Clinical Review

Disposable Navigation for Total Knee Arthroplasty

Am J Orthop. 2016 May;45(4):240-245

Recent developments in surgical techniques and technologies have advanced accuracy and increased implant survival of total knee arthroplasty (TKA). The introduction of mechanical guides and computer-assisted navigation has improved component alignment and the ability to accurately reproduce component position. Over the past decade, computer navigation and intraoperative guides have been introduced to help control surgical variables and overcome the limitations and inaccuracies of traditional mechanical instrumentation. The use of disposable navigation increases the accuracy of component placement while decreasing the incidence of outliers compared to standard mechanical guides without the need for a large computer console in the operating room.

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References

1. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014;96(8):624-630.

2. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57-63.

3. Schroer WC, Berend KR, Lombardi AV, et al. Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty. 2013;28( 8 Suppl):116-119.

4. Sassoon A, Nam D, Nunley R, Barrack R. Systematic review of patient-specific instrumentation in total knee arthroplasty: new but not improved. Clin Orthop Relat Res. 2015;473(1):151-158.

5. Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty. 2005;20(7 Suppl 3):132-138.

6. Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;22(8):1097-1106.

7. Khakha RS, Chowdhry M, Sivaprakasam M, Kheiran A, Chauhan SK. Radiological and functional outcomes in computer assisted total knee arthroplasty between consultants and trainees - a prospective randomized controlled trial. J Arthroplasty. 2015;30(8):1344-1347.

8. Zhu M, Ang CL, Yeo SJ, Lo NN, Chia SL, Chong HC. Minimally invasive computer-assisted total knee arthroplasty compared with conventional total knee arthroplasty: a prospective 9-year follow-up. J Arthroplasty. 2015. [Epub ahead of print]

9. Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty. 2015;30(9 Suppl):59-63.

10. de Steiger RN, Liu YL, Graves SE. Computer navigation for total knee arthroplasty reduces revision rate for patients less than sixty-five years of age. J Bone Joint Surg Am. 2015;97(8):635-642.

11. Fehring TK, Mason JB, Moskal J, Pollock DC, Mann J, Williams VJ. When computer-assisted knee replacement is the best alternative. Clin Orthop Relat Res. 2006;452:132-136.

12. Iorio R, Mazza D, Drogo P, et al. Clinical and radiographic outcomes of an accelerometer-based system for the tibial resection in total knee arthroplasty. Int Orthop. 2015;39(3):461-466.

13. 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.

14. Ollivier M, Tribot-Laspiere Q, Amzallag J, Boisrenoult P, Pujol N, Beaufils P. Abnormal rate of intraoperative and postoperative implant positioning outliers using “MRI-based patient-specific” compared to “computer assisted” instrumentation in total knee replacement. Knee Surg Sports Traumatol Arthrosc. 2015. [Epub ahead of print]

15. 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(3):895-902.

16. Nunley RM, Ellison BS, Ruh EL, et al. Are patient-specific cutting blocks cost-effective for total knee arthroplasty? Clin Orthop Relat Res. 2012;470(3):889-894.

17. Barrack RL, Ruh EL, Williams BM, Ford AD, Foreman K, Nunley RM. Patient specific cutting blocks are currently of no proven value. J Bone Joint Surg Br. 2012;94(11 Suppl A):95-99.

18. Chen JY, Chin PL, Tay DK, Chia SL, Lo NN, Yeo SJ. Functional outcome and quality of life after patient-specific instrumentation in total knee arthroplasty. J Arthroplasty. 2015;30(10):1724-1728.

19. Goyal N, Patel AR, Yaffe MA, Luo MY, Stulberg SD. Does implant design influence the accuracy of patient specific instrumentation in total knee arthroplasty? J Arthroplasty. 2015;30(9):1526-1530.

20. Bauwens K, Matthes G, Wich M, et al. Navigated total knee replacement. A meta-analysis. J Bone Joint Surg Am. 2007;89(2):261-269.

