Surgeon-defined assessment is a poor predictor of knee balance in total knee arthroplasty: a prospective, multicenter study.

Aged Arthroplasty, Replacement, Knee / methods Biomechanical Phenomena Female Humans Knee Joint / physiopathology Knee Prosthesis Male Middle Aged Monitoring, Intraoperative / methods Orthopedic Surgeons Osteoarthritis, Knee / surgery Postural Balance Prospective Studies Range of Motion, Articular Single-Blind Method Treatment Outcome

Assessment Balance Pressure Sensors Soft tissue Total knee arthroplasty

Journal

Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA

ISSN: 1433-7347

Titre abrégé: Knee Surg Sports Traumatol Arthrosc

Pays: Germany

ID NLM: 9314730

Informations de publication

Date de publication:
Feb 2021

Historique:

received: 20 11 2019

accepted: 25 02 2020

pubmed: 15 3 2020

medline: 13 4 2021

entrez: 15 3 2020

Statut: ppublish

Résumé

The accuracy of surgeon-defined assessment (SDA) of soft tissue balance in total knee arthroplasty (TKA) is poorly understood despite balance being considered a significant determinant of surgical success. The study's hypothesis was that intra-operative SDA is a poor predictor of coronal balance in TKA. A prospective, multicenter study assessing accuracy of SDA of balance was conducted in 250 patients (285 TKAs). Eight surgeons and thirteen trainees participated, and all were blinded to sensor measurements. The primary outcome was test accuracy of SDA measured at 10°, 45° and 90° compared to sensor measures as the gold standard test. Cohen's kappa coefficient was calculated to determine chance-corrected agreement. Secondary outcomes include the relationship of SDA to level of surgical experience, analysis of between-surgeon differences, and the influence of patient and operative factors on SDA accuracy. Average accuracy of SDA was 58.3%, 61.2% and 66.5% at 10°, 45° and 90° respectively. Cohen's kappa coefficient was 0.18 at all angles and rated as "slight agreement". SDA sensitivities to correctly identify a balanced knee (76.2% at 10°; 82.6% at 45°; 83.2% at 90°) were approximately twice specificities to correctly identify an unbalanced knee (42.6% at 10°; 34.1% at 45°; 41.4% at 90°). Surgical experience (surgeon versus trainee) had no effect on capacity to determine balance. Considerable between-surgeon variability was found (33-65% at 10°, 41-73% at 45°, 55-89% at 90°). SDA was a poor predictor of balance, particularly when assessing the unbalanced TKA. Surgeon experience had no effect on test accuracy and considerable between-surgeon variability was recorded. These findings question the accuracy of SDA in TKA. ACTRN# 12618000817246.

Sections du résumé

BACKGROUND BACKGROUND

METHODS METHODS

A prospective, multicenter study assessing accuracy of SDA of balance was conducted in 250 patients (285 TKAs). Eight surgeons and thirteen trainees participated, and all were blinded to sensor measurements. The primary outcome was test accuracy of SDA measured at 10°, 45° and 90° compared to sensor measures as the gold standard test. Cohen's kappa coefficient was calculated to determine chance-corrected agreement. Secondary outcomes include the relationship of SDA to level of surgical experience, analysis of between-surgeon differences, and the influence of patient and operative factors on SDA accuracy.

RESULTS RESULTS

Average accuracy of SDA was 58.3%, 61.2% and 66.5% at 10°, 45° and 90° respectively. Cohen's kappa coefficient was 0.18 at all angles and rated as "slight agreement". SDA sensitivities to correctly identify a balanced knee (76.2% at 10°; 82.6% at 45°; 83.2% at 90°) were approximately twice specificities to correctly identify an unbalanced knee (42.6% at 10°; 34.1% at 45°; 41.4% at 90°). Surgical experience (surgeon versus trainee) had no effect on capacity to determine balance. Considerable between-surgeon variability was found (33-65% at 10°, 41-73% at 45°, 55-89% at 90°).

CONCLUSION CONCLUSIONS

SDA was a poor predictor of balance, particularly when assessing the unbalanced TKA. Surgeon experience had no effect on test accuracy and considerable between-surgeon variability was recorded. These findings question the accuracy of SDA in TKA.

TRIAL REGISTRATION NUMBER BACKGROUND

ACTRN# 12618000817246.

