INTRODUCTION

The direct anterior approach (DAA) for total hip arthroplasty has become a popular technique. Proponents of the anterior approach cite advantages such as less muscle damage, lower dislocation risk, faster recovery, and more accurate implant placement for the approach. However, there is a steep, complex learning curve associated with the technique. The present study seeks to define the learning curve based on individual surgical and outcome variables for a high-volume surgeon.

Introduction

Total knee arthroplasty is a highly effective procedure to improve the quality of life in patients with advanced osteoarthritis. The number of these procedures are expected to grow 174% by 2030. This growth rate is expected to economically strain the health care system. A potential solution to alleviate this problem is the utilization of single use instruments (SUI). Potential advantages of SUI include: improved operating room efficiencies, decreased costs associated with traditional instrument management (sterile processing, shipping), and decreased infection risk. The present study examines the clinical results of SUI compared to standard instrumentation. Furthermore, economic modeling is performed to examine the cost savings that is potentially realized with their use.

INTRODUCTION

The Dorr Bone Classification, devised in 1993 is commonly used to categorize bone types prior to hip reconstruction. The purpose of the present study is to quantify the Dorr classification system using 4 morphologic parameters – morphologic cortical index (MCI), canal-flare index (CFI), canal-bone ratio (CBR), and canal-calcar ratio (CCR).

The present IRB approved study evaluates the early results of 100 TKAs using CT-based Patient-Specific Instrumentation (PSI) (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland). For this technique, a CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made [Fig. 1].

Outcomes measured for the present study include surgical factors such as Tourniquet Time (TT) as a measure of surgical efficiency, the actual intraoperative bony resection thicknesses to be compared to the planned resections from the CT scan, and complication data. Furthermore, pre- and post-operative long standing alignment and Knee Society Scores (KSS) were obtained.

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. No osteophytes are removed as the blocks use the positive topography of the osteophytes for registration. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

There were 50 Left and 50 Right TKA's performed in 61 females and 39 males. All patients had diagnosis of osteoarthritis. The average BMI was 31.1 and average age was 64.5 (range 41–90). 79 patients had pre-operative varus deformities with Hip Knee Angle (HKA) average of 174.7° (range 167°–179.5°). 19 patients had pre-operative valgus deformities averaging 184.4° (range 180.5°–190°). Three patients were neutral.

Average TT was 31.2 minutes (range 21–51 minutes). With regard to the bony resections, the actual vs. planned resections for the distal medial femoral resection was 8.7 mm vs. 8.9 mm respectively. Further actual vs. planned femoral resections include distal lateral 7.2 vs. 6.7 mm; posterior medial 8.3 vs. 8.9 mm; and posterior lateral 6.2 vs. 6.8 mm. The actual vs. planned tibial resections recorded include medial 6.4 vs. 6.3 mm and lateral 8.3 vs. 8.2. The planned vs. actual bony cuts are strongly correlated, and highly predictive for all 6 measured cuts (p=<.001) [Fig. 3]. No intraoperative complications occurred.

Average KSS improved from 45.9 to 81.4, and KSS Function Score improved from 57.7 to 73.5 at 6 weeks postoperative visit. There were no thromboembolic complications. Two patients had a post-operative infection requiring surgical intervention.

Post-operative alignment was 179.36° (range 175°–186°) for all patients. Alignment was neutral, within 3° in 95.9% of patients. There were only 4 outliers with maximal post-operative angulation of 6° [Fig. 2].

In conclusion, these early results demonstrate efficacy of CT-based PSI for TKA. The surgery can be performed efficiently, accurately, and safely. Furthermore, excellent short term clinical and radiographic results can be achieved.

Hardware in or about the knee joint presents a number of challenges to the surgeon in performance of Total Knee Arthroplasty (TKA). Conventional instrumentation usually requires a modification of technique or removal of the metallic implants. Computer-Assisted TKA (CAOS) is another option, but adds complexity and time to the procedure. MRI-based Patient-Specific Instrumentation (PSI) cannot be used as metal causes unwanted artifact and renders the images for planning, useless. However, CT scans are not affected by metal and thus CT-based PSI can be used in TKA patients with pre-existing hardware.

The present IRB approved study evaluates 12 consecutive knees (10 patients) with pre-existing hardware using CT-based PSI (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland).

In this technique, CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made [Fig 1].

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining femoral resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

Of the 12 TKAs, there were 5 left and 7 right knees performed in 6 females and 6 males. The average BMI was 33.19 and average age was 53 (range 44–63). All diagnoses were either osteoarthritis or post-traumatic osteoarthritis. Follow-up averaged 59 weeks (range 18.6–113.7).

Nine patients had pre-operative varus deformities with HKA deformities average of 171.9° (range 154°–178.5°). One patient had pre-operative valgus deformity of 184.5°. Two patients were neutral (180°). Post-operative alignment for all patients (n = 11) was 179° (range 177°–180°). All patients were within 3° neutral, post operatively. Four patients measured 180°, 4 measured at 179°, 2 measured at 178°, and only one at 177°.

Hardware consisted of 5 patients with femur or tibia staples, 3 with plate(s) and screws [Fig. 2], 3 patients with ACL interference screws, and one titanium rod. No hardware was removed unless necessary for implantation. Only 3 patients required some hardware removal.

The pre-operative Range of Motion (ROM) averaged 2.9° to 98.3° (Extension range 0–15° and flexion range 30–115°). Post-operative ROM was 2.9° to 101.3°. (Extension range 0–5° and flexion range 65–125°). Knee Society Score (KSS) improved from 42.3 to 82.3, and KSS Function Score improved from 52.1 to 77.5. No intraoperative complications were recorded. Average tourniquet time was 42.1 minutes (range 28–102).

Regardless of the deformity, the patient's post-operative mechanical axes HKA averaged 179° (range 177–180). Clinical scores were typical for TKA patients with improvement in both KSS and ROM.

In conclusion, early results using PSI in patients with pre-existing hardware in or about the joint, is safe, efficient, and accurate in performance of TKA.