Bone Cuts Research Articles

A Study of Surgical Accuracy with X-Ray-Based Patient-Specific Instrument (X3DPSI®) vs Conventional Instrument in Total Knee Arthroplasty Surgeries.

Patient-specific instruments (PSI) have been shown to be a good solution in getting accurate bone cuts in total knee arthroplasty (TKA) in many studies. However, the need for an extra CT/MRI makes the existing PSI method costly and unsafe. X-ray-based PSI can solve these problems, if proven to be accurate. The purpose of this study was to introduce a novel method to measure the performance of X-ray to 3D-based PSI (X3DPSI ® ) in achieving planned bone cuts by comparing with conventional instruments (CI). This was a prospective study of a total of ten patients undergoing TKA surgery. Preoperative full length lower limb scanogram was done with specialized calibration strap-on marker to develop X3DPSI ® which was used intraoperatively for the placement of guiding pins for the cutting jig. Similarly, intraoperative guide pins were placed using CI also. Calibrated intraoperative X-ray images, in AP and LAT view, were taken while the cutting-block guiding pins were placed on the distal femur and proximal tibia. These X-ray images were used to calculate the cutting plane alignments for femur and tibia and to simulate the postoperative hip-knee-ankle (HKA) angle and MAD (mechanical axis deviation), in a virtual Tabplan3D environment for both the methods. The results showed that there was a significant difference between the two methods in terms of femoral cutting plane angles and in terms of the HKA angles and MAD. There was no significant difference in the tibial cutting plane angles in the coronal plane. The mechanical axis alignment achieved based on the virtual cuts made using the X3DPSI ® was significantly better than the alignment achieved based on the cuts made using the CI, in terms of both HKA and MAD. This novel method of X-ray-based PSI is a low-cost alternative to CT/MRI-based PSI if found to be accurate in future planned studies.

Tibial reference point in total knee arthroplasty in patient with proximal tibia vara: A case report.

IntroductionCenter of the intercondylar eminence at the proximal tibia had been widely used as a reference point for tibial bone cut in the Total Knee Arthroplasty (TKA) procedure. However, in the presence of preexisting tibia vara, the center of intercondylar eminence as tibial bone cut reference point often leads to varus malalignment after TKA procedure.Case report75 years old male patient complained of worsening pain on the left knee. The patient has had a history of knee osteoarthritis for the past seven years. The radiograph on the right knee revealed osteoarthritis grade 3 and left knee osteoarthritis grade 4, both with tibia vara. We planned to perform total knee arthroplasty surgery on his left knee with a preoperative planning tibial reference point of 10 mm lateral to the center. Six months after the knee replacement, there was minimal pain on activity, and full ROM was achieved on his left knee. On the radiographic X-ray evaluation, the alignment between the tibial implant surface and mechanical axis is 0.43 degrees valgus.Clinical discussionIn a varus knee malignment, the mechanical axis passes through one-third of the medial side of the knee, which makes the medial side of the implant wear off faster, resulting in the collapse of the medial tibia, thus decreasing implant survival and increasing the need for revision for TKA.ConclusionIn patients with preexisting tibia vara, tibial bone cut reference point planning before TKA procedure is important to provide longevity of implant survival and better quality of life.

Posteromedial Accessory Incision for Posterior Capsular Release and Retractor Placement in a Total Ankle Replacement.

The standard approach for performing a total ankle replacement (TAR) is the anterior approach as this offers good direct visualization of the tibiotalar joint. Irrespective of implant system used, most commonly, bone cuts are made in the anterior to posterior direction and may potentially injure the posterior neurovascular structures and tendons running close to the ankle joint. Careful consideration must be taken to ensure these structures are protected. We introduce a new intraoperative technique of protection for the posteromedial soft tissues and neurovascular structures and include the early results of 60 consecutive patients where the described technique was employed. There were no technique-related complications, or evidence of injury to the PTT, FHL, flexor digitorum longus (FDL), or neurovascular bundles.

