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Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery
THEKNE-02395; No of Pages 6 The Knee xxx (2017) xxx–xxx
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The Knee
Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery Jodie A. McClelland a,⁎, Kate E. Webster a, Alankar A. Ramteke b, Julian A. Feller c a b c
School of Allied Health, La Trobe University, Bundoora, Australia Arthritis & Joint Replacement Clinic and Alexis Hospital, Nagpur, India OrthoSport Victoria Research Unit, Epworth Healthcare and Deakin University, Melbourne, Australia
a r t i c l e
i n f o
Article history: Received 10 June 2016 Received in revised form 30 November 2016 Accepted 19 December 2016 Available online xxxx Keywords: Total knee arthroplasty Computer-assisted navigation Biomechanics Gait Osteoarthritis
a b s t r a c t Background: Computer-assisted navigation in total knee arthroplasty (TKA) reduces variability and may improve accuracy in the postoperative static alignment. The effect of navigation on alignment and biomechanics during more dynamic movements has not been investigated. Methods: This study compared knee biomechanics during level walking of 121 participants: 39 with conventional TKA, 42 with computer-assisted navigation TKA and 40 unimpaired control participants. Results: Standing lower-limb alignment was significantly closer to ideal in participants with navigation TKA. During gait, when differences in walking speed were accounted for, participants with conventional TKA had less knee flexion during stance and swing than controls (P b 0.01), but there were no differences between participants with navigation TKA and controls for the same variables. Both groups of participants with TKA had lower knee adduction moments than controls (P b 0.01). Conclusions: In summary, there were fewer differences in the biomechanics of computerassisted navigation TKA patients compared to controls than for patients with conventional TKA. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA. © 2017 Elsevier B.V. All rights reserved.
1. Introduction For patients with disabling knee osteoarthritis (OA), total knee arthroplasty (TKA) is widely considered as the most viable and successful management option. Following TKA, most patients can expect long-term reduction in pain and improvements in quality of life [1,2], and between 72% and 86% of patients report that they are satisfied with their postoperative outcome [3–5]. However, these improvements in function may not be sustained over longer periods of time. Functional performance may decline as little as three years after surgery, but perhaps more importantly up to 10% may require revision surgery within 10 years of the initial TKA primarily because of prosthesis loosening [6]. The most important determinants of failure secondary to prosthesis loosening are poor positioning of the prosthesis and subsequent malalignment of the postoperative lower limb. A recent meta-analysis found that as little as three degrees of deviation from ideal alignment in the coronal plane significantly increased the risk of TKA failure [7]. Greater bone stress on the medial side of the knee in failed arthroplasties suggests that lower-limb malalignment alters the distribution of forces across ⁎ Corresponding author at: School of Allied Health, La Trobe University, Kingsbury Drive, Bundoora 3068, Australia. E-mail address: [email protected] (J.A. McClelland).
http://dx.doi.org/10.1016/j.knee.2016.12.009 0968-0160/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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the knee and that this in turn accelerates prosthesis failure [8]. Clearly, strategies that increase the accuracy of prosthesis positioning may improve long-term prosthesis survival rates for patients. Computer-assisted navigation was introduced as an adjunct to TKA surgery with the potential to improve positioning and alignment of the TKA prosthesis. A recent meta-analysis demonstrated that although the average coronal plane alignment after computer-assisted navigation TKA was not different from conventional TKA, the variability in the outcome was reduced [7,9,10]. It was therefore concluded that computer-assisted navigation TKA may be employed as a method of reducing error in prosthesis positioning and subsequent limb alignment. Computer-assisted navigation is now widely used to facilitate improved accuracy of postoperative lower-limb alignment. In addition to measurement of static limb alignment, we have the ability to measure knee joint alignment and motion during more dynamic tasks. Assessment of patients during walking using three-dimensional motion analysis allows measurement of the motion of the joint as well as the forces acting across the knee. The external knee adduction moment remains the closest non-invasive estimate of the forces acting on the medial knee joint, and higher moments have been associated with higher risk of prosthesis failure [11,12]. Three-dimensional motion analysis has been able to detect subtle differences in function between patients with different prosthesis designs and technical approaches [13–15], and may therefore detect subtle differences in outcome between patients with navigated TKA and those with conventional TKA. We are unaware of any studies that compare knee biomechanics during walking between patients with navigated and conventional TKA, and that is therefore the aim of this study. We hypothesised that patients with computerassisted navigated TKA would walk with biomechanics that more closely resembled normal gait than patients with conventional TKA. 2. Material and methods This study was approved by the institution's Human Ethics Committee. All participants gave informed consent prior to participation. 2.1. Participants All consecutive patients of a single experienced knee surgeon between April 2005 and June 2008 were invited to participate in the study if they had received a primary TKA in the management of disabling knee OA at least 12 months prior to testing. Patients also needed to be able to walk 10 m without the use of gait aid, and be free from other orthopaedic, neurological or visual disturbances that may affect gait, including advanced knee OA of the contralateral knee and other joint replacement. From an initial pool of 166 consecutive patients, 111 were eligible and invited to participate in the study. Of these, 81 agreed to participate and attended the gait laboratory at La Trobe University for biomechanical testing. All patients received a Genesis II PS TKA prosthesis (Smith and Nephew, Memphis, TN, USA) with traditional technique and patellar resurfacing. In 42 of these patients the Image Free BrainLAB Navigation System (BrainLAB, Munich, Germany) was used by the surgeon during surgery. These patients were not randomised, but received navigation TKA