Identifiants

DOI: 10.1007/s00167-020-05925-6 PMID: 32170358

pubmed: 32170358

doi: 10.1007/s00167-020-05925-6

pii: 10.1007/s00167-020-05925-6

doi:

Banques de données

ANZCTR

['ACTRN#12618000817246']

Types de publication

Journal Article Multicenter Study Randomized Controlled Trial

Langues

eng

Sous-ensembles de citation

Pagination

498-506

Investigateurs

Aziz Bhimani (A)

Alexander W R Burns (AWR)

Darren B Chen (DB)

Ashish D Diwan (AD)

Ian A Harris (IA)

Anthony K L Leong (AKL)

Samuel J MacDessi (SJ)

Robert B Molnar (RB)

Jonathan S Mulford (JS)

Richard M Walker (RM)

Jil A Wood (JA)

Références

Chow JC, Breslauer L (2017) The use of intraoperative sensors significantly increases the patient-reported rate of improvement in primary total knee arthroplasty. Orthopedics 40:e648–e651. https://doi.org/10.3928/01477447-20170503-01

doi: 10.3928/01477447-20170503-01 pubmed: 28481384

Dennis DA, Komistek RD, Walker SA, Cheal EJ, Stiehl JB (2001) Femoral condylar lift-off in vivo in total knee arthroplasty. J Bone Joint Surg Br 83:33–39. https://doi.org/10.1302/0301-620x.83b1.10632

doi: 10.1302/0301-620x.83b1.10632 pubmed: 11245535

Elmallah RK, Mistry JB, Cherian JJ, Chughtai M, Bhave A, Roche MW et al (2016) Can we really "feel" a balanced total knee arthroplasty? J Arthroplasty 31:102–105. https://doi.org/10.1016/j.arth.2016.03.054

doi: 10.1016/j.arth.2016.03.054 pubmed: 27155994

Golladay GJ, Bradbury TL, Gordon AC, Fernandez-Madrid IJ, Krebs VE, Patel PD et al (2019) Are patients more satisfied with a balanced total knee arthroplasty? J Arthroplasty 34:S195–S200. https://doi.org/10.1016/j.arth.2019.03.036

doi: 10.1016/j.arth.2019.03.036 pubmed: 31079993

Gustke K (2012) Use of smart trials for soft-tissue balancing in total knee replacement surgery. J Bone Joint Surg Br 94:147–150. https://doi.org/10.1302/0301-620X.94B11.30621

doi: 10.1302/0301-620X.94B11.30621 pubmed: 23118404

Gustke KA, Golladay GJ, Roche MW, Elson LC, Anderson CR (2014) A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA. J Arthroplasty 29:955–960. https://doi.org/10.1016/j.arth.2013.10.020

doi: 10.1016/j.arth.2013.10.020 pubmed: 24269069

Gustke KA, Golladay GJ, Roche MW, Elson LC (2014) Anderson CR (2014) Primary TKA patients with quantifiably balanced soft-tissue achieve significant clinical gains sooner than unbalanced patients. Adv Orthop 2014:628695. https://doi.org/10.1155/2014/628695

doi: 10.1155/2014/628695 pubmed: 25210632 pmcid: 4151591

Gustke KA, Golladay GJ, Roche MW, Jerry GJ, Elson LC, Anderson CR (2014) Increased satisfaction after total knee replacement using sensor-guided technology. Bone Joint J 96-b:1333–1338. https://doi.org/10.1302/0301-620X.96B10.34068

doi: 10.1302/0301-620X.96B10.34068 pubmed: 25274917

Heesterbeek PJC, Haffner N, Wymenga AB, Stifter J, Ritschl P (2017) Patient-related factors influence stiffness of the soft tissue complex during intraoperative gap balancing in cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25(9):2760–2768. https://doi.org/10.1007/s00167-015-3694-5

doi: 10.1007/s00167-015-3694-5 pubmed: 26174467

Hirschmann MT, Karlsson J, Becker R (2018) Hot topic: alignment in total knee arthroplasty-systematic versus more individualised alignment strategies. Knee Surg Sports Traumatol Arthrosc 26:1587–1588. https://doi.org/10.1007/s00167-018-4946-y

doi: 10.1007/s00167-018-4946-y pubmed: 29680906

Insall JN, Scuderi GR, Komistek RD, Math K, Dennis DA, Anderson DT (2002) Correlation between condylar lift-off and femoral component alignment. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-200210000-00022

doi: 10.1097/00003086-200210000-00022 pubmed: 12439241

Jennings LM, Bell CI, Ingham E, Komistek RD, Stone MH, Fisher J (2007) The influence of femoral condylar lift-off on the wear of artificial knee joints. Proc Inst Mech Eng H 221:305–314. https://doi.org/10.1243/09544119JEIM215

doi: 10.1243/09544119JEIM215 pubmed: 17539585

Leah E, Gustke KA, Gregory G, Martin R, Christopher A (2013) Modified MCL release: sensor-guided technique used to quantify intercompartmental balance in TKA. Orthop Proc 95:505–505

