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46 (); 24-50
doi:
10.1016/j.jor.2023.10.012

An updated meta-analysis comparing complications, functional, clinically relevant and radiological outcomes of accelerometer based portable navigation and conventional technique of total knee arthroplasty

, , ,
a Parul Institute of Medical Sciences and Research, Parul University, Vadodara, India
b Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
c Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India
d Rela Institute and Medical Center, Chennai, India

∗Corresponding author: Karthik Vishwanathan. karthik_vishwanathan@yahoo.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Since previous studies, including small-scale meta-analyses comparing accelerometer-based portable navigation (APN-TKA) and conventional techniqueof total knee arthroplasty (CONV-TKA), have reported divergent results, there is a need for an updated meta-analysis to compare complications, functional outcomes, clinically relevant outcomes and radiographic alignment of components.

This meta-analysis was conducted as per PRISMA guidelines. Randomised controlled trials, and non-randomised comparative cohort studies in English language on primary TKA were included. The complications compared were Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), infection, manipulation under anaesthesia (MUA) for postoperative knee stiffness, re-operation and mortality. The functional outcomes compared were the Knee Society Knee Score, Knee Society Score function, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Arthritis Index. The evaluated clinically relevant outcomes were surgical time, blood loss, drop in haematocrit, tourniquet time, postoperative knee flexion and complications). The number of radiological outliers; as well as the absolute values of the alignment of the overall prosthesis, femoral and tibial components in both coronal and sagittal planes, was assessed.

Twenty-five studies were included. Both the groups were comparable in terms of preoperative demographic features. There was no difference in complications and functional outcomes. Operation time was longer in APN-TKA (p < 0.00001) but there was no difference in rest of the clinically relevant outcomes. Restoration of the lower limb mechanical axis (p = 0.003) and coronal femoral alignment angle (p = 0.0002) was better with APN. APN also significantly reduced the risk of the odds of outliers of lower limb mechanical axis (p < 0.0001), coronal femoral alignment (p = 0.03), coronal tibial alignment (p < 0.0001) and sagittal tibial alignment (p = 0.0001).

The improvement in the accuracy of implantation by the use of APN-TKA, as determined by the overall alignments of prosthesis, or femoral and tibial components, does not necessarily translate into lesser complications and better functional and clinical outcomes.

Therapeutic study, Level II.

Keywords

Surgical navigation systems
Surgery
Computer-assisted
Arthroplasty
Replacement
Knee
Total knee replacement
Postoperative complications
Patient outcome assessment
1

1 Introduction

Accelerometer-based portable navigation total kneearthroplasty (APN - TKA) was introduced in 2009 to improve the accuracy of prosthetic placement and obviate the need for additional skin incisions, additional pins and trackers in the bones or larger computer console for visualizing the placement of the prosthetic components.1,2 Conventional total knee arthroplasty (CONV-TKA) avoids the use of additional sophisticated instrumentation and relies completely on the operating surgeon's intraoperative judgement regarding prosthetic alignment and ligament balancing.

There is one systematic review3 and five meta-analyses comparing APN and CONV – TKA.4–8 Three meta-analyses4–6 comparing APN and CONV did not report complications of the techniques. One systematic review3 reported the findings of complications but there was no pooling of data from the four included studies. Two meta-analyses7,8 reported the overall complication rate instead of mentioning each of the complication separately. The complications of APN and CONV need detailed evaluation so that the surgeons make a fair judgement about the efficacy and safety of the techniques. The present study aims to compare the complication rate of APN and CONV. There was no pooling of data on various clinical and radiographic parameters in the systematic review.3 The clinical outcome was not reported in one meta-analysis4 and four meta-analyses5–8 have reported no difference in the clinical outcomes. The possible reasons for the absence of substantial difference in clinical outcomes could be either a relatively small number of reviewed studies (8–13 studies) or the use of fewer clinical outcome measures. Only one meta-analysis has reported the absolute alignment values of the femoral and tibial components in both frontal and lateral planes.6 Given the lack of conclusive evidence, there is a need for an updated meta-analysis that includes recently published studies with a larger sample size, so that credible scientific conclusionsmaybe inferred.

The primary objective of the present study was to compare the complications after APN and CONV-TKA. The secondary objective was to compare functional outcomes and clinically relevant outcomes. Additional objectives were to evaluate the number of outliers and the absolute values of the radiological alignment of the prosthesis in both coronal and sagittal planes.

2

2 Methods

This meta-analysis was conducted according to PRISMA 2020 guidelines.9 Institutional Ethics Committee approval was not required as the study involved the analysis of data that is available on the public platform.

2.1

2.1 Eligibility criteria

Randomized controlled trials (RCTs), prospective cohort studies (PCS) and retrospective case control studies (RCCS) published in the English language, comparing patients undergoing primary arthroplasty using APN-TKA and CONV-TKA were included in the present meta-analysis. Only the studies, whichreported the comparison of clinical and functional outcomes, and/or radiological alignment, were included. Case series, narrative reviews, commentaries, abstracts of scientific meetings, and cadaveric/biomechanical studies were excluded. All articles published until December 31, 2022 was included in the meta-analysis.

2.2

2.2 Information sources

The databases that were electronically searched were PubMed, Scopus and Web of Science. The terms used for identification were (“accelerometer" [All Fields] OR “accelerometer s" [All Fields] OR “accelerometers" [All Fields]) AND (“arthroplasty, replacement, knee" [MeSH Terms] OR (“arthroplasty" [All Fields] AND “replacement" [All Fields] AND “knee" [All Fields]) OR “knee replacement arthroplasty" [All Fields] OR (“total" [All Fields] AND “knee" [All Fields] AND “arthroplasty" [All Fields]) OR “total knee arthroplasty" [All Fields] OR (“arthroplasty, replacement, knee" [MeSH Terms] OR (“arthroplasty" [All Fields] AND “replacement" [All Fields] AND “knee" [All Fields]) OR “knee replacement arthroplasty" [All Fields] OR (“total" [All Fields] AND “knee" [All Fields] AND “replacement" [All Fields]) OR “total knee replacement" [All Fields])).

