Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (4): 658-664. doi: 10.19723/j.issn.1671-167X.2023.04.015

Previous Articles     Next Articles

Cumulative sum control chart analysis of soft tissue balance in total knee replacement assisted by electronic pressure sensor

Ran ZHAO,Yan-qing LIU*(),Hua TIAN*()   

  1. Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
  • Received:2020-11-04 Online:2023-08-18 Published:2023-08-03
  • Contact: Yan-qing LIU,Hua TIAN E-mail:yanqing_liu@sohu.com;tianhua@bjmu.edu.cn
  • Supported by:
    Beijing Municipal Science & Technology Commission(D171100003217001)

RICH HTML

  

Abstract:

Objective: To explore the training ability of pad to guide the balance of soft tissue by drawing cumulative sum (CUSUM) control chart total knee arthroplasty (TKA) sensor. Methods: The data of 73 knees of TKA assisted by electronic gasket initially completed by a senior physician were analyzed retrospectively. There were 8 males (8 knees) and 52 females (65 knees), with an average age of (67.5±5.9) years (57-82 years). The balance of the internal and external space of knee joint was measured at 0°, 45°, 90°, and 120°, in order to observe the pressure distribution of the medial and la-teral compartments, and CUSUM learning curve was drawn. Results: In 0° extension, the medial pressure was higher than the lateral (P < 0.01), when flexion began, the medial and lateral pressures decreased, and became stable and approximately equal during 45°-120°. In the learning curve, by knee 34, CUSUM 0° curve crossed the acceptable control line from above, which showed that it was easy to grasp the soft tissue balance at 0° position through sensor learning. CUSUM 45° curve was above the unacceptable control line in the end, which meant that it was difficult to grasp the technique at the mid-flexion angle. CUSUM 90° and 120° crossed the acceptable control line from above by knee 68 and 57 respectively, which showed that the technique of balance could be improved with the aid of more cases. Conclusion: The electronic pressure sensor can effectively guide the soft tissue balance in TKA. The learning process is simple and does not increase the risk of complications. It can be used as a tool for learning TKA soft tissue balance technology to guide joint surgeons to further master or improve the soft tissue balance technology.

Key words: Arthroplasty, replacement, knee, Electronic pressure sensor, Soft tissue balance, Learning curve, Cumulative sum control chart

CLC Number: 

  • R687.4

Figure 1

Shape and output data of electronic pressure sensor A, intraoperative knee joint pressure sensor, with the shape conforming to GenesisiⅡ prosthesis; B, data acquisition interface of electronic gasket."

Table 1

Comparison of lateral and medial pressure of knee joint after adjustment of balance by sensor"

AngleMedial pressure/N, M (P25, P75)Lateral pressure/N, M (P25, P75)ZP
43.1 (27.6, 63.1)28.8 (13.8, 45.0)-3.0320.002
45°8.6 (4.9, 20.6)15.8 (7.9, 27.4)-1.3940.163
90°9.7 (4.4, 18.0)16.1 (7.6, 24.0)-1.7320.083
120°11.1 (5.5, 18.4)17.2 (5.8, 26.6)-1.7880.074

Figure 2

The CUSUM learning curve using sensor assisted soft tissue balance during primary total knee arthroplasty 0°, 45°, 90° and 120° were accumulated respectively. The soft tissue balance accumulated curve downward, and the imbalance accumulated curve upward. CUSUM, cumulative sum."

Figure 3

Adjusting intraoperative pressure balance in patients with preoperative flexion contracture during TKA A 79-year-old female with right knee osteoarthritis underwent total knee arthroplasty (TKA). The range of motion of knee joint was 20° to 80° before operation, and the ligament contracture was obvious. A, B, preoperative antero-posterior and medial-lateral radiographs shows that the grade of osteoarthritis was Kellgren-Lawrence grade Ⅲ. C, D, the patient completed osteotomy and adjusted the extension and flexion balance by using gap balancer. When the medial ligament was slightly released, the stress decreased significantly. Sensor was used to measure the medial compartment of flexion was 13.2 N and lateral was 54.9 N. Considering that the flexion gap has been balanced by gap balancer, further soft tissue release will continue to increase the pressure imbalance of the space, leading to instability of flexion, we received the pressure imbalance and completed the operation. E, F, the patient' s postoperative X-ray showed that the prosthesis position was good, and the medial and lateral gap was balanced."

