Sources of Error in Total Knee Arthroplasty

by LoukasKoyonos, MD; S. David Stulberg, MD; Todd C. Moen, MD; Gina Bart, PAC; Michael Granieri, BS

Abstract
The purpose of this study was to identify the procedural steps in a total knee arthroplasty (TKA) in which technical errors occur and to quantify the magnitude of these errors. Forty-nine consecutive TKAs were performed using a traditional exposure and manual instrumentation. An image-free computer navigation system (OrthoPilot; Aesculap AG, Tuttlingen, Germany) was used to measure and compare femoral and tibial alignment at specific procedural points during the TKA; this data was then used to evaluate possible sources of error in the procedure. The femoral cut tended to be made in hyperextension, the tibial cut tended to be made in hyperextension and valgus, and the tibial component tended to be implanted in valgus. This study identified specific points during the performance of a TKA where technical errors occur. This information suggests technical considerations that can help a surgeon achieve more reproducible, durable, and successful outcomes for his or her patients. The outcome of a total knee arthroplasty (TKA) is dependent on a number of factors, one of the most important being implant alignment. Improper alignment of the implants can lead to accelerated wear and early failure, whereas properly positioned components have shown increased longevity.1-6 Numerous studies have shown that errors in alignment in the coronal plane >3 lead to earlier failures and suboptimal results in TKAs.
7,8

The alignment of the implants, and thus the outcome of a TKA, has been shown to be particularly sensitive to surgical technique.
5,9-13

Despite continual refinement in manual instrumentation systems to improve accuracy

14

of implant alignment, errors continue to occur. occur at numerous points in a TKA.

From the placement of the alignment guides and the securing

of the cutting blocks to the actual bony cuts themselves and the final cementing of the implants, errors can

Although studies have evaluated the accuracy of traditional TKA instrumentation, to our knowledge there has been no study examining the precise procedural steps during a TKA in which alignment errors occur. The purpose of this study was to identify the technical steps in which these errors occur and quantify the magnitude of these errors with the use of an image-free computer navigation system (OrthoPilot; Aesculap AG, Tuttlingen, Germany).

Materials and Methods

This study was approved by our Institutional Review Board. Informed consent for this study was obtained from all participants. The senior author (S.D.S.) performed a TKA on 49 consecutive patients using a currently available intramedullary instrumentation system. Prior to beginning the procedure, tracking diodes for the navigation system were secured percutaneously to the distal femur and proximal tibia. The centers of rotation of the head of the femur, knee, and ankleand thus the mechanical axis of the limbwere established using kinematic and surface registration techniques. The knee was exposed using a standard median parapatellar approach. The femoral intramedullary alignment guide was set at the anatomic axis (5-9) that would result in a mechanical frontal axis of 0 based on the

measurements of preoperative long radiographs taken with the patient standing. The AP intercondylar (Whitesides) line was used to establish the rotation of the femoral component. The femoral cutting block was placed perpendicular to the AP intercondylar line. The tibial cutting block was positioned on the intramedullary alignment guide to allow a cut to be made perpendicular to the intramedullary axis of the tibia. A 0 posteriorly sloped cutting block was used. Both the femoral and tibial cutting guides were slotted. The navigation system has a check plate to which is attached a diode-containing tracker. This check plate can be applied to each of the cutting blocks that have been attached to the femur and tibia to determine their alignment. The check plate can also be applied directly to the cut surfaces of the femur and tibia to measure the alignment accuracy of the cuts. The check plate was used to measure the alignment of the femoral and tibial cutting blocks before and after each actual cut was made. Alignment was recorded in the frontal, sagittal, and axial planes. The difference between the alignment values before and after each cut was termed the movement of the cutting block. The check plate was also used to check the final alignment of the cut. Alignment was measured in the frontal, sagittal, and axial planes for the femoral cut, and in the frontal and sagittal planes for the tibial cut. The final bony cuts alignment was then compared to the final alignment of the cutting block. The difference between these 2 values was termed the accuracy of the cut. It should be noted that after the measurements of the alignment of the initial cut were made, the senior surgeon (S.D.S.) used the navigation system and check plate to adjust the bony resection appropriately to match the alignment of the cutting blocks. Finally, the check plate was used to measure frontal and sagittal alignment of the tibial component following final implantation and cementation. This alignment was then compared to the final alignment of the bony cuts; the difference between these 2 values was termed the accuracy of implantation. The accuracy of implantation of the femoral component was not measured due to the femoral components lack of a flat surface on which to apply the check plate. Given the nonparametric distribution of the data, a paired t test and Wilcoxins signed rank test was used to measure the differences between measurements.