Combined quadriceps tendon reconstruction and total knee replacement with computer navigation: a case report

BackgroundChronic quadriceps tendon rupture is technically challenging for surgeons due to scarring and tendon retraction. The presence of concurrent ipsilateral knee osteoarthritis compounds the issue even further. Although a combined presentation is rare, treatment options to manage each coexisting pathology simultaneously are scarcely reported. We describe the case of a 67-year-old Caucasian male who had such a presentation, and was subsequently treated with a one-stage extensor mechanism autograft reconstruction and total knee replacement with computer navigation.CaseThe patient was a 67-year-old male Caucasian, who had previously sustained an acute rupture of his right quadriceps tendon that was adequately repaired 6 months prior. Despite an initial satisfactory result, he reported deterioration in his mobility in the few months thereafter, with worsening knee pain. His comorbidities consisted of hypertension, asthma, and a body mass index of 40.4 kg/m2. Otherwise, there were no risk factors for tendon rerupture. Clinical examination later revealed a large palpable gap in the right suprapatellar region and weakness of active knee extension. No traumatic cause for this new presentation was identified. Suspicion of a chronic quadriceps tendon rupture was confirmed on radiological imaging, but the investigations also noted the presence of severe tricompartmental osteoarthritis of the ipsilateral, native knee joint. The combined procedure took place in one surgical sitting. The total knee replacement with patella resurfacing was performed first and assisted by computer navigation. The quadriceps tendon reconstruction was then conducted sequentially using the patient’s hamstring tendons (semitendinosus and gracilis). The tensile strength was reinforced with use of a Ligament Augmentation and Reconstruction System (LARS) ligament. Initial outcomes were excellent, and these results were maintained at 6 months postoperatively, with the patient reporting no pain and having full range of movement.ConclusionOur techniques used have not previously been reported, but are successful options in treating coexisting chronic quadriceps tendon rupture and ipsilateral knee osteoarthritis. The advantage of using computer navigation with an extramedullary femoral jig can lead to improved accuracy of bone cuts, which is important in the presence of anatomical disruption. Chronic failures of the extensor mechanism require different approaches depending on the inherent and underlying pathology. We feel that the multidisciplinary team approach to the management and use of two surgeons with differing expertise added to the successful outcome of this complex case.

Assessing the reliability of zygomatic bone landmarks as guides to reach the inferior orbital fissure in orbitozygomatic osteotomy: anatomical study of 83 human skulls.

To perform an adequate orbitozygomatic craniotomy, it is very important that the bone cut which passes through the body of the zygoma reaches the inferior orbital fissure (IOF). To reach the IOF, two surface landmarks on the body of the zygoma are described: a point located directly superior to the malar eminence and the zygomaticofacial foramen. The article explores the reliability of these landmarks and three other alternative points to reach the IOF. Eighty-three adult skulls were used in this study. The IOF dimensions and the relationship with the malar eminence, the point superior to the malar eminence, the zygomaticofacial foramen, and 3 alternative points (E, C, F) were analyzed. The malar eminence was unacceptable for use as a guide to the IOF. The point superior to the malar eminence was also unacceptable as a guide as only 9.4% and 10.9% were in the projection of the IOF on the right and left, respectively. 59.7% of the total zygomaticofacial foramina fell in the IOF projection. The point F fell in the projection of the IOF in 98.8% and 100.0% on the right and left, respectively. The use of the malar eminence as a guide to reach the IOF is unreliable in one third of cases as it is not easily identified intraoperatively in these cases. The zygomaticofacial foramen cannot be considered a reliable surgical landmark to reach the IOF. The authors recommend using a novel landmark which may be identified as a midpoint between intersections of the anterior and posterior margins of the zygomatic frontal process on a line extending from the inferior margin of the zygomatic arc. This point is reliable in 98.8-100% of cases.

High accuracy of a new robotically assisted technique for total knee arthroplasty: an in vivo study.

