THEKNE-02045; No of Pages 3 The Knee xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
The Knee
Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases R.S. Khakha ⁎, M. Chowdhry, M. Norris, A. Kheiran, S.K. Chauhan Brighton and Sussex University Hospitals, Eastern Road, Brighton BN2 5BE, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 May 2014 Received in revised form 30 January 2015 Accepted 16 February 2015 Available online xxxx Keywords: Arthroplasty Computer navigation Complications
a b s t r a c t Background: Computer assisted total knee arthroplasty (CATKA) has its own unique complications. The aim of this study was to present our experience of early complications in a large consecutive series of CATKA. Method: We investigated retrospective data on the complications specific to computer navigation that were encountered with a consecutive series of 1596 CATKA. Results: Intraoperatively, eight episodes of software failure occurred, two requiring conversion to conventional jig based TKA. There were four broken drill bits when positioning the pins for data entry. Repeat cuts of bone due to malalignment were required on two occasions. There were 17 episodes of superficial pin site infections at the tibial pin-site managed conservatively with antibiotics. One tibial fracture occurred through an old tibial tracker pin site hole. Conclusion: This large study shows a low complication rate related to CATKA which is reassuring to the orthopaedic community. Clinical relevance: Level of evidence: III © 2015 Elsevier B.V. All rights reserved.
1. Introduction The benefits of improved component alignment in computer assisted total knee arthroplasty (CATKA) are well documented [1–5]. Infra-red trackers attached to bone combined with advanced computerised software permit the necessary triangulation required to allow precise bone cuts and component positioning. However, more recently concerns have been raised about complications associated with this technique. Pin site infection, pin site induced fractures, nerve injuries, software failure and peri-prosthetic fractures have all been associated with computer assisted surgery (CAS) [6–16]. Reports in the literature have been largely anecdotal, comprising mainly short case series and case reports, focussing on singular problems [8–16]. To our knowledge there has been no large series that has attempted to categorise the range of early complications associated with computer assisted total knee arthroplasty. The aim of this study is to present our experience of early complications specific to CAS associated with a large series of CATKA. 2. Materials and methods A retrospective review was performed of 1596 consecutive primary total knee replacements performed using navigation by the senior
⁎ Corresponding author. Tel.: + 44 7973266230. E-mail address: [email protected] (R.S. Khakha).
author (Table 1). These procedures were performed over a nine year period between June 2003 and June 2012. All patients were implanted with the Stryker Scorpio or Triathlon Total Knee Replacement using the Stryker Navigation System (Stryker Orthopaedics, Kalamazoo, Michigan). During the study period there where five software upgrades. Single bicortical five millimeter pins were used to fix trackers for navigation to the meta-diaphyseal regions of the femur and tibia (Fig. 1). The femoral pin insertion site was included within the primary incision. The tibial tracker was inserted through a stab incision that was closed separately at the end of the procedure. CAS specific data was recorded prospectively and stored in a computerised database. Patients of all ages who had either a primary cruciate retaining or posterior stabilised total knee replacement for osteoarthritis were included in this study. The senior author routinely used navigation for all knee arthroplasty cases. Each patient was seen by a physiotherapist within 24 h of the operation and permitted to weight bear as comfort allowed. Patients were discharged from hospital when they were deemed safe to use stairs. Bandages were removed at 48 h and the clips used to close the skin were removed at 10 days. All patients were followed up at six weeks and three and 12 months. Plain radiographs were performed routinely post-operatively and at three months unless otherwise required. Complications, reasons for pain, readmission and revision surgery were recorded. This database, patient clinical records and clinic correspondence were retrospectively reviewed for any indication of post-operative pain, infection, instability, loosening, stiffness, implant malposition, extensor mechanism failure or peri-prosthetic fracture or other complications within the follow-up period.
http://dx.doi.org/10.1016/j.knee.2015.02.009 0968-0160/© 2015 Elsevier B.V. All rights reserved.
Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
2
R.S. Khakha et al. / The Knee xxx (2015) xxx–xxx Table 1 Demographic and pre-operative data.
Table 2 Complications associated with CATKA.
Variable
Data
Complication
Age Gender (M/F) Flexion Mechanical axis
68 (45–94) 1:1.8 120° (110–130) 12° varus (–5 to 15)
Software failure
All patients were consented for their inclusion in our database. No further ethical approval was required for this study.
