Clin Orthop Surg.  2018 Jun;10(2):167-173. 10.4055/cios.2018.10.2.167.

Is Immediate Postoperative Mechanical Axis Associated with the Revision Rate of Primary Total Knee Arthroplasty? A 10-Year Follow-up Study

• Park JK
• Seon JK
• Cho KJ
• Lee NH
• Song EK

• KMID: 2411741
• DOI: http://doi.org/10.4055/cios.2018.10.2.167

Abstract

BACKGROUND
Achieving neutral limb alignment during total knee arthroplasty (TKA) has been considered an important determinant in the long-term prosthesis survival. The purpose of this study was to evaluate the association between the immediate postoperative mechanical alignment of the lower limb and the rate of revision TKA by comparing an acceptable mechanical axis group (within ± 3° from neutral alignment) and an outlier group (> 3° deviation from neutral alignment).
METHODS
Between 2000 and 2006, clinical and radiographic data of 334 primary TKAs were retrospectively reviewed to determine the 10-year Kaplan-Meier survival rate. Patients were divided into acceptable and outlier groups according to the mechanical axis checked postoperatively within a month. Clinical outcomes were assessed using Hospital for Special Surgery, Knee Society Score, and Western Ontario and McMaster Universities Osteoarthritis Index score preoperatively and at the final follow-up. Postoperative complications and revision rates were also evaluated.
RESULTS
The mean change in mechanical axis between the immediate postoperative examination and the last follow-up was greater in the outlier group (1.6 ± 2.7) than in the acceptable group (0.8 ± 2.4). The revision rates were significantly different between the two groups (p = 0.04). At the last follow-up, clinical scores were all improved in both groups compared to each preoperative condition. There were no significant differences in clinical scores between the two groups at the last follow-up. The 10-year Kaplan-Meier survival analysis showed a tendency towards better survival with restoration of neutral mechanical axis. However, the difference was not statistically significant (p = 0.25).
CONCLUSIONS
Restoration of neutral limb alignment is a factor that can result in a lower revision rate and higher longevity in TKA. However, there were no significant differences in clinical outcomes between the two groups.

Keyword

Total knee arthroplasty; Mechanical alignment; Outliers; Survival rate

MeSH Terms

Arthroplasty, Replacement, Knee*
Extremities
Follow-Up Studies*
Humans
Knee
Longevity
Lower Extremity
Ontario
Osteoarthritis
Postoperative Complications
Prosthesis Failure
Retrospective Studies
Survival Rate

Figure

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  Fig. 1 Kaplan-Meier survival curve for acceptable and outlier groups for 10-year follow-up.

Reference

1. Jeffery RS, Morris RW, Denham RA. Coronal alignment after total knee replacement. J Bone Joint Surg Br. 1991; 73(5):709–714. PMID: 1894655.

2. Bauwens K, Matthes G, Wich M, et al. Navigated total knee replacement: a meta-analysis. J Bone Joint Surg Am. 2007; 89(2):261–269. PMID: 17272438.

3. Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C. A prospective, randomized study of computer-assisted and conventional total knee arthroplasty: three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am. 2007; 89(2):236–243. PMID: 17272435.

4. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010; 468(1):57–63. PMID: 19844772.

5. Bargren JH, Blaha JD, Freeman MA. Alignment in total knee arthroplasty: correlated biomechanical and clinical observations. Clin Orthop Relat Res. 1983; (173):178–183.

6. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML. Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res. 2013; 471(3):1000–1007. PMID: 22996362.

7. Howell SM, Papadopoulos S, Kuznik KT, Hull ML. Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc. 2013; 21(10):2271–2280. PMID: 23948721.

8. Hsu RW, Himeno S, Coventry MB, Chao EY. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clin Orthop Relat Res. 1990; (255):215–227.

9. Hvid I, Nielsen S. Total condylar knee arthroplasty: prosthetic component positioning and radiolucent lines. Acta Orthop Scand. 1984; 55(2):160–165. PMID: 6711282.

10. Lotke PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg Am. 1977; 59(1):77–79. PMID: 833180.

11. Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement: its effect on survival. Clin Orthop Relat Res. 1994; (299):153–156. PMID: 8119010.

12. Bellemans J, Colyn W, Vandenneucker H, Victor J. 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. PMID: 21656315.

13. 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(4):560–569. PMID: 18534397.

14. Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2009; 24(4):570–578. PMID: 18534396.

15. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986; 1(8476):307–310. PMID: 2868172.

16. Tew M, Waugh W. Estimating the survival time of knee replacement. J Bone Joint Surg Br. 1982; 64(5):579–582. PMID: 7142266.

17. Berend ME, Ritter MA, Meding JB, et al. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res. 2004; (428):26–34.

18. D'Lima DD, Chen PC, Colwell CW Jr. Polyethylene contact stresses, articular congruity, and knee alignment. Clin Orthop Relat Res. 2001; (392):232–238.

19. D'Lima DD, Hermida JC, Chen PC, Colwell CW Jr. Polyethylene wear and variations in knee kinematics. Clin Orthop Relat Res. 2001; (392):124–130.

20. Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S. Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res. 2007; 457:156–162. PMID: 17195810.

21. Sikorski JM. Alignment in total knee replacement. J Bone Joint Surg Br. 2008; 90(9):1121–1127. PMID: 18757949.

22. Schiavone Panni A, Falez F, D'Apolito R, Corona K, Perisano C, Vasso M. Long-term follow-up of a non-randomised prospective cohort of one hundred and ninety two total knee arthroplasties using the NexGen implant. Int Orthop. 2017; 41(6):1155–1162. PMID: 28326442.

23. Howie DF, Love GJ, Deakin AH, Kinninmonth AW. Intraoperative deviation in limb alignment occurring at implantation in total knee arthroplasty. Knee. 2015; 22(1):47–50. PMID: 25476128.

24. Matziolis G, Adam J, Perka C. Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement. Arch Orthop Trauma Surg. 2010; 130(12):1487–1491. PMID: 20165859.

25. Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010; 92(12):2143–2149. PMID: 20844155.

26. Bellemans J. Neutral mechanical alignment: a requirement for successful TKA: opposes. Orthopedics. 2011; 34(9):e507–e509. PMID: 21902146.

27. Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc. 2013; 21(10):2325–2330. PMID: 23552665.

28. Green GV, Berend KR, Berend ME, Glisson RR, Vail TP. The effects of varus tibial alignment on proximal tibial surface strain in total knee arthroplasty: the posteromedial hot spot. J Arthroplasty. 2002; 17(8):1033–1039. PMID: 12478515.

29. Liau JJ, Cheng CK, Huang CH, Lo WH. The effect of malalignment on stresses in polyethylene component of total knee prostheses: a finite element analysis. Clin Biomech (Bristol, Avon). 2002; 17(2):140–146.

30. Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Metaanalysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007; 22(8):1097–1106. PMID: 18078876.