2.3

2.3 Data items

The publication details collected were author, name of the journal, year of publication, type of study, inclusion criteria, cruciate substituting (PS) or cruciate retaining (CR) prostheses and corresponding manufacturers. The preoperative demographic features extracted from the included studies were age, gender, body mass index (BMI), affected side, lower limb mechanical axis (LLMA), knee range of motion (ROM), Knee Society Knee Score (KSKS), Knee Society Score for function (KSSf), Oxford Knee Score (OKS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). The postoperative complications included deep vein thrombosis (DVT), pulmonary embolism (PE), infection, manipulation under anaesthesia (MUA) for stiffness, re-operation and mortality. The postoperative functional and clinically relevant outcomes included were KSKS,10 KSSf,10 OKS,10,11 KOOS,12 Western Ontario and McMaster Universities Arthritis Index (WOMAC),10 knee flexion, operative time, tourniquet time, blood loss and drop in haematocrit. The postoperative radiological outcomes compared were the absolute values and the number of outliers of LLMA, coronal femoral component alignment (CFA), sagittal femoral component alignment (SFA), coronal tibial component alignment (CTA), and sagittal tibial component alignment (STA). The target alignment values postoperatively were as follows: (LLMA = 0°13; CFA = 0°14; SFA = 3° flexion relative to the mechanical axis15,16; CTA = 0°14; STA = 3° in PS-TKA and 7° in CR-TKA.14–16 Any deviation greater than 3°of the target alignment value was considered an outlier.14–16 All the relevant data from each of the studies were collected by a reviewer. All the retrieved data were stored on a Microsoft Excel sheet.

2.4

2.4 Study risk of bias assessment

The quality of RCTs was assessed using the Modified Jadad Scale (MJS)17,18 and the quality of non-randomized studies was assessed using the Newcastle Ottawa Scale (NOS).17,19 MJS score >/ = 4 suggests good quality RCT. NOS score >/ = 6 suggests good quality non-RCT study.20

2.5

2.5 Statistical analysis

The Weighted Mean Difference (WMD) and the Standardised Mean Difference (SMD) were used to determine the significance of the difference in numerical parameters depending on the uniformity of the assessment method. The Odds ratio (OR) was used to determine the significance of the difference in nominal and categorical data. Some studies did not report the mean and the standard deviation; and these parameters were calculated based on parameters reported in those studies to avoidexclusion of data.21–23

Heterogeneity was determined using the value of I2 and a random effect model was used if I2 ≥ 50 %. The statistical analysis was performed using Review Manager Version 4.5.1 for Windows (The Cochrane Collaboration) and StatsDirect software Version 2.7.2 (StatsDirect Ltd, Merseyside, UK). The presence of publication bias was determined using the Funnel plot, BeggMazumdar test and the Egger test.

3

3 Results

3.1

3.1 Study selection and study characteristics

The literature search has been presented in Fig. 1. Twenty-five studies met the inclusion criteria.13–16,24–44 Two studies45,46 compared conventional computer navigation systems with APN, one study47 did not report clinical/radiologically relevant data, another study was in non-English language 48, and hence these studies were excluded. The demographic characteristics of both groups are presented in Tables 1–3.