Number (%) Outcome 8 (0.5)
Broken drill bit 4 (0.3) Intra-op malalignment 2 (0.1) Pin-site infection 17 (one) Fractured tibia 1 (0.06) Fractured femur 0
6 retrieved & 2 converted to conventional TKA 4 retrieved successfully Trackers repositioned Treated with oral antibiotics Converted to long-stem TKA
were no cases of femoral fracture in this series. The total percentage complication rate of our cohort was 1.9% (see Fig. 2).
3. Results Information was available for all 1596 patients up to 12 months of follow-up. Radiographs were available for review for all patients. Intra-operatively, there were eight episodes of software failure. On six occasions a software problem caused the navigation programme to stop working. This occurred at different stages of the operation each time and was easily overcome by rebooting the programme. As all the data was saved up to that point it was possible to go on and complete the procedure using navigation. A complete system failure was experienced on two occasions. On both occasions the lead between the optical system and main computer failed when the patient information was being registered. It was not possible to rectify this problem within a reasonable timeframe and so the procedure was converted to a conventional jig based TKA. On four occasions the 2.5 mm drill bit used to make pilot holes for the navigation trackers broke. Each time the drill bits were successfully retrieved under direct vision without needing to enlarge the hole in the bone and the patient went on to have an uncomplicated procedure. Navigation was still possible in these instances. There were no episodes of pin loosening or fracture of the pin intra-operatively. The pins were not responsible for any fractures of bone intra-operatively. On two occasions repeat bone cuts were required due to initial malalignment. This requirement was identified intra-operatively on inspection. Further corrective resections were then made as necessary. Both cases involved version 1.1 software in 2004. There have been no further instances since then. Each intra-operative complication resulted in a longer than average operating time but did not have a significant impact on recovery or outcome. There were a total of 17 episodes of superficial tibial pin-site infections. Any patient seen at six weeks for the routine follow-up post-operative appointment who described either redness related to their wound or who had been given antibiotics by their General Practitioner, GP for wound infection was classified as having had a superficial wound infection. All were managed conservatively with a seven-day course of oral antibiotics unless already started by their GP. The infections resolved in each case without the need for further antibiotics or investigation. No further imaging was required as spontaneous resolution was seen in all patients. No patient with infection required hospital admission or re-operation during the follow-up period. There was a single episode of a fractured tibia at the level of the tibial pin site. This occurred three months after the operation. The fracture occurred when the patient twisted her leg standing up from a sitting position. The patient underwent revision to a long stemmed tibial component the next day after admission. At one year, the patient had made a successful recovery and no further complication was noted (Table 2.). There
4. Discussion Concerns have been raised about unforeseen complications of CAS [6–16]. Our series of 1596 cases shows that these additional complications are of a low incidence (total complication rate 1.9%). In the most part they are easily rectifiable. Limited comparable data exists in the literature. To our knowledge we present the largest series of patients evaluated for early CAS related complications. One other series reviewed 984 cases but specifically reviewed pin site complications [17]. They described a 1.7% minor pin site complication rate, which comprised mainly of reversible pin site infections (1.2%). This was comparable to our own series. They had five cases (0.5%) where intra-operative dislodgement of a tracker pins that meant conversion to a conventional jig based knee replacement system which we did not experience. There were no cases of peri-prosthetic fracture in that series compared to our single episode. No navigation hardware issues were noted in our study. Software problems did occur. Most software issues were correctable and surgery was completed by navigation. In two cases navigation had to be abandoned and conventional instrumentation had to be used. These issues were rectified by an updated version of navigation software and have not occurred again to date. Superficial infection, both in our series and others reported, was the most prevalent problem [8,13,16,17]. All of our infections occurred at the tibial pin site. The superficial nature of the tibial pin site may be a risk factor for developing infection. No other obvious differences were evident in these patients compared to the rest of the cohort. The femoral pin-sites were included in the midline wound for the total knee replacement and did not appear to cause the same problems. All infections were noted within the first six weeks following the procedure and all
Software Failure Broken Drill Bit Intra-op malalignment Pin-site infection Fractured tibia
Fig. 1. Tibial tracker during CATKA.
Fig. 2. Pie-chart representing complications in CATKA.
Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
R.S. Khakha et al. / The Knee xxx (2015) xxx–xxx
were managed successfully with oral antibiotics. Pin site infection did not correlate with deep infection. We feel that meticulous cleaning and suturing of the wound limit the chances of developing superficial infection. There were no associated patient risk factors identified in our study. Pin site infection did not correlate with deep infection. The resulting infection requires an additional review in clinic. There are cost implications associated with developing a tibial pin site infection. While the incidence in our series was low, 1.7%, it is a cost that needs to be considered when undertaking CATKA surgery. Pin site fractures have only been reported as case reports or short case series [8–16]. Metaphyseal pins, small diameter pins, self tapping pins and pins that are not trans-cortical appear to be the most important factors in preventing fractures [13,16]. In our single case of tibial pin site fracture none of these factors appeared to be evident. It is likely that the cause was multifactorial. All of our tracker pins were bicortical and no intraoperative loosening of pins was witnessed. No repeat pilot holes were required to insert pins. We feel that these factors enabled us to achieve a low rate of fracture. Unicortical pins have a higher rate of loosening in our opinion [13]. Navigation remains to be more widely accepted as a means to perform knee arthroplasty. Concerns about higher institutional costs, steep learning curves, potential complications, and a lack of longerterm studies demonstrating improved function, and lower revision rates are often cited as potential reasons [18-22]. However a number of recent meta-analyses have confirmed statistically significant improvements in component alignment and clinical outcome using CAS [23,24]. Ten year outcomes of TKA from the Australian National Joint Registry show no greater a revision rate amongst CATKA compared to non-navigated TKA [25]. Our own series shows that the unforeseen complications of navigated surgery remain low in incidence and are mostly easily managed. The complication of peri-prosthetic fracture is rare and can be avoided by careful pin placement. 5. Conclusion This study demonstrated that the complications related to CATKA remain low in incidence (1.9%) in 1596 cases and are mostly easily managed. The most prevalent complication was superficial infection of the tibial tracker pin site. References [1] Konyves A, Willis-Owen CA, Spriggins AJ. The long-term benefit of computerassisted surgical navigation in unicompartmental knee arthroplasty. J Orthop Surg Res 2010;5:94. [2] Willcox NMJ, Clarke JV, Smith BRK, Deakin AH, Deep K. A comparison of radiological and computer navigation measurements of lower limb coronal alignment before and after total knee replacement. J Bone Joint Surg Br Sep 2012;94(9):1234–40. [3] Decking R, Markmann Y, Fuchs J, Puhl W, Scharf HP. Leg axis after computernavigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation. J Arthoplasty 2005;20:282–8.
3
[4] Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A. Computerassisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res 2005;152–9. [5] Lützner J, Günther K-P, Kirschner S. Functional outcome after computer-assisted versus conventional total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc Oct 2010;18(10):1339–44. [6] Hernandez-Vaquero D, Suarez-Vazquez A. Complications of fixed infrared emitters in computer assisted total knee arthroplasties. BMC Musculoskelet Disord 2007;8: 71. [7] Sikorski JM, Blythe MC. Learning the vagaries of computer-assisted total knee replacement. J Bone Joint Surg Br 2005;87:903–10. [8] Bonutti P, Dethmers D, Stiehl JB. Case report: femoral shaft fracture resulting from femoral tracker placement in navigated TKA. Clin Orthop Relat Res 2008;466: 1499–502. [9] Hj Jung, Jung YB, Song KS, Park SJ, Lee JS. Fractures associated with computernavigated total knee arthroplasty. A report of two cases. J Bone Joint Surg Am 2007;89:2280–4. [10] Li CH, Chen TH, Su YP, Shao PC, Lee KS, Chen WM. Periprosthetic femoral supracondylar fracture after total knee arthroplastywith navigation system. J Arthroplasty 2008;23:304–7. [11] Ossendorf C, Fuchs B, Koch P. Femoral stress fracture after computer navigated total knee arthroplasty. Knee 2006;13:397–9. [12] Manzotti A, Confalonieri N, Pullen C. Intra-operative tibial fracture during computer assisted total knee replacement: a case report. Knee Surg Sports Traumatol Arthrosc May 2008;16(5):493–6. [13] Beldame J, Boisrenoult P, Beaufils P. Pin track induced fractures around computerassisted TKA. Orthop Traumatol Surg Res May 2010;96(3):249–55. [14] Massai F, Conteduca F, Vadalà A, Iorio R, Basiglini L, Ferretti A. Tibial stress fracture after computer-navigated total knee arthroplasty. J Orthop Traumatol Jun 2010; 11(2):123–7. [15] Wysocki RW, Sheinkop MB, Virkus WW, Valle Della CJ. Femoral fracture through a previous