Knee Surg Sports Traumatol Arthrosc (2011) 19:1608–1609

DOI 10.1007/s00167-011-1578-x

LETTER TO THE EDITORS

Comparison of two minimally invasive implantation

instrument-sets for total knee arthroplasty
Yasuo Niki

Received: 23 November 2010 / Accepted: 9 June 2011 / Published online: 30 June 2011
Ó Springer-Verlag 2011

Dear Editor, such selection bias on postoperative radiographic results

might not have been fully eliminated. Third, in the group of
I read with great interest the article from Martin et al. entitled
side-cutting jigs with a navigation system, if the navigator
‘‘Comparison of two minimally invasive implantation
indicated an inadequate bone cut of the distal femur, free-
instrument-sets for total knee arthroplasty’’ recently pub-
hand correction of the side-cutting jig might be difficult
lished in this journal. I would like to congratulate the authors
because use of an intramedullary nail was mandatory during
on elucidating the reduced implantation accuracy after
fixation of the jig. Therefore, it is possible that the navigation
MIS-TKA using side-cutting instrumentation (MIS Quad-
TM system did not benefit implantation accuracy when using a
Sparing instrumentation, Zimmer, Warsaw) in a prospec-
side-cutting jig.
tive randomized trial with sufficient statistical power. I
To date, numerous studies have revealed inaccurate
found the data convincing, but I would like to mention three
implant positioning after MIS-TKA [1, 2, 4, 11, 13].
concerns. First, three different surgeons participated in this
Recently, MIS-TKA has reportedly achieved radiographic
study, but the difference in implantation accuracy among
results comparable with those of conventional TKA, when
them was not analyzed. Although the three surgeons were
combined with a navigation system [3, 5–7, 12]. However,
equivalently allocated to the groups with and without side-
the authors showed that navigation technology could not
cutting jigs, the surgeon might still be considered a factor
overcome reduced implantation accuracy of MIS-TKA due
affecting radiographic results. In fact, numerous variables
to loose fixation of the side-cutting jig. In fact, according to
besides usage of side-cutting jigs or navigation systems
my experience with more than 400 MIS-TKAs, there are
might influence postoperative implant accuracy. These
several key points to consider when attempting to fix the
include the surgeon’s experience and patient characteristics
side-cutting jig firmly to the femoral or tibial cortex. First,
(e.g., BMI, bone quality, degree of preoperative deformity,
marginal bone spur should be removed to gain a good fit and
and anatomical variations of the femur or tibia, particularly
subsequent firm fixation of the jig. Second, maximizing the
coronal or sagittal bowing). I presume that logistic regres-
distance between the first pin and the second pin fixing
sion analysis might be used to simultaneously calculate each
the jigs to the femoral cortex may ensure rigid fixation of
factor’s contribution to the radiographic success rate (\3°
the jig. According to the Fig. 2 of the author’s article,
from the ideal) as an odds ratio. Second, in terms of the
another pin should be inserted through a posterior hole of
preoperative patient characteristics, the side-cutting group
the jig to gain rigid fixation. Third, a low-profile intra-
demonstrated worse mechanical alignment and higher BMI
medullary rod should be used when fixing the jig to both
than the mini-incision group, despite strict randomization
femur and tibia, and this should be left in place until the
(P \ 0.001 and P \ 0.005, respectively). The effects of
bone cut of the medial compartment is finished. Although
the previous studies have reported that a bone cut that was
longer in the mediolateral direction than in the anteriopos-
Y. Niki (&)
terior direction reduced resection accuracy [10], the use of
Department of Orthopaedic Surgery, Keio University,
35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan an intramedullary rod may minimize micromotion of the
e-mail: y.niki@lib.bekkoame.ne.jp jig and improve resection accuracy during bone cutting.