Results
The mean movement of the femoral cutting block in the coronal plane was 0.03 valgus (.34; P>.05; range, 0-1). The mean movement of the femoral cutting block in the sagittal plane was 0.04 extension (.46; P>.05; range, 0-1). The mean movement of the femoral cutting block in the axial plane was .03 external rotation (0.41; P>.05; Table 1). The mean movement of the tibial cutting block in the coronal plane was 0.06 varus (0.61; P>.05; range, 01). The mean movement of the tibial cutting block in the sagittal plane was 0.10 extension (0.61; P>.05; range, 0-1; Table 1). In the coronal plane, the femoral cut was found to be in 0.06 of varus (0.55; P>.05) with respect to the final alignment of the cutting block. In the axial plane, the femoral cut was found to be in neutral rotation (0.36; P>.05) with respect to the final alignment of the cutting block. In the sagittal plane, the femoral cut was found to be in 0.96 of extension (1.19; P<.0005; range, 0-3) with respect to the final alignment of the cutting block; this result was statistically significant (Table 2). In the coronal plane, the tibial cut was found to be in 0.18 of valgus (0.56; P,.02; range, 0-3) with respect to the final alignment of the cutting block. This result was statistically significant. In the sagittal plane, the tibial cut was found to be in 0.50 of extension (0.83; P<.0005; range, 0-2) with respect to the final alignment of the cutting block. This result was statistically significant (Table 2).

In the coronal plane, the final alignment of the tibial component was found to be in 0.22 of valgus (0.62; P<.02) with respect to the alignment of the final cut; this result was statistically significant. In the sagittal plane, the final alignment of the tibial component was found to be in 0.06 of hyperextension (0.95; P<.05) with respect to the final cut; this result was not statistically significant (Table 3).

Discussion
The results of this study identified specific points during a TKA where technical errors tend to occur and quantified the nature of these errors. Equally as important, the results of this study identified specific points where errors did not tend to occur. This information is relevant as it alerts the surgeon to points during a TKA where particular attention must be paid to prevent the introduction of errors into the procedure. The study should also alert surgeons that small errors that occur at each step of a TKA may compound into larger, significant errors.

In the sagittal plane on both the tibial and femoral side, the initial bony cuts tended to be left in hyperextension with respect to the alignment of the cutting block, with some discrepancies as high as 3. Given that the alignment of the cutting blocks did not significantly change before and after the actual cut, these errors were introduced during the performance of the cut itself. These errors were likely a result of deflection of the saw blade off hardened sclerotic bone as the bony resection was performed. In the coronal plane on the tibial side only, there was a small but statistically significant trend for the initial bony cut to be left in valgus with respect to final alignment of the cutting block. Again, as the alignment of the cutting blocks was found to be stable before and after the bony cut, this error was introduced during the cut itself and again was likely due to the deflection of the saw blade off sclerotic, osteoarthritic bone. It is noteworthy that the only significant source of error in the coronal plane occurred during the tibial resection. The initial deformity and predominant location of osteoarthritis was not accounted for, and knees with predominantly medial compartment diseaseand thus varus deformityand predominantly lateral compartment diseaseand thus valgus deformitywere included. The predominance of medial compartment osteoarthritis accounts for the small but significant trend toward a cut made in excessive valgus. If the cohort of patients in this study were separated and studied based on location of disease, we anticipate there would be statistically stronger trends in the anticipated direction, ie, medial compartment disease causing a cut made in excessive valgus. The alignment of the final tibial implant following cementation also showed a small but statistically significant trend toward implantation in valgus with respect to the alignment of the final tibial cut. This was independent of errors introduced during the performance of the bony cuts. As mentioned, following the initial measurement of the alignment of the bone cut, the navigation system was used to adjust the bony resection to insure an accurate cut. Thus, the valgus error introduced was not influenced by any errors in alignment of the bone cuts. Although the reason for this trend toward implantation in valgus is not entirely clear, in patients with medial compartment osteoarthritis the bone of the lateral tibial plateau is softer than the sclerotic bone of the medial plateau. This may predispose placement of the implant into valgus. The sources of errors identified in this study suggest specific measures that can be taken to avoid these technical pitfalls. Inherent in this discussion is the assumption that the cutting blocks were aligned correctly and that each error compounds on itself. First, it is vital to use rigid, stiff, sharp cutting blades that can resect sclerotic bone without deflection from the cutting block and thus avoid an inaccurate cut. Second, to further prevent deflection from sclerotic bone, it is important to use an instrumentation system where the saw blade fits as flush as possible within the cutting block. Third, the more sclerotic the osteoarthritic bone, the more vigilance required by the surgeon to ensure that the bony cut that was made is flush with the alignment of the cutting block. This point is particularly important in modern minimally invasive instrumentation systems in which visualization of the cut surface may be suboptimal. This study had some notable limitations. The sample size was relatively small. Although significant trends declared themselves, there may be further conclusions to be drawn with a larger cohort of patients. Also, the distribution of disease and deformity was not accounted for in the evaluation of errors. Inferences can be made given the prevalence of medial compartment osteoarthritis; however, if the specific disease patterns were evaluated independently, a more concrete conclusion could be made as to the nature of errors. This study identified specific points during a TKA where technical errors tend to be made. The femoral cut tended to be made in hyperextension, the tibial cut tended to be made in hyperextension and valgus, and the tibial component tended to be implanted in valgus. This information and the technical considerations it suggests can assist the surgeon in achieving more reproducible, durable, and successful outcomes for their patients following TKA.