pin site after computer-assisted total knee arthroplasty. J Arthroplasty Apr 2008;23(3):462–5. [16] Hoke D, Jafari M, Orozco F, Ong A. Tibial shaft stress fractures resulting from placement of navigation tracker pins. J Arthrolpasty 2011;26(3):504e5–8. [17] Owens RF, Swank ML. Low incidence of postoperative complications due to pin placement in computer-navigated total knee arthroplasty. J Arthroplasty Oct 2010; 25(7):1096–8. [18] Hoffart H-E, Langenstein E, Vasak N. A prospective study comparing the functional outcome of computer-assisted and conventional total knee replacement. J Bone Joint Surg Br Feb 2012;94(2):194–9. [19] Zhang G-Q, Chen J-Y, Chai W, Liu M, Wang Y. Comparison between computerassisted-navigation and conventional total knee arthroplasties in patients undergoing simultaneous bilateral procedures: a randomized clinical trial. J Bone Joint Surg Am Jul 2011;93(13):1190–6. [20] Lützner J, Krummenauer F, Wolf C, Günther K-P, Kirschner S. Computer-assisted and conventional total knee replacement: a comparative, prospective, randomised study with radiological and CT evaluation. J Bone Joint Surg Br Aug 2008;90(8):1039–44. [21] Burnett RS, Barrack RL. Computer assisted knee arthroplasty is currently of no proven clinical benefit: a systematic review. Clin Orthop Relat Res Jan 2013; 471(1):264–76. [22] Clayton AW, Cheria JJ, Banerjee S, Kapadia BH, Jauregui JJ, Harwin SF, et al. Does the use of navigation in total knee arthroplasty affect outcomes? J Knee Surg Jun 2014; 27(3):171–5. [23] Cheng T, Zhao S, Peng X, Zhang X. Does computer assisted surgery improve postoperative leg alignment and implant positioning following total knee arthroplasty? A meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc Jul 2012;20(7):1307–22. [24] Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK. Metaanalysis of navigation vs conventional total knee arthroplasty. J Arthroplasty Jun 2012;27(6):1177–82. [25] Australian Orthopaedic Association National Joint Replacement Registry. Annual report; 2013 [https://aoanjrr.dmac.adelaide.edu.au/documents/10180/172286/ Annual%20Report%202014 (accessed 02/10/2014)].
Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
Contents lists available at ScienceDirect
The Knee
Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases R.S. Khakha ⁎, M. Chowdhry, M. Norris, A. Kheiran, S.K. Chauhan Brighton and Sussex University Hospitals, Eastern Road, Brighton BN2 5BE, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 May 2014 Received in revised form 30 January 2015 Accepted 16 February 2015 Available online xxxx Keywords: Arthroplasty Computer navigation Complications
a b s t r a c t Background: Computer assisted total knee arthroplasty (CATKA) has its own unique complications. The aim of this study was to present our experience of early complications in a large consecutive series of CATKA. Method: We investigated retrospective data on the complications specific to computer navigation that were encountered with a consecutive series of 1596 CATKA. Results: Intraoperatively, eight episodes of software failure occurred, two requiring conversion to conventional jig based TKA. There were four broken drill bits when positioning the pins for data entry. Repeat cuts of bone due to malalignment were required on two occasions. There were 17 episodes of superficial pin site infections at the tibial pin-site managed conservatively with antibiotics. One tibial fracture occurred through an old tibial tracker pin site hole. Conclusion: This large study shows a low complication rate related to CATKA which is reassuring to the orthopaedic community. Clinical relevance: Level of evidence: III © 2015 Elsevier B.V. All rights reserved.
1. Introduction The benefits of improved component alignment in computer assisted total knee arthroplasty (CATKA) are well documented [1–5]. Infra-red trackers attached to bone combined with advanced computerised software permit the necessary triangulation required to allow precise bone cuts and component positioning. However, more recently concerns have been raised about complications associated with this technique. Pin site infection, pin site induced fractures, nerve injuries, software failure and peri-prosthetic fractures have all been associated with computer assisted surgery (CAS) [6–16]. Reports in the literature have been largely anecdotal, comprising mainly short case series and case reports, focussing on singular problems [8–16]. To our knowledge there has been no large series that has attempted to categorise the range of early complications associated with computer assisted total knee arthroplasty. The aim of this study is to present our experience of early complications specific to CAS associated with a large series of CATKA. 2. Materials and methods A retrospective review was performed of 1596 consecutive primary total knee replacements performed using navigation by the senior
⁎ Corresponding author. Tel.: + 44 7973266230. E-mail address: [email protected] (R.S. Khakha).
