Accuracy of analog two-dimensional and digital three-dimensional preoperative templating for predicting implant size in total knee arthroplasty

doi:10.3969/j.issn.2095-4344.2016.35.001

Abstract

Abstract:

BACKGROUND: It is the key point to choose the right size of the prosthesis, and grasp the direction and thickness for osteotomy during total knee arthroplasty. In order to achieve the goal, accurate preoperative planning is very important.

OBJECTIVE: To compare the accuracy of preoperative templating in total knee arthroplasty using conventional two-dimensional (2D) and computed tomography (CT)-based three-dimensional (3D) procedures (templating on 3D image & surgical rehearsing on rapid prototype technology-models), and to confirm the necessity of 3D evaluation for preoperative planning.

METHODS: A total of 25 patients undergoing primary total knee arthroplasty were randomly selected, including 10 males and 15 females, at the age of 58 and 79 years old. 2D and 3D images were collected from all patients. Preoperative templating was performed for each total knee arthroplasty using both conventional 2D radiographs and a CT-based 3D image model. Accuracies with regard to the predicted and actual implant sizes were determined for each procedure.

RESULTS AND CONCLUSION：The 3D procedure was found to be more accurate in predicting implant size of 80% femoral and 72% tibial components than those of the 2D procedure (4% femoral and 12% tibial components). Significant differences in the consistent rate of femoral and tibial prosthesis models were detected significantly (P < 0.05). Kappa coefficient statistics demonstrated that goodness of fit of prosthesis model was good in 3D preoperative templating. Results confirmed that the superiority of 3D preoperative templating over 2D conventional evaluation is in predicting implant size, and provides more comprehensive information on skeletal anatomy.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Prostheses and Implants, Arthroplasty, Replacement, Knee, Computer-Aided Design, Tissue Engineering

CLC Number:

R318

Xu Jie, Li Deng, Zhang Ying-bin, Huang Yu-lin, Cai Zhi-qing, Ma Ruo-fan. Accuracy of analog two-dimensional and digital three-dimensional preoperative templating for predicting implant size in total knee arthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2016, 20(35): 5173-5179.

Figures/Tables 1

2.1 参与者数量分析 25例患者手术完成即开始进行假体型号的比对，均获得随访，最长随访时间18个月。 2.2 不良反应患者均无假体周围骨折、血管神经损伤、感染、切口皮肤坏死、血栓形成等并发症发生，随访期间假体稳定性良好。 2.3 两种术前计划对假体型号大小的预测准确度见图1。股骨髁假体型号拟定：基于二维影像所进行的术前计划，仅有4%(1/25)拟定假体尺寸与实际手术应用相一致，而将型号相差不大于1个尺寸者纳入可接受吻合度进行统计，则有76%(19/25)符合。与之相比较，对于基于三维影像所进行的术前计划，80%(20/25)拟定假体尺寸与实际手术应用相一致，而将型号相差不大于1个尺寸者纳入可接受吻合度进行统计，则有100%(25/25)符合。由此，与二维影像所进行的术前计划比较，基于三维影像进行的假体尺寸拟定匹配度较高(χ2=29.64，P < 0.05)。胫骨平台假体型号拟定：基于二维影像所进行的术前计划，仅有12%(3/25)拟定假体尺寸与实际手术应用相一致，而将型号相差不大于1个尺寸者纳入可接受吻合度进行统计，则有92%(23/25)符合。与之相比较，对于基于三维影像所进行的术前计划，72%(18/25)拟定假体尺寸与实际手术应用相一致，而将型号相差不大于1个尺寸者纳入可接受吻合度进行统计，则有100%(25/25)符合。由此，与二维影像所进行的术前计划比较，基于三维影像进行的假体尺寸拟定匹配度较高(χ2=18.47，P< 0.05)。 2.4 Kappa系数评估结果两术前计划所得数据与实际的吻合度，就股骨髁假体的型号拟定，对于二维术前计划，吻合系数K=0.23，吻合度较差，具有统计学意义(P < 0.05)。对于三维术前计划，吻合系数K=0.74，吻合度较强且具有统计学意义(P < 0.05)。就胫骨平台假体的型号拟定，二维及三维术前计划吻合系数K分别为0.225和0.587，均具有统计学意义，但三维术前计划的假体型号拟定吻合度较好。 2.5 典型病例 65岁女性患者，右膝反复疼痛、活动障碍10年余，既往结合症状及血生化、免疫检查确诊为类风湿性关节炎。专科检查：右膝屈曲畸形，伸屈受限，下肢肌力、感觉正常。膝关节正侧位X射线片显示，关节间隙变窄、骨赘形成，股骨远段前方有骨皮质凹陷区(图2A)；CT三维成像更清晰显示，骨赘增生及关节退变程度，股骨髁内骨质存在缺损及密度降低区(图2B)。基于正侧位X射线片进行术前计划，应用摄片时与股骨水平等高放置的硬币影进行放大率校正，拟定股骨髁假体为E号，胫骨平台假体为4号。对采集的三维影像资料进行影像重建及三维虚拟手术(图3)。模拟作股骨及胫骨截骨，去除骨赘并置入假体，拟定股骨髁假体为D号，胫骨平台假体为2号。同时因关节周骨质存在畸形，打印三维模型(图4A)并实物操作截骨，考虑到股骨远段前方有骨皮质凹陷区存在而调整股骨髁截骨前参照置放位置(图4B)，作假体模板测量(图4C，D)，拟定假体尺寸与三维虚拟手术选定一致(图4E)。手术中作软组织松解及暴露，参考术前计划及软组织平衡状况进行截骨及假体选择，股骨远段前方有骨皮质凹陷区存在，致骨面与假体间出现间隙，予以骨水泥填充，应用假体型号与三维术前计划(三维虚拟手术及实物模型手术)吻合(图5)。"