PurposeOver the last decade, robotic TKA gained popularity for improving the accuracy of implant positioning and reducing outliers in limb alignment comparing to conventional jig-based TKA. Hypothesis of this study was that this newly designed robotically assisted system will achieve a high level of accuracy for bone resection. Purpose of the study was to evaluate the accuracy of the system.MethodsFor this study, 75 knees in 75 patients were operated using a new, robotic system (ROSA® Knee System; Zimmer Biomet, Warsaw, IN) with a Posterior Stabilized Total Knee Arthroplasty (Persona® Knee System). The planned, validated and measured angles and cuts for the distal and posterior femur, for the proximal tibia and for the final coronal alignment on long standing x-rays were compared.ResultsA statistically significant difference was found only between the average planned and the average validated angle for femoral flexion, tibial coronal axis, medial and lateral cuts; the average difference was in any case below 1 mm or under 1 degree with SD < 1. No statistical difference was found between planned validated and measured cuts. Average difference between planned HKA and measured was 1.2 ± 1.1. No statistically significant difference was found.ConclusionsThe results of this study demonstrated that using this new surgical robot in total knee arthroplasty it is possible to perform accurate bone cuts and to achieve the planned angles and resections.

THE ADVANTAGES OF MINIMAL BONE CUTS RESECTION IN TOTAL KNEE REPLACEMENT

THE ADVANTAGES OF MINIMAL BONE CUTS RESECTION IN TOTAL KNEE REPLACEMENT

Accuracy of Patient-Specific Instrument for Cylindrical Axis Implementation in Kinematically Aligned Total Knee Arthroplasty.

In kinematically aligned total knee arthroplasty (KA-TKA), the cylindrical axis (CA) is very important in restoring the native joint line and kinematics of the pre-arthritic knee. This study aimed to determine the accuracy of patient-specific instrument (PSI) for restoring the CA for femoral bone resection in KA-TKA. Thirty KA-TKAs were performed using a computed tomography (CT)-based PSI system. Data from preoperative CT were reconstructed into three-dimensional (3D) models using 3D-planning software. The CA was created by connecting the centers of each virtual sphere to the medial and lateral femoral condyles using computer software. Femoral bone resection of the distal and posterior condyles was performed parallel to the sagittal planes of the CA. The thickness of the CA-referenced bone resection was determined based on the thickness necessary for the respective regions of the femoral component. The PSI was manufactured to locate the guide pin for a conventional cutting block. The accuracy of PSI for KA-TKA was evaluated as the absolute error between the preoperatively predicted thickness and the intraoperative measurements in each of the four regions, as well as the difference in error between distal-medial (DM) and posterior-medial (PM) and between distal-lateral (DL) and posterior-lateral (PL). The differences in thickness of bone cut in the DM, DL, PM, and PL were 0.79 ± 0.39 mm (range, -1.20 to 1.50), 0.70 ± 0.42 mm (range, -1.50 to 1.50), 0.80 ± 0.46 mm (range, -0.80 to 1.50), and 0.75 ± 0.47 mm (range, -2.10 to 1.40), respectively. There was no significant difference in the thickness error between DM and PM (p = 0.959) and between DL and PL (p = 0.812). In KA-TKA, PSI was effective for accurate femoral bone resection based on virtually planned thickness.

The use of imageless navigation to quantify cutting error in total knee arthroplasty