21. Scuderi GR, Fallaha M, Masse V, Lavigne P, Amiot LP, Berthiaume MJ. Total knee arthroplasty with a novel navigation system within the surgical field. Orthop Clin North Am. 2014;45(2):167-173.

22. Goh GS, Liow MH, Lim WS, Tay DK, Yeo SJ, Tan MH. Accelerometer-based navigation is as accurate as optical computer navigation in restoring the joint line and mechanical axis after total knee arthroplasty: a prospective matched study. J Arthroplasty. 2016;31(1):92-97.

23. Berend KR, Lombardi AV Jr. Liberal indications for minimally invasive oxford unicondylar arthroplasty provide rapid functional recovery and pain relief. Surg Technol Int. 2007;16:193-197.

24. Nam D, Jerabek SA, Cross MB, Mayman DJ. Cadaveric analysis of an accelerometer-based portable navigation device for distal femoral cutting block alignment in total knee arthroplasty. Comput Aided Surg. 2012;17(4):205-210.

25. Nam D, Cody EA, Nguyen JT, Figgie MP, Mayman DJ. Extramedullary guides versus portable, accelerometer-based navigation for tibial alignment in total knee arthroplasty: a randomized, controlled trial: winner of the 2013 HAP PAUL award. J Arthroplasty. 2014;29(2):288-294.

26. Bugbee WD, Kermanshahi AY, Munro MM, McCauley JC, Copp SN. Accuracy of a hand-held surgical navigation system for tibial resection in total knee arthroplasty. Knee. 2014;21(6):1225-1228.

27. Schai PA, Thornhill TS, Scott RD. Total knee arthroplasty with the PFC system. Results at a minimum of ten years and survivorship analysis. J Bone Joint Surg Br. 1998;80(5):850-858.

28. Pradhan NR, Gambhir A, Porter ML. Survivorship analysis of 3234 primary knee arthroplasties implanted over a 26-year period: a study of eight different implant designs. Knee. 2006;13(1):7-11.

29. 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.

30. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24(6 Suppl):39-43.

31. Cherian JJ, Kapadia BH, Banerjee S, Jauregui JJ, Issa K, Mont MA. Mechanical, anatomical, and kinematic axis in TKA: concepts and practical applications. Curr Rev Musculoskelet Med. 2014;7(2):89-95.

32. Howell SM, Papadopoulos S, Kuznik K, Ghaly LR, Hull ML. Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty? Int Orthop. 2015;39(11):2117-2124.

33. 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.

34. Huang EH, Copp SN, Bugbee WD. Accuracy of a handheld accelerometer-based navigation system for femoral and tibial resection in total knee arthroplasty. J Arthroplasty. 2015;30(11):1906-1910.

Total knee arthroplasty (TKA) continues to be a widely utilized treatment option for end-stage knee osteoarthritis, and the number of patients undergoing TKA is projected to continually increase over the next decade.¹ Although TKA is highly successful for many patients, studies continue to report that approximately 20% of patients are dissatisfied after undergoing TKA, and nearly 25% of knee revisions are performed for instability or malalignment.^2,3 Technological advances have been developed to help improve clinical outcomes and implant survivorship. Over the past decade, computer navigation and intraoperative guides have been introduced to help control surgical variables and overcome the limitations and inaccuracies of traditional mechanical instrumentation. Currently, there are a variety of technologies available to assist surgeons with component alignment, including extramedullary devices, computer-assisted navigation systems (CAS), and patient-specific instrumentation (PSI) that help achieve desired alignment goals.^4,5