1 ElmallahRK,MistryJB,CherianJJ,et al.Can we really "feel" a balanced total knee arthroplasty?[J].J Arthroplasty,2016,31(Suppl 9):102-105.
2 GustkeKA,GolladayGJ,RocheMW,et al.Increased satisfaction after total knee replacement using sensor-guided technology[J].Bone Joint J,2014,96-B(10):1333-1338.
doi: 10.1302/0301-620X.96B10.34068
3 BellemansJ,VandenneuckerH,Van LauweJ,et al.A new surgical technique for medial collateral ligament balancing: Multiple needle puncturing[J].J Arthroplasty,2010,25(7):1151-1156.
doi: 10.1016/j.arth.2010.03.007
4 YapCH,ColsonME,WattersDA.Cumulative sum techniques for surgeons: A brief review[J].ANZ J Surg,2007,77(7):583-586.
doi: 10.1111/j.1445-2197.2007.04155.x
5 WoonCYL,CarrollKM,LymanS,et al.Dynamic sensor-balanced knee arthroplasty: Can the sensor "train" the surgeon?[J].Arthroplast Today,2019,5(2):202-210.
doi: 10.1016/j.artd.2019.03.001
6 CanovasF,DagneauxL.Quality of life after total knee arthroplasty[J].Orthop Traumatol Surg Res,2018,104(Suppl 1):S41-S46.
7 Van DammeG,DefoortK,DucoulombierY,et al.What should the surgeon aim for when performing computer-assisted total knee arthroplasty?[J].J Bone Joint Surg Am,2005,87(Suppl 2):52-58.
8 KhanN,AbboudiH,KhanMS,et al.Measuring the surgical "learning curve": Methods, variables and competency[J].BJU Int,2014,113(3):504-508.
doi: 10.1111/bju.12197
9 RamsayCR,GrantAM,WallaceSA,et al.Assessment of the learning curve in health technologies. A systematic review[[J].Int J Technol Assess Health Care,2000,16(4):1095-1108.
doi: 10.1017/S0266462300103149
10 ZhaoR,LiuY,TianH.Accuracy of soft tissue balancing in total knee arthroplasty using surgeon-defined assessment versus a gap-balancer or electronic sensor[J].J Orthop Surg Res,2021,16(1):305.
doi: 10.1186/s13018-021-02439-w
11 孙晓威,张启栋,任鹏鹏,等.全膝关节置换关节间隙压力传感器的研究现状[J].中国矫形外科杂志,2020,28(19):1774-1778.
12 GustkeKA,GolladayGJ,RocheMW,et al.A new method for defining balance: Promising short-term clinical outcomes of sensor-guided TKA[J].J Arthroplasty,2014,29(5):955-960.
doi: 10.1016/j.arth.2013.10.020
13 MacDessiSJ,GharaibehMA,HarrisIA.How accurately can soft tissue balance be determined in total knee arthroplasty?[J].J Arthroplasty,2019,34(2):290-294. e1.
doi: 10.1016/j.arth.2018.10.003
14 LakraA,SarpongNO,JenningsEL,et al.The learning curve by operative time for soft tissue balancing in total knee arthroplasty using electronic sensor technology[J].J Arthroplasty,2019,34(3):483-487.
doi: 10.1016/j.arth.2018.11.014
15 MeneghiniRM,Ziemba-DavisMM,LovroLR,et al.Can intra-operative sensors determine the "target" ligament balance? Early outcomes in total knee arthroplasty[J].J Arthroplasty,2016,31(10):2181-2187.
doi: 10.1016/j.arth.2016.03.046
16 VerstraeteMA,MeerePA,SalvadoreG,et al.Contact forces in the tibiofemoral joint from soft tissue tensions: Implications to soft tissue balancing in total knee arthroplasty[J].J Biomech,2017,58,195-202.
doi: 10.1016/j.jbiomech.2017.05.008
17 RocheM,ElsonL,AndersonC.Dynamic soft tissue balancing in total knee arthroplasty[J].Orthop Clin North Am,2014,45(2):157-165.
doi: 10.1016/j.ocl.2013.11.001
18 LeDH,GoodmanSB,MaloneyWJ,et al.Current modes of fai-lure in TKA: Infection, instabi-lity, and stiffness predominate[J].Clin Orthop Relat Res,2014,472(7):2197-2200.
doi: 10.1007/s11999-014-3540-y
19 StamboughJB,EdwardsPK,MannenEM,et al.Flexion instabi-lity after total knee arthroplasty[J].J Am Acad Orthop Surg,2019,27(17):642-651.