References

[1] Fawzy E,Pandit H,Jenkins C,et al.Determination of femoral component size in unicompartmental knee replacement.Knee.2008;5(15):403-406.
[2] 丁裕润,王伟力.CT三维重建在全膝关节置换中的应用[J].中国组织工程研究,2012,16(48):9020-9024.
[3] Tyagi V,Kim TH,Hwang JH,et al.Imageless navigation assisted total knee arthroplasty with comprehensive gap balancing in medial osteoarthritic varus knees with anatomic variations.Comput Aided Surg.2010;15(4-6): 90-97.
[4] van der Linden-van DZH,Wolterbeek R,Nelissen RG.Computer assisted orthopedic surgery; its influence on prosthesis size in total knee replacement. Knee.2008;15(4):281-285.
[5] Friederich N,Verdonk R.The use of computer-assisted orthopedic surgery for total knee replacement in daily practice: a survey among ESSKA/SGO-SSO members. Knee Surg Sports Traumatol Arthrosc.2008; 16(6): 536-543.
[6] Unnanuntana A,Arunakul M,Unnanuntana A.The accuracy of preoperative templating in total knee arthroplasty.J Med Assoc Thai.2007;90(11):2338-2343.
[7] Arora J,Sharma S,Blyth M.The role of pre-operative templating in primary total knee replacement.Knee Surg Sports Traumatol Arthrosc.2005;13(3):187-189.
[8] Aslam N,Lo S,Nagarajah Ket al.Reliability of preoperative templating in total knee arthroplasty.Acta Orthop Belg.2004;70(6):560-564.
[9] Lonner JH, Laird MT,Stuchin SA.Effect of rotation and knee flexion on radiographic alignment in total knee arthroplasties.Clin Orthop Relat Res.1996;331: 102-106.
[10] Won SH,Lee YK,Ha YC,et al.Improving pre-operative planning for complex total hip replacement with a Rapid Prototype model enabling surgical simulation.Bone Joint J.2013;11(95-B):1458-1463.
[11] Mazzoni S,Marchetti C,Sgarzani R,et al.Prosthetically guided maxillofacial surgery: evaluation of the accuracy of a surgical guide and custom-made bone plate in oncology patients after mandibular reconstruction. Plast Reconstr Surg.2013;131(6): 1376-1385.
[12] Olszewski R.Three-dimensional rapid prototyping models in craniomaxillofacial surgery:systematic review and new clinical applications.P Belg Roy Acad Med.2013;11(2):43-77.
[13] Sciberras N,Frame M,Bharadwaj RG,et al.A novel technique for preoperative planning of severe acetabular defects during revision hip arthroplasty. Bone Joint J.2013;95B(Suppl 30):63.
[14] Lee M,Wu BM.Recent advances in 3D printing of tissue engineering scaffolds. Methods Mol Biol.2012; (868):257-267.
[15] Levine JP,Patel A,Saadeh PB,et al.Computer-aided design and manufacturing in craniomaxillofacial surgery: the new state of the art.J Craniofac Surg. 2012;23(1):288-293.