Literature search flow diagram as per PRISMA guidelines.
Fig. 1 Literature search flow diagram as per PRISMA guidelines.
Table 1 Baseline demographic characteristics in both cohorts.
Author, Journal, Year Type of study Inclusion of pathological condition Type of prosthesis Number of knees Age (years) [mean ± SD] Gender (Male and Female) BMI[mean ± SD] Side (Right and Left)
Gao et al. BMC MSK dis, 2021 RCCS Not specified PS APN – 24CONV - 78 APN -71.0 ± 6.8CONV - 69.2 ± 7.3 APN – 2 and 22CONV - 10 and 68 APN -27.8 ± 2.85CONV - 27.4 ± 3.5 APN -10 and 14CONV - 35 and 43
Tsuda et al. The Knee, 2021 RCT OA PS/CR APN – 42CONV - 41 APN – 74.2 ± 8.1CONV−75.9 ± 9.0 APN – 7 and 35CONV – 10 and 31 APN – 25.4 ± 4.0CONV – 26.2 ± 4.4 APN – NRCONV–NR
Wood et al. JOO 2021 RCCS OA, AVN PS APN – 71CONV - 37 APN – 65.7 ± 9.2 *CONV – 68 ± 9.5* APN – 38 and 33CONV – 14 and 23 APN – 30 ± 4.1*CONV –30.8 ± 4.2 * APN – 34 and 37CONV – 17 and 20
Lai et al. JOTR 2021 RCCS OA PS APN – 38CONV - 44 APN –68 (range and SD not reported)CONV –69.1 (range and SD not reported) APN – 13 and 25CONV – 14 and 30 APN – NRCONV–NR APN – NRCONV–NR
Livermore et al. BJJ 2020 RCCS OA CR APN – 103CONV - 194 APN – 65 ± 9.3CONV – 65 ± 9.5 APN – 49 and 94CONV – 84 and 110 APN – 30 ± 7.3CONV – 29 ± 5.7 APN – NRCONV–NR
Zhu et al. AOTS 2020 PCCS OA PS/CR APN –110CONV - 28 APN – 67 ± 10.4CONV – 68.2 ± 8.5 APN – 48 and 62CONV – 10 and 18 APN – 33.2 ± 7.3CONV – 33.8 ± 7.9 APN – NRCONV–NR
Gao et al. JOSR 2019 RCCS OA NR APN – 41CONV - 41 APN – 67.9 ± 7.3CONV – 67.7 ± 7.1 APN – 2 and 39CONV – 2 and 39 APN – 26.8 ± 2.6CONV – 26.5 ± 1.5 APN – NRCONV–NR
Moo et al. JOS 2018 RCCS OA PS APN – 30CONV – 30 APN – Median (67); IQR (59, 76)67.3 # ± 13.2*CONV – Median (64); IQR (59, 73)65.3 # ± 10.9 * APN – 10 and 20CONV – 12 and 18 APN – Median (26.2); IQR (23.4, 30.3)26.6 # ± 5.4*CONV – Median (27.5); IQR (23.1, 29.8)26.8 # ± 5.2 * APN – 17 and 13CONV – 16 and 14
Tsukeoka et al. AOTS, 2019 RCCS OA, RA CR APN – 55CONV - 55 APN – 73.5 ± 8.1CONV – 74.7 ± 7.8 APN – 5 and 43 (48 patients)CONV – 6 and 43 (49 patients) APN – 27.4 ± 4.3CONV –27.4 ± 4.4 APN – NRCONV–NR
Ueyema et al. KSSTA 2019 PCCS OA PS APN – 78CONV –81 APN – 77.8 ± 6.4CONV – 78.5 ± 4.5 APN – 15 and 63CONV – 9 and 72 APN – 25.4 ± 3.7CONV – 24.2 ± 2.8 APN – NRCONV–NR
Xu et al. Ann Transl Med, 2019 RCT OA PS APN – 39CONV – 40 APN – 65.3 ± 6.8CONV – 65.3 ± 7.6 APN – 9 and 30CONV – 9 and 31 APN – NRCONV–NR APN – 24 and 15CONV – 19 and 21
Chi-Kin et al., JOTR, 2018 RCCS OA PS APN – 46CONV – 46 APN – 69.0 ± 6.2CONV – 71.1 ± 8.4 APN – 8 and 38CONV – 8 and 38 APN – NRCONV–NR APN – NRCONV–NR
Goh et al. J Arthroplasty, 2018 PCCS OA NR APN – 38CONV – 76 APN – 63.9 ± 7.4CONV – 66.4 ± 7.3 APN – 10 and 28CONV – 20 and 56 APN – 28.9 ± 5.7CONV – 27.6 ± 5.4 APN – 19 and 19CONV – 39 and 37
Kinney et al. J Arthroplasty, 2018 RCT OA, RA PS APN – 25CONV – 25 APN – 66.4 ± 2.3CONV – 65.0 ± 2.0 APN – 12 and 13CONV – 9 and 16 APN – 30.4 ± 1.2CONV – 31.1 ± 1.2 APN – NRCONV–NR
Matsumoto et al. J Knee Surg, 2017 NR (probably RCCS since not specified) OA, RA PS (though not specified, because PCL resected)Mobile bearing insert APN – 50CONV – 50 APN – 74.7 ± 9.1*CONV – 73.1 ± 11.1* APN – 11 and 39CONV – 13 and 37 APN – 25.4 ± 4.9 *CONV – 26.4 ± 4.5 * APN – NRCONV–NR
Gharaibeh, J Arthroplasty, 2017 RCT OA NR (Fixed and mobile bearings) APN – 89CONV – 90 APN – 69.2 ± 8.7CONV – 69.0 ± 8.3 APN – 34 and 55CONV – 39 and 50 APN – 29.2 ± 4.8CONV – 29.6 ± 5.4 APN – 45 and 44CONV – 57 and 33
Ikawa et al. BJJ, 2017 RCT OA PS (Fixed and mobile bearings) APN – 121CONV – 120 APN – 74.0 ± 6.8CONV – 74.1 ± 6.8 APN – 15 and 106CONV – 19 and 101 APN – 26.1 ± 3.7CONV – 26.8 ± 4.1 APN – NRCONV–NR
Kawaguchi et al. KSRR, 2017 RCCS OA PS APN – 32CONV – 32 APN – 76.0 ± 5.2CONV – 72.3 ± 5.1 APN – 6 and 26CONV – 7 and 25 APN – 25.3 ± 2.5CONV – 27.2 ± 3.5 APN – NRCONV–NR
Ueyama et al. Orthopedics, 2017 RCCS OA, RA PS APN – 67CONV – 75 APN – 76.9 ± 4.8CONV – 78.1 ± 5.1 APN – 8 and 59CONV – 14 and 61 APN – 26.0 ± 3.8CONV – 25.1 ± 4.4 APN – NRCONV–NR
Liow et al. AOTS, 2016 RCCS OA, RA NR APN – 92CONV – 100 APN – 65.0 ± 6.2CONV – 66.3 ± 7.3 APN – 26 and 66CONV – 27 and 73 APN – 28.1 ± 4.9CONV – 27.6 ± 5.3 APN – 46 and 46CONV – 49 and 51
Thiengwittayaporn et al. Int Orthop, 2016 RCT OA MIS, HiflexPS (fixed bearing) APN – 40CONV – 40 APN – 68.0 ± 8.0CONV – APN – 8 and 32CONV – 6 and 34 APN – 26.6 ± 3.7CONV – 26.2 ± 3.2 APN – 22 and 18CONV – 22 and 18
Nam et al. J Arthroplasty, 2014 RCT OA PS APN – 47CONV – 47 APN – 67.1 ± 7.5CONV – 66.1 ± 10.1 APN – 18 and 29CONV – 20 and 27 APN – 31.1 ± 5.9CONV – 31.2 ± 5.6 APN – 19 and 28CONV – 21 and 26
Minoda et al. JBJS Am 2020 RCT OA NR APN – 45CONV – 45 APN – 76.0 ± 5.0CONV – 74.0 ± 7.0 APN – 9 and 36CONV – 9 and 36 APN – 26.5 ± 4.4CONV – 27.4 ± 4.2 APN – NRCONV–NR
Jagadeesh et al. Cureus 2022 PCCS OA PS – fixed bearing APN – 35CONV – 35 APN – 61.9 (range and SD not reported)CONV – 63.9 (range and SD not reported) APN – 12 and 23CONV – 12 and 23 APN – NRCONV–NR APN – 16 and 19CONV – 14 and 21
Ali et al. ANZ J Surg 2021 RCT OA PS APN – 89CONV - 89 APN – 86.1 (range and SD not reported)CONV – 68.2 (range and SD not reported) APN – 32 and 57CONV – 39 and 50 APN – NRCONV–NR APN – NRCONV–NR
Table 2 Preoperative radiographic parameters and functional scores in both cohorts.
Author, Journal, Year APN - device CONV - technique Reported LLMA (°)[Mean ± SD] Estimated LLMA (°)[Mean ± SD] Preoperative Knee Society Knee Score[Mean ± SD] Preoperative Knee Society Score (function) [Mean ± SD]
Gao et al. BMC MSK dis, 2021 iAssist (Zimmer) Femur: IM and Tibia: EM APN –7.80 ± 8.76CONV –8.04 ± 6.13 APN –7.8 ± 8.8CONV –8.0 ± 6.1 APN –40.8 ± 15.2CONV –39.8 ± 16.3 APN –46.5 ± 19.3CONV – 49.9 ± 21.0
Tsuda et al. The Knee, 2021 iAssist (Zimmer) Femur: IM and Tibia: EM APN –183.2 ± 4.1CONV –184.3 ± 4.1 APN –3.2 ± 4.1CONV – 4.3 ± 4.1 APN –69.9 ± 29.8CONV –79.2 ± 25.1 APN –36.5 ± 20.4CONV –41.4 ± 17.2
Wood et al. JOO 2021 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR
Lai et al. JOTR 2021 iAssist (Zimmer) Femur: IM and Tibia: EM APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR
Livermore et al. BJJ 2020 iAssist (Zimmer) Femur: IM and Tibia: EM APN – 2.8 ± 7.7CONV – 3.3 ± 7.3 APN – 2.8 ± 7.7CONV – 3.3 ± 7.3 APN –NRCONV–NR APN –NRCONV–NR
Zhu et al. AOTS 2020 iAssist (Zimmer) Femur: IM and Tibia: EM APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR
Gao et al. JOSR 2019 iAssist (Zimmer) Femur: IM and Tibia: EM APN –175.4 ± 8.4CONV –175.1 ± 7.7 APN –4.6 ± 8.4CONV –4.9 ± 7.7 APN –39.6 ± 14.1APN –38.8 ± 14.2 APN –50.6 ± 12.7APN –49.3 ± 8.7
