Optimal lower limb alignment and soft tissue balancing strategy for robot-assisted total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Qiaojie ,  ZHANG Xianlong

Department of Orthopaedics, Shanghai Jiaotong University Affiliated Shanghai Sixth People’s Hospital, Shanghai, 200233, P.R.China;

Corresponding author：

ZHANG Xianlong, Email: dr_zhangxianlong@sjtu.edu.cn

Keywords：

Robot-assisted total knee arthroplasty; mechanical alignment; kinematic alignment; functional alignment; soft tissue balance

DOI：

10.7507/1002-1892.202107069

Video：

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Abstract Full text Figures/Tables Video References Cited by

Lower limb alignment and soft tissue balance are important factors affecting patient satisfaction, clinical functional outcome, and prosthetic long-term survival rate after total knee arthroplasty (TKA). Robot-assisted TKA (rTKA) has the advantages of achieving precise osteotomy and soft tissue balance. However, rTKA under the guidance of classic mechanical alignment principles does not significantly improve the functional outcome after operation. The new TKA alignment principles, such as kinematic alignment (KA) and functional alignment (FA), can better consider the patient’s own knee joint morphology and kinematic characteristics, which may help improve the clinical results of TKA. With the help of more objective and accurate soft tissue balance assessment tool such as pressure sensors, KA and FA have been proven to better achieve soft tissue balance. rTKA can achieve non-neutral alignment goals such as KA or FA more accurately and reproducibly. The use of these lower limb alignment and soft tissue balancing strategies will be expected to further increase the patients’ satisfaction rate after rTKA.

Citation： WANG Qiaojie, ZHANG Xianlong. Optimal lower limb alignment and soft tissue balancing strategy for robot-assisted total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(10): 1221-1226. doi: 10.7507/1002-1892.202107069 Copy