as it was introduced into routine practice following a period of surgeon training in using the navigation system. A smaller cohort of these patients has been reported previously [16–18]. A control group recruited for this previous work was used as a comparison cohort in the current study. These participants were without knee surgery or knee pain. 2.2. Equipment All participants attended a single session at the gait laboratory for biomechanical assessment. Thirteen passive reflective markers were fixed to anatomical bony landmarks according to the Modified Helen Hayes model using double-sided adhesive tape [19,20]. These landmarks included a single marker on the sacrum, and bilateral markers on the anterior superior iliac spines of the pelvis, lateral epicondyles of the knee, lateral and medial malleoli, calcanei and head of the fifth metatarsals. Markers on five-centimetre wands were placed bilaterally on the thighs and shanks, and a Knee Alignment Device (Vicon, Oxford, UK) was used to calculate the centre of the knee joint in three dimensions. An additional two markers were placed over the lateral aspect of the iliac crest to facilitate definition of the pelvis given the challenges of pelvis marker placement and occlusion in this population [21]. An eight-camera Vicon motion analysis system (Vicon Motion Systems Ltd., UK) was used to collect video data from the passive reflective markers as the participants walked through the calibrated space (approximately six metres in length, two metres in width and two metres in height) at a sampling rate of 100 Hz. Two force platforms (Kistler, Switzerland and AMTI, MA, USA) embedded into a 10-m walkway were used to collect ground reaction force data at a sampling rate of 400 Hz. 2.3. Gait analysis protocol All participants were asked to walk at a self-selected comfortable speed along a 10-m walkway. Participants were not informed of the embedded force platforms, but starting position was adjusted to facilitate stance of at least a single limb within a force platform. After a period of familiarisation (at least 10 passes of the walkway), data was collected until six trials of force platform data had been collected on each limb. 2.4. Clinical assessment The American Knee Society Knee Score was completed by all participants. Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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2.5. Radiographic assessment As part of routine postsurgical management, a long-leg radiograph of double limb stance was taken 12 months following TKA. Lower-limb alignment was assessed from these radiographs by measuring the mechanical axis and the position of the weightbearing line as it crossed the knee joint. The mechanical axis was defined as the angle between two lines: a line from the centre of the femoral head to the centre of the tibial plateau and a line between the same point on the tibial plateau to the centre of the distal articular surface of the tibia. A weightbearing line representing the effect of gravity was drawn between the centre of the femoral head and the centre of the talus. At the knee joint, the position of this line from the medial border was described as percentage of the width of the tibial plateau (position of weightbearing line). 2.6. Data analysis Joint kinematics and kinetics were calculated using Vicon PlugIn Gait software (Vicon Motion Systems, UK). In this software, joint kinematics were calculated using Euler angles where the movement of the distal segment is described relative to the proximal segment. Joint kinetics were calculated using standard inverse dynamics. The moments described in this manuscript are external and normalised to bodyweight and height (%Bw-ht). A single gait stride (from initial contact to initial contact) from each walking trial was used in analysis and time normalised to 100%. Key biomechanical variables from each trial were selected and averaged across the six successful trials of each participant to create a participant average. These variables were: knee flexion angle at initial contact, maximum knee flexion angle during stance, minimum knee flexion angle during stance (or maximum knee extension angle), maximum knee flexion angle during swing, maximum knee flexion moment, minimum knee flexion moment (or maximum knee extension moment), and maximum knee adduction moment. In previous studies of gait in patients with TKA, three patterns of the knee moment in the sagittal plane have been described: (1) a biphasic pattern that is typically associated with normal gait where a maximum flexion moment in early stance is followed by an extension moment in late stance; (2) a flexor pattern where a flexion moment is prolonged and the extension moment in late stance is absent; and (3) an extensor pattern where there flexion moment in early stance is absent (Figure 1) [22,23]. The profile of the sagittal moment for each individual in the current study was analysed for the presence of either a biphasic, flexor or extensor moment pattern. These patterns during level gait have been described previously. All data were tested for normality using the Kolmogorov–Smirnov goodness of fit test (in this test samples are standardized and compared with a standard normal distribution). The proportion of males, and the prevalence of moment patterns were compared between groups using chi-squared. Walking speed, outcome scores and radiographic averages were compared between groups using a univariate analysis of variance. Significant findings (P b 0.05) were explored further by post hoc comparisons using independent ttests. Peak biomechanical variables were compared between groups using a univariate analysis of covariance (ANCOVA) where walking speed was treated as a covariate. For these analyses, significant findings were explored further by calculating simple contrasts that compared each of the conventional and navigated TKA groups with the control group. 3. Results Eighty-one participants with TKA (39 with conventional TKA and 42 with navigation TKA) were assessed an average of 19.9 months (standard deviation (SD) = 7.8) after surgery. An additional 40 control participants without knee surgery or knee pain were also assessed. There were no differences between groups in terms of age (P = 0.65), height (P = 0.64) and the gender distribution (P = 0.98), but both the conventional and navigation TKA groups were heavier than controls (P = 0.03) (Table 1), which is typical for patients with TKA as obesity is a risk factor for the development of knee OA [24,25]. The Knee Society Knee Score was not
Figure 1. Three patterns of the sagittal knee moment throughout stance: biphasic (typical of normal gait), flexor (where the external moment is maintained throughout stance phase in a flexion direction) and extensor (where the moment is maintained throughout stance phase in an extension direction).
