DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20174714

Radiographic evaluation of tibial component alignment in total knee arthroplasty following extramedullary and intramedullary tibial referencing

B. Harikrishnan, Anjan Prabhakara, Gururaj R. Joshi

Abstract


Background: Long term survivorship of total knee arthroplasty (TKA) is significantly dependant on prostheses alignment. The debate on optimal referencing for femoral component is largely resolved with Intra-medullary jigs reproducing superior alignment. However there is still a contention about whether intramedullary or extramedullary jigs are better for tibial referencing. This study aims to compare the accuracy of tibial component alignment in TKA using intramedullary and extramedullary tibial referencing jigs.

Methods: Between December 2012 and September 2014, 66 primary conventional cemented TKAs were performed using Nexgen-LPS Flex (Zimmer) implants in 55 patients, 50-80 y old (mean 65.54 y) with osteoarthritis/rheumatoid arthritis. Intramedullary and extramedullary tibial referencing was used in alternate patients undergoing TKA after excluding patients with BMI >35 kg/m2, knee deformity >150,excessive tibial bowing, previous fractures/surgeries/retained metalwork around knee. Postoperatively, tibial component alignment (TCA) in coronal plane was assessed using AP radiograph of leg. A 3º cutoff from neutral mechanical axis (i.e., 90o±3o) was considered acceptable.

Results: The intramedullary group (n=33) had 4 outliers (TCA >93º or <87º) whereas the extramedullary group (n=33) had 7 outliers (p=0.511). The difference in mean TCA between intramedullary and extramedullary groups was not statistically significant [90.70±2.43 and 90.55±2.17 (p=0.790)]. There were no significant per-operative/post-operative complications in either group.

Conclusions: We conclude that both intramedullary and extramedullary tibial referencing guides can be used to achieve desired tibial component alignment (90±3º) in TKA. However the surgeon should appreciate the benefits and deficiencies of either types of tibial referencing and use whichever is suited in a particular case. 


Keywords


Intramedullary, Extramedullary, Tibial component, Tibial referencing guide, TKA

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References


Gill GS, Joshi AB, Mills DM. Total condylar knee arthroplasty: 16- to 21-years results. Clin Orthop Relat Res. 1999;367:210–5.

Konig A, Walther M, Kirschner S, Gohlke F. Balance sheets of knee and functional scores 5 years after total knee arthroplasty for osteoarthritis: a source for patient information. J Arthroplasty. 2000;15:289–94.

Choong PF, Dowsey MM, Stoney JD. Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplasty. 2009;24:560-9.

Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R, et al. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res. 2004;428:26-34.

Sikorski JM. Alignment in total knee replacement. J Bone Joint Surg Br. 2008;90:1121–7.

Mihalko WM, Boyle J, Clark LD, Krackow KA. The variability of intramedullary alignment of the femoral component during total knee arthroplasty. J Arthroplasty. 2005;20:25.

Collier MB, Engh CA, McAuley JP, Engh GA. Factors associated with the loss of thickness of polyethylene tibial bearings after knee arthroplasty. J Bone Joint Surg Am. 2007;89:1306.

Jessup DE, Worland RL, Clelland C, Arredondo J. Restoration of limb alignment in total knee arthroplasty: evaluation and methods. J South Orthop Assoc. 1997;6(1):37-47

Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am. 2011;93(17):1588-96.

Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty. J Arthroplasty. 2009;24:39-43.

Kim YH, Park JW, Kim JS, Park SD. The relationship between the survival of total knee arthroplasty and postoperative coronal, sagittal and rotational alignment of knee prosthesis. Int Orthop. 2014;38(2):379-85.

Lozano LM, Segur JM, Macule F, Nunez M, Torner P, Castillo F, et al. Intramedullary versus extramedullary tibial cutting guide in severely obese patients undergoing total knee replacement: a randomized study of 70 patients with body mass index >35 kg/m2. Obes Surg. 2008;18(12):1599-604.

D’Lima DD, Hermida JC, Chen PC, Colwell CW. Polyethylene wear and variations in knee kinematics. Clin Orthop Relat Res. 2001;(392):124-30.

Werner FW, Ayers DC, Maletsky LP, Rullkoetter PJ. The effect of valgus/ varus malalignment on load distribution in total knee replacements. J Biomech. 2005;38(2):349–55.

Bono JV, Roger DJ, Laskin RS, Peterson MG, Paulsen CA. Tibial intramedullary alignment in total knee arthroplasty. Am J Knee Surg. 1995;8(1):7-12.

Dennis DA, Channer M, Susman MH, Stringer EA. Intramedullary versus extramedullary tibial alignment systems in total knee arthroplasty. J Arthroplasty. 1993;8(1):43-7.

Parmet JL, Horrow JC, Berman AT, Miller F, Pharo G, Collins L. The incidence of venous emboli during extramedullary guided total knee arthroplasty. Anesth Analg. 1995;81:757-62.

Brys DA, Lombardi AV Jr, Mallory TH, Vaughn BK. A comparison of intramedullary and extramedullary alignment systems for tibial component placement in total knee arthroplasty. Clin Orthop Relat Res. 1991;(263):175-9.

Maestro A, Harwin SF, Sandoval MG, Vaquero DH, Murcia A. Influence of intramedullary versus extramedullary alignment guides on final total knee arthroplasty component position: a radiographic analysis. J Arthroplasty. 1998;13(5):552-8.

Yang SH, Liu TK. Intramedullary versus extramedullary tibial alignment guides in total knee arthroplasty. J Formos Med Assoc. 1998;97:564-8.

Rottman SJ, Dvorkin M, Gold D. Extramedullary versus intramedullary tibial alignment guides for total knee arthroplasty. Orthopedics. 2005;28(12):1445-8.