1.	Nam D, Nunley RM, Barrack RL. Patient dissatisfaction following total knee replacement: a growing concern? Bone Joint J, 2014, 96-B(11 Supple A): 96-100.
2.	Gunaratne R, Pratt DN, Banda J, et al. Patient dissatisfaction following total knee arthroplasty: A systematic review of the literature. J Arthroplasty, 2017, 32(12): 3854-3860.
3.	夏润之, 童志成, 张经纬, 等. 国产“鸿鹄”膝关节置换手术机器人的早期临床研究. 实用骨科杂志, 2021, 27(2): 108-113, 117.
4.	王炜, 陈鑫, 范彧, 等. 机器人辅助全膝关节置换术治疗严重膝骨关节炎的临床研究. 中华骨与关节外科杂志, 2021, 14(5): 393-398.
5.	Jacofsky DJ, Allen M. Robotics in arthroplasty: A comprehensive review. J Arthroplasty, 2016, 31(10): 2353-2363.
6.	Han S, Rodriguez-Quintana D, Freedhand AM, et al. Contemporary robotic systems in total knee arthroplasty: A review of accuracy and outcomes. Orthop Clin North Am, 2021, 52(2): 83-92.
7.	Moon YW, Ha CW, Do KH, et al. Comparison of robot-assisted and conventional total knee arthroplasty: a controlled cadaver study using multiparameter quantitative three-dimensional CT assessment of alignment. Comput Aided Surg, 2012, 17(2): 86-95.
8.	Song EK, Seon JK, Yim JH, et al. Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop Relat Res, 2013, 471(1): 118-126.
9.	Sires JD, Craik JD, Wilson CJ. Accuracy of bone resection in MAKO total knee robotic-assisted surgery. J Knee Surg, 2021, 34(7): 745-748.
10.	Sires JD, Wilson CJ. CT Validation of intraoperative implant position and knee alignment as determined by the MAKO total knee arthroplasty system. J Knee Surg, 2021, 34(10): 1133-1137.
11.	Scholl LY, Hampp EL, de Souza KM, et al. How does robotic-arm assisted technology influence total knee arthroplasty implant placement for surgeons in fellowship training? J Knee Surg, 2020. doi: 10.1055/s-0040-1716983.
12.	Hampp EL, Sodhi N, Scholl L, et al. Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach: A blinded assessment. Bone Joint Res, 2019, 8(10): 495-501.
13.	Kayani B, Konan S, Pietrzak JRT, et al. Iatrogenic bone and soft tissue trauma in robotic-arm assisted total knee arthroplasty compared with conventional jig-based total knee arthroplasty: A prospective cohort study and validation of a new classification system. J Arthroplasty, 2018, 33(8): 2496-2501.
14.	Kim YH, Yoon SH, Park JW. Does robotic-assisted tka result in better outcome scores or long-term survivorship than conventional TKA? A randomized, controlled trial. Clin Orthop Relat Res, 2020, 478(2): 266-275.
15.	Cho KJ, Seon JK, Jang WY, et al. Robotic versus conventional primary total knee arthroplasty: clinical and radiological long-term results with a minimum follow-up of ten years. Int Orthop, 2019, 43(6): 1345-1354.
16.	Park SE, Lee CT. Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty, 2007, 22(7): 1054-1059.
17.	Dorr LD. CORR Insights^®: Does robotic-assisted TKA result in better outcome scores or long-term survivorship than conventional TKA? A randomized, controlled trial Clin Orthop Relat Res, 2020, 478(2): 276-278.
18.	Marchand RC, Sodhi N, Khlopas A, et al. Patient satisfaction outcomes after robotic arm-assisted total knee arthroplasty: A short-term evaluation. J Knee Surg, 2017, 30(9): 849-853.
19.	Smith AF, Eccles CJ, Bhimani SJ, et al. Improved patient satisfaction following robotic-assisted total knee arthroplasty. J Knee Surg, 2021, 34(7): 730-738.
20.	Kayani B, Konan S, Tahmassebi J, et al. 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: a prospective cohort study. Bone Joint J, 2018, 100-B(7): 930-937.
21.	Cavinatto L, Bronson MJ, Chen DD, et al. Robotic-assisted versus standard unicompartmental knee arthroplasty-evaluation of manuscript conflict of interests, funding, scientific quality and bibliometrics. Int Orthop, 2019, 43(8): 1865-1871.
22.	Naziri Q, Cusson BC, Chaudhri M, et al. Making the transition from traditional to robotic-arm assisted TKA: What to expect? A single-surgeon comparative-analysis of the first-40 consecutive cases. J Orthop, 2019, 16(4): 364-368.
23.	Liow MHL, Goh GS, Wong MK, et al. Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2942-2951.