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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Table 1 Demographics of participants.
Age (years) Height (cm) Weight (kg) BMI M:F
Controls
Navigated TKA
Conventional TKA
P
69.6 (8.3) 165.0 (9.5) 76.2 (14.9) 28.0 (4.6) 18:22
68.7 (6.3) 165.7 (10.0) 85.1 (15.2) 31.1 (4.8) 20:22
71.8 (8.4) 164.6 (8.4) 83.6 (16.6) 30.3 (5.6) 17:22
0.65 0.64 0.03 0.02 0.98
BMI, body mass index; M:F, ratio of males to females; TKA, total knee arthroplasty. Bold and italics represent significant difference between groups.
significantly different for participants in the navigation TKA group (Knee score average = 87.5, SD = 14.1) from those in the conventional TKA group (average = 84.2, SD = 11.6) (P = 0.361). 3.1. Radiographic analysis The mechanical axis and position of the weightbearing line in relation to the medial tibial border were significantly closer to ideal alignment (180° and 50%) in the group with navigated TKA (average = 179°, SD = 2, average = 46%, SD = 1) than in the group with conventional TKA (average = 177°, SD = 4, average = 32%, SD = 2; P b 0.01 and P = 0.01, respectively). 3.2. Gait analysis There was a significant difference in walking speed between the three groups (P b 0.01). Post hoc testing revealed that the participants with conventional TKA walked slower (average = 1.14, SD = 0.02 m/s) than both the participants with navigation TKA (average = 1.24, SD = 0.02 m/s, P = 0.03) and the control participants (average = 1.27, SD = 0.02 m/s, P b 0.01). When this variability in walking speed was accounted for there was a significant difference between groups in terms of the maximum knee flexion angle during both the stance (P = 0.02) and swing (P = 0.04) phases of the gait cycle (Table 2). Post hoc testing showed that in both cases the participants with conventional TKA had significantly less knee flexion than the control group (P ≤ 0.01). Whilst the navigation TKA also had less knee flexion than the control group, the difference did not reach statistical significance (P = 0.06 and P = 0.28, for stance and swing phases, respectively). The only difference between groups in terms of the peak moments was for the knee adduction moment (P b 0.01) (Table 3). Post hoc contrasts showed that both the conventional TKA and navigation TKA groups had significantly lower maximum knee adduction moment than the controls. In terms of the profile of the sagittal moment pattern, significantly fewer participants with conventional TKA demonstrated a biphasic moment pattern than both control participants and participants with navigation TKA (Table 4). 4. Discussion This study identified differences between groups that suggest that knee biomechanics of walking in patients with computerassisted navigation TKA are closer to normal than for patients with conventional TKA. Patients with navigation TKA were different from controls on fewer peak biomechanical variables that are commonly assessed in this patient group than patients with conventional TKA. But in what may be considered more reflective of overall walking pattern, significantly fewer patients with navigation TKA walked with a moment profile that was abnormal compared to patients with conventional TKA. These findings suggest that navigation TKA may facilitate more normal biomechanical outcomes for patients. Walking speed is an important predictor of mortality and morbidity in older adults [26,27]. Traditionally, TKA has improved walking speed in patients with severe knee OA only marginally, and patients have continued to walk at slower speeds than normal [25,28]. In the current study, however, patients with navigation TKA walked faster than patients with conventional TKA, and walking speed in these patients was comparable to people without knee pathology. Compared to conventional TKA, a much larger proportion of patients with navigated TKA walked with a moment in the sagittal plane that changed in a biphasic pattern throughout the gait cycle. This biphasic pattern is typically associated with normal gait, and as expected, was found in 97% of the control participants of this study. The external knee flexion moment represents the demand for an internal force (assumed to be the quadriceps) that encourages knee extension to maintain upright posture and forward Table 2 ANCOVA comparisons between groups for peak knee angles during gait (degrees).
Flexion angle at initial contact Maximum flexion angle during stance phase Minimum flexion during stance phase Maximum flexion angle during swing phase
Controls
Navigated TKA
Conventional TKA
P
7.1 (4.0) 17.3 (5.8) −0.5 (5.0) 55.4 (4.4)
6.7 (5.8) 14.4 (7.1) 1.3 (6.8) 53.9 (7.3)
5.4 (5.2) 12.1⁎ (6.6) 1.3 (6.1) 51.1⁎ (4.8)
0.32 0.02 0.45 0.04
TKA, total knee arthroplasty. Walking speed was treated as a covariate. Values are means (standard deviations). Bold and italics represent significant difference between groups. ⁎ Post hoc test difference between conventional TKA and controls. P b 0.01.
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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Table 3 ANCOVA comparisons between groups for peak knee moments during gait (%body weight-height).
