Aims

The aims of this prospective study were to determine the effect of osteophyte excision on deformity correction and soft- tissue gap balance in varus knees undergoing total knee arthroplasty (TKA).

Aims

The aims of this retrospective study were to determine the incidence of extra-articular deformities (EADs), and determine their effect on postoperative alignment in knees undergoing mobile-bearing, medial unicompartmental knee arthroplasty (UKA).

Navigation has shown to improve limb and component alignment during total knee arthroplasty (TKA). However, most navigation systems involve bulky and expensive hardware, increased operative time and cost. A novel hand-held image-free navigation device has been recently approved with the aim to reduce inventory, cost and surgical time with its small size and quick registration features. We aimed to determine limb and component alignment and validate the accuracy of the iPod based navigation system.

Intraoperative navigation data for proximal tibia and distal femur cuts, femoral component rotation, limb alignment and component alignment in routine imageless navigation system (Ci Navigation, Brainlab) was compared with the novel iPod-based hand-held navigation system (DASH, Smith & Nephew) in 20 TKAs. Postoperative full-length hip-to-ankle and lateral radiographs were evaluated to measure the hip-knee-ankle (HKA) angle and coronal and sagittal alignment of the femoral and tibial component.

The iPod-based navigation system showed good agreement with the Ci Navigation system for limb alignment, tibial and distal femoral cuts in the majority of the limbs despite its quick registration feature. The iPod-based system is hence a positive step towards making navigation systems for TKA more compact, user-friendly, time and cost-effective.

The combination of obesity and malalignment may result in increased revision rates following total knee arthroplasty (TKA). The purpose of this retrospective matched-pair study was to compare the accuracy of limb and component alignment after TKA using conventional versus computer-assisted technique in obese patients. Radiographic data regarding limb alignment, coronal and sagittal component alignment of 72 conventional TKAs (52 patients) were compared with data of a matched group of 72 computer-assisted TKAs. All procedures were performed by a single surgeon, using a single approach and a cruciate-substituting design.

The mean postoperative limb alignment in the conventional group was 177.2° ± 2.5° compared to 179.3°± 1° in the computer-assisted group (p=0.0001). The coronal and sagittal alignment of both femoral and tibial components in the computer-assisted group was significantly accurate compared to the conventional group. In the conventional group, 40.2% of limbs (29 out of 72) had a postoperative HKA angle > ±3° from the neutral compared to 1.3% of the limbs (1 out of 72) in the computer-assisted group (p=0.0001).

Computer-assisted total knee arthroplasty performed in obese patients showed excellent limb and component alignment with very few outliers when compared to conventional total knee arthroplasty. Obesity is an appropriate indication for the use of computer navigation during TKA where use of conventional techniques may result in significant limb and component malalignment.

Excessive under correction of varus deformity may lead to early failure and overcorrection may cause progressive degeneration of the lateral compartment following medial unicompartmental knee arthroplasty (UKA). However, what influences the postoperative limb alignment in UKA is still not clear. This study aimed to evaluate postoperative limb alignment in minimally-invasive Oxford medial UKAs and the influence of factors such as preoperative limb alignment, insert thickness, age, BMI, gender and surgeon's experience on postoperative limb alignment.

Clinical and radiographic data of 122 consecutive minimally-invasive Oxford phase 3 medial unicompartmental knee arthroplasties (UKAs) performed in 109 patients by a single surgeon was analysed. Ninety-four limbs had a preoperative hip-knee-ankle (HKA) angle between 170°-180° and 28 limbs (23%) had a preoperative hip-knee-ankle (HKA) angle <170°. The mean preoperative HKA angle of 172.6±3.1° changed to 177.1±2.8° postoperatively. For a surgical goal of achieving 3° varus limb alignment (HKA angle=177°) postoperatively, 25% of limbs had an HKA angle >3° of 177° and 11% of limbs were left overcorrected (>180°). Preoperative HKA angle had a strong correlation (r=0.53) with postoperative HKA angle whereas insert thickness, age, BMI, gender and surgeon's experience had no influence on the postoperative limb alignment.

Minimally invasive Oxford phase 3 UKA can restore the limb alignment within acceptable limits in majority of cases. Preoperative limb alignment may be the only factor which influences postoperative alignment in minimally-invasive Oxford medial UKAs. Although the degree of correction achieved postoperatively from the preoperative deformity was greater in limbs with more severe preoperative varus deformity, these knees tend to remain in more varus or under corrected postoperatively. Overcorrection was more in knees with lesser preoperative deformity. Hence enough bone may need to be resected from the tibia in knees with lesser preoperative deformity to avoid overcorrection whereas limbs with large preoperative varus deformities may remain under corrected.

Computer navigation has been advocated as a means to improve limb and component alignment and reduce the number of outliers after total knee arthroplasty (TKA). We aimed to determine the alignment outcomes of 1500 consecutive computer-assisted TKAs performed by a single surgeon, using the same implant, with a minimum 1 year follow-up, and to analyze the outliers. Based on radiographic analysis, 112 limbs (7.5%) in 109 patients with mechanical axis malalignment of > 3° were identified and analyzed.

The indication for TKA was osteoarthritis in 107 patients and rheumatoid arthritis in 2 patients. Fifty-eight patients (53%) had undergone simultaneous bilateral TKA and 13 patients (12%) had a BMI >30. Preoperative varus deformity was seen in 100 limbs and valgus deformity in 12 limbs. Thirty limbs (27%) had an extra-articular deformity (2 post HTO limbs, 3 malunited fractures, 1 stress fracture, 21 severe femoral bowing and 3 tibial bowing) and 21 limbs (19%) had severe lateral laxity or subluxation. Thirty-eight limbs (34%) had a preoperative deformity of =10° and 24 limbs (21.5%) had varus or valgus deformity of >20°.

Postoperatively, 11 limbs were malaligned at ±3°, 74 limbs at ±4°, 22 limbs at ±5°, 2 limbs at ±6°, and 2 limbs at ±7°. Coronal plane malalignment of > ±3° of the femoral component was seen in 28 limbs, tibial component in 32 limbs, and both femoral and tibial components in 13 limbs. Twenty-six limbs with preoperative varus deformity had a postoperative valgus alignment of >183° and 3 limbs with valgus deformity had a postoperative varus alignment of <177°.

The incidence of outliers for postoperative limb alignment was low at 7.5% with the tibial component showing a higher incidence of coronal malalignment. Malalignment may be more common in cases of simultaneous bilateral procedures, preoperative limb alignment of =10°, limbs with extra-articular deformities and severe lateral instability. There was a tendency towards over-correction of the hip-knee-ankle axis in both varus- and valgus-deformed knees. Further detailed statistical analysis of the data will be presented.

This is the largest single-surgeon series of consecutive navigated TKAs and consequently the largest analysis of outliers that highlights which knees are likely to fall outside the +3 degrees of acceptable alignment and which therefore behoove the surgeon to exercise greater caution.

The weight bearing axis of the limb goes from the pelvis to the ground and includes the hindfoot. However, the influence of hindfoot alignment on mechanical axis deviation and overall limb alignment after total knee arthroplasty (TKA) is unknown. This study aimed to assess the change in hindfoot alignment after TKA for knee osteoarthritis, the difference in mechanical axis deviation at the knee when calculated using the ground mechanical axis as compared to the conventional mechanical axis, and the effect of hindfoot alignment on the overall postoperative limb alignment after TKA.

We evaluated the pre- and postoperative hip-knee-ankle (HKA) angle, conventional mechanical axis deviation (CMAD), ground mechanical axis deviation (GMAD), and tibiocalcaneal angle (TCA) in 125 patients who underwent 165 consecutive TKAs. Overall, the change in pre- and postoperative mean TCA was not significant (p=0.48) whereas it was significant (p=0.01) in knees with =15° deformity where the hindfoot valgus decreased by approximately 25%. Preoperatively, there was no significant difference between mean CMAD and mean GMAD whereas postoperatively the difference was significant (p=0.0001). Hindfoot valgus alignment of =10° was present in 22.5% of limbs and 29% limbs had a postoperative GMAD of =10 mm in spite of the limb alignment being restored to within 3° of neutral after TKA.

Despite accurate restoration of limb alignment after TKA, as a result of persistent hindfoot valgus alignment the ground mechanical axis may pass lateral to the centre of the knee joint - with potential detrimental effects on bone, ligaments and implants.

Genu recurvatum deformity is uncommon in arthritic knees undergoing total knee arthroplasty (TKA). We retrospectively analysed radiographs and navigation data to determine the clinical and radiographic results of computer-assisted TKA in knee arthritis with recurvatum deformity.

Based on alignment data obtained during computer assisted (CAS) TKA, 40 arthritic knees (36 patients) with a recurvatum deformity of at least 5° were identified. The mean recurvatum deformity was 8.7° (6° to 14°). On preoperative standing hip-ankle radiographs, 23 limbs (57.5%) had a mean varus deformity of 169.4° (153° to 178°) and 17 limbs had a mean valgus deformity of 189.2° (182° to 224°). The intraoperative navigation data showed mean tibial resection of 7.5mm (4.6 to 13.4mm) and distal femur resection of 7.5mm (3.3 to 13mm) with a mean final extension gap of 21.2mm and a flexion gap at 90° of 21.1mm and on extension. On table, the mean knee deformity in sagittal plane was 3° flexion (1.5° to 4.5° flexion).