Computer-assisted navigation tools were introduced in an effort to improve implant alignment and clinical outcomes compared to traditional mechanical guides. Some argue that the use of computer-assisted surgery has a steep learning curve and successful use is dependent on the user’s experience; however, studies have suggested computer-assisted surgery may allow less experienced surgeons to reliably achieve anticipated intraoperative alignment goals with a low complication rate.^6,7 Various studies have looked at computer-assisted TKA at short to mid-term follow-up, but few studies have reported long-term outcomes.^6-9 de Steiger and colleagues¹⁰ recently found that computer-assisted TKA reduced the overall revision rate for aseptic loosening following TKA in patients younger than age 65 years, which suggests benefit of CAS for younger patients. Short-term follow-up has also shown the benefit of CAS TKA in patients with severe extra-articular deformity, where traditional instrumentation cannot be utilized.¹¹ Currently, there is no consensus that computer-assisted TKA leads to improved postoperative patient reported outcomes, because many studies are limited by study design or small cohorts; however, current literature does show an improvement in component alignment as compared to mechanical instrumentation.^9,12,13 As future implant and position targets are defined to improve implant survivorship and clinical outcomes in total joint arthroplasty, computer-assisted devices will be useful to help achieve more precise and accurate component positioning.

In addition to CAS devices, some companies have sought to improve TKA surgery by introducing PSI. PSI was introduced to improve component alignment in TKA, with the purported advantages of a shorter surgical time, decrease in the number of instruments needed, and improved clinical outcomes. PSI accuracy remains variable, which may be attributed to the various systems and implant designs in each study.^14-17 In addition, advanced preoperative imaging is necessary, which further adds to the overall cost.¹⁷ While the recent advancement in technology may provide decreased costs at the time of surgery, the increased cost and time incurred by the patient preoperatively has not resulted in significantly better clinical outcomes.^18,19 Additionally, recent work has not shown PSI to have superior accuracy as compared to currently available CAS devices.¹⁴ These findings suggest that the additional cost and time incurred by patients may limit the widespread use of PSI.

Although computer navigation has been shown to be more accurate than conventional instrumentation and PSI, the lack of improvement in long-term clinical outcome data has limited its use. In a meta-analysis, Bauwens and colleagues²⁰ suggested that while navigated TKAs have improved component alignment outcomes as compared to conventional surgery, the clinical benefit remains unclear. Less than 5% of surgeons are currently using navigation systems due to the perceived learning curve, cost, additional surgical time, and imaging required to utilize these systems. Certain navigation systems can be seemingly cumbersome, with large consoles, increased number of instruments required, and optical instruments with line-of-sight issues. Recent technological advances have worked to decrease this challenge by using accelerometer- and gyroscope-based electronic components, which combine the accuracy of computer-assisted technology with the ease of use of mechanical guides.

Accelerometer and gyroscope technology systems, such as the iAssist system, are portable devices that do not require a large computer console or navigation arrays. This technology relies on accelerator-based navigation without additional preoperative imaging. A recent study demonstrated the iAssist had reproducible accuracy in component alignment that could be easily incorporated into the operating room without optical trackers.²¹ The use of portable computer-assisted devices provides a more compact and easily accessible technology that can be used to achieve accurate component alignment without additional large equipment in the operating room.²² These new handheld intraoperative tools have been introduced to place implants according to a preoperative plan in order to minimize failure due to preoperative extra-articular deformity or intraoperative technical miscues.²³ Nam and colleagues²⁴ used an accelerometer-based surgical navigation system to perform tibial resections in cadaveric models, and found that the accelerometer-based guide was accurate for tibial resection in both the coronal and sagittal planes. In a prospective randomized controlled trial evaluating 100 patients undergoing a TKA using either an accelerometer-based guide or conventional alignment methods, the authors showed that the accelerometer-based guide decreased outliers in tibial component alignment compared to conventional guides.²⁵ In the accelerometer-based guide cohort, 95.7% of tibial components were within 2° of perpendicular to the tibial mechanical axis, compared to 68.1% in the conventional group (P < .001). These results suggested that portable accelerometer-based navigation allows surgeons to achieve satisfactory tibial component alignment with a decrease in the number of potential outliers.^24,25 Similarly, Bugbee and colleagues²⁶ found that accelerometer-based handheld navigation was accurate for tibial coronal and sagittal alignment and no additional surgical time was required compared to conventional techniques.