Computer-assisted total knee replacement arthroplasty (2022)


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Operative Techniques in Orthopaedics

Volume 10, Issue 1,

January 2000

, Pages 25-39

The reliability of techniques to position a total knee replacement (TKR) is still limited by the relative inaccuracy of the instrumentation. The main obstacle encountered by mechanical instrumentation systems is the inconsistency of the reference points. These reference points are the centers of joint articulation that will allow the establishment of the mechanical axis for the lower limb. These references guide the placement of the bone-cutting guides. At present, it is impossible to accurately locate these articular centers preoperatively. This handicaps the accuracy of the mechanical instruments and limits their accuracy. The goal of the total knee instrumentation procedure is to achieve cuts that are perpendicular to the mechanical axes of the femur and the tibia. The longevity of total knee arthroplasty is closely related to its intraoperative positioning. The computer-assisted procedure offers an effective and novel positioning method that improves the accuracy of the surgical technique of the TKR. We have chosen to present the steps of the computer-assisted TKR technique next to the corresponding steps of a currently available, mechanically based technique that is representative of many that are presently in use.

(Video) Computer-assisted Total Knee Replacement

References (21)

  • FreemanMAR et al.

    ICLH-Arthroplasty of the knee: 1968–1977

    J Bone Joint Surg


  • InsallJN et al.

    Total knee arthroplasty

    Clin Orthop


  • InsallJN et al.

    A comparison of four models of total knee-replacement prostheses

    J Bone Joint Surg Am


  • InsallJ et al.

    The total Condylar prosthesis. A report of the hundred cases

    J Bone Joint Surg Am


  • GoodfellowJW et al.

    Clinical results of the Oxford knee

    Clin Orthop


  • RanawatCS et al.

    Survivorship analysis and results of total condylar knee arthroplasty

    Clin Orthop


  • FengEL et al.

    Progressive subluxation and polyethylene wear in total knee replacements with flat articular surfaces

    Clin Orthop


  • EckerML et al.

    Long-term results after Total Condylar knee arthroplasty. Significance of radiolucent lines

    Clin Orthop


  • RitterMA et al.

    Radiolucency at the bone-cement interface in total knee replacement

    J Bone Joint Surg Am


  • LaskinRS

    Total Condylar knee replacement in patients who have rheumatoid arthritis. A ten-year follow-up study

    J Bone Joint Surg Am


There are more references available in the full text version of this article.

Cited by (45)

  • Prevalence and predictors of post-operative coronal alignment outliers and their association with the functional outcomes in navigated total knee arthroplasty

    2014, Journal of Arthroplasty

    (Video) Computer Assisted Total Knee Replacement Surgery | Middlesex Hospital

    In accordance with our hypothesis, the prevalence of coronal limb alignment outliers was considerably high in our navigated TKA series, and the degree of preoperative coronal deformity was the strongest predictive factor of being an outlier. Improved coronal alignment is one of the claimed inherent advantages of computer-assisted navigation in TKA [28–30], and numerous studies have provided evidence in its favor, claiming that the use of navigation improved coronal alignment in their patient samples [6,13,31,32]. This advantage of improved alignment was evidently echoed by several recent meta-analyses [7–11].

    We aimed to determine the prevalence and predictors for being an outlier after navigated TKA and asked whether navigated TKAs with perfect coronal alignment have better functional outcomes than those without it. Alignment was measured in 124 patients (191 knees) with navigated TKAs who were available for 1year functional outcome assessment. The outcomes were compared among the 3 subgroups divided by the deviation of mechanical axis from neutral (0°): the perfect, 0° or within 1°; the acceptable, 1°–3°; and the outlier, beyond 3°. The prevalence of outliers was 20.4%, and the severity of preoperative varus deformity was the strongest predictor. Accuracy of coronal alignment in radiographs did not correlate consistently with functional outcomes.

  • Imageless computer navigation in total knee arthroplasty provides superior short term functional outcomes: A meta-analysis

    2014, Journal of Arthroplasty

    Three were eliminated for using image-based (CT) computer navigation [27–29]. Twelve were eliminated for pseudorandomization or a lack of response to our request for clarification of randomization method [16–18,30–38]. Three papers were eliminated due to redundant data from a study already included in our analysis [39–41].

    Computer navigation in total knee arthroplasty (TKA) is intended to produce more reliable results, but its impact on functional outcomes has not been firmly demonstrated. Literature searches were performed for Level I randomized trials that compared TKA using imageless computer navigation to those performed with conventional instruments. Radiographic and functional outcomes were extracted and statistically analyzed. TKA performed with computer navigation was more likely to be within 3° of ideal mechanical alignment (87.1% vs. 73.7%, P<.01). Navigated TKAs had a higher increase in Knee Society Score at 3-month follow-up (68.5 vs. 58.1, P=.03) and at 12–32month follow-up (53.1 vs. 45.8, P<.01). Computer navigation in TKA provides more accurate alignment and superior functional outcomes at short-term follow-up.