[16] Sun W,Li J,Li Q,et al.Clinical effectiveness of hemipelvic reconstruction using computer-aided custom-made prostheses after resection of malignant pelvic tumors. J Arthroplasty.2011;26(8):1508-1513.
[17] 汪光晔,张春才,许硕贵,等.基于真实CT数据骨科虚拟手术计划在髋臼骨折手术中的运用[J].中国组织工程研究与临床康复,2011,15(43):7987-7990.
[18] Rengier F,Mehndiratta A,von Tengg-Kobligk H,et al.3D printing based on imaging data: review of medical applications.Int J Comput Assist Radiol Surg. 2010; 4(5):335-341.
[19] He J,Li D,Lu B,Wang Z,et al.Custom fabrication of a composite hemi-knee joint based on rapid prototyping. Rapid Prototyping J.2006;12(4):198-205.
[20] Franceschi JP,Sbihi A.3D templating and patient-specific cutting guides (Knee-Plan) in total knee arthroplasty: postoperative CT-based assessment of implant positioning. Orthop Traumatol Surg Res.2014;100(6 Suppl):S281-S286.
[21] Costa AJ,Lustig S,Scholes CJ,et al.Can tibial coverage in total knee replacement be reliably evaluated with three-dimensional image-based digital templating? Bone Joint Res.2013;2(1):1-8.
[22] Brooks P.Seven cuts to the perfect total knee. Orthopedics. 2009;32(9):27.
[23] 王军帅,姜娥先,魏本和,等.双下肢全长负重位与非负重位摄影在全膝关节置换术前评估的研究[J].医学影像学杂志,2014,24(9):1608-1611.
[24] 吴昊,邱维加,Van Driessche Stéphane,等.计算机辅助下相关数字影像资料对人工全膝关节置换术的优化作用[J].中国临床康复,2005,9(22):1-3.
[25] 王新光,史占军,郭汉明,等.术前胫骨力线X线定位对提高膝关节置换术后假体力线的作用[J].实用医学杂志,2015, 31(16):2669-2672.
[26] Howcroft DW,Fehily MJ,Peck C,et al.The role of preoperative templating in total knee arthroplasty: comparison of three prostheses.Knee.2006; 13(6): 427-429.
[27] The B,Diercks RL,van Ooijen PM,et al.Comparison of analog and digital preoperative planning in total hip and knee arthroplasties. A prospective study of 173 hips and 65 total knees.Acta Orthop.2005;76(1):78-84.
[28] Heal J,Blewitt N.Kinemax total knee arthroplasty: trial by template.J Arthroplasty.2002;17(1):90-94.
[29] Swanson KE,Stocks GW,Warren PD,et al.Does axial limb rotation affect the alignment measurements in deformed limbs?Clin Orthop Relat Res.2000;371: 246-252.
[30] Bothra V,Lemon G,Lang D,et al.Reliability of templating in estimating the size of uni-condylar knee arthroplasty. J Arthroplasty.2003;18(6):780-783.
[31] Sparmann M,Wolke B,Czupalla H,et al.Positioning of total knee arthroplasty with and without navigation support.A prospective, randomised study.J Bone Joint Surg Br. 2003;85(6):830-835.
[32] Gervaise A,Naulet P,Beuret F,et al.Low-dose CT with automatic tube current modulation, adaptive statistical iterative reconstruction, and low tube voltage for the diagnosis of renal colic: impact of body mass index.AJR Am J Roentgenol. 2014;202(3):553-560.