Maximum flexion moment Minimum flexion moment Maximum adduction moment
Controls
Navigated TKA
Conventional TKA
P
3.0 (1.4) −1.2 (1.0) 3.6 −0.7
2.7 (1.2) −1.8 (1.0) 2.9† (0.6)
2.1 (1.2) −1.8 (1.0) 2.9⁎ (0.6)
0.10 0.56 b0.01
TKA, total knee arthroplasty. Bold and italics represent significant difference between groups. ⁎ Post hoc test difference between conventional TKA and controls, P b 0.01. † Post hoc differences between navigation TKA and controls, P b 0.01.
momentum. Deviations in the generation of an external knee flexion moment can therefore indicate abnormal neuromuscular control of the quadriceps throughout gait. Traditionally, as few as 40% of patients with TKA walk with this biphasic moment pattern [25]. Instead, patients have typically adopted a monophasic moment pattern where the knee flexion moment was either prolonged or avoided, thereby altering the demand for quadriceps control [29]. In these previous studies, the presence of an abnormal monophasic moment pattern has been considered representative of knee instability secondary to inferior prosthesis design [13,22,30]. In the current study, 87% of patients with navigated TKA walked with a normal biphasic moment pattern, which was significantly more than for the conventional TKA group, and is also more than previously reported for a TKA patient group [25]. These findings suggest that navigated TKA may facilitate outcomes that promote greater neuromuscular control of the knee during dynamic activities. Most evaluations of the benefits of computer-assisted navigation have focused on outcomes that assess lower-limb alignment in the coronal plane. Assessment of biomechanics in the coronal plane is vital for TKA, because excessive forces acting on the medial knee may contribute to loosening of the prosthesis and subsequent TKA failure [11]. The external knee adduction moment is considered the best non-invasive estimate of medial knee joint forces that is readily available [12]. This study is the first to compare the knee adduction moment in patients with a navigated TKA to those with a conventional TKA. We found that there was no difference in the magnitude of the knee adduction moment between the patient groups, but that both patient groups had lower moments than controls. This is despite a significant improvement in the static lower-limb alignment (mechanical axis) for patients with navigation, and suggests that other factors associated with knee force during dynamic activities (such as walking speed, and muscular control) may mitigate any small differences in static alignment. Previous attempts to quantify the relationship between lower-limb alignment and the knee adduction moment have produced substantially different findings. Some have been unable to determine a relationship, and it appears that, at best, the lower-limb alignment predicts only 50% of the external knee adduction moment [31]. This explains the findings of the current study that computerassisted navigation may improve lower-limb alignment but not the knee adduction moment. Collectively, these findings emphasise that caution needs to be taken when interpreting the findings of static measures of lower-limb alignment and the implications for long-term prosthesis survival. Perhaps assessment of patients over a longer timeframe is necessary to evaluate the potential for longer-term benefits of computer-assisted navigation in terms of medial knee forces and prosthesis longevity. The findings of the current study suggest that computer-assisted navigated TKA may lead to sagittal plane biomechanics that are closer to normal than conventional TKA. Patients with a navigated TKA walked with a greater peak knee flexion during both the stance and swing phases of gait compared to patients with conventional TKA. The knee flexion of patients with a navigated TKA was similar to that of controls, and therefore may be considered as closer to normal than the knee biomechanics of patients with a conventional TKA. Typically, greater knee flexion during stance has been associated with greater capacity to attenuate impact forces at the knee [32]. Higher degrees of maximum postoperative knee flexion have been related to a greater posterior tibial slope [33], and it is possible that computer-assisted navigation facilitates greater accuracy in tibial cutting to generate these outcomes. However, knee flexion during gait does not approach maximal knee flexion capacity, and it is more likely that these superior biomechanics represent an overall improvement in the function of the knee. A limitation of this study is that patients were not randomised to receive either computer-assisted or navigation TKA. However, all patients received the same prosthesis from the same surgeon and the patient groups were similar with regard to all primary confounders. Therefore, we are confident that the findings of this study are accurate. These findings represent the outcome of a case series of patients from a single experienced knee surgeon, and potential for greater variability in the gait outcomes from knee arthroplasty may be more likely in less experienced surgeons. 5. Conclusions In conclusion, the findings of this study suggest that computer-assisted navigated TKA may result in biomechanics during walking that are closer to normal than conventional TKA. Table 4 Proportion of participants who demonstrated either a biphasic, flexor or extensor moment pattern during level walking.
Biphasic pattern Flexor pattern Extensor pattern
Controls
Navigated TKA
Conventional TKA
P
39 (97%) 1 (3%) 0 (0%)
37 (87%) 3 (7%) 3 (6%)
27 (68%) 1 (3%) 11 (29%)
0.00
TKA, total knee arthroplasty. Bold and italics represent significant difference between groups.
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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Conflict of interest The authors have no conflicts of interest to declare.
Acknowledgements The authors would like to acknowledge the contribution of Dr. Joanne Wittwer in her assistance with data collection for this study, and Ms. Joanna Tallis for her assistance with computer-assisted navigation. This study was completed with assistance from a La Trobe University Faculty of Health Sciences Research Grant.