author (Table 1). These procedures were performed over a nine year period between June 2003 and June 2012. All patients were implanted with the Stryker Scorpio or Triathlon Total Knee Replacement using the Stryker Navigation System (Stryker Orthopaedics, Kalamazoo, Michigan). During the study period there where five software upgrades. Single bicortical five millimeter pins were used to fix trackers for navigation to the meta-diaphyseal regions of the femur and tibia (Fig. 1). The femoral pin insertion site was included within the primary incision. The tibial tracker was inserted through a stab incision that was closed separately at the end of the procedure. CAS specific data was recorded prospectively and stored in a computerised database. Patients of all ages who had either a primary cruciate retaining or posterior stabilised total knee replacement for osteoarthritis were included in this study. The senior author routinely used navigation for all knee arthroplasty cases. Each patient was seen by a physiotherapist within 24 h of the operation and permitted to weight bear as comfort allowed. Patients were discharged from hospital when they were deemed safe to use stairs. Bandages were removed at 48 h and the clips used to close the skin were removed at 10 days. All patients were followed up at six weeks and three and 12 months. Plain radiographs were performed routinely post-operatively and at three months unless otherwise required. Complications, reasons for pain, readmission and revision surgery were recorded. This database, patient clinical records and clinic correspondence were retrospectively reviewed for any indication of post-operative pain, infection, instability, loosening, stiffness, implant malposition, extensor mechanism failure or peri-prosthetic fracture or other complications within the follow-up period.
http://dx.doi.org/10.1016/j.knee.2015.02.009 0968-0160/© 2015 Elsevier B.V. All rights reserved.
Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
2
R.S. Khakha et al. / The Knee xxx (2015) xxx–xxx Table 1 Demographic and pre-operative data.
Table 2 Complications associated with CATKA.
Variable
Data
Complication
Age Gender (M/F) Flexion Mechanical axis
68 (45–94) 1:1.8 120° (110–130) 12° varus (–5 to 15)
Software failure
All patients were consented for their inclusion in our database. No further ethical approval was required for this study.
Number (%) Outcome 8 (0.5)
Broken drill bit 4 (0.3) Intra-op malalignment 2 (0.1) Pin-site infection 17 (one) Fractured tibia 1 (0.06) Fractured femur 0
6 retrieved & 2 converted to conventional TKA 4 retrieved successfully Trackers repositioned Treated with oral antibiotics Converted to long-stem TKA
were no cases of femoral fracture in this series. The total percentage complication rate of our cohort was 1.9% (see Fig. 2).
3. Results Information was available for all 1596 patients up to 12 months of follow-up. Radiographs were available for review for all patients. Intra-operatively, there were eight episodes of software failure. On six occasions a software problem caused the navigation programme to stop working. This occurred at different stages of the operation each time and was easily overcome by rebooting the programme. As all the data was saved up to that point it was possible to go on and complete the procedure using navigation. A complete system failure was experienced on two occasions. On both occasions the lead between the optical system and main computer failed when the patient information was being registered. It was not possible to rectify this problem within a reasonable timeframe and so the procedure was converted to a conventional jig based TKA. On four occasions the 2.5 mm drill bit used to make pilot holes for the navigation trackers broke. Each time the drill bits were successfully retrieved under direct vision without needing to enlarge the hole in the bone and the patient went on to have an uncomplicated procedure. Navigation was still possible in these instances. There were no episodes of pin loosening or fracture of the pin intra-operatively. The pins were not responsible for any fractures of bone intra-operatively. On two occasions repeat bone cuts were required due to initial malalignment. This requirement was identified intra-operatively on inspection. Further corrective resections were then made as necessary. Both cases involved version 1.1 software in 2004. There have been no further instances since then. Each intra-operative complication resulted in a longer than average operating time but did not have a significant impact on recovery or outcome. There were a total of 17 episodes of superficial tibial pin-site infections. Any patient seen at six weeks for the routine follow-up post-operative appointment who described either redness related to their wound or who had been given antibiotics by their General Practitioner, GP for wound infection was classified as having had a superficial wound infection. All were managed conservatively with a seven-day course of oral antibiotics unless already started by their GP. The infections resolved in each case without the need for further antibiotics or investigation. No further imaging was required as spontaneous resolution was seen in all patients. No patient with infection required hospital admission or re-operation during the follow-up period. There was a single episode of a fractured tibia at the level of the tibial pin site. This occurred three months after the operation. The fracture occurred when the patient twisted her leg standing up from a sitting position. The patient underwent revision to a long stemmed tibial component the next day after admission. At one year, the patient had made a successful recovery and no further complication was noted (Table 2.). There