PurposeNavigated total knee arthroplasty (TKA) improves implant alignment by providing feedback on resection parameters based on femoral and tibial cutting guide positions. However, saw blade thickness, deflection, and cutting guide motion may lead to final bone cuts differing from planned resections, potentially contributing to suboptimal component alignment. We used an imageless navigation device to intraoperatively quantify the magnitude of error between planned and actual resections, hypothesizing final bone cuts will differ from planned alignment.Materials and methodsA retrospective study including 60 consecutive patients undergoing primary TKA using a novel imageless navigation device was conducted. Device measurements of resection parameters were obtained via attachment of optical trackers to femoral and tibial cutting guides prior to resection. Following resection, optical trackers were placed directly on the bone cut surface and measurements were recorded. Cutting guide and bone resection measurements of both femoral and tibial varus/valgus, femoral flexion, tibial slope angles, and both femoral and tibial medial and lateral resection depths were compared using a Student's t-test.ResultsFemoral cutting guide position differed from the actual cut by an average 0.6 ± 0.5° (p = 0.85) in the varus/valgus angle and 1.0 ± 1.0° (p = 0.003) in the flexion/extension angle. The difference between planned and actual cut measurements for medial and lateral femoral resection depth was 1.1 ± 1.1 mm (p = 0.32) and 1.2 ± 1.0 mm (p = 0.067), respectively. Planned cut measurements based on tibial guide position differed from the actual cut by an average of 0.9 ± 0.8° (p = 0.63) in the varus/valgus angle and 1.1 ± 1.0° (p = 0.95) in slope angle. Measurement of medial and lateral tibial resection depth differed by an average of 0.1 ± 1.8 mm (p = 0.78) and 0.2 ± 2.1 mm (p = 0.85), respectively.ConclusionsSignificant discrepancies between planned and actual femoral bone resection were demonstrated for flexion/extension angle, likely the result of cutting error. Our data highlights the importance of cut verification postresection to confirm planned resections are achieved, and suggests imageless navigation may be a source of feedback that would allow surgeons to intraoperatively adjust resections to achieve optimal implant alignment.

Morphologic differences in the bone cuts of the knee between Han Chinese and Mongolian Chinese and their correlation with current knee prostheses.

Morphologic differences in the bone cuts of the knee between Han Chinese and Mongolian Chinese and their correlation with current knee prostheses.

A Novel Approach to First-Rib Resection in Neurogenic Thoracic Outlet Syndrome.

Objectives: The treatment for neurogenic thoracic outlet syndrome (NTOS) conventionally involves first-rib resection (FRR) surgery, which is quite challenging to perform, especially for novices, and is often associated with postoperative complications. Herein, we report a new segmental resection approach through piezo surgery that involves using a bone cutter, which can uniquely provide a soft tissue protective effect.Methods: This retrospective study involved the examination of 26 NTOS patients who underwent piezo surgery and another group of 30 patients who underwent FRR using the conventional technique. In the patient group that underwent piezo surgery, the rib was first resected into two pieces using a piezoelectric device and subsequently removed. In the patient group that underwent conventional surgery, the first rib was removed as one piece using a rib cutter and rongeurs.Results: The piezo surgery group had significantly shorter operative time (96.85 ± 14.66 vs. 143.33 ± 25.64 min, P < 0.001) and FRR duration (8.73 ± 2.11 vs. 22.23 ± 6.27 min, P < 0.001) than the conventional group. The posterior stump length of the residual rib was shorter in the piezo surgery group than in the conventional group (0.54 ± 0.19 vs. 0.65 ± 0.15 cm, P < 0.05). There were no significant differences in postoperative complications and scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Cervical Brachial Symptom Questionnaire (CBSQ), and the visual analog scale (VAS). Even the TOS index (NTOS Index = [DASH + (0.83 × CBSQ) + (10 × VAS)]/3) and patient self-assessments of both the groups showed no significant differences. Univariate analyses indicated that the type of treatment affected operative time.Conclusion: Our results suggest that piezo surgery is safe, effective, and simple for segmental FRR in NTOS patients. Piezo surgery provides a more thorough FRR without damaging adjacent soft tissues in a relatively short duration and achieves similar functional recovery as conventional techniques. Therefore, piezo surgery can be a promising alternative for FRR during the surgical treatment of NTOS.