Moo et al. JOS 2018 iAssist (Zimmer) Femur: IM and Tibia: EM APN –Median - 168 (IQR: 166,170) Mean, SD not reported169.3 # ± 5.5 #CONV -Median - 169 (IQR: 166, 173) Mean, SD not reported169.3 # ± 5.5 # APN –10.7 ± 5.5CONV –10.7 ± 5.5 APN –NRCONV –NR APN –NRCONV –NR
Tsukeoka et al. AOTS, 2019 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –8.8 ± 8.2CONV –11.1 ± 6.6 APN –8.8 ± 8.2CONV –11.1 ± 6.6 APN –NRCONV –NR APN –NRCONV –NR
Ueyema et al. KSSTA 2019 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –NRCONV –NR APN –NRCONV –NR APN –NRCONV –NR APN –NRCONV –NR
Xu et al. Ann Transl Med, 2019 i-JOIN Femur: IM and Tibia: EM APN –NRCONV –NR APN –NRCONV –NR APN –NRCONV –NR APN –NRCONV –NR
Chi-Kin et al., JOTR, 2018 iAssist (Zimmer) Femur: IM and Tibia: EM APN – minus 9.59 ± 9.07CONV – minus 10.74 ± 8.16 APN – 9.6 ± 9.1CONV –10.7 ± 8.2 APN –NRCONV –NR APN –NRCONV –NR
Goh et al. J Arthroplasty, 2018 iAssist (Zimmer) Femur: IM and Tibia: EM APN –10.9 ± 5.9CONV –9.9 ± 5.0 APN –10.9 ± 5.9CONV –9.9 ± 5.0 APN –35.6 (range: 7 to 78) SD not given35.6 ± 16.4*CONV –37.1 (range: 8 to 80) SD not given37.1 ± 14.8* APN –52.8 (range: 5 to 100) SD not given52.8 ± 22*CONV –56.8 (range: 5 to 100) SD not given56.8 ± 19.6*
Kinney et al. J Arthroplasty, 2018 iAssist (Zimmer) Femur: IM and Tibia: EM APN –6.96 ± 0.90CONV –7.45 ± 1.12 APN –7.0 ± 0.9CONV –7.5 ± 1.1 APN –NRCONV –NR APN –NRCONV –NR
Matsumoto et al. J Knee Surg, 2017 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –8.4 ± 14.6CONV –9.1 ± 14.6 APN –8.4 ± 14.6CONV –9.1 ± 14.6 APN –NRCONV –NR APN –NRCONV –NR
Gharaibeh, J Arthroplasty, 2017 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN – minus 1.7 ± 6.6CONV – minus 2.5 ± 7.5 APN –1.7 ± 6.6CONV –2.5 ± 7.5 APN –NRCONV –NR APN –NRCONV –NR
Ikawa et al. BJJ, 2017 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –6.31 ± 1.3CONV –6.44 ± 1.5 APN –6.3 ± 1.3CONV –6.4 ± 1.5 APN –NRCONV –NR APN –NRCONV –NR
Kawaguchi et al. KSRR, 2017 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –167.2 ± 4.8CONV –168.1 ± 6.1 APN –12.8 ± 4.8CONV –11.9 ± 6.1 APN –46.2 ± 8.4CONV –47.3 ± 5.9 APN –42.9 ± 21.3CONV –44.3 ± 12.9
Ueyama et al. Orthopedics, 2017 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –169.3 ± 3.8CONV –168.7 ± 5.1 APN –10.7 ± 3.8CONV –11.3 ± 5.1 APN –42.4 ± 9.8CONV –44.9 ± 9.9 APN –45.1 ± 8.8CONV –44.1 ± 9.2
Liow et al. AOTS, 2016 iAssist (Zimmer) Femur: IM and Tibia: EM APN –10.7 ± 5.2CONV –9.1 ± 2.8 APN – 10.7 ± 5.2CONV –9.1 ± 2.8 APN –34.8 ± 16CONV –36.9 ± 20 APN –51.7 ± 22CONV –56.5 ± 18
Thiengwittayaporn et al. Int Orthop, 2016 iAssist (Zimmer) Femur: IM and Tibia: EM APN – varus 8.1 ± 7.9CONV – varus 7.6 ± 7.7 APN –8.1 ± 7.9CONV –7.6 ± 7.7 APN –44.0 ± 17.0CONV –40.0 ± 18.4 APN –48.0 ± 16.4CONV – 43.0 ± 16.1
Nam et al. J Arthroplasty, 2014 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN – minus 2.5 ± 7.1CONV – minus 3.4 ± 6.7 APN –2.5 ± 7.1CONV –3.4 ± 6.7 APN –NRCONV –NR APN –NRCONV –NR
Minoda et al. JBJS Am 2020 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –183 ± 3CONV –183 ± 3 APN –3.0 ± 3.0CONV –3.0 ± 3.0 APN –36.1 ± 18.4 (2011 KSS – objective score)CONV –36.1 ± 19.9 (2011 KSS – objective score) APN –33.2 ± 17.2 (2011 KSS – function scoreCONV –43.2 ± 17 (2011 KSS – objective score)
Jagadeesh et al. Cureus 2022 KneeAlign (OrthAlign) Femur: IM and Tibia: EM APN –168.9 ± 8.2CONV –169.5 ± 6.7 APN –11.1 ± 8.2CONV –10.5 ± 6.7 APN –41.8 ± 5.4CONV – 44.4 ± 5.9 APN –53.2 ± 4.3CONV –50.3 ± 5.5
Ali et al. ANZ J Surg 2021 KneeAlign [OrthoAlign] (not reported whether KA or KA2) Femur: IM and Tibia: EM APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR APN –NRCONV–NR
Table 3 Preoperative functional scores and knee range of motion in both cohorts.
Author, Journal, Year Preoperative OKS[Mean ± SD] Preooperative KOOS[Mean ± SD] Preoperative Knee range of motion [Mean ± SD]
Gao et al. BMC MSK dis, 2021 APN – NRCONV–NR APN – NRCONV–NR APN – 95.8 ± 18.5CONV – 93.1 ± 22.2Both the above are maximum knee flexion
Tsuda et al. The Knee, 2021 APN – 22 ± 8.9CONV – 25.4 ± 9.0 APN – NRCONV–NR APN – 110.5 ± 21.6CONV – 108.7 ± 17.8Both the above are knee range of motion
Wood et al. JOO 2021 APN – NRCONV–NR APN – 40 (range: 0 to 68.3) SD not given40 ± 14.3*CONV – 44 (range: 0 to 68.3)44 ± 15.8*KOOS-JR was used in the study APN – NRCONV–NR
Lai et al. JOTR 2021 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Livermore et al. BJJ 2020 APN – NRCONV–NR APN – 49.8 ± 11.5CONV – 49.5 ± 14.6KOOS was used in the study APN – NRCONV–NR
Zhu et al. AOTS 2020 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Gao et al. JOSR 2019 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Moo et al. JOS 2018 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Tsukeoka et al. AOTS, 2019 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Ueyema et al. KSSTA 2019 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Xu et al. Ann Transl Med, 2019 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Chi-Kin et al., JOTR, 2018 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Goh et al. J Arthroplasty, 2018 APN – 35.4 (range: 21 to 49) SD not given35.4 ± 6.5*CONV – 33.7 (range: 17 to 48) SD not given33.7 ± 6.4* APN – NRCONV–NR APN – 118 ± 18.7CONV – 116.9 ± 14.1Both of the above are knee flexion
Kinney et al. J Arthroplasty, 2018 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Matsumoto et al. J Knee Surg, 2017 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Gharaibeh, J Arthroplasty, 2017 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Ikawa et al. BJJ, 2017 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Kawaguchi et al. KSRR, 2017 APN – NRCONV–NR APN – NRCONV–NR APN – 111.1 ± 16.1CONV – 107.5 ± 22.8Both the above are knee range of motion
Ueyama et al. Orthopedics, 2017 APN – NRCONV–NR APN – NRCONV–NR APN – 112.7 ± 14CONV – 117.8 ± 14Both of the above are knee flexion
Liow et al. AOTS, 2016 APN – 37.4 ± 8.8CONV – 33.8 ± 6.6 APN – NRCONV–NR APN – NRCONV–NR
Thiengwittayaporn et al. Int Orthop, 2016 APN – NRCONV–NR APN – NRCONV–NR APN – 113 ± 15.4CONV – 106 ± 18.1Both the above are knee range of motion
Nam et al. J Arthroplasty, 2014 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Minoda et al. JBJS Am 2020 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
Jagadeesh et al. Cureus 2022 APN – 18.6 ± 3.8CONV – 18.6 ± 4.2 APN – NRCONV–NR APN – NRCONV–NR
Ali et al. ANZ J Surg 2021 APN – NRCONV–NR APN – NRCONV–NR APN – NRCONV–NR
3.2

