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      Total knee arthroplasty using patient-specific instrumentation for osteoarthritis of the knee: a meta-analysis

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          Abstract

          Background

          Total knee arthroplasty using patient-specific instrumentation (TKA-PSI), which are disposable cutting block guides generated to fit each patient’s 3-dimensional knee anatomy, has been developed to treat patients with end-stage osteoarthritis of the knee. Surrogate markers such as radiographic malalignment have been well investigated, however, patient-important outcomes are not well examined to elucidate the efficacy of TKA-PSI. The aim of this review is to determine if TKA-PSI improves patient-reported outcome measures (PROM), surgery time, blood loss, transfusion and complications (e.g. surgical site infection, deep venous thrombosis, and revision TKA).

          Methods

          We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ongoing clinical trials. For PROMs, surgery time, blood loss, and transfusion rate, we included randomized controlled trials (RCT) comparing TKA-PSI and standard TKA to treat osteoarthritis of the knee. For complications, we also included non-randomized comparative studies (non-RCT).

          Results

          This review includes 38 studies, 24 of which were RCT and 14 of which were non-RCT. These included a total of 3487 patients. The predominant population in the included studies highly reflected the general population, with 62% being female, aged over 60 and having end-stage osteoarthritis of the knee. TKA-PSI did not improve PROMs as compared to standard TKA for less than 1-year (mean difference 0.48, 95% confidence interval (CI) -1.92–0.97 in the Oxford knee score, mean 3-month follow-up) and for 1-year or more (mean difference 0.25, 95%CI − 4.39–4.89 in the WOMAC score, mean 29-month follow-up). TKA-PSI did not reduce surgery time (mean difference − 3.09 min, 95%CI -6.73–0.55). TKA-PSI decreased blood loss with a small effect size corresponding to a 0.4 g/dl hemoglobin decrease (95%CI 0.18–0.88), but did not decrease transfusion rate (risk difference − 0.04, 95%CI -0.09–0.01). TKA-PSI did not reduce complication rates (risk difference 0.00, 95%CI − 0.01–0.01 in the composite outcome).

          Conclusions

          TKA-PSI does not improve patient-reported outcome measures, surgery time, and complication rates as compared to standard TKA. TKA-PSI decreases blood loss with a small effect, which is not enough to reduce transfusion rate.

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          Most cited references69

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          Projected increase in total knee arthroplasty in the United States - an alternative projection model.

          The purpose of our study was to estimate the future incidence rate (IR) and volume of primary total knee arthroplasty (TKA) in the United States from 2015 to 2050 using a conservative projection model that assumes a maximum IR of procedures. Furthermore, our study compared these projections to a model assuming exponential growth, as done in previous studies, for illustrative purposes.
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            Coronal alignment in total knee arthroplasty: just how important is it?

            A recent study has challenged the premise that well-aligned total knee arthroplasties (TKAs) have better survival than outliers. This study examines the importance of overall coronal alignment as a predictor for revision. Patients with primary TKAs were stratified into neutral, varus, and valgus alignment groups based on the postoperative tibiofemoral angle. In 6070 knees (3992 patients), there were 51 failures (0.84%): 21 (0.5%) in the neutral group, 18 (1.8%) in the varus group, and 12 (1.5%) in the valgus group. The best survival was for overall alignment between 2.4 degrees and 7.2 degrees of valgus. Varus knees failed primarily by medial tibia collapse, whereas valgus knees failed from ligament instability. Outliers in overall alignment have a higher rate of revision than well-aligned knees. The goal of TKA should be to restore alignment within 2.4 degrees to 7.2 degrees of valgus.
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              Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty

              Aims The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA. Patients and Methods This prospective cohort study included 40 consecutive patients undergoing conventional jig-based TKA followed by 40 consecutive patients receiving robotic-arm assisted TKA. All surgical procedures were performed by a single surgeon using the medial parapatellar approach with identical implant designs and standardized postoperative inpatient rehabilitation. Inpatient functional outcomes and time to hospital discharge were collected in all study patients. Results There were no systematic differences in baseline characteristics between the conventional jig-based TKA and robotic-arm assisted TKA treatment groups with respect to age (p = 0.32), gender (p = 0.50), body mass index (p = 0.17), American Society of Anesthesiologists score (p = 0.88), and preoperative haemoglobin level (p = 0.82). Robotic-arm assisted TKA was associated with reduced postoperative pain (p < 0.001), decreased analgesia requirements (p < 0.001), decreased reduction in postoperative haemoglobin levels (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001) and improved maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based TKA. Median time to hospital discharge in robotic-arm assisted TKA was 77 hours (interquartile range (IQR) 74 to 81) compared with 105 hours (IQR 98 to 126) in conventional jig-based TKA (p < 0.001). Conclusion Robotic-arm assisted TKA was associated with decreased pain, improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based TKA. Cite this article: Bone Joint J 2018;100-B:930–7.
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                Author and article information

                Contributors
                kizakik@mcmaster.ca
                ajayshanm@gmail.com
                yf194304@gmail.com
                simunon@mcmaster.ca
                duonga@mcmaster.ca
                vickas.khanna@medportal.ca
                ayenif@mcmaster.ca
                Journal
                BMC Musculoskelet Disord
                BMC Musculoskelet Disord
                BMC Musculoskeletal Disorders
                BioMed Central (London )
                1471-2474
                23 November 2019
                23 November 2019
                2019
                : 20
                : 561
                Affiliations
                [1 ]ISNI 0000 0004 1936 8227, GRID grid.25073.33, Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, , McMaster University, ; 1200 Main St W, Hamilton, Ontario L8N 3Z5 Canada
                [2 ]ISNI 0000 0004 1936 8227, GRID grid.25073.33, Division of Orthopaedic Surgery, , McMaster University, ; 1200 Main St W, Hamilton, Ontario L8N 3Z5 Canada
                [3 ]Department of Orthopaedic surgery and rheumatology, Kyoto Shimogamo Hospital, 17 Shimogamo, Kyoto, 606-0866 Japan
                Article
                2940
                10.1186/s12891-019-2940-2
                6875166
                31759392
                57269345-8c6f-4ead-bd29-932efcb83709
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 11 July 2019
                : 11 November 2019
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Orthopedics
                total knee replacement,total knee arthroplasty,patient-specific instrumentation,patient-matched instrumentation,knee osteoarthritis,patient-important outcome,patient-reported outcome measure,systematic review,meta-analysis

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