Postoperatively, the mean HKA angle on standing hip-ankle radiographs was 179.2° (177° to 182°). On postoperative lateral radiographs, joint line in extension was moved distally in 35 limbs by 2.3mm (0.3 to 4mm) and proximally in 5 limbs by 2.2mm (2.2 to 2.4mm); the mean preoperative posterior femoral offset of 28.7 mm changed to 27.9 mm postoperatively. At a mean follow up 28 months (14- 48 months) the knee, function, and pain scores improved by 61, 48, and 28 points, respectively and there was no recurrence of recurvatum deformity at final follow up.

Genu recurvatum is a notoriously difficult condition to address at TKA. The challenges are to be able to detect it at surgery and take appropriate measures in terms of resection and releases to correct it satisfactorily. Computer assisted TKA helps to achieve excellent deformity correction, limb alignment, gap balancing and function in patients with recurvatum deformity by accurately quantifying and helping to modify the amount of bone cuts and titrate soft tissue release.

Extensive release of postero-lateral structures may be required to correct rigid and severe valgus deformities during total knee arthroplasty. Current techniques are technically difficult, may not accurately restore soft tissue balance, and are associated with postoperative complications. We evaluated the results of using computer navigation for lateral epicondylar osteotomy during total knee arthroplasty for rigid severe valgus arthritis.

We had performed this procedure during navigated TKA in 10 valgus arthritic knees (2 bilateral TKAs) in 8 patients (1 male and 7 female). The mean age at the time of surgery was 65.7 years (range, 48–77 years) and the mean preoperative valgus deformity was 19.25° (range, 10°–36.5°). The mean postoperative limb alignment at the end of a mean follow-up of 20 months (range, 14–31 months) was 0.5° valgus (range, 2° varus–1.8° valgus). None of the patients had any complications related to the procedure with no obvious clinical mediolateral instability and complete union at the osteotomy site was noted in all patients radiographically at the last followup.

Computer navigation allows for precisely measuring the difference between medial and lateral gaps as well as the limb alignment and to determine the effect of sequential soft-tissue releases on both. Our technique takes advantage of this feature to accurately re-position the lateral epicondylar block in order to equalize medial and lateral gaps thereby ensuring a stable knee. Internal fixation with compression screws coupled with large contact surfaces of cancellous bone at the osteotomy site allow for early post-operative rehabilitation and ensure union at the osteotomy site.

Total knee arthroplasty becomes more challenging when knee arthritis is associated with an extra-articular deformity of the femur or tibia. We evaluated the outcome of navigated total knee arthroplasty in a large series of arthritic knees with extra-articular deformity.

We retrospectively reviewed the records of 950 patients who had undergone navigated TKA between January 2005 and February 2008. There were 40 extra-articular deformities in 34 patients, with bilateral involvement in 6 patients which were included in the study. Twenty-two limbs had deformity in the femur and the tibia had deformity in 18 limbs. There were 24 females and 10 males with a mean age of 63.1 years (range, 46–80 years).

The etiologies included malunited fractures (13 patients), stress fractures (4 patients), post high tibial osteotomy (3 patients), and excessive coronal bowing (14 patients). The mean femoral extra-articular deformity in the coronal plane was 9.3° varus (range, 24° varus to 2.8° varus) and the mean tibial extra-articular deformity in the coronal plane was 6.3° varus (range, 20° varus to 8.5° valgus). Three limbs underwent simultaneous corrective osteotomy and the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty. The limb alignment changed from a mean of 166.7° preoperatively to 179.1° postoperatively. At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean pre-operative score of 49.7 points to 90.4 points postoperatively; function score improved from 47.3 points to 84.9 points.

The results of our study indicate that computer-assisted total knee arthroplasty is a useful alternative to conventional total knee arthroplasty for knee arthritis with extraarticular deformity where accurate restoration of limb alignment may be challenging due to the presence of a deformed tibia or femur or in the presence of hardware.

We studied 15 patients with healed tuberculosis of the spine and a resultant kyphosis. We selected only those with no neurological deficit and performed a wedge resection of the vertebra using a transpedicular approach. The wedge was removed from the apex of the deformity. For those with a neurological deficit, we chose the conventional anterior debridement and decompression with 360° circumferential fusion. At a mean follow-up of 26.8 months (8 to 46) the outcome was good with an increase in the mean Oswestry Disability Index from 56.26 (48 to 62) pre-operatively to 11.2 (6 to 16) at the latest follow-up.