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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


Contemporary techniques to perform total knee arthroplasty use either conventional instrumentation with intramedullary and extramedullary referencing or use a computer navigation system that requires insertion of femoral and tibial tracking pins and an intra-operative registration process. Much of the initial enthusiasm for computer navigation in TKA has waned as many of these systems have proved cumbersome, time consuming and expensive with no substantial evidence of a clinical benefit. Patient specific instrumentation is an additional option that is now widely available which seeks to harness some of the accuracy of computer navigation while improving intra-operative surgical efficiency. In 2015 there are now patient specific options available from multiple vendors and these vary in several different ways including: alignment goals; imaging modality; pin guide vs. cutting guide; all plastic vs. metal-plastic composite; and the degree of surgeon input into pre-operative planning. In all systems but one alignment is typically set relative to the mechanical axis; one system uses so-called kinematic alignment. Imaging can be done via CT, MRI, or MRI in conjunction with a hip-knee-ankle radiograph. The guides that are produced are typically made of a plastic material and in some cases are meant only to position pins onto which traditional metal cutting guides are then placed. In some systems the plastic guides come pre-assembled with an integrated metal cutting-guide that allows resection of the distal femur or proximal tibia in one step; in other systems cutting is intended to be carried out through a plastic captured guide. Finally there is wide variability in the degree of surgeon involvement in the pre-operative planning for the guides, ranging from no involvement in the so-called kinematic approach all the way to the ability for surgeons to dictate the depth, location, flexion-extension angle, varus-valgus angle, and rotation in some systems. At this point relatively little comparative data exists to objectively compare one system versus another.

Surgeons most likely to find substantial benefit from patient specific instrumentation are those who perform moderate numbers of TKA each year but who have inconsistent surgical scrub teams. For those surgeons, substantial surgical inefficiency can be attributable to the scrub team's unfamiliarity with the complex instrumentation needed for TKA. Patient specific instrumentation can bypass many of those relatively complex instruments and allow the surgeon to complete TKA in a timely and efficient manner. For TKA subspecialists, patient specific instrumentation may have an appeal from a precision standpoint or from an ease-of-room turnover perspective but are unlikely to yield major intra-operative time savings at this point. In the future, combining patient specific instruments with size-specific disposable instruments that are financially and environmentally favorable may make this technology more applicable to even broader groups of surgeons.