Evolving techniques: the need for better technology.

Abstract

The Bone & Joint JournalVol. 99-B, No. 2 EditorialFree AccessEvolving techniques the need for better technologyCrossMarkF. S. HaddadF. S. HaddadProfessor of Orthopaedic Surgery, Editor-in-ChiefCorrespondence should be sent to Professor F. S. Haddad; e-mail: E-mail Address: [email protected]The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK.Search for more papers by this authorPublished Online:1 Feb 2017https://doi.org/10.1302/0301-620X.99B2.38085AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail In this issue of The BJJ, we have two specialty updates in knee surgery that will be of interest to clinicians all around the world. Jonathan Eldridge and his team provide a clear perspective on adolescent patellar instability – a problem with many variations and even more solutions.1Wang et al have undertaken a meta-analysis of gap balancing and measured resection techniques in total knee arthroplasty (TKA).2 This is a fascinating concept to address, and one that brings out strong views and feelings in knee circles. Some are committed to an approach based primarily on bony cuts, others to using soft-tissue techniques in order to obtain a balanced knee arthroplasty. The proponents of both techniques have the same objective in mind - a well aligned functional knee in a happy patient with an excellent clinical outcome. Indeed, it would appear that the reality now is that many surgeons have adopted a hybrid technique whereby they adopt a combination of the two methods, which is very difficult to encapsulate in individual studies, let alone within a meta-analysis.The goals of knee arthroplasty have also evolved. The aims of the originators were to achieve pain relief and to regain a reasonable range of movement in patients who were barely ambulant. In recent times, our focus has shifted towards patient satisfaction and high-level functional outcomes after knee surgery. We are increasingly looking at solutions that preserve both the natural kinematics and the anterior cruciate ligament and four-bar linkage of the knee. Procedures such as unicompartmental, and indeed, bicompartmental arthroplasty, are likely to become more and more popular, as are innovative techniques such as focal resurfacing.3-12If TKA is required, the current debate concerns the rules that were set many years ago for alignment. These primarily regarded the tools that we had to perform the procedure, the type of implants that were available, and the fixation that was possible. As we move forward, many are now considering changing these rules and trying to restore patients’ own ‘more physiological’ alignment in order to get them back to the functional levels to which they aspire. The BJJ has led the way in publishing papers that support both standard techniques, and also more controversial ‘kinematic’ techniques of knee alignment.13-20 The comparison of gap balancing and measured resection philosophies, as well as the middle grey area, brings to mind the fidelity problem that has afflicted the studies that have compared traditional mechanical alignment with kinematic alignment. For each of these techniques, like many other areas of orthopaedics, there is a wide range of what each individual surgeon may deliver on any day, and what different surgeons would deliver on their best day. It is critical over the next few years that we define what we are aiming for clearly and agree on it in order to be able to study it. We also need to understand the modern technologies available, including computer assistance and robotics in order to hit these targets. We must also agree the mechanisms and sensitive tools that will allow us to pick up any differences when these techniques are compared. Once we can assure the fidelity of our interventions, and the sensitivity of our outcome measures, we will be able to answer critical questions. The debate between traditional and innovative alignment techniques is