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High tibial osteotomy (HTO) is a relatively conservative surgical option in the management of medial knee pain. Thus far, the outcomes have been variable, and apparently worse than the arthroplasty alternatives when judged using conventional metrics, owing in large part to uncertainty around the extent of the correction planned and achieved.
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This review paper introduces the concept of detailed 3D planning of the procedure, and describes the 3D printing technology that enables the plan to be performed.
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The different ways that the osteotomy can be undertaken, and the varying guide designs that enable accurate registration are discussed and described. The system accuracy is reported.
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In keeping with other assistive technologies, 3D printing enables the surgeon to achieve a preoperative plan with a degree of accuracy that is not possible using conventional instruments. With the advent of low dose CT, it has been possible to confirm that the procedure has been undertaken accurately too.
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HTO is the ‘ultimate’ personal intervention: the amount of correction needed for optimal offloading is not yet completely understood.
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For the athletic person with early medial joint line overload who still runs and enjoys life, HTO using 3D printing is an attractive option. The clinical effectiveness remains unproven.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170075.
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In suitable patients, unicompartmental knee arthroplasty (UKA) offers a number of advantages compared with total knee arthroplasty. However, the procedure is technically demanding, with a small tolerance for error. Assistive technology has the potential to improve the accuracy of implant positioning.
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This review paper describes the concept of detailed UKA planning in 3D, and the 3D printing technology that enables a plan to be delivered intraoperatively using patient-specific instrumentation (PSI).
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The varying guide designs that enable accurate registration are discussed and described. The system accuracy is reported.
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Future studies need to ascertain whether accuracy for low-volume surgeons can be delivered in the operating theatre using PSI, and reflected in improved patient reported outcome measures, and lower revision rates.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180001
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Mechanical or anatomical alignment techniques create a supposedly ‘biomechanically friendly’ but often functionally limited prosthetic knee.
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Alternative techniques for alignment in total knee arthroplasty (TKA) aim at being more anatomical and patient-specific, aiming to improve functional outcomes after TKA.
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The kinematic alignment (KA) technique for TKA has shown good early clinical outcomes. Its role in extreme anatomical variation remains to be defined.
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The restricted KA technique for TKA might be a reasonable option for patients with extreme anatomical variation.
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While unicompartmental knee arthroplasty (UKA) has many advantages over TKA, the revision rate remains higher compared with TKA. One major explanation is the relative ease with which a UKA can be converted to a TKA, compared with revising a TKA. This can be considered as an additional advantage of UKA. Another reason is that surgeons favour revising a UKA to a TKA in cases of degeneration of the other femorotibial compartment rather than performing a relatively simple re-operation of the knee by doing an additional UKA (staged bi-UKA).
Cite this article: EFORT Open Rev 2018;3:1–6. DOI: 10.1302/2058-5241.3.170021
South West London Elective Orthopaedic Centre, UK
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Patients with hip osteoarthritis often have an abnormal spine-hip relation (SHR), meaning the presence of a clinically deleterious spine-hip and/or hip-spine syndrome.
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Definition of the individual SHR is ideally done using the EOS® imaging system or, if not available, with conventional lumbopelvic lateral radiographs.
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By pre-operatively screening patients with abnormal SHR, it is possible to refine total hip replacement (THR) surgical planning, which may improve outcomes.
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An important component of the concept of kinematically aligned total hip arthroplasty (KA THA) consists of defining the optimal acetabular cup design and orientation based on the assessment of an individual’s SHR, and use of the transverse acetabular ligament to adjust the cup positioning.
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The Bordeaux classification might advance the understanding of SHR and hopefully help improve THR outcomes.
Cite this article: EFORT Open Rev 2018;3:39-44. DOI: 10.1302/2058-5241.3.170020
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Conventional techniques for hip and knee arthroplasty have led to good long-term clinical outcomes, but complications remain despite better surgical precision and improvements in implant design and quality.
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Technological improvements and a better understanding of joint kinematics have facilitated the progression to ‘personalized’ implant positioning (kinematic alignment) for total hip (THA) and knee (TKA) arthroplasty, the true value of which remains to be determined.
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By achieving a true knee resurfacing, the kinematic alignment (KA) technique for TKA aims at aligning the components with the physiological kinematic axes of the knee and restoring the constitutional tibio-femoral joint line frontal and axial orientation and soft-tissue laxity.
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The KA technique for THA aims at restoring the native ‘combined femoro-acetabular anteversion’ and the hip’s centre of rotation, and occasionally adjusting the cup position and design based on the assessment of the individual spine-hip relation.
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The key element for optimal prosthetic joint kinematics (hip or knee) is to reproduce the femoral anatomy.
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The transverse acetabular ligament (TAL) is the reference landmark to adjust the cup position.
Cite this article: EFORT Open Rev 2018;3:98-105. DOI: 10.1302/2058-5241.3.170022