4. Discussion Concerns have been raised about unforeseen complications of CAS [6–16]. Our series of 1596 cases shows that these additional complications are of a low incidence (total complication rate 1.9%). In the most part they are easily rectifiable. Limited comparable data exists in the literature. To our knowledge we present the largest series of patients evaluated for early CAS related complications. One other series reviewed 984 cases but specifically reviewed pin site complications [17]. They described a 1.7% minor pin site complication rate, which comprised mainly of reversible pin site infections (1.2%). This was comparable to our own series. They had five cases (0.5%) where intra-operative dislodgement of a tracker pins that meant conversion to a conventional jig based knee replacement system which we did not experience. There were no cases of peri-prosthetic fracture in that series compared to our single episode. No navigation hardware issues were noted in our study. Software problems did occur. Most software issues were correctable and surgery was completed by navigation. In two cases navigation had to be abandoned and conventional instrumentation had to be used. These issues were rectified by an updated version of navigation software and have not occurred again to date. Superficial infection, both in our series and others reported, was the most prevalent problem [8,13,16,17]. All of our infections occurred at the tibial pin site. The superficial nature of the tibial pin site may be a risk factor for developing infection. No other obvious differences were evident in these patients compared to the rest of the cohort. The femoral pin-sites were included in the midline wound for the total knee replacement and did not appear to cause the same problems. All infections were noted within the first six weeks following the procedure and all
Software Failure Broken Drill Bit Intra-op malalignment Pin-site infection Fractured tibia
Fig. 1. Tibial tracker during CATKA.
Fig. 2. Pie-chart representing complications in CATKA.
Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
R.S. Khakha et al. / The Knee xxx (2015) xxx–xxx
were managed successfully with oral antibiotics. Pin site infection did not correlate with deep infection. We feel that meticulous cleaning and suturing of the wound limit the chances of developing superficial infection. There were no associated patient risk factors identified in our study. Pin site infection did not correlate with deep infection. The resulting infection requires an additional review in clinic. There are cost implications associated with developing a tibial pin site infection. While the incidence in our series was low, 1.7%, it is a cost that needs to be considered when undertaking CATKA surgery. Pin site fractures have only been reported as case reports or short case series [8–16]. Metaphyseal pins, small diameter pins, self tapping pins and pins that are not trans-cortical appear to be the most important factors in preventing fractures [13,16]. In our single case of tibial pin site fracture none of these factors appeared to be evident. It is likely that the cause was multifactorial. All of our tracker pins were bicortical and no intraoperative loosening of pins was witnessed. No repeat pilot holes were required to insert pins. We feel that these factors enabled us to achieve a low rate of fracture. Unicortical pins have a higher rate of loosening in our opinion [13]. Navigation remains to be more widely accepted as a means to perform knee arthroplasty. Concerns about higher institutional costs, steep learning curves, potential complications, and a lack of longerterm studies demonstrating improved function, and lower revision rates are often cited as potential reasons [18-22]. However a number of recent meta-analyses have confirmed statistically significant improvements in component alignment and clinical outcome using CAS [23,24]. Ten year outcomes of TKA from the Australian National Joint Registry show no greater a revision rate amongst CATKA compared to non-navigated TKA [25]. Our own series shows that the unforeseen complications of navigated surgery remain low in incidence and are mostly easily managed. The complication of peri-prosthetic fracture is rare and can be avoided by careful pin placement. 5. Conclusion This study demonstrated that the complications related to CATKA remain low in incidence (1.9%) in 1596 cases and are mostly easily managed. The most prevalent complication was superficial infection of the tibial tracker pin site. References [1] Konyves A, Willis-Owen CA, Spriggins AJ. The long-term benefit of computerassisted surgical navigation in unicompartmental knee arthroplasty. J Orthop Surg Res 2010;5:94. [2] Willcox NMJ, Clarke JV, Smith BRK, Deakin AH, Deep K. A comparison of radiological and computer navigation measurements of lower limb coronal alignment before and after total knee replacement. J Bone Joint Surg Br Sep 2012;94(9):1234–40. [3] Decking R, Markmann Y, Fuchs J, Puhl W, Scharf HP. Leg axis after computernavigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation. J Arthoplasty 2005;20:282–8.
3
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Please cite this article as: Khakha RS, et al, Low incidence of complications in computer assisted total knee arthroplasty—A retrospective review of 1596 cases, Knee (2015), http://dx.doi.org/10.1016/j.knee.2015.02.009