therefore set to continue for some time. We must also be careful not to enhance function in a proportion of our patients at the risk of higher failure rates for others. Like many innovations before it, a change in the alignment of the knee may have adverse unintended consequences.21-25Ultimately, we may realise and prove that there are several subgroups of patients, some of whom will need one form of knee arthroplasty, while others will benefit from a completely different technique.26-28Individualisation, and the creation of an environment and platform whereby a patient’s anatomy, physiology and kinematics dictate how, when and with which technology their procedure is undertaken, is not that far away. These arguments and issues do not just pertain to the knee. They also are highly relevant to every other joint, as is well illustrated in some of the hip, ankle and upper extremity papers in this issue.29,30The relationship between orthopaedic surgery and technology is likely to get stronger. We must work together with our engineering and computing and industry colleagues to ensure that we identify appropriate problems, and focus our energy on them. We must use technology efficiently in order to understand the optimal solution for each of our patients, and introduce and evaluate that technology using high-level research at every stage of the pathway. References 1 Clark D, Metcalfe A, Wogan C, Mandalia V, Eldridge J. Adolescent patella instability; current concepts review. Bone Joint J 2017;99-B:159–170. Link, ISI, Google Scholar2 Huang T, Long Y, George D, Wang W. Meta-analysis of gap balancing versus measured resection techniques in total knee arthroplasty. Bone Joint J 2017;99-B:151–158 Link, ISI, Google Scholar3 Scott CE, Oliver WM, MacDonald D, et al. Predicting dissatisfaction following total knee arthroplasty in patients under 55 years of age. Bone Joint J 2016;98-B:1625–1634. Link, ISI, Google Scholar4 Lum ZC, Lombardi AV, Hurst JM, et al. Early outcomes of twin-peg mobile-bearing unicompartmental knee arthroplasty compared with primary total knee arthroplasty. Bone Joint J 2016;98-B (10 Supple B):28–33. Link, ISI, Google Scholar5 Lisowski LA, Meijer LI, Bekerom MP, Pilot P, Lisowski AE. Ten- to 15-year results of the Oxford Phase III mobile unicompartmental knee arthroplasty. Bone Joint J 2016;98-B (10 Supple B):41–47. Link, ISI, Google Scholar6 Hamilton TW, Pandit HG, Lombardi AV, et al. Radiological Decision Aid to determine suitability for medial unicompartmental knee arthroplasty. Bone Joint J 2016;98-B (10 Supple B):3–10. Link, ISI, Google Scholar7 Konan S, Haddad FS. Does location of patellofemoral chondral lesion influence outcome after Oxford medial compartmental knee arthroplasty? Bone Joint J 2016;98-B (10 Supple B):11–15. Link, ISI, Google Scholar8 Bottomley N, Jones LD Rout R, et al. A survival analysis of 1084 knees of the Oxford unicompartmental knee arthroplasty. Bone Joint J 2016;98-B (10 Supple B):22–27. Link, ISI, Google Scholar9 Parratte S, Ollivier M, Lunebourg A, Abdel MP. Argenson JN. Long-term results of compartmental arthroplasties of the knee. Bone Joint J 2015;97-B (10 Supple A):9–15. Link, ISI, Google Scholar10 Hooper N, Snell D, Hooper G, Maxwell R, Frampton C. The five-year radiological results of the uncemented Oxford medial compartment knee arthroplasty. Bone Joint J2015;97-B:1358–1363. Link, ISI, Google Scholar11 Pandit H, Hamilton TW, Jenkins C, et al. The clinical outcome of minimally invasive Phase 3 Oxford unicompartmental knee arthroplasty. Bone Joint J 2015;97-B:1493–1500. Link, ISI, Google Scholar12 Liddle AD, Pandit H, Judge A, Murray DW. Optimal usage of unicompartmental knee arthroplasty. Bone Joint J 2015;97-B:1506–1511. Link, ISI, Google Scholar13 Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J 2014;96-B:907–913. Link, ISI, Google Scholar14 Oussedik S, Abdel MP, Cross MB, Haddad FS. Alignment and fixation in total knee arthroplasty: changing paradigms. Bone Joint J 2015;97-B(10 Suppl A):16–19. Link, ISI, Google Scholar15 Abdel MP, Oussedik S, Parratte S, Lustig S, Haddad FS. Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction. Bone Joint J 2014;96-B:857–862. Link, ISI, Google Scholar16 Haddad FS, Oussedik S. Shifting paradigms in knee arthroplasty. Bone Joint J 2014;96-B:855–856. Link, ISI, Google Scholar17 Waterson HB, Clement ND, Eyres KS, Mandalia VI, Toms AD. The early outcome of kinematic versus mechanical alignment in total knee arthroplasty. Bone Joint J 2016;98-B:1360–1368. Link, ISI, Google Scholar18 Huijbregts HJ, Khan RJ, Fick DP, et al. Component alignment and clinical outcome following total knee arthroplasty. Bone Joint J 2016;98-B:1043–1049. Link, ISI, Google Scholar19 Boonen B, Schotanus MG, Kerens B, et al. No difference in clinical outcome between patient-matched positioning guides and conventional instrumented total knee arthroplasty two years post-operatively. Bone Joint J 2016;98-B:939–944. Link, ISI, Google Scholar20 Mullaji AB, Shetty GM. Correcting deformity in total knee arthroplasty: techniques to avoid the release of collateral ligaments in severely deformed knees. Bone Joint J 2016;98-B (1 Supple A):101–104. Link, ISI, Google Scholar21 Hossain FS, Konan S, Patel S, Rodriguez-Merchan EC, Haddad FS. The assessment of outcome after total knee arthroplasty: are we there yet? Bone Joint J 2015;97-B:3–9. Link, ISI, Google Scholar22 Konan S, Hossain F, Patel S, Haddad FS. Measuring function after hip and knee surgery: the evidence to support performance-based functional outcome tasks. Bone Joint J 2014;96-B:1431–1435. Link, ISI, Google Scholar23 Liddle AD, Pandit H, Judge A, Murray DW. Patient-reported outcomes after total and unicompartmental knee arthroplasty. Bone Joint J 2015;97-B:793–801. Link, ISI, Google Scholar24 Murphy MT, Vardi R, Journeaux SF, Whitehouse SL. A patient’s recollection of pre-operative status is not accurate one year after arthroplasty of the hip or knee. Bone Joint J 2015;97-B:1070–1075. Link, ISI, Google Scholar25 Hamilton D, Loth F, Giesinger J, et al. Validation of the English language Forgotten Joint Score-12 as an outcome measure for total hip and knee arthroplasty in a British population. Bone Joint J 2017;99-B:218–224. Link, ISI, Google Scholar26 Mooney LT, Smith A, Sloan K, Clark GW. The effect of the native kinematics of the knee on the outcome following total knee arthroplasty. Bone Joint J 2016;98-B:1471–1478. Link, ISI, Google Scholar27 Bonnin MP, Saffarini M, Bossard N, Dantony E, Victor J. Morphometric analysis of the distal femur in total knee arthroplasty and native knees. Bone Joint J 2016;98-B:49–57. Link, ISI, Google Scholar28 Karachalios T, Varitimidis S, Bargiotas K, et al. An 11- to 15-year clinical outcome study of the Advance Medial Pivot total knee arthroplasty. Bone Joint J 2016;98-B:1050–1055. Link, ISI, Google Scholar29 Pierrepont J, Hawdon G, Miles B, et al. Variation in functional pelvic tilt in patients undergoing total hip arthroplasty. Bone Joint J 2017;99-B:184–191. Link, ISI, Google Scholar30 Wagener J, Gross CE, Schweizer C, Horn Lang T, Hintermann B. Custom-made total ankle arthroplasty for the salvage of major talar bone loss. Bone Joint J 2017;99-B:231–236. Link, ISI, Google ScholarFiguresReferencesRelatedDetailsCited ByUnicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA2 September 2020 | Journal of Orthopaedics and Traumatology, Vol. 21, No. 1Artificial intelligence and surgical innovation: lower limb arthroplastyBritish Journal of Hospital Medicine, Vol. 81, No. 10Robotic total knee arthroplastyclinical outcomes and directions for future researchBabar Kayani, Fares S. 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Haddad20 December 2018 | Bone & Joint Research, Vol. 7, No. 12 Vol. 99-B, No. 2 Metrics Downloaded 114 times History Published online 1 February 2017 Published in print 1 February 2017 InformationCopyright © 2017, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download