doi: 10.5435/JAAOS-D-18-00347
20 HinoK,KutsunaT,OonishiY,et al.Assessment of the midfle-xion rotational laxity in posterior-stabilized total knee arthroplasty[J].Knee Surg Sports Traumatol Arthrosc,2017,25(11):3495-3500.
doi: 10.1007/s00167-016-4175-1
21 ParratteS,PagnanoMW.Instability after total knee arthroplasty[J].J Bone Joint Surg Am,2008,90(1):184-194.
22 VajapeySP,PettitRJ,LiM,et al.Risk factors for mid-flexion instability after total knee arthroplasty: A systematic review[J].J Arthroplasty,2020,35(10):3046-3054.
doi: 10.1016/j.arth.2020.05.026
23 ClaryCW,FitzpatrickCK,MaletskyLP,et al.The influence of total knee arthroplasty geometry on mid-flexion stability: An expe-rimental and finite element study[J].J Biomech,2013,46(7):1351-1357.
doi: 10.1016/j.jbiomech.2013.01.025
24 HinoK,IshimaruM,IsekiY,et al.Mid-flexion laxity is greater after posterior-stabilised total knee replacement than with cruciate-retaining procedures: A computer navigation study[J].Bone Joint J,2013,95-B(4):493-497.
doi: 10.1302/0301-620X.95B4.30664
25 EvangelistaPJ,LasterSK,LenzNM,et al.A computer model of mid-flexion instability in a balanced total knee arthroplasty[J].J Arthroplasty,2018,33(Suppl 7):S265-S269.
26 LuyckxT,VandenneuckerH,IngLS,et al.Raising the joint line in TKA is associated with mid-flexion laxity: A study in cadaver knees[J].Clin Orthop Relat Res,2018,476(3):601-611.
doi: 10.1007/s11999.0000000000000067
27 MatziolisG,BrodtS,WindischC,et al.The reversed gap technique produces anatomical alignment with less midflexion instability in total knee arthroplasty: A prospective randomized trial[J].Knee Surg Sports Traumatol Arthrosc,2016,24(8):2430-2435.
doi: 10.1007/s00167-015-3798-y
28 MochizukiT,TanifujiO,SatoT,et al.Association between anteroposterior laxity in mid-range flexion and subjective healing of instability after total knee arthroplasty[J].Knee Surg Sports Traumatol Arthrosc,2017,25(11):3543-3548.
doi: 10.1007/s00167-016-4375-8
29 BabisGC,TrousdaleRT,MorreyBF.The effectiveness of isolated tibial insert exchange in revision total knee arthroplasty[J].J Bone Joint Surg Am,2002,84(1):64-68.
doi: 10.2106/00004623-200201000-00010
30 AbdelMP,PulidoL,SeversonEP,et al.Stepwise surgical correction of instability in flexion after total knee replacement[J].Bone Joint J,2014,96-B(12):1644-1648.
doi: 10.1302/0301-620X.96B12.34821
31 SchwabJH,HaidukewychGJ,HanssenAD,et al.Flexion instability without dislocation after posterior stabilized total knees[J].Clin Orthop Relat Res,2005,440,96-100.
doi: 10.1097/00003086-200511000-00018
32 LongoUG,CiuffredaM,ManneringN,et al.Outcomes of posterior-stabilized compared with cruciate-retaining total knee arthroplasty[J].J Knee Surg,2018,31(4):321-340.
doi: 10.1055/s-0037-1603902
33 van der LindeJA,BeathKJ,LeongAKL.The reliability of sensor-assisted soft tissue measurements in primary total knee arthroplasty[J].J Arthroplasty,2018,33(8):2502-2505. e12.
doi: 10.1016/j.arth.2018.03.067
[1] Si-yu WU,Ya-ning LI,Xiao ZHANG,Long-wei LV,Yun-song LIU,Hong-qiang YE,Yong-sheng ZHOU. Prediction, analysis and application of learning curve of tooth preparation for all ceramic crowns of maxillary central incisors [J]. Journal of Peking University (Health Sciences), 2023, 55(1): 108-113.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
No Suggested Reading articles found!