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Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
Contents lists available at ScienceDirect
The Knee
Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery Jodie A. McClelland a,⁎, Kate E. Webster a, Alankar A. Ramteke b, Julian A. Feller c a b c
School of Allied Health, La Trobe University, Bundoora, Australia Arthritis & Joint Replacement Clinic and Alexis Hospital, Nagpur, India OrthoSport Victoria Research Unit, Epworth Healthcare and Deakin University, Melbourne, Australia
a r t i c l e
i n f o
Article history: Received 10 June 2016 Received in revised form 30 November 2016 Accepted 19 December 2016 Available online xxxx Keywords: Total knee arthroplasty Computer-assisted navigation Biomechanics Gait Osteoarthritis
a b s t r a c t Background: Computer-assisted navigation in total knee arthroplasty (TKA) reduces variability and may improve accuracy in the postoperative static alignment. The effect of navigation on alignment and biomechanics during more dynamic movements has not been investigated. Methods: This study compared knee biomechanics during level walking of 121 participants: 39 with conventional TKA, 42 with computer-assisted navigation TKA and 40 unimpaired control participants. Results: Standing lower-limb alignment was significantly closer to ideal in participants with navigation TKA. During gait, when differences in walking speed were accounted for, participants with conventional TKA had less knee flexion during stance and swing than controls (P b 0.01), but there were no differences between participants with navigation TKA and controls for the same variables. Both groups of participants with TKA had lower knee adduction moments than controls (P b 0.01). Conclusions: In summary, there were fewer differences in the biomechanics of computerassisted navigation TKA patients compared to controls than for patients with conventional TKA. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA. © 2017 Elsevier B.V. All rights reserved.
1. Introduction For patients with disabling knee osteoarthritis (OA), total knee arthroplasty (TKA) is widely considered as the most viable and successful management option. Following TKA, most patients can expect long-term reduction in pain and improvements in quality of life [1,2], and between 72% and 86% of patients report that they are satisfied with their postoperative outcome [3–5]. However, these improvements in function may not be sustained over longer periods of time. Functional performance may decline as little as three years after surgery, but perhaps more importantly up to 10% may require revision surgery within 10 years of the initial TKA primarily because of prosthesis loosening [6]. The most important determinants of failure secondary to prosthesis loosening are poor positioning of the prosthesis and subsequent malalignment of the postoperative lower limb. A recent meta-analysis found that as little as three degrees of deviation from ideal alignment in the coronal plane significantly increased the risk of TKA failure [7]. Greater bone stress on the medial side of the knee in failed arthroplasties suggests that lower-limb malalignment alters the distribution of forces across ⁎ Corresponding author at: School of Allied Health, La Trobe University, Kingsbury Drive, Bundoora 3068, Australia. E-mail address: [email protected] (J.A. McClelland).
http://dx.doi.org/10.1016/j.knee.2016.12.009 0968-0160/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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the knee and that this in turn accelerates prosthesis failure [8]. Clearly, strategies that increase the accuracy of prosthesis positioning may improve long-term prosthesis survival rates for patients. Computer-assisted navigation was introduced as an adjunct to TKA surgery with the potential to improve positioning and alignment of the TKA prosthesis. A recent meta-analysis demonstrated that although the average coronal plane alignment after computer-assisted navigation TKA was not different from conventional TKA, the variability in the outcome was reduced [7,9,10]. It was therefore concluded that computer-assisted navigation TKA may be employed as a method of reducing error in prosthesis positioning and subsequent limb alignment. Computer-assisted navigation is now widely used to facilitate improved accuracy of postoperative lower-limb alignment. In addition to measurement of static limb alignment, we have the ability to measure knee joint alignment and motion during more dynamic tasks. Assessment of patients during walking using three-dimensional motion analysis allows measurement of the motion of the joint as well as the forces acting across the knee. The external knee adduction moment remains the closest non-invasive estimate of the forces acting on the medial knee joint, and higher moments have been associated with higher risk of prosthesis failure [11,12]. Three-dimensional motion analysis has been able to detect subtle differences in function between patients with different prosthesis designs and technical approaches [13–15], and may therefore detect subtle differences in outcome between patients with navigated TKA and those with conventional TKA. We are unaware of any studies that compare knee biomechanics during walking between patients with navigated and conventional TKA, and that is therefore the aim of this study. We hypothesised that patients with computerassisted navigated TKA would walk with biomechanics that more closely resembled normal gait than patients with conventional TKA. 2. Material and methods This study was approved by the institution's Human Ethics Committee. All participants gave informed consent prior to participation. 2.1. Participants All consecutive patients of a single experienced knee surgeon between April 2005 and June 2008 were invited to participate in the study if they had received a primary TKA in the management of disabling knee OA at least 12 months prior to testing. Patients also needed to be able to walk 10 m without the use of gait aid, and be free from other orthopaedic, neurological or visual disturbances that may affect gait, including advanced knee OA of the contralateral knee and other joint replacement. From an initial pool of 166 consecutive patients, 111 were eligible and invited to participate in the study. Of these, 81 agreed to participate and attended the gait laboratory at La Trobe University for biomechanical testing. All patients received a Genesis II PS TKA prosthesis (Smith and Nephew, Memphis, TN, USA) with traditional technique and patellar resurfacing. In 42 of these patients the Image Free BrainLAB Navigation System (BrainLAB, Munich, Germany) was used by the surgeon during surgery. These patients were not randomised, but received navigation TKA as it was introduced into routine