Linnet K, Bossuyt PM, Moons KG, Reitsma JB (2012) Quantifying the accuracy of a diagnostic test or marker. Clin Chem 58:1292–1301. https://doi.org/10.1373/clinchem.2012.182543

doi: 10.1373/clinchem.2012.182543 pubmed: 22829313

Lombardi AV Jr, Berend KR, Adams JB (2014) Why knee replacements fail in 2013: patient, surgeon, or implant? Bone Joint J 96-b:101–104. https://doi.org/10.1302/0301-620X.96B11.34350

doi: 10.1302/0301-620X.96B11.34350 pubmed: 25381419

MacDessi SJ, Bhimani A, Burns AWR, Chen DB, Leong AKL, Molnar RB et al (2019) Does soft tissue balancing using intraoperative pressure sensors improve clinical outcomes in total knee arthroplasty? A protocol of a multicentre randomised controlled trial. BMJ Open 9:e027812. https://doi.org/10.1136/bmjopen-2018-027812

doi: 10.1136/bmjopen-2018-027812 pubmed: 31079087 pmcid: 6530442

MacDessi SJ, Gharaibeh MA, Harris IA (2019) How accurately can soft tissue balance be determined in total knee arthroplasty? J Arthroplasty 34(290–294):e291. https://doi.org/10.1016/j.arth.2018.10.003

doi: 10.1016/j.arth.2018.10.003

Manning WA, Blain A, Longstaff L, Deehan DJ (2019) A load-measuring device can achieve fine-tuning of mediolateral load at knee arthroplasty but may lead to a more lax knee state. Knee Surg Sports Traumatol Arthrosc 27(7):2238–2250. https://doi.org/10.1007/s00167-018-5164-3

doi: 10.1007/s00167-018-5164-3 pubmed: 30288569

Mulhall KJ, Ghomrawi HM, Scully S, Callaghan JJ, Saleh KJ (2006) Current etiologies and modes of failure in total knee arthroplasty revision. Clin Orthop Relat Res 446:45–50. https://doi.org/10.1097/01.blo.0000214421.21712.62

doi: 10.1097/01.blo.0000214421.21712.62 pubmed: 16672871

Roche M, Elson L, Anderson C (2014) Dynamic soft tissue balancing in total knee arthroplasty. Orthop Clin N Am 45:157–165. https://doi.org/10.1016/j.ocl.2013.11.001

doi: 10.1016/j.ocl.2013.11.001

Sanz-Pena I, Zapata GE, Verstraete MA, Meere PA, Walker PS (2019) Relationship between ligament forces and contact forces in balancing at total knee surgery. J Arthroplasty 34:1261–1266. https://doi.org/10.1016/j.arth.2019.02.016

doi: 10.1016/j.arth.2019.02.016 pubmed: 30890388

Schnaser E, Lee YY, Boettner F, Gonzalez Della Valle A (2015) The position of the patella and extensor mechanism affects intraoperative compartmental loads during total knee arthroplasty: a pilot study using intraoperative sensing to guide soft tissue balance. J Arthroplasty 30(1348–1353):e1343. https://doi.org/10.1016/j.arth.2015.03.004

doi: 10.1016/j.arth.2015.03.004

Schroer WC, Berend KR, Lombardi AV, Barnes CL, Bolognesi MP, Berend ME et al (2013) Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty 28:116–119. https://doi.org/10.1016/j.arth.2013.04.056

doi: 10.1016/j.arth.2013.04.056 pubmed: 23954423

Song SJ, Kang SG, Lee YJ, Kim KI, Park CH (2018) An intraoperative load sensor did not improve the early postoperative results of posterior-stabilized TKA for osteoarthritis with varus deformities. Knee Surg Sports Traumatol Arthrosc 27(5):1671–1679. https://doi.org/10.1007/s00167-108-5314-7

doi: 10.1007/s00167-108-5314-7 pubmed: 30511096

Thompson R, Novikov D, Cizmic Z, Feng JE, Fideler K, Sayeed Z et al (2019) Arthrofibrosis after total knee arthroplasty: pathophysiology, diagnosis, and management. Orthop Clin N Am 50:269–279. https://doi.org/10.1016/j.ocl.2019.02.005

doi: 10.1016/j.ocl.2019.02.005

van der Linde JA, Beath KJ, Leong AKL (2018) The reliability of sensor-assisted soft tissue measurements in primary total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2018.03.067

doi: 10.1016/j.arth.2018.03.067 pubmed: 29748068

Vandekerckhove PTK, Teeter MG, Naudie DDR, Howard JL, MacDonald SJ, Lanting BA (2017) The impact of coronal plane alignment on polyethylene wear and damage in total knee arthroplasty: a retrieval study. J Arthroplasty 32:2012–2016. https://doi.org/10.1016/j.arth.2016.12.048

doi: 10.1016/j.arth.2016.12.048 pubmed: 28209278

Viera AJ, Garrett JM (2005) Understanding interobserver agreement: the kappa statistic. Fam Med 37:360–363

pubmed: 15883903

Wylde V, Hewlett S, Learmonth ID, Dieppe P (2011) Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain 152:566–572. https://doi.org/10.1016/j.pain.2010.11.023

doi: 10.1016/j.pain.2010.11.023 pubmed: 21239114