Modified Le Fort II approach with adequate vascularization preservation in midface allotransplantation: Mock surgery

IntroductionIt is critical to preserve adequate vascularization in midface allotransplantation, the major complication of which is inadequate blood supply in palate area supplying mainly by internal maxillary artery. Therefore, the aim of this study is to explore a modified Le Fort II approach entailing midface vascularization enhancement. Materials and methodsTen cadaveric heads were used in mock surgery. A conventional approach was used on seven cadaveric heads to harvest external carotid artery-facial artery-internal maxillary artery axis. On the remaining three cadaveric heads, modified Le Fort II approach was applied where the internal maxillary artery was harvested after cutting off zygomatic arches and rami of the mandible. ResultsThe conventional approach had difficulty harvesting internal maxillary artery, which left the facial artery the only blood supply to midface. Modified Le Fort II approach with Computerized surgical planning (CSP) assisted, on the other hand, could completely unveil and harvest intact internal maxillary artery after osteotomy of mandibular ramus. ConclusionThe modified Le Fort II approach with CSP and ultrasonic bone cutter assisted can maximally preserve internal maxillary system with ease. This approach optimizes midface allotransplantation in clinical practice in future.

The Disproportionate Increase of the Intraoperative Flexion and Extension Gap Space after Posterior Cruciate Ligament Resection in Total Knee Arthroplasty.

Purpose: Maintaining gap balance is critical for total knee arthroplasty (TKA). This study aimed to elucidate if the extension–flexion gaps would be changed with posterior cruciate ligament (PCL) intact (PI) and PCL resection (PR) during TKA. The flexion gaps were measured using two methods, open-(Fo) and closed-chain position (Fc), based on the definition of kinetic chain position, respectively. Methods: This retrospective study enrolled a total of 33 patients who underwent posterior-stabilized (PS) TKA for symptomatic advanced osteoarthritis of knees. After bone cuts were completed, the extension–flexion gaps before and after PCL resection during TKA were measured using a calibrated tensioning device set at a 100 Nm distraction force. To further differentiate the effect of thigh weight on the 90° flexion gap, two varied methods of examination, either in closed chain (Fc) or open chain (Fo) were performed. Results: The increases in the 90° knee flexion gap after PCL resection were measured by both methods, i.e., ΔFc (PR-Fc—PI-Fc): 2.04 ± 2.06 mm, p < 0.001; and mean ΔFo (PR-Fo—PI-Fo): 1.64 ± 1.36 mm, p < 0.001. However, there were no differences between ΔFc and ΔFo before and after PCL resection. A greater amount of flexion gap was identified in open chain than in closed chain after PCL resection, and the PR-Fo and PR-Fc were 14.36 ± 3.13 and 11.40 ± 3.47 (p < 0.001), respectively. Conclusions: The resection of PCL during TKA distinctly increased the flexion gap, but not the extension gap. This disproportionate increase of the gap will cause a gap balance mismatch. The tensioning maneuver in open-chain was more effective to detect the gap differences than in closed-chain before and after PCL resection during TKA.

Use of 3D Printed Models to Determine Accurate Bone Cuts during a Periacetabular Osteotomy for Developmental Hip Dysplasia