practice following a period of surgeon training in using the navigation system. A smaller cohort of these patients has been reported previously [16–18]. A control group recruited for this previous work was used as a comparison cohort in the current study. These participants were without knee surgery or knee pain. 2.2. Equipment All participants attended a single session at the gait laboratory for biomechanical assessment. Thirteen passive reflective markers were fixed to anatomical bony landmarks according to the Modified Helen Hayes model using double-sided adhesive tape [19,20]. These landmarks included a single marker on the sacrum, and bilateral markers on the anterior superior iliac spines of the pelvis, lateral epicondyles of the knee, lateral and medial malleoli, calcanei and head of the fifth metatarsals. Markers on five-centimetre wands were placed bilaterally on the thighs and shanks, and a Knee Alignment Device (Vicon, Oxford, UK) was used to calculate the centre of the knee joint in three dimensions. An additional two markers were placed over the lateral aspect of the iliac crest to facilitate definition of the pelvis given the challenges of pelvis marker placement and occlusion in this population [21]. An eight-camera Vicon motion analysis system (Vicon Motion Systems Ltd., UK) was used to collect video data from the passive reflective markers as the participants walked through the calibrated space (approximately six metres in length, two metres in width and two metres in height) at a sampling rate of 100 Hz. Two force platforms (Kistler, Switzerland and AMTI, MA, USA) embedded into a 10-m walkway were used to collect ground reaction force data at a sampling rate of 400 Hz. 2.3. Gait analysis protocol All participants were asked to walk at a self-selected comfortable speed along a 10-m walkway. Participants were not informed of the embedded force platforms, but starting position was adjusted to facilitate stance of at least a single limb within a force platform. After a period of familiarisation (at least 10 passes of the walkway), data was collected until six trials of force platform data had been collected on each limb. 2.4. Clinical assessment The American Knee Society Knee Score was completed by all participants. Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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2.5. Radiographic assessment As part of routine postsurgical management, a long-leg radiograph of double limb stance was taken 12 months following TKA. Lower-limb alignment was assessed from these radiographs by measuring the mechanical axis and the position of the weightbearing line as it crossed the knee joint. The mechanical axis was defined as the angle between two lines: a line from the centre of the femoral head to the centre of the tibial plateau and a line between the same point on the tibial plateau to the centre of the distal articular surface of the tibia. A weightbearing line representing the effect of gravity was drawn between the centre of the femoral head and the centre of the talus. At the knee joint, the position of this line from the medial border was described as percentage of the width of the tibial plateau (position of weightbearing line). 2.6. Data analysis Joint kinematics and kinetics were calculated using Vicon PlugIn Gait software (Vicon Motion Systems, UK). In this software, joint kinematics were calculated using Euler angles where the movement of the distal segment is described relative to the proximal segment. Joint kinetics were calculated using standard inverse dynamics. The moments described in this manuscript are external and normalised to bodyweight and height (%Bw-ht). A single gait stride (from initial contact to initial contact) from each walking trial was used in analysis and time normalised to 100%. Key biomechanical variables from each trial were selected and averaged across the six successful trials of each participant to create a participant average. These variables were: knee flexion angle at initial contact, maximum knee flexion angle during stance, minimum knee flexion angle during stance (or maximum knee extension angle), maximum knee flexion angle during swing, maximum knee flexion moment, minimum knee flexion moment (or maximum knee extension moment), and maximum knee adduction moment. In previous studies of gait in patients with TKA, three patterns of the knee moment in the sagittal plane have been described: (1) a biphasic pattern that is typically associated with normal gait where a maximum flexion moment in early stance is followed by an extension moment in late stance; (2) a flexor pattern where a flexion moment is prolonged and the extension moment in late stance is absent; and (3) an extensor pattern where there flexion moment in early stance is absent (Figure 1) [22,23]. The profile of the sagittal moment for each individual in the current study was analysed for the presence of either a biphasic, flexor or extensor moment pattern. These patterns during level gait have been described previously. All data were tested for normality using the Kolmogorov–Smirnov goodness of fit test (in this test samples are standardized and compared with a standard normal distribution). The proportion of males, and the prevalence of moment patterns were compared between groups using chi-squared. Walking speed, outcome scores and radiographic averages were compared between groups using a univariate analysis of variance. Significant findings (P b 0.05) were explored further by post hoc comparisons using independent ttests. Peak biomechanical variables were compared between groups using a univariate analysis of covariance (ANCOVA) where walking speed was treated as a covariate. For these analyses, significant findings were explored further by calculating simple contrasts that compared each of the conventional and navigated TKA groups with the control group. 3. Results Eighty-one participants with TKA (39 with conventional TKA and 42 with navigation TKA) were assessed an average of 19.9 months (standard deviation (SD) = 7.8) after surgery. An additional 40 control participants without knee surgery or knee pain were also assessed. There were no differences between groups in terms of age (P = 0.65), height (P = 0.64) and the gender distribution (P = 0.98), but both the conventional and navigation TKA groups were heavier than controls (P = 0.03) (Table 1), which is typical for patients with TKA as obesity is a risk factor for the development of knee OA [24,25]. The Knee Society Knee Score was not
Figure 1. Three patterns of the sagittal knee moment throughout stance: biphasic (typical of normal gait), flexor (where the external moment is maintained throughout stance phase in a flexion direction) and extensor (where the moment is maintained throughout stance phase in an extension direction).
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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Table 1 Demographics of participants.
Age (years) Height (cm) Weight (kg) BMI M:F
Controls
Navigated TKA
Conventional TKA
P
69.6 (8.3) 165.0 (9.5) 76.2 (14.9) 28.0 (4.6) 18:22
68.7 (6.3) 165.7 (10.0) 85.1 (15.2) 31.1 (4.8) 20:22
71.8 (8.4) 164.6 (8.4) 83.6 (16.6) 30.3 (5.6) 17:22
0.65 0.64 0.03 0.02 0.98
BMI, body mass index; M:F, ratio of males to females; TKA, total knee arthroplasty. Bold and italics represent significant difference between groups.
significantly different for participants in the navigation TKA group (Knee score average = 87.5, SD = 14.1) from those in the conventional TKA group (average = 84.2, SD = 11.6) (P = 0.361). 3.1. Radiographic analysis The mechanical axis and position of the weightbearing line in relation to the medial tibial border were significantly closer to ideal alignment (180° and 50%) in the group with navigated TKA (average = 179°, SD = 2, average = 46%, SD = 1) than in the group with conventional TKA (average = 177°, SD = 4, average = 32%, SD = 2; P b 0.01 and P = 0.01, respectively). 3.2. Gait analysis There was a significant difference in walking speed between the three groups (P b 0.01). Post hoc testing revealed that the participants with conventional TKA walked slower (average = 1.14, SD = 0.02 m/s) than both the participants with navigation TKA (average = 1.24, SD = 0.02 m/s, P = 0.03) and the control participants (average = 1.27, SD = 0.02 m/s, P b 0.01). When this variability in walking speed was accounted for there was a significant difference between groups in terms of the maximum knee flexion angle during both the stance (P = 0.02) and swing (P = 0.04) phases of the gait cycle (Table 2). Post hoc testing showed that in both cases the participants with conventional TKA had significantly less knee flexion than the control group (P ≤ 0.01). Whilst the navigation TKA also had less knee flexion than the control group, the difference did not reach statistical significance (P = 0.06 and P = 0.28, for stance and swing phases, respectively). The only difference between groups in terms of the peak moments was for the knee adduction moment (P b 0.01) (Table 3). Post hoc contrasts showed that both the conventional TKA and navigation TKA groups had significantly lower maximum knee adduction moment than the controls. In terms of the profile of the sagittal moment pattern, significantly fewer participants with conventional TKA demonstrated a biphasic moment pattern than both control participants and participants with navigation TKA (Table 4). 4. Discussion This study identified differences between groups that suggest that knee biomechanics of walking in patients with computerassisted navigation TKA are closer to normal than for patients with conventional TKA. Patients with navigation TKA were different from controls on fewer peak biomechanical variables that are commonly assessed in this patient group than patients with conventional TKA. But in what may be considered more reflective of overall walking pattern, significantly fewer patients with navigation TKA walked with a moment profile that was abnormal compared to patients with conventional TKA. These findings suggest that navigation TKA may facilitate more normal biomechanical outcomes for patients. Walking speed is an important predictor of mortality and morbidity in older adults [26,27]. Traditionally, TKA has improved walking speed in patients with severe knee OA only marginally, and patients have continued to walk at slower speeds than normal [25,28]. In the current study, however, patients with navigation TKA walked faster than patients with conventional TKA, and walking speed in these patients was comparable to people without knee pathology. Compared to conventional TKA, a much larger proportion of patients with navigated TKA walked with a moment in the sagittal plane that changed in a biphasic pattern throughout the gait cycle. This biphasic pattern is typically associated with normal gait, and as expected, was found in 97% of the control participants of this study. The external knee flexion moment represents the demand for an internal force (assumed to be the quadriceps) that encourages knee extension to maintain upright posture and forward Table 2 ANCOVA comparisons between groups for peak knee angles during gait (degrees).
Flexion angle at initial contact Maximum flexion angle during stance phase Minimum flexion during stance phase Maximum flexion angle during swing phase
Controls
Navigated TKA
Conventional TKA
P
7.1 (4.0) 17.3 (5.8) −0.5 (5.0) 55.4 (4.4)
6.7 (5.8) 14.4 (7.1) 1.3 (6.8) 53.9 (7.3)
5.4 (5.2) 12.1⁎ (6.6) 1.3 (6.1) 51.1⁎ (4.8)
0.32 0.02 0.45 0.04
TKA, total knee arthroplasty. Walking speed was treated as a covariate. Values are means (standard deviations). Bold and italics represent significant difference between groups. ⁎ Post hoc test difference between conventional TKA and controls. P b 0.01.
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Table 3 ANCOVA comparisons between groups for peak knee moments during gait (%body weight-height).
Maximum flexion moment Minimum flexion moment Maximum adduction moment
Controls
Navigated TKA
Conventional TKA
P
3.0 (1.4) −1.2 (1.0) 3.6 −0.7
2.7 (1.2) −1.8 (1.0) 2.9† (0.6)
2.1 (1.2) −1.8 (1.0) 2.9⁎ (0.6)
0.10 0.56 b0.01
TKA, total knee arthroplasty. Bold and italics represent significant difference between groups. ⁎ Post hoc test difference between conventional TKA and controls, P b 0.01. † Post hoc differences between navigation TKA and controls, P b 0.01.
momentum. Deviations in the generation of an external knee flexion moment can therefore indicate abnormal neuromuscular control of the quadriceps throughout gait. Traditionally, as few as 40% of patients with TKA walk with this biphasic moment pattern [25]. Instead, patients have typically adopted a monophasic moment pattern where the knee flexion moment was either prolonged or avoided, thereby altering the demand for quadriceps control [29]. In these previous studies, the presence of an abnormal monophasic moment pattern has been considered representative of knee instability secondary to inferior prosthesis design [13,22,30]. In the current study, 87% of patients with navigated TKA walked with a normal biphasic moment pattern, which was significantly more than for the conventional TKA group, and is also more than previously reported for a TKA patient group [25]. These findings suggest that navigated TKA may facilitate outcomes that promote greater neuromuscular control of the knee during dynamic activities. Most evaluations of the benefits of computer-assisted navigation have focused on outcomes that assess lower-limb alignment in the coronal plane. Assessment of biomechanics in the coronal plane is vital for TKA, because excessive forces acting on the medial knee may contribute to loosening of the prosthesis and subsequent TKA failure [11]. The external knee adduction moment is considered the best non-invasive estimate of medial knee joint forces that is readily available [12]. This study is the first to compare the knee adduction moment in patients with a navigated TKA to those with a conventional TKA. We found that there was no difference in the magnitude of the knee adduction moment between the patient groups, but that both patient groups had lower moments than controls. This is despite a significant improvement in the static lower-limb alignment (mechanical axis) for patients with navigation, and suggests that other factors associated with knee force during dynamic activities (such as walking speed, and muscular control) may mitigate any small differences in static alignment. Previous attempts to quantify the relationship between lower-limb alignment and the knee adduction moment have produced substantially different findings. Some have been unable to determine a relationship, and it appears that, at best, the lower-limb alignment predicts only 50% of the external knee adduction moment [31]. This explains the findings of the current study that computerassisted navigation may improve lower-limb alignment but not the knee adduction moment. Collectively, these findings emphasise that caution needs to be taken when interpreting the findings of static measures of lower-limb alignment and the implications for long-term prosthesis survival. Perhaps assessment of patients over a longer timeframe is necessary to evaluate the potential for longer-term benefits of computer-assisted navigation in terms of medial knee forces and prosthesis longevity. The findings of the current study suggest that computer-assisted navigated TKA may lead to sagittal plane biomechanics that are closer to normal than conventional TKA. Patients with a navigated TKA walked with a greater peak knee flexion during both the stance and swing phases of gait compared to patients with conventional TKA. The knee flexion of patients with a navigated TKA was similar to that of controls, and therefore may be considered as closer to normal than the knee biomechanics of patients with a conventional TKA. Typically, greater knee flexion during stance has been associated with greater capacity to attenuate impact forces at the knee [32]. Higher degrees of maximum postoperative knee flexion have been related to a greater posterior tibial slope [33], and it is possible that computer-assisted navigation facilitates greater accuracy in tibial cutting to generate these outcomes. However, knee flexion during gait does not approach maximal knee flexion capacity, and it is more likely that these superior biomechanics represent an overall improvement in the function of the knee. A limitation of this study is that patients were not randomised to receive either computer-assisted or navigation TKA. However, all patients received the same prosthesis from the same surgeon and the patient groups were similar with regard to all primary confounders. Therefore, we are confident that the findings of this study are accurate. These findings represent the outcome of a case series of patients from a single experienced knee surgeon, and potential for greater variability in the gait outcomes from knee arthroplasty may be more likely in less experienced surgeons. 5. Conclusions In conclusion, the findings of this study suggest that computer-assisted navigated TKA may result in biomechanics during walking that are closer to normal than conventional TKA. Table 4 Proportion of participants who demonstrated either a biphasic, flexor or extensor moment pattern during level walking.
Biphasic pattern Flexor pattern Extensor pattern
Controls
Navigated TKA
Conventional TKA
P
39 (97%) 1 (3%) 0 (0%)
37 (87%) 3 (7%) 3 (6%)
27 (68%) 1 (3%) 11 (29%)
0.00
TKA, total knee arthroplasty. Bold and italics represent significant difference between groups.
Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009
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Conflict of interest The authors have no conflicts of interest to declare.
Acknowledgements The authors would like to acknowledge the contribution of Dr. Joanne Wittwer in her assistance with data collection for this study, and Ms. Joanna Tallis for her assistance with computer-assisted navigation. This study was completed with assistance from a La Trobe University Faculty of Health Sciences Research Grant.
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Please cite this article as: McClelland JA, et al, Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surge..., Knee (2017), http://dx.doi.org/10.1016/j.knee.2016.12.009