  • Meta-Analysis of Navigation vs Conventional Total Knee Arthroplasty

    2012, Journal of Arthroplasty

    After application of exclusion criteria and removal of duplicate titles, 27 RCTs were assessed, of which 2 studies were excluded because of lack of relevance and a further 2 were excluded because they were meta-analyses. Of these 23 studies [7,17-38], 20 were in the English language, 1 was in French, and 2 were in German. In total, 2541 patients were included, of which 1374 patients were treated with navigation-assisted TKA and 1302 were of the conventional group.

    Navigated total knee arthroplasty (TKA) is promoted as a means to improve limb and prosthesis alignment. This study involved a systematic review and meta-analysis for all randomized controlled trials in the literature from 1986 to 2009 comparing alignment outcomes between navigated and conventional TKA. Alignment outcomes were pooled using a random-effects model, and heterogeneity was explored. Twenty-three randomized controlled trials were identified comparing navigated vs conventional TKA involving 2541 patients. Patients who underwent navigated TKA had a significantly lower risk of implant malalignment at more than 3° as well as more than 2°. In addition, the risk of malalignment was reduced for the coronal plane tibial and femoral components as well as femoral and tibial slope. This meta-analysis demonstrates that navigated TKA provides significant improvement in prosthesis alignment.

  • Meta-Analysis of Alignment Outcomes in Computer-Assisted Total Knee Arthroplasty Surgery

    2007, Journal of Arthroplasty

    Computer-assisted surgery (CAS) has been advocated as a means to improve limb and prosthesis alignment and assist in ligament balancing in total knee arthroplasty (TKA). Thus, we sought to examine alignment outcomes in CAS vs conventional TKA. A systematic review of literature from 1990 to 2007 was performed. Direct comparison of alignment outcomes was performed using random effects meta-analyses. Twenty-nine studies of CAS vs conventional TKA were identified, and included mechanical axis malalignment of greater than 3° occurred in 9.0% of CAS vs 31.8% of conventional TKA patients. The risk of greater than 3° malalignment was significantly less with CAS than conventional techniques for mechanical axis and frontal plane femoral and tibial component alignment. Tibial and femoral slope both showed statistical significance in favor of CAS at greater than 2° malalignment. Meta-analysis of alignment outcomes for CAS vs conventional TKA indicates significant improvement in component orientation and mechanical axis when CAS is used.

  • (iv) Computer-assisted knee replacement techniques

    2007, Current Orthopaedics

    (Video) Computer Assisted Navigation for Total Knee Replacement

    Implant alignment errors are associated with inferior results after total knee arthroplasty. Computer assistance supplements mechanical instrumentation by the addition of measurements which are used to locate landmarks, direct surgical tools and thereby better align prosthetic components. Modern navigation systems are based on infrared-light tracking or, more recently, on electromagnetic guidance. After initial scepticism a variety of systems have found acceptance and a remarkable number of clinical and laboratory studies have been published. There appears to be a consensus that computer assistance brings about a significant reduction in the number of outliers and improved varus/valgus, rotation and slope alignment of components. Most studies conclude with the prediction that individual and cumulative improvement in component alignment will ultimately lead to better long-term results. The controversies surrounding routine use of computer assistance in knee arthroplasy are discussed. Data analysis founded on navigated dynamic intra-operative investigation will possibly be the key to future implant design and alignment.

  • A Cadaveric Study to Assess the Accuracy of Computer-Assisted Surgery in Locating the Hip Center During Total Knee Arthroplasty

    2007, Journal of Arthroplasty

    We found that, first, high hip circle rotation gives better accuracy and precision than small hip circle rotation and that, second, 75% of results had a margin of error of less than 1°, 95% of the results had a margin of error less than 1.5°, and 100% had a error inferior to 2° (1.91°). Technique B, using only 1 tracker in the femur, was as accurate as technique A, which needs 2 trackers around the hip joint [10]. There was no statistical difference between techniques A and B, nor between the intra- and inter-observer analyses.

    Computer-assisted technology allows the accurate location of inaccessible landmarks such as the center of the hip in total hip arthroplasty. Using 7 fresh normal cadaveric hips, we conducted 2 studies. The first study compared iliac (A) vs no iliac (B) tracking. The second study assessed the reliability of the hip center acquisition using the range of hip motion during manipulation. The first study revealed no statistical difference between the 2 techniques A (mean, 0.67; SD, 0.15) and B (mean, 0.66; SD, 0.32) used to locate the center of the hip. In the second study, a range of motion less than 10° negatively affected accuracy. Using this technology, without an iliac tracker, allows accurate and precise determination of the center of the hip.

View all citing articles on Scopus

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View full text

Copyright © 2000 Published by Elsevier Inc.


1. Computer Assisted Navigation Helps with Knee Replacement Surgery
(TSAOG Orthopaedics & Spine)
2. Primary Total Knee Arthroplasty Using Imageless Computer-Assisted Navigation | Dr. Morteza Mefta, MD
(Munjed Al Muderis)
4. An Overview of Computer-Assisted Knee Replacement Surgery
(Barrington Orthopedic Specialists)
5. Minimally Invasive Computer Assisted Total Knee Replacement
(Tampa General Hospital)
6. AAHKS Robotic & Computer-Assisted Joint Replacement Surgery
(American Association of Hip and Knee Surgeons)

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