Total knee arthroplasty in femoral bowing: does patient specific instrumentation have something to add? A randomized controlled trial

Sammy Abdullah ALShammari, Keun Young Choi, In Jun Koh, Man Soo Kim, Yong In, Sammy Abdullah ALShammari, Keun Young Choi, In Jun Koh, Man Soo Kim, Yong In

Abstract

Background: Patient-specific instrumentation (PSI) proponents have suggested the benefits of improved component alignment and reduced outliers. In this randomized controlled trial, we attempted to assess the advantage of using PSI over conventional intermedullary (IM) guides for primary total knee arthroplasty (TKA) with bilateral severe femoral bowing (> 5°). A parallel trial design was used with 1:1 allocation. We hypothesize that PSI would support more accurate alignment of components and the lower-limb axis during TKA with severe femoral bowing in comparison with conventional IM guides.

Methods: Among 336 patients undergoing bilateral TKAs due to knee osteoarthritis, 29 patients with bilateral lateral femoral bowing of more than 5° were included in this study. Every patient was assigned randomly to PSI on one side and to conventional instrumentation lateralization of the entry point of the femoral IM guide was applied on the other with a goal of neutral mechanical alignment. The assessment of coronal alignment was completed by measuring the hip-knee-ankle (HKA) angle on preoperative and postoperative long film standing radiographs. Coronal and sagittal orientations of femoral and tibial components were assessed on weight-bearing radiographs. The rotational alignment of the femoral component was evaluated using computed tomography.

Results: The postoperative mean ± standard deviation (SD) HKA angle was varus 4.0° (± 2.7°) for conventional technique and varus 4.1° (± 3.1°) for PSI, with no differences between the two groups (p = 0.459). The component orientation showed no significant differences except with respect to the sagittal alignment of the femoral component (p = 0.001), with a PSI mean ± SD flexion of 5.8° (± 3.7°) and a conventional method mean ± SD flexion of 3.2° (± 2.5°), due to the intentional 3° flexion incorporated in the sagittal plane to prevent femoral notching in PSI planning. Computed tomography assessment for rotational alignment of the femoral components showed no difference between the two groups concerning the transepicondylar axis (p = 0.485) with a PSI mean ± SD external rotation of 1.5° (± 1.3°) and conventional mean ± SD external rotation of 1.5° (± 1.6°).

Conclusion: PSI showed no advantage over lateralization of the femoral entry for IM guidance.

Level of evidence: 1 TRIAL REGISTRATION: Registered on US national library of medicine ClinicalTrials.gov ( NCT02993016 ) on December 12th 2016.

Keywords: Alignment; Component position; Femoral bowing; Patient specific instrument; Total knee arthroplasty.

Conflict of interest statement

No competing interests to declare.

Figures

Fig. 1
Fig. 1
Consolidated Standards of Reporting Trials flow diagram
Fig. 2
Fig. 2
Planning for lateralization of the IM guide with lateral femoral bowing. Mechanical axis of the femur and potential IM guide axis from the apex of the intercondylar notches is marked with red lines. A yellow dotted line is drawn traversing the lateral cortex that represents the most capable path of passing through the IM canal. The lateralized entry point is in a position equivalent to half the diameter of the guide (orange arrow) (a). A perpendicular line to the mechanical axis is drawn (blue line), representing the distal femoral cut. The cutting angle is the product of 90° subtracted from angle “a” (b)
Fig. 3
Fig. 3
Lateralization of the entry point intraoperatively in the left knee. a marks the traditional entry point for the guide at the apex of the intercondylar notch. b represents the mark of the lateralized entry point. (a) the lateralized entry point is opened in a wide fashion by conically rotating the drill bit (b)
Fig. 4
Fig. 4
Lower limb long-film X-ray. Severe genu varum in a 57-year-old female patient with no extraarticular deformity (a). Bilateral severe femoral bowing seen preoperatively in an 85-year-old female patient enrolled in this study (b). Postoperative X-rays of patient B (c). The right side was treated using conventional instruments and the left side was treated using PSI

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