ORTHOPEDICS THIS WEEK VOLUME 14, ISSUE 23 | JULY 17, 2018 14
But that’ s not really been proven.
Mark Pagnano at our place, I think, was one of the first people to question the role of the mechanical axis as far as durability and function with total knee replacements. If you look at a series of Mayo Clinic patients at 15-year follow-up, 275 patients, 399 knees, the mechanical axis was measured in 5 zones( Parratte, et al., JBJS Am 2010). Most of the patients ended up in zone 3, that’ s the middle. But there were some outliers— a little bit of varus; a little bit of valgus.
And the authors also looked at the overall durability of the knee. Revision for any reason was no different at 15 years whether the knees were in the well-aligned group, or if they were in the outlier group. They looked at survival free revision for aseptic loosening or wear / osteolysis by alignment. Again, no difference.
This study doesn’ t mean that alignment isn’ t important. All of us would agree, I think, that alignment is one of the factors that is important in total knee surgery. What this study does tell us is that there are other factors that are more important for 15-year durability. Alignment is important, but if you have a little bit of varus in your knee I’ m not sure the durability is going to be badly affected if other factors aren’ t taken into consideration.
CAS is more complex. There are tracking devices. You’ ve got a camera in the operating room. The work is more complex for your assistants.
I do think we should want to harness the power of the computer for our knee replacements, if accuracy, efficiency, decreased cost( potentially) and fewer complications can be achieved.
I think, however, it may be better to use the computer outside the operating room. There are a lot of techniques that are coming into play with advances in 3D reconstruction. I think in the future it’ s going to be patient-specific solutions, not generic average solutions— putting the mechanical axis down the middle— that’ s going to really shift the bar for our patients.
I argue to you that, today, routine use of a computer in the operating room remains a cumbersome, relatively time consuming, relatively expensive tool, with very limited proven clinical benefit for your patients.
As a research tool it will help us, I think in the future, to find the right targets and once we find that for the individual patient, I think then the computer is going to help us with that individual patient— put that alignment exactly where that patient needs to be.
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