AbstractThe periacetabular osteotomy (PAO) is a powerful tool to delay the progression of hip arthritis by reorienting the acetabulum. This study aimed to use three-dimensional (3D)-printed models of the pelvis, reconstructed from the computed tomography (CT) scans of patients, to model how the level of dysplasia and its location ilium osteotomy affect radiographic outcomes following PAO. This pilot study aims to determine if preoperative 3D printing/planning can assist in predicting radiographic outcomes. We performed a retrospective review of five patients with differing levels of hip dysplasia for whom we had obtained CT scans before PAO surgery. For each patient, we printed two pelvis models that would undergo standardized cuts of the PAO procedure, with variations only in the distance of the ilium start point (one-third of the distance between the anterior superior iliac spine and anterior inferior iliac spine [AIIS] vs. two-thirds of the distance). We then mobilized the acetabular fragment into eight reproducible positions in space by moving the ilium cut a combination of 0, 1, or 2 cm anterior/lateral. Each position of the newly realigned acetabula was examined under fluoroscopy to obtain a standardized anteroposterior view, and to obtain standardized radiographic measurements in the form of lateral center edge angle (CEA), acetabular depth, Tonnis angle, and acetabular inclination. We performed 80 simulations of the PAO with varying degrees of acetabular mobilization. On average, in the models where the supra-acetabular cut was closer to the AIIS, we found more significant degrees of radiographic correction, regarding Tonnis angles (12.91 vs. 7.95, p = 0.0175), acetabular inclination (20.25 vs. 9.875, p = 0.027), and lateral CEA (11.75 vs. 2.5, p = 0.061). Patients who had greater dysplasia also had more significant degrees of radiographic Tonnis angle correction with the same mobilization movements of the acetabula (p = 0.005). When utilizing 3D printing to model PAO in dysplasia pelvises, we found that both a higher level of preoperative dysplasia and starting the supra-acetabular osteotomy closer to the AIIS were associated with more powerful corrections following smaller manipulations.

The opening size of the laminoplasty is dependent on the groove size: A numerical study

BackgroundThe expansion of the cervical vertebrae lamina appears to be crucial to related surgical procedures. The dimensions of the groove influence the strain concentration within the lamina of the vertebra and, thus, the potential success or failure of respective surgical procedure. The aim of this computational study is to clarify both the role of the size of the groove with concern to both the open door and the double door laminoplasty techniques. MethodsFinite element models were created via computer tomography with varying lamina groove dimensions. Displacements were applied to the models at the open side of the vertebral arch and the vertebral body was constrained prior to movement along all the axes. The maximal opening size measured on the inner side of the lamina and the percentage increase in the initial spinal areas were subsequently analyzed. FindingsThe elastic strain concentration value was observed for the groove in all cases, while the maximal principal elastic strain concentration value was observed at the opposite side to the groove cut into the lamina, also in all cases. The maximal area increase related to the 4 mm groove accompanied by the preservation of the ventral cortex of the bone. InterpretationThe study suggested three conclusions a) the wider the groove, the greater is the opening potential, b) the maximal opening size following laminoplasty is not dependent on the depth of the bone cut for this type of groove, c) no benefit accrues in terms of the opening size following the cutting of a supplementary groove at the beginning of the lamina.

Preoperative varus deformity of the knee affects the intraoperative joint gap in unicompartmental knee arthroplasty

BackgroundIt is generally believed that contraction of the soft tissue structures on the medial side may occur in the knee with severe varus deformity. However, the relationship between the severity of varus deformity of the knee and the intraoperative soft tissue balance in unicompartmental knee arthroplasty (UKA) has not been well reported thus far. MethodsOne hundred and three consecutive medial UKAs were enrolled. After the femoral trial prosthesis was placed, the component gap was measured at 10° (extension) and 120° (flexion) of flexion using a UKA tensor. The pre-osteotomy gap was then calculated from the thickness of the bone cut. Paired Student’s t-test was used to compare the component gap, as well as the pre-osteotomy gap, in extension and those in flexion. The relationship between the preoperative Hip-Knee-Ankle (HKA) angle and the pre-osteotomy gap was analysed using Pearson’s correlation coefficient and simple linear regression analysis. ResultsThe component gap in extension was significantly smaller than that in flexion while the pre-osteotomy gap in extension was significantly wider than that in flexion. There was a positive correlation between the severity of varus deformation in preoperative knee and the pre-osteotomy gap in extension, while there was no correlation between the preoperative HKA angle and the pre-osteotomy gap in flexion. ConclusionsThe tension of the medial tightness does not correlate with the degree of preoperative varus deformity in UKA.