3.2 Risk of bias in included studies

The MJS score for the nine RCTs ranged from six to eight suggesting that all the RCTs were good-quality studies. Fig. 2 depicts the risk of bias in the included RCTs. The NOS for the 16 non-randomized comparative studies ranged from six to nine, thereby suggesting that all the studies were of good methodological quality. The risk of bias of the non-RCTs has been summarised in Fig. 3.

Risk of bias assessment in the included RCTs using the Modified Jadad Scale.
Fig. 2 Risk of bias assessment in the included RCTs using the Modified Jadad Scale.
Risk of bias assessment in the included non-RCTs using the Newcastle Ottawa Scale.
Fig. 3 Risk of bias assessment in the included non-RCTs using the Newcastle Ottawa Scale.
Complications compared in the meta-analysis-1.
Fig. 4 Complications compared in the meta-analysis-1.
Complications compared in the meta-analysis-2.
Fig. 5 Complications compared in the meta-analysis-2.
Functional outcomes assessed in the meta-analysis.
Fig. 6 Functional outcomes assessed in the meta-analysis.
Clinically relevant outcomes compared in the meta-analysis.
Fig. 7 Clinically relevant outcomes compared in the meta-analysis.
Comparison of absolute values of overall limb alignment and femoral component alignment.
Fig. 8 Comparison of absolute values of overall limb alignment and femoral component alignment.
Comparison of absolute values of tibial component alignment.
Fig. 9 Comparison of absolute values of tibial component alignment.
Comparison of radiological outliers of overall limb alignment and femoral component alignment.
Fig. 10 Comparison of radiological outliers of overall limb alignment and femoral component alignment.
Comparison of radiological outliers of tibial component alignment.
Fig. 11 Comparison of radiological outliers of tibial component alignment.
3.3

3.3 Results of individual studies

Fourteen studies reported the incidence and prevalence of complications and 22 studies reported clinically relevant information (Table 4). Twelve studies reported various functional outcomes (Table 5). The absolute values of the radiological prosthetic alignment in various planes were reported in 20 studies (Table 6). The number of outliers in the radiological assessment of the alignment of various components was reported in 23 studies (Table 7).