24.	Cherian JJ, Kapadia BH, Banerjee S, et al. Mechanical, anatomical, and kinematic axis in TKA: Concepts and practical applications. Curr Rev Musculoskelet Med, 2014, 7(2): 89-95.
25.	Hirschmann MT, Karlsson J, Becker R. Hot topic: alignment in total knee arthroplasty-systematic versus more individualised alignment strategies. Knee Surg Sports Traumatol Arthrosc, 2018, 26(6): 1587-1588.
26.	Insall JN, Binazzi R, Soudry M, et al. Total knee arthroplasty. Clin Orthop Relat Res, 1985, (192): 13-22.
27.	Bellemans J, Colyn W, Vandenneucker H, et al. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res, 2012, 470(1): 45-53.
28.	Salzmann M, Fennema P, Becker R, et al. Does postoperative mechanical axis alignment have an effect on clinical outcome of primary total knee arthroplasty? A retrospective cohort study. Open Orthop J, 2017, 11: 1330-1336.
29.	Magnussen RA, Weppe F, Demey G, et al. Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res, 2011, 469(12): 3443-3450.
30.	Schiffner E, Wild M, Regenbrecht B, et al. Neutral or natural? Functional impact of the coronal alignment in total knee arthroplasty. J Knee Surg, 2019, 32(8): 820-824.
31.	Nishida K, Matsumoto T, Takayama K, et al. Remaining mild varus limb alignment leads to better clinical outcome in total knee arthroplasty for varus osteoarthritis. Knee Surg Sports Traumatol Arthrosc, 2017, 25(11): 3488-3494.
32.	Vanlommel L, Vanlommel J, Claes S, et al. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc, 2013, 21(10): 2325-2330.
33.	MacDessi SJ, Griffiths-Jones W, Harris IA, et al. Coronal Plane Alignment of the Knee (CPAK) classification. Bone Joint J, 2021, 103-B(2): 329-337.
34.	Howell SM, Kuznik K, Hull ML, et al. Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48 patients. Orthopedics, 2008, 31(9): 857-863.
35.	Maderbacher G, Keshmiri A, Krieg B, et al. Kinematic component alignment in total knee arthroplasty leads to better restoration of natural tibiofemoral kinematics compared to mechanic alignment. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1427-1433.
36.	Blakeney W, Clément J, Desmeules F, et al. Kinematic alignment in total knee arthroplasty better reproduces normal gait than mechanical alignment. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1410-1417.
37.	MacDessi SJ, Griffiths-Jones W, Chen DB, et al. Restoring the constitutional alignment with a restrictive kinematic protocol improves quantitative soft-tissue balance in total knee arthroplasty: a randomized controlled trial. Bone Joint J, 2020, 102-B(1): 117-124.
38.	Kayani B, Konan S, Tahmassebi J, et al. A prospective double-blinded randomised control trial comparing robotic arm-assisted functionally aligned total knee arthroplasty versus robotic arm-assisted mechanically aligned total knee arthroplasty. Trials, 2020, 21(1): 194. doi: 10.1186/s13063-020-4123-8.
39.	MacDessi SJ, Wood JA, Diwan AD, et al. Surgeon-defined assessment is a poor predictor of knee balance in total knee arthroplasty: a prospective, multicenter study. Knee Surg Sports Traumatol Arthrosc, 2021, 29(2): 498-506.
40.	孙晓威, 张启栋, 任鹏鹏, 等. 全膝关节置换关节间隙压力传感器的研究现状. 中国矫形外科杂志, 2020, 28(19): 1774-1778.
41.	Gustke KA, Golladay GJ, Roche MW, et al. A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA. J Arthroplasty, 2014, 29(5): 955-960.
42.	Song SJ, Lee HW, Kim KI, et al. Load imbalances existed as determined by a sensor after conventional gap balancing with a tensiometer in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2020, 28(9): 2953-2961.
43.	Golladay GJ, Bradbury TL, Gordon AC, et al. Are patients more satisfied with a balanced total knee arthroplasty? J Arthroplasty, 2019, 34(7S): S195-S200.
44.	Gustke KA, Golladay GJ, Roche MW, et al. Increased satisfaction after total knee replacement using sensor-guided technology. Bone Joint J, 2014, 96-B(10): 1333-1338.
45.	Chang JS, Kayani B, Wallace C, et al. Functional alignment achieves soft-tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology. Bone Joint J, 2021, 103-B(3): 507-514.
46.	Tokuhara Y, Kadoya Y, Nakagawa S, et al. The flexion gap in normal knees. An MRI study. J Bone Joint Surg (Br), 2004, 86: 1133-1136.

1. Nam D, Nunley RM, Barrack RL. Patient dissatisfaction following total knee replacement: a growing concern? Bone Joint J, 2014, 96-B(11 Supple A): 96-100.
2. Gunaratne R, Pratt DN, Banda J, et al. Patient dissatisfaction following total knee arthroplasty: A systematic review of the literature. J Arthroplasty, 2017, 32(12): 3854-3860.
3. 夏润之, 童志成, 张经纬, 等. 国产“鸿鹄”膝关节置换手术机器人的早期临床研究. 实用骨科杂志, 2021, 27(2): 108-113, 117.
4. 王炜, 陈鑫, 范彧, 等. 机器人辅助全膝关节置换术治疗严重膝骨关节炎的临床研究. 中华骨与关节外科杂志, 2021, 14(5): 393-398.
5. Jacofsky DJ, Allen M. Robotics in arthroplasty: A comprehensive review. J Arthroplasty, 2016, 31(10): 2353-2363.
6. Han S, Rodriguez-Quintana D, Freedhand AM, et al. Contemporary robotic systems in total knee arthroplasty: A review of accuracy and outcomes. Orthop Clin North Am, 2021, 52(2): 83-92.
7. Moon YW, Ha CW, Do KH, et al. Comparison of robot-assisted and conventional total knee arthroplasty: a controlled cadaver study using multiparameter quantitative three-dimensional CT assessment of alignment. Comput Aided Surg, 2012, 17(2): 86-95.
8. Song EK, Seon JK, Yim JH, et al. Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop Relat Res, 2013, 471(1): 118-126.
9. Sires JD, Craik JD, Wilson CJ. Accuracy of bone resection in MAKO total knee robotic-assisted surgery. J Knee Surg, 2021, 34(7): 745-748.
10. Sires JD, Wilson CJ. CT Validation of intraoperative implant position and knee alignment as determined by the MAKO total knee arthroplasty system. J Knee Surg, 2021, 34(10): 1133-1137.
11. Scholl LY, Hampp EL, de Souza KM, et al. How does robotic-arm assisted technology influence total knee arthroplasty implant placement for surgeons in fellowship training? J Knee Surg, 2020. doi: 10.1055/s-0040-1716983.
12. Hampp EL, Sodhi N, Scholl L, et al. Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach: A blinded assessment. Bone Joint Res, 2019, 8(10): 495-501.
13. Kayani B, Konan S, Pietrzak JRT, et al. Iatrogenic bone and soft tissue trauma in robotic-arm assisted total knee arthroplasty compared with conventional jig-based total knee arthroplasty: A prospective cohort study and validation of a new classification system. J Arthroplasty, 2018, 33(8): 2496-2501.
14. Kim YH, Yoon SH, Park JW. Does robotic-assisted tka result in better outcome scores or long-term survivorship than conventional TKA? A randomized, controlled trial. Clin Orthop Relat Res, 2020, 478(2): 266-275.
15. Cho KJ, Seon JK, Jang WY, et al. Robotic versus conventional primary total knee arthroplasty: clinical and radiological long-term results with a minimum follow-up of ten years. Int Orthop, 2019, 43(6): 1345-1354.
16. Park SE, Lee CT. Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty, 2007, 22(7): 1054-1059.
17. Dorr LD. CORR Insights^®: Does robotic-assisted TKA result in better outcome scores or long-term survivorship than conventional TKA? A randomized, controlled trial Clin Orthop Relat Res, 2020, 478(2): 276-278.
18. Marchand RC, Sodhi N, Khlopas A, et al. Patient satisfaction outcomes after robotic arm-assisted total knee arthroplasty: A short-term evaluation. J Knee Surg, 2017, 30(9): 849-853.
19. Smith AF, Eccles CJ, Bhimani SJ, et al. Improved patient satisfaction following robotic-assisted total knee arthroplasty. J Knee Surg, 2021, 34(7): 730-738.
20. Kayani B, Konan S, Tahmassebi J, et al. 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: a prospective cohort study. Bone Joint J, 2018, 100-B(7): 930-937.
21. Cavinatto L, Bronson MJ, Chen DD, et al. Robotic-assisted versus standard unicompartmental knee arthroplasty-evaluation of manuscript conflict of interests, funding, scientific quality and bibliometrics. Int Orthop, 2019, 43(8): 1865-1871.
22. Naziri Q, Cusson BC, Chaudhri M, et al. Making the transition from traditional to robotic-arm assisted TKA: What to expect? A single-surgeon comparative-analysis of the first-40 consecutive cases. J Orthop, 2019, 16(4): 364-368.
23. Liow MHL, Goh GS, Wong MK, et al. Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc, 2017, 25(9): 2942-2951.
24. Cherian JJ, Kapadia BH, Banerjee S, et al. Mechanical, anatomical, and kinematic axis in TKA: Concepts and practical applications. Curr Rev Musculoskelet Med, 2014, 7(2): 89-95.
25. Hirschmann MT, Karlsson J, Becker R. Hot topic: alignment in total knee arthroplasty-systematic versus more individualised alignment strategies. Knee Surg Sports Traumatol Arthrosc, 2018, 26(6): 1587-1588.
26. Insall JN, Binazzi R, Soudry M, et al. Total knee arthroplasty. Clin Orthop Relat Res, 1985, (192): 13-22.
27. Bellemans J, Colyn W, Vandenneucker H, et al. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res, 2012, 470(1): 45-53.
28. Salzmann M, Fennema P, Becker R, et al. Does postoperative mechanical axis alignment have an effect on clinical outcome of primary total knee arthroplasty? A retrospective cohort study. Open Orthop J, 2017, 11: 1330-1336.
29. Magnussen RA, Weppe F, Demey G, et al. Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res, 2011, 469(12): 3443-3450.
30. Schiffner E, Wild M, Regenbrecht B, et al. Neutral or natural? Functional impact of the coronal alignment in total knee arthroplasty. J Knee Surg, 2019, 32(8): 820-824.
31. Nishida K, Matsumoto T, Takayama K, et al. Remaining mild varus limb alignment leads to better clinical outcome in total knee arthroplasty for varus osteoarthritis. Knee Surg Sports Traumatol Arthrosc, 2017, 25(11): 3488-3494.
32. Vanlommel L, Vanlommel J, Claes S, et al. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc, 2013, 21(10): 2325-2330.
33. MacDessi SJ, Griffiths-Jones W, Harris IA, et al. Coronal Plane Alignment of the Knee (CPAK) classification. Bone Joint J, 2021, 103-B(2): 329-337.
34. Howell SM, Kuznik K, Hull ML, et al. Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48 patients. Orthopedics, 2008, 31(9): 857-863.
35. Maderbacher G, Keshmiri A, Krieg B, et al. Kinematic component alignment in total knee arthroplasty leads to better restoration of natural tibiofemoral kinematics compared to mechanic alignment. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1427-1433.
36. Blakeney W, Clément J, Desmeules F, et al. Kinematic alignment in total knee arthroplasty better reproduces normal gait than mechanical alignment. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1410-1417.
37. MacDessi SJ, Griffiths-Jones W, Chen DB, et al. Restoring the constitutional alignment with a restrictive kinematic protocol improves quantitative soft-tissue balance in total knee arthroplasty: a randomized controlled trial. Bone Joint J, 2020, 102-B(1): 117-124.
38. Kayani B, Konan S, Tahmassebi J, et al. A prospective double-blinded randomised control trial comparing robotic arm-assisted functionally aligned total knee arthroplasty versus robotic arm-assisted mechanically aligned total knee arthroplasty. Trials, 2020, 21(1): 194. doi: 10.1186/s13063-020-4123-8.
39. MacDessi SJ, Wood JA, Diwan AD, et al. Surgeon-defined assessment is a poor predictor of knee balance in total knee arthroplasty: a prospective, multicenter study. Knee Surg Sports Traumatol Arthrosc, 2021, 29(2): 498-506.
40. 孙晓威, 张启栋, 任鹏鹏, 等. 全膝关节置换关节间隙压力传感器的研究现状. 中国矫形外科杂志, 2020, 28(19): 1774-1778.
41. Gustke KA, Golladay GJ, Roche MW, et al. A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA. J Arthroplasty, 2014, 29(5): 955-960.
42. Song SJ, Lee HW, Kim KI, et al. Load imbalances existed as determined by a sensor after conventional gap balancing with a tensiometer in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2020, 28(9): 2953-2961.
43. Golladay GJ, Bradbury TL, Gordon AC, et al. Are patients more satisfied with a balanced total knee arthroplasty? J Arthroplasty, 2019, 34(7S): S195-S200.
44. Gustke KA, Golladay GJ, Roche MW, et al. Increased satisfaction after total knee replacement using sensor-guided technology. Bone Joint J, 2014, 96-B(10): 1333-1338.
45. Chang JS, Kayani B, Wallace C, et al. Functional alignment achieves soft-tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology. Bone Joint J, 2021, 103-B(3): 507-514.
46. Tokuhara Y, Kadoya Y, Nakagawa S, et al. The flexion gap in normal knees. An MRI study. J Bone Joint Surg (Br), 2004, 86: 1133-1136.

Chinese Journal of Reparative and Reconstructive Surgery

Optimal lower limb alignment and soft tissue balancing strategy for robot-assisted total knee arthroplasty

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