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CLINICAL REVIEW: Sam Gidwani and Adrian Fairbank The orthopaedic approach to managing osteoarthritis of the knee BMJ 2004; 329: 1220-1224 [Full text]

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The orthopaedic approach to managing osteoarthritis of the knee - Computer Assisted Surgery - A technology for today not tomorrow.

Graeme Holt, Mr AG Gregori   (5 December 2004)

The orthopaedic approach to managing osteoarthritis of the knee - Computer Assisted Surgery - A technology for today not tomorrow. 5 December 2004
Graeme Holt, Specialist Registrar, Trauma and Orthopaedic Surgery Hairmyres Hospital, Eaglesham Road, East Kilbride. G75 8RG, Mr AG Gregori Send response to journal: Re: The orthopaedic approach to managing osteoarthritis of the knee - Computer Assisted Surgery - A technology for today not tomorrow.	Editor – In their article Gidwani et al.1 give a detailed and informative summary of the treatment options available for painful arthritis of the knee. However their address of computer assisted arthroplasty raises some interesting points. As accurately stated, computer assisted surgery (CAS) is not standard practice by the majority of orthopaedic surgeons in the United Kingdom. Many cite a lack of long term follow-up data for this technique to justify their reluctance to embrace this technology. However navigated arthroplasty surgery has been widely validated in the orthopaedic literature.2,3 Lower limb mechanical alignment represents one of the principal factors which determines the survivorship of a total knee arthroplasty. As many as 10-15 % of all knee prostheses ultimately require revision, many due to poor quality placement of the prosthetic components.4 The failure rate of poorly aligned implants is more than 2 fold higher than that of well aligned implants.5 The main reason for poor alignment arises from the difficulty of using anatomical reference points and human judgement alone cannot ensure reproducibility of alignment. Reported mechanical alignment outcomes obtained using CAS have consistently been superior to that obtained using traditional alignment methods.2,3 The majority of reported survivorship data regarding total knee arthroplasty originates from centres specialising in such surgery and therefore does not reflect the normal Gaussian spread of outcome obtained throughout the country. Computer assisted arthroplasty allows us to narrow the spread of alignment outcome and so improve the long term outcome of such surgery. It is interesting to note that very few orthopaedic surgeons formally assess post-operative mechanical alignment by lower-limb alignment films or computer tomography. Despite their inability to qualitatively assess their outcomes many would state that their technique does not require modification. This in our opinion represents a lack of insight which must be addressed if we are to maximise the survivorship of our arthroplasty surgery. 1. Gidwani S, Fairbank A. The orthopaedic approach to managing osteoarthritis of the knee. BMJ. 2004; 329: 1220-1224. 2. Oberst M, Bersch C, Wurstlin S, Holz U. CT analysis of leg alignment after conventional vs. navigated knee prosthesis implantation. Initial results of a controlled, prospective and randomised study. Unfallchirurg. Nov 2003; 106(11): 941-8. 3. Saragaglia D, Picard F, Chaussard C, Montbarbon E, Leitner F, Cinquin P. Computer assisted knee arthroplasty: Comparison with a conventional procedure. Rev Chir Orthop Reparatrice Appar Mot. 2001; 87(1): 18-28. 4. Coyte PC. Hawker G. Croxford R. Wright JG. Revision knee replacement in Ontario, Canada. J. Bone J. Surg. American Volume. 1999 Jun; 81(6): 773- 82. 5. Ritter MA., Faris PM., Keating EM., Meding JB. : Post-operative alignment of total knee replacement. Its effect on survival. Clin. Orthop. 1994; 299: 153-156. Competing interests: None declared