Favourable rotational alignment outcomes in PSI knee arthroplasty: A Level 1 systematic review and meta-analysis

Background: Implant malposition in total knee arthroplasty (TKA) often results in unsatisfactory outcomes. Rotational malalignment leads to impaired patellar tracking, stability and joint biomechanics. Patient-specific instrumentation aims to improve three-dimensional implant positioning while reducing overall costs of instrumentation. Methods: A PRISMA compliant search of all relevant literature between 2000 and 2014 was performed. The primary outcome of interest was deviation from a neutral femoral and tibial axial alignment of patient-specific instrumentation (PSI) vs conventional instrumentation. Femoral rotation was measured with reference to the transepicondylar axis. Tibial rotation was reported with reference to the anterior tibial tuberosity and a "best fit" with the anterior tibial cortex. Results: Six randomised studies met the inclusion criteria reporting on a total of 414 knees. Computed tomography (CT) based PSI systems were used exclusively in three studies, and two further studies in association with magnetic resonance imaging (MRI). MRI was used exclusively in one study. Mean femoral rotation in the conventional group was: -1.7 to 1.6 degrees (vs -1.7 to 1 degrees in the PSI group). Meta-analysis demonstrated a significant treatment effect favouring PSI with increased accuracy in "three-degree outliers" with femoral rotation: Z = 2.07, P = 0.04. A single study reported tibial rotational outcomes with no significant difference demonstrated in conventional instrumentation vs PSI. Conclusions: This Level 1 meta-analysis demonstrates favourable femoral rotational alignment outcomes in PSI knee arthroplasty. Only limited data is available for tibial rotational outcomes. Further studies with standardised "gold standard" measurement criteria are required to clarify tibial rotational outcomes in PSI TKA. (C) 2015 Elsevier B.V. All rights reserved.