Computer Aided Engineering in Surgery KU Leuven

Reading Assignment 2 Date: May 11th 17

Name: Phin Yuan Ting Student ID: R0648529

Give a critical appreciation of the use of surgical navigation as an intraoperative control of
the accuracy in total knee arthroplasty. Refer to relevant literature to back up any
statement you make.

It has been reported that up to 19% of patients remain dissatisfied following a total
knee replacement (TKR) for various failure causes [1]. The introduction of computer-aided
surgery (CAS) in recent years aims to improve the alignment of the components by building
customized blocks of patient specific guides (PSG) from pre-operative 3D model scans.
However, the addition of computer-navigated and robotic systems require an additional
stage of registration that increases complexity and can be time-consuming.

This comes in the form of 3D data that can be acquired either through MRI or CT
scans. Due to the various measuring stages and manufacturing processes, the final models
will inevitably suffer a degree of variability from the true shape and dimension of the bone.
Furthermore, bone models generated from CT scans have been shown to be more accurate
and their external surface boundaries smoother and less distorting artefact than MRI-
generated models [2]. This means that measurements taken from CT models are slightly
larger than those of real bones, while MRI models are generally smaller. However, CT has
limitations in delineating articular cartilage and is also susceptible to dimensional errors
(3D model inaccuracies) [3].

That being said, literature does not suggest PSG techniques as the gold standard in
TKR. In addition, literature does not highlight any improvement in components alignment,
surgical time, blood loss or functional outcomes [4]. Of course, there are compelling studies
which showed significantly less outliers in PSGs compared to conventional techniques. This
study even claims that PSGs are ready for primetime [5]. In terms of cost-effectiveness, a
study based on Markov decision modelling suggests that routine use of PSGs would not be
cost-effective unless it resulted in a significantly reduced revision rate [6]. But we know
that this is not the case as of now according to various literature.

All in all, the use of CAS in TKR is encouraging technologically-wise, albeit its
disputable clinical results. Their accuracy could still be improved, leading to greater
reliability and adoption. Nonetheless, PSGs could be very useful in particular situations such
as for patients who have underwent TKA, or have deformities with malalignment in their
bones. PSGs are also advantageous for less experienced surgeons in reducing chances of
misalignment during surgery.
Computer Aided Engineering in Surgery KU Leuven

References
[1] 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; 468:5763.

[2] Whi te D, Chelule KL, Seedhom BB. Accuracy of MRI vs CT imaging with particular
reference to patient specific templates for total knee replacement surgery. Int J Med
Robot 2008; 4:224231.

[3] Choi JY, Choi JH, Kim NK, et al. Analysis of erros in medical rapid prototyping models. Int J Oral
Maxillofac Surg 2002; 31:23-32.

[4] Mattei L, Pellegrino P, Cal M, Bistolfi A, Castoldi F. Patient specific instrumentation in total knee
arthroplasty: a state of the art. Annals of Translational Medicine. 2016;4(7):126.
doi:10.21037/atm.2016.03.33.

[5] Schotanus MG, Boonen B, Kort NP. Patient specific guides for total knee arthroplasty are ready
for primetime. World Journal of Orthopedics. 2016;7(1):61-68. doi:10.5312/wjo.v7.i1.61.

[6] Slover J, Rubash H, Malchau H, Bosco JA. Cost-effectiveness analysis of custom total knee
cutting blocks. J Arthroplasty 2012;27:180-185.