Achilles Tendon Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction: A Technical Note

Several factors associated with graft preparation for the surgery of the anterior cruciate ligament (ACL) like the wrong thawed, prophylaxis, bone cuts, excessive bone removal as well as positioning problems like a tunnels-graft mismatch, insufficient harvesting of the donor's tendon, size graft limitations (length and diameter), uncontrolled rotation of graft in their longitudinal axis, over or under tensioned graft, fixation mistakes, bone defects, secondary arthrofibrosis or morbidity of the donor site, and others factors importantly affect the outcomes of the ACL surgery. In this sense, the Achilles tendon Allograft is an advantageous technique where many of the previous limitation factors described can be controlled during an appropriate preparation. However, to obtain the maximum potentialities of the graft a detailed knowledge of the preparation is required. Hence, we aimed to describe how to prepare the Achilles tendon Allograft to control the graft's length and diameter, bone removal, and fixation requirements.

Bone Cuts Accuracy of a System for Total Knee Arthroplasty including an Active Robotic Arm

Introduction: This study aimed to assess the bone cuts accuracy of a system for total knee arthroplasty including an active robotic arm. A second objective was to compare the accuracy among orthopaedic surgeons of different levels of experience. Methods: Three orthopaedic surgeons cut 10 sawbone knees each. Planned and actual bone cuts were compared using computed tomography. Difference with respect to the planning was expressed as three position and three orientation errors following the anatomical planes. Statistical tests were performed to detect bias and compare surgeons. Results: None of the 30 knees presented an outlier error, meaning an error ≥3 mm or ≥3°. The root-mean-square values of the 12 error types were below 0.8 mm or 0.8°, except for the femoral proximal–distal errors (1.7 mm) and the tibial anterior-posterior errors (1.4 mm). Biases were observed, particularly in femoral proximal–distal and tibial anterior–posterior positions. Median differences between surgeons were all lower than 0.8 mm and 0.5°, with statistically significant differences among surgeons in the femoral proximal–distal errors and the tibial anterior–posterior errors. Conclusions: The system tested in this study achieved accurate bone cuts independently of the surgeon’s level of experience. Biases were observed, suggesting that there might be options to improve the accuracy, particularly in proximal–distal position for the femur and in anterior–posterior position for the tibia.

Is Robotic TKA Having Added Advantage over Conventional TKA? A Comparative Study of Functional and Radiological Outcome of Robotic versus Conventional Total Knee Arthroplasty

Abstract Objective Total knee arthroplasty (TKA) is most commonly performed procedure in patients who are not showing improvement in pain, activities of daily living, and quality of life by conservative modalities. Precise component implantation and soft tissue management is required to achieve desired outcome following TKA. 1.3% patients remain disappointed due to persistent pain, 24% due to instability, and 2.5% due to malalignment following TKA. Robotic TKA is associated with the use of customized implants and bone cuts leading to precise component implantation and reduced deviation from mechanical axis in coronal, transverse, and sagittal plane and proper soft tissue management. This study compares conventional against robotic TKA in terms of clinical, functional, and radiological outcome. Materials and Methods This is a prospective randomized control trial carried over period of 3 years where patients were selected on the basis of inclusion and exclusion criteria and were randomly divided into both groups and compared using their pre- and postoperative radiological and functional outcomes as well as intraoperative and postoperative complications and statistical significance of difference was calculated. Results There was no significant difference in terms of ROM, KOOS (Knee Injury and Osteoarthritis Outcome Score), (Knee Society Score) KSS, Eq. 5D, (Western Ontario and McMaster Universities Osteoarthritis Index) WOMAC, and (visual analog scale) VAS scores while we found significant difference in mechanical axis deviation, femoral and tibial implant alignment in both planes. Discussion Advantages of using robotic TKA are customized preoperative planning, implants, cuts, accuracy of the intraoperative procedure, and radiological superiority with no significant differences in clinical and functional outcomes. In fact, robotic TKA is associated with steep learning curve, increased cost, and operative time. Still there are no added complications caused by it.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N=51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.