tracker setup and registration are both additional tasks that are not required when using manual instrumentation, and it has been shown that knee navigation increases the overall time of surgery in comparison to conventional TKA by up to 30 minutes [1,5-11,26,27].
This randomized controlled trial validated a redesigned version of navigated total knee arthroplasty software with a streamlined registration (Smart) against the previous version (Classic). The objectives were to determine if Smart software had the same accuracy of component positioning and whether registration and operative time were reduced.
A total of 220 patients were recruited and had a navigated total knee arthroplasty performed. With the exception of the software, all patients had the same perioperative care. At 6-week follow-up with an independent arthroplasty service, all patients had a computerized tomography scan. This was assessed by an independent radiologist to measure the mechanical alignment of the components.
The mean postoperative mechanical femorotibial angles were equivalent between groups (mean difference −0.2°, 95% confidence interval −0.7° to 0.3°, P = .407). Component positions were similar in both groups. Mean registration time was significantly shorter for the Smart group (2 minutes 30 seconds ± 54 seconds) than the Classic group (3 minutes 23 seconds ± 39 seconds), P < .001. The mean operative time was 72 ± 12 minutes in both groups (P = .855). At 6-week follow-up, both groups had similar clinical outcomes with 96.5% of patients being satisfied or very satisfied.
The study verified that a reduced registration time did not alter the accuracy of component placement. However, despite a shorter registration time, the overall surgical time was not reduced.
Meta-Analysis of Outcomes of a Single-Radius Versus Multi-Radius Femoral Design in Total Knee Arthroplasty
2016, Journal of Arthroplasty
Although the single-radius (SR) femoral design is known to have theoretical advantages in many aspects, studies of clinical outcomes that compare the SR with the multiple-radius (MR) femoral design are controversial. We performed a meta-analysis to address the hypothesis that a SR femoral design in primary total knee arthroplasty improves patient outcomes.
The meta-analysis identified 15 articles reporting the clinical outcomes of 2212 knee replacements using the SR (n = 948) compared with the multiradius (MR; n = 1361) femoral design. Comparing SR with MR, we examined the Knee Society Score for the knee (KSS-knee), KSS-function, knee flexion, range of motion, complications, isometric peak torque of knee, and survival rate.
The range of motion of SR knees was lower than that of MR knees. No differences were found in the analyses of KSS-knee, KSS-function, knee flexion, complications, isometric peak torque of the knee, and survival rate.
Our meta-analysis does not provide clinical support for the previously reported theoretical advantages of the SR implant design.
Limited femoral navigation versus conventional intramedullary femoral jig based instrumentation for achieving optimal restoration of mechanical axis post total knee arthroplasty: A prospective comparative study of 200 knees
2015, Journal of Arthroplasty
Citation Excerpt :
Despite this, it is regarded as being less invasive (with no risk of fracture associated with bicortical tracker pin placement) and a faster system to use than the fully navigated system. Harvie et al in a prospective randomized study compared full tibio-femoral navigation and ASM navigation [24]. Forty patients participated (20 fully navigated and 20 ASM-navigated TKAs).
A prospective comparative study was conducted to compare the mechanical axis post total knee arthroplasty (TKA) between two groups: In the first group of 100 knees (ASM group) Articular Surface Mounted navigation system was used to guide the distal femoral cut. In the second group of 100 knees (JIG group) conventional intramedullary femoral jig was used. The postoperative mechanical axis of the leg was within 3° of neutral alignment in 90% of the TKA in the ASM group (mean 178.12°) as compared to 74% in the JIG group (mean 177.02°). This difference was statistically significant (P < 0.05). The data presented show that the use of limited femoral navigation leads to more accurate restoration of mechanical axis alignment when compared to conventional intramedullary femoral jigs.

View all citing articles on Scopus

: The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2010.12.022.

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Three-Dimensional Component Alignment and Functional Outcome in Computer-Navigated Total Knee Arthroplasty: A Prospective, Randomized Study Comparing Two Navigation Systems

Abstract

Section snippets

Full Navigation System

Articular Surface Mounted Navigation System

Methods

Results

Discussion

Acknowledgment

J Arthroplasty

J Arthroplasty

J Arthroplasty

Computer-assited knee arthroplasty versus a conventional jig-based technique: a randomised, prospective trial

J Bone Joint Surg Br

Functional impact of navigation-assisted minimally invasive total knee arthroplasty

Orthopedics

Navigated total knee replacement: a meta-analysis

J Bone Joint Surg Am

Computer navigation versus conventional total knee replacement: no difference in functional results at two years

J Bone Joint Surg Br

Rationale of the Knee Society clinical rating system

Clin Orthop Relat Res

Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes in antirheumatic drug therapy in patients with osteoarthritis of the hip or knee

J Rheumatology

The MOS 26-item Short-Form Health Survey (SF-36)

Medical Care