123
Knee Surg Sports Traumatol Arthrosc (2011) 19:1608–1609
In my experience, side-cutting jigs are preferentially fixed
with the knee in 20–30° of flexion, and the bone cut is
performed at such a flexion angle.
Finally, we have recently published a study of radio-
graphic implant accuracy after MIS-TKA using a side-
cutting jig, with particular emphasis on a comparison
between knees with severe varus deformity and those with
mild deformity [8]. Despite the absence of a navigation
system, several radiographic parameters were aligned ±3°
from the ideal in [70% of knees in the mildly varus group
(\15°); however, this declined to around 50% of knees in
the severely varus group (C15°) because of the significant
coronal bowing of the femoral shaft inherent in severe genu
varus. Therefore, we now use 3D planning software to
check the distal cutting angle preoperatively, particularly in
patients with a large bowing angle of the femur. Currently,
we believe that \11° of varus and \2° of coronal bowing
offer a safe area for gaining successful radiographic
alignment, when side-cutting jigs are used without a nav-
igation system [8]. Moreover, we believe that the more
vastus medialis muscle attempted to be preserved, the more
useful the side-cutting jig. Further, side-cutting jigs are also
proven to be useful in lateral MIS-TKA through a lateral
subvastus approach [9].
References
1. Chen AF, Alan RK, Redziniak DE, Tria AJ Jr (2006) Quadriceps
sparing total knee replacement. The initial experience with results
at two to four years. J Bone Joint Surg 88-B:1448–1453
2. Chin PL, Foo LS, Yang KY, Yeo SJ, Lo NN (2007) Randomized
controlled trial comparing the radiologic outcomes of conven-
tional and minimally invasive techniques for total knee arthro-
plasty. J Arthroplasty 22:800–806
1609
3. Confalonieri N, Manzotti A, Pullen C, Ragone V (2007)
Miniincision versus mini-incision and computer-assisted surgery
in total knee replacement: a radiological prospective randomized
study. Knee 14:443–447
4. Dalury DF, Dennis DA (2005) Mini-incision total knee arthro-
plasty can increase risk of component malalignment. Clin Orthop
Relat Res 440:77–81
5. Dutton AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong HC
(2008) Computer-assisted minimally invasive total knee arthro-
plasty compared with standard total knee arthroplasty. A pro-
spective, randomized study. J Bone Joint Surg Am 90:2–9
6. Hart R, Janecek M, Cizmar I, Stipcak V, Kucera B, Filan P
(2006) Minimally invasive and navigated implantation for
total knee arthroplasty: X-ray analysis and early clinical results.
Orthopade 35:552–557
7. Hasegawa M, Yoshida K, Wakabayashi H, Sudo A (2011) Min-
imally invasive total knee arthroplasty: comparison of jig-based
technique versus computer navigation for clinical and alignment
outcome. Knee Surg Sports Traumatol Arthrosc 19(6):904–910
8. Niki Y, Matsumoto H, Otani T, Enomoto H, Toyama Y, Suda Y
(2010) Accuracy of implant positioning for minimally invasive
total knee arthroplasty in patients with severe varus deformity.
J Arthroplasty 25:381–386
9. Niki Y, Matsumoto H, Hakozaki A, Kanagawa H, Toyama Y,
Suda Y (2010) Clinical and radiographic outcomes of minimally
invasive total knee arthroplasty through a lateral approach. Knee
Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-010-1323-x.
(in press)
10. Plaskos C, Hodgson AJ, Inkpen K, McGraw RW (2002) Bone
cutting errors in total knee arthroplasty. J Arthroplasty
17:698–705
11. Schroer WC, Diesfeld PJ, Ready ME, Lemarr AR (2008) Surgical
accuracy with the mini-sub vastus total knee arthroplasty a
computer tomography scan analysis of postoperative implant
alignment. J Arthroplasty 23:543–549
12. Seon JK, Song EK (2006) Navigation-assisted less invasive total
knee arthroplasty compared with conventional total knee arthro-
plasty: a randomized prospective trial. J Arthroplasty 21:777–782
13. Yau WP, Leung A, Liu KG, Yan CH, Wong LS, Chiu KY (2008)
Errors in the identification of the transepicondylar and antero-
posterior axes of the distal femur in total knee replacement using
minimally-invasive and conventional approaches: a cadaver
study. J Bone Joint Surg 90-B:520–526
123