Table 4 Complications and postoperative clinically relevant outcomes in both cohorts.
Author, Journal, Year Complications (number of cases) Operation time (minutes)[Mean ± SD] Tourniquet time (minutes)[Mean ± SD] Blood loss (ml)[Mean ± SD] Drop in haematocrit (gm/dL) [Mean ± SD] Knee flexion (°)[Mean ± SD]
Gao et al. BMC MSK dis, 2021 APN – 0CONV - 0 NR NR NR NR APN -109.4 ± 13.7CONV -109.7 ± 16.8
Tsuda et al. The Knee, 2021 APN – 0CONV - 0 APN -123.9 ± 27.7CONV -115.0 ± 33.7 NR APN -94.1 ± 107.2CONV -94.2 ± 93.7 NR APN -121.3 ± 11.8CONV -120.2 ± 14.7
Wood et al. JOO 2021 NR NR APN - 70.7 ± 11.6* (range: 53–108; SD not reported)CONV -65.2 ± 6.5* (range: 51–79; SD not reported) NR NR NR
Lai et al. JOTR 2021 NR APN -100 ± 17.6CONV -87 ± 17.1 NR NR APN -2.8 ± 1.1CONV -2.7 ± 1.1 NR
Livermore et al. BJJ 2020 Stiffness requiring MUAAPN – 2CONV – 5ReoperationAPN – 3CONV - 4 NR NR NR APN -4.6 ± 2.8CONV -5.2 ± 2.9 APN -116 ± 12.4CONV -116 ± 14
Zhu et al. AOTS 2020 NR APN - 105 ± 21.3* (range:63 to 170; SD not reported)101 ± 22.5* (range: 62 to 154; SD not reported) NR NR NR NR
Gao et al. JOSR 2019 NR NR NR NR APN -1.9 ± 0.3CONV -2.9 ± 0.4 NR
Moo et al. JOS 2018 NR APN -Median 95 (IQR: 85, 110; mean and SD not reported)96.7 ± 19.5 #CONV -Median 90 (IQR: 82.5, 100; mean and SD not reported)90.8 ± 13.6 # NR NR APN -Median 2.8 (IQR: 1.9, 3.8; mean and SD not reported) 2.8 ± 1.5#CONV -Median 2.3 (IQR: 1.6, 3.0; mean and SD not reported) 2.3 ± 1.1# NR
Ueyema et al. KSSTA 2019 DVTAPN – 10CONV – 12PEAPN – 5CONV - 7 APN -109 ± 16CONV -108 ± 21 NR APN -552 ± 84CONV -544 ± 90 NR NR
Xu et al. Ann Transl Med, 2019 DVTAPN – 7CONV – 8PEAPN – 0CONV – 1 APN -114.5 ± 35.3CONV -100.3 ± 28.4 NR APN -105.1 ± 58.7CONV -113.0 ± 71.6 NR NR
Chi-Kin et al., JOTR, 2018 NR APN -91.5 ± 15.6CONV -93.3 ± 18.1 NR NR NR NR
Goh et al. J Arthroplasty, 2018 APN – 0CONV – 0 APN -83.9 ± 21.8CONV -76.6 ± 17.9 NR NR NR APN -114.3 ± 12.3CONV -111 ± 13
Kinney et al. J Arthroplasty, 2018 InfectionAPN – 1CONV – 0MortalityAPN – 0CONV - 1 NR APN -113.6 ± 12.5@ (SEM = 2.5; SD not reported)CONV -114.3 ± 16@ (SEM = 3.2, SD not reported) NR APN -7.3 ± 3.0@ (SEM = 0.6; SD not reported)CONV -6.6 ± 2.5@ (SEM = 0.5; SD not reported) NR
Matsumoto et al. J Knee Surg, 2017 APN – 0CONV – 0 APN -118 ± 35* (range: 73–216; SD not reported)CONV -113.7 ± 30.9* (range: 91–217; SD not reported) NR NR NR NR
Gharaibeh, J Arthroplasty, 2017 DVTAPN – 0CONV – 1 APN -77.5 ± 10CONV -74.3 ± 11.8 NR NR NR NR
Ikawa et al. BJJ, 2017 APN – 0CONV – 0 NR APN -77.1 ± 8.5CONV -77.5 ± 8.9 APN -784 ± 357CONV -1071 ± 310 NR NR
Kawaguchi et al. KSRR, 2017 APN – 0CONV – 0 APN -123.3 ± 20.8CONV -121.1 ± 18.3 NR APN -422.5 ± 187.5CONV -563.6 ± 261.9 NR APN -122.3 ± 9.9CONV -123.5 ± 9.6
Ueyama et al. Orthopedics, 2017 NR APN -115 ± 10CONV -113 ± 13 NR APN -686 ± 321CONV -646 ± 296 NR APN -121.8 ± 9.4CONV -123.7 ± 9.3
Liow et al. AOTS, 2016 APN – 0CONV – 0 APN -83.9 ± 21.8CONV -72.5 ± 14.6 NR NR NR NR
Thiengwittayaporn et al. Int Orthop, 2016 NR APN -96.0 ± 14.2CONV -94 ± 18.7 NR APN -464 ± 271.2CONV -547 ± 267.9 NR NR
Minoda et al. JBJS Am 2020 InfectionAPN – 1CONV – 0ReoperationAPN – 1CONV - 0 APN –102 ± 27CONV –93 ± 28 NR NR NR NR
Ali et al. ANZ J Surg 2021 DVTAPN – 4CONV – 2InfectionAPN – 2CONV – 5Stiffness requiring MUAAPN – 6CONV – 3ReoperationAPN – 2CONV – 2MortalityAPN – 0CONV – 4 NR NR NR NR NR
Table 5 Functional outcome.
Author, Journal, year Postop KSKS[Mean ± SD] Postop KSSf[Mean ± SD] Postop OKS[Mean ± SD] Postop KOOS[Mean ± SD] Postop WOMAC[Mean ± SD]
Gao et al. BMC MSK dis, 2021 APN -90.4 ± 10.5CONV -88.1 ± 13.8 APN -84.6 ± 14.1CONV -84.5 ± 15.0 NR NR NR
Tsuda et al. The Knee, 2021 APN – 114.1 ± 34.8CONV – 115 ± 28.8 APN -61.4 ± 23.8CONV -62.0 ± 18.9 APN -35.9 ± 9.1CONV -37.8 ± 7.0 NR NR
Wood et al. JOO 2021 NR NR NR APN - 68.5 ± 13.8* (range: 34.2 to 100; SD not reported)CONV - 62.5 ± 14.7* (range: 20.9 to 84.6; SD not reported) NR
Livermore et al. BJJ 2020 NR NR NR APN -60.6 ± 12.6CONV -60.1 ± 12.2 NR
Gao et al. JOSR 2019 APN -76.4 ± 20.1CONV -78.3 ± 17.1 APN -75.5 ± 15.2CONV -70.7 ± 13.9 NR NR APN -32.7 ± 4.8CONV -34.5 ± 4.5
Goh et al. J Arthroplasty, 2018 APN -82.4 ± 12.8CONV -84.9 ± 12.5 APN -71.0 ± 18.5CONV -75.2 ± 16.4 APN -19.4 ± 5.8CONV -17.9 ± 3.4 NR NR
Kawaguchi et al. KSRR, 2017 APN -92.1 ± 6.7CONV -91.4 ± 8.0 APN -75.7 ± 12.3CONV -78.4 ± 14.1 NR NR NR
Ueyama et al. Orthopedics, 2017 APN -76.8 ± 7.8CONV -74.9 ± 7.7 APN -75.3 ± 5.7CONV -74.1 ± 6.1 NR NR NR
Liow et al. AOTS, 2016 APN -74.9 ± 7.7CONV -81.2 ± 12.7 APN -71.7 ± 16.6CONV -69.9 ± 16.4 APN -19.3 ± 4.8CONV -19.5 ± 4.4 NR NR
Minoda et al. JBJS Am 2020 APN -87.3 ± 5.7 (2011 KSS - objective score)CONV -83.7 ± 12.9 (2011 KSS - objective score) APN - 63.1 ± 18.7CONV - 62.9 ± 18.7Both were 2011 KSS - objective score NR NR NR
Jagadeesh et al. Cureus 2022 APN -95.6 ± 1.4CONV -94.8 ± 1.7 APN -94.2 ± 1.6CONV -94.2 ± 1.6 APN -47.7 ± 0.5CONV -47 ± 0.5 NR NR
Ali et al. ANZ J Surg 2021 NR NR NR APN - 41 ± 33.1CONV - 43 ± 24 APN -39 ± 17.9CONV -41 ± 18.7
Table 6 Postoperative alignment angles of components in both cohorts.
Author, Journal, Year LLMA (°) [Mean ± SD] CFA (°) [Mean ± SD] SFA (°) [Mean ± SD] CTA (°) [Mean ± SD] STA (°) [Mean ± SD]
Gao et al. BMC MSK dis, 2021 APN –0.3 ± 2.2CONV –1.7 ± 3.4 APN –0.3 ± 2.2CONV –1.7 ± 3.1 APN –1.2 ± 1.9CONV –2.3 ± 4.2 APN –0.5 ± 1.8CONV –0 ± 1.8 APN –6.8 ± 2.3CONV –4.4 ± 3.5
Lai et al. JOTR 2021 APN –0.6 ± 3.4CONV –0.9 ± 3.5 APN –0.1 ± 2.6CONV –0.40 ± 2.50 APN –4.9 ± 2.4CONV –4.7 ± 2.9 APN –0.5 ± 1.8CONV –0.2 ± 2.3 APN –5.7 ± 2.5CONV –7.1 ± 3.1
Livermore et al. BJJ 2020 NR NR APN –5.4 ± 2.8CONV –6.5 ± 2.8 NR NR
Zhu et al. AOTS 2020 NR APN –0.3 ± 1.0CONV –0.5 ± 1.8 NR APN –0 ± 1CONV –0.1 ± 1.6 NR
Moo et al. JOS 2018 APN –Median - 177 (IQR: 175, 178; mean and SD not reported)3 ± 2.3 #CONV -Median - 177 (IQR: 175, 178; mean and SD not reported)3 ± 2.3 # APN –Median - 92 (IQR: 90, 93; mean and SD not reported) 1.7 ± 2.3 #CONV –Median - 92 (IQR: 91, 93; mean and SD not reported)0.7 ± 1.6 # APN -Median −90 (IQR: 88, 91; mean and SD not reported)0.3 ± 2.3 #CONV –Median - 92 (IQR: 89, 95; mean and SD not reported)2.0 ± 4.7 # APN –Median - 91 (IQR: 90, 93; mean and SD not reported)1.3 ± 2.3 #CONV –Median - 90 (IQR: 89, 91; mean and SD not reported)0 ± 1.6 # APN -Median - 84 (IQR: 83, 86; mean and SD not reported)5.7 ± 2.3 #CONV –Median - 85 (IQR: 83, 87; mean and SD not reported)5 ± 3.1 #
Ueyema et al. KSSTA 2019 NR APN –1.2 ± 0.9CONV –1.6 ± 1.5 APN –3.1 ± 1.9CONV –3.2 ± 2.2 APN –1.0 ± 0.8CONV –1.2 ± 1.1 APN –2.4 ± 1.3CONV –2.8 ± 1.7
Xu et al. Ann Transl Med, 2019 NR APN –0.2 ± 1.2CONV –0.2 ± 2.2 NR NR NR
Chi-Kin et al., JOTR, 2018 APN –0.2 ± 2.1CONV –0.7 ± 3.2 APN –0.4 ± 1.4CONV –0.9 ± 2.2 NR APN –0.2 ± 1.4CONV –0.3 ± 2.6 NR
Goh et al. J Arthroplasty, 2018 APN –1.8 ± 1.3CONV –2.8 ± 2.1 APN –1.3 ± 1.1CONV –2.2 ± 1.6 NR APN –1.6 ± 1.3CONV –2.1 ± 1.6 NR
Kinney et al. J Arthroplasty, 2018 APN –1.9 ± 1.7@ (SEM = 0.34, SD not reported)CONV –2.8 ± 2.1@ (SEM = 0.41; SD not reported) APN –1.7 ± 0.9 @ (SEM = 0.17, SD not reported)CONV –2.2 ± 1.7 @ (SEM = 0.33; SD not reported) NR APN –1.3 ± 0.7 @ (SEM = 0.13, SD not reported)CONV –1.7 ± 1.2 @ (SEM = 0.24, SD not reported) NR
Matsumoto et al. J Knee Surg, 2017 APN –1.0 ± 3.8CONV –1.5 ± 3.1 APN –0.2 ± 2.2CONV –0.1 ± 1.6 APN –2.3 ± 3.3CONV –1.8 ± 1.7 APN –1.1 ± 1.4CONV –0.4 ± 1.3 APN –0.3 ± 3.5CONV –0.1 ± 1.3
Gharaibeh, J Arthroplasty, 2017 APN –1.2 ± 2.0CONV -0.4 ± 2.7 APN –0.5 ± 1.6CONV –0.1 ± 1.8 APN –2.4 ± 1.2CONV –2.4 ± 1.2 APN –0.7 ± 1.3CONV –0.4 ± 1.4 APN –2.1 ± 1.5CONV –2.3 ± 1.6
Ikawa et al. BJJ, 2017 APN –1.0 ± 1.0CONV –1.9 ± 1.7 APN –0.3 ± 1.4CONV –1.3 ± 2.2 NR NR NR
Kawaguchi et al. KSRR, 2017 APN –1.1 ± 1.6CONV –2.4 ± 2.2 APN –0.9 ± 1.1CONV –2.4 ± 2.1 NR APN –0.7 ± 1.6CONV –0.4 ± 1.8 NR
Ueyama et al. Orthopedics, 2017 APN –2.8 ± 1.2CONV –2.5 ± 1.6 APN –0.2 ± 1.1CONV –1.0 ± 1.9 APN –0.4 ± 2.6CONV –0.5 ± 2.6 APN –0.2 ± 1.4CONV –0.1 ± 1.4 APN –2.8 ± 1.9CONV –3.1 ± 2.1
Liow et al. AOTS, 2016 APN –1.9 ± 1.4CONV –2.8 ± 2.0 APN –1.6 ± 1.3CONV –2.1 ± 1.5 NR APN –1.6 ± 1.2CONV –2.1 ± 1.5 NR
Thiengwittayaporn et al. Int Orthop, 2016 APN –0.8 ± 2.1CONV –0.1 ± 3.2 APN –0.3 ± 1.0CONV –0.7 ± 2.2 APN –3.6 ± 1.6CONV –4.4 ± 1.7 APN –0.5 ± 1.8CONV –0.7 ± 1.9 APN –6.3 ± 1.6CONV –7.4 ± 3.7
Nam et al. J Arthroplasty, 2014 NR NR NR APN –0.6 ± 0.9CONV –0.9 ± 1.6 APN –3.3 ± 1.5CONV –3.3 ± 2.5
Minoda et al. JBJS Am 2020 APN –1.4 ± 1.3CONV –2.5 ± 2.2 APN –1.2 ± 1.0CONV –1.8 ± 1.3 NR APN –1.1 ± 0.9CONV –1.7 ± 1.0 NR
Jagadeesh et al. Cureus 2022 APN –0.8 ± 1.8CONV –2.7 ± 2.2 APN –5.4 ± 1.7CONV –5.5 ± 1.1 NR APN –0.8 ± 1.3CONV –2.6 ± 1.5 APN –4.4 ± 0.9CONV –2.1 ± 1.8
Table 7 Summary table showing the number of outliers on radiological assessment of prosthetic components.
Author, Journal, Year LLMA number of outliers in the cohort CFA number of outliers in the cohort SFA number of outliers in the cohort CTA number of outliers in the cohort STA number of outliers in the cohort
Gao et al. BMC MSK dis, 2021 APN –1 out of 24CONV –27 out of 78 APN –2 out of 24CONV –25 out of 78 APN –6 out of 24CONV –37 out of 78 APN –2 out of 24CONV –4 out of 78 APN – 3 out of 24CONV – 31 out of 78
Tsuda et al. The Knee, 2021 NR NR APN –6 out of 42CONV –17 out of 41 APN –10 out of 42CONV –18 out of 41 APN –7 out of 42CONV –9 out of 41
Lai et al. JOTR 2021 APN –15 out of 38CONV –17 out of 44 APN –6 out of 38CONV –17 out of 44 NR APN –2 out of 38CONV –7 out of 44 NR
Livermore et al. BJJ 2020 APN –26 out of 103 (77 - non-outliers)CONV –55 out of 194 (139 non-outliers) APN –17 out of 103 (86 – non-outliers)CONV –30 out of 194 (164 non-outliers) NR APN – 11 out of 103CONV – 18 out of 194 NR
Zhu et al. AOTS 2020 NR NR NR APN – 9 out of 110CONV – 0 out of 28 NR
Gao et al. JOSR 2019 APN –2 out of 41CONV –8 out of 41 APN –0 out of 41CONV –5 out of 41 APN –1 out of 41CONV –2 out of 41 APN – 1 out of 41CONV –4 out of 41 APN – 2 out of 41CONV –9 out of 41
Moo et al. JOS 2018 APN –13 out of 30CONV –11 out of 30 APN –8 out of 30CONV –9 out of 30 APN –13 out of 30CONV –16 out of 30 APN – 3 out of 30CONV –4 out of 30 APN – 7 out of 30CONV –5 out of 30
Tsukeoka et al. AOTS, 2019 NR APN –6 out of 55 (estimated based on 10.9% outlier)CONV –2 out of 55 (estimated based on 3.6% outlier) APN –14 out of 55 (estimated based on 25.5% outlier)CONV –2 out of 55 (estimated based on 3.6% outlier) NR NR
Ueyema et al. KSSTA 2019 NR NR APN –12 out of 78CONV –35 out of 81 APN – 1 out of 78CONV – 6 out of 81 APN – 9 out of 78CONV – 12 out of 81
Xu et al. Ann Transl Med, 2019 APN –1 out of 39 (97.4% - non-outliers)CONV –5 out of 40 (87.5% - non-outliers) NR NR NR NR
Chi-Kin et al., JOTR, 2018 APN –6 out of 46 (13% outliers)CONV –15 out of 46 (32.6 % outliers) NR NR NR NR
Goh et al. J Arthroplasty, 2018 APN –4 out of 38CONV –19 out of 76 APN –3 out of 38CONV –19 out of 76 NR APN – 6 out of 38CONV – 15 out of 76 NR
Kinney et al. J Arthroplasty, 2018 NR NR NR APN – 0 out of 25CONV – 2 out of 25 NR
Matsumoto et al. J Knee Surg, 2017 APN –9 out of 50 (82% - non-outliers)CONV –7 out of 50 (86% - non-outliers) APN –5 out of 50 (90% - non-outliers)CONV –3 out of 50 (94% - non-outliers) APN –10 out of 50 (80% - non-outliers)CONV –5 out of 50 (90% - non-outliers) APN – 1 out of 50 (98% - non-outliers)CONV - 1 out of 50 (98% - non-outliers) APN – 2 out of 50 (96% non-outlier)CONV - 1 out of 50 (98% - non-outliers)
Gharaibeh, J Arthroplasty, 2017 APN –12 out of 89 (13.5% - outliers)CONV –16 out of 90 (17.8% - outliers) APN –1 out of 89 (1.1% - outlier)CONV –5 out of 90 (5.6% - outliers) APN –0 out of 89 (0% outlier)CONV –2 out of 90 (2.2% - outliers) APN – 2 out of 89 (2.2% outlier)CONV – 1 out of 90 (1.1% outlier) APN – 2 out of 89 (2.2% outlier)CONV – 1 out of 90 (1.1% outlier)
Ikawa et al. BJJ, 2017 APN –1 out of 121 (0.8% - outlier)CONV –19 out of 120 (15.8% - outliers) NR NR NR NR
Kawaguchi et al. KSRR, 2017 APN –3 out of 32 (9.1% - outliers)CONV –9 out of 32 (28.1% - outliers) APN –0 out of 32 (0% outlier)CONV –10 out of 32 (31.3% - outliers) APN –3 out of 32 (9.0 % - outlier)CONV –0 out of 32 (0% - outlier) NR NR
Ueyama et al. Orthopedics, 2017 NR NR APN –9 out of 67CONV –16 out of 75 APN – 2 out of 67CONV – 3 out of 75 APN – 2 out of 67CONV – 6 out of 75
Liow et al. AOTS, 2016 APN –8 out of 92CONV –26 out of 100 NR NR NR NR
Thiengwittayaporn et al. Int Orthop, 2016 APN –3 out of 40 (7.5% outlier)CONV –10 out of 40 (25% outlier) APN –0 out of 40 (0% outlier)CONV –6 out of 40 (15% outlier) APN –1 out of 40 (3% outlier)CONV –5 out of 40 (13% outlier) APN – 1 out of 40 (2.5% outlier)CONV – 6 out of 40 (15% outlier) APN – 1 out of 40 (3% outlier)CONV – 8 out of 40 (20% outlier)
Nam et al. J Arthroplasty, 2014 APN –5 out of 47 (10.6% outlier)CONV –12 out of 47 (25.5% outlier) APN –14 out of 47 (29.8% outlier)CONV –16 out of 47 (34% outlier) NR APN – 2 out of 47 (4.3% outlier)CONV – 15 out of 47 (31.9% outlier) APN – 2 out of 47 (5 % outlier)CONV – 13 out of 47 (27.9% outlier)
Minoda et al. JBJS Am 2020 APN –12 out of 45 (27% outlier)CONV –22 out of 45 (49% outlier) APN –10 out of 45 (22% outlier)CONV –17 out of 45 (38% outlier) NR APN – 4 out of 45 (9% outlier)CONV – 14 out of 45 (31% outlier) NR
Jagadeesh et al. Cureus 2022 NR NR NR APN – 3 out of 35 (8.6% outlier)CONV – 8 out of 35 (22.9% outlier) NR
Table 8 Assessment of publication bias and interpretation.
Parameters Shape of Funnel plot Begg Mazumdar Test (p-value) Egger test (p-value) Likelihood of publication bias
DVT Symmetrical 0.75 0.9434 Low
PE Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
Infection Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
MUA for stiffness Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
Reoperation Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
Mortality Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
KSKS Symmetrical 0.2595 0.1482 Low
KSSf Symmetrical 0.3585 0.1967 Low
OKS Could not be drawn 0.3333 0.3277 Low
KOOS Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
WOMAC Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
Operative time Asymmetrical 0.0926 0.2166 Moderate
Tourniquet time Could not be drawn Could not be evaluated Could not be evaluated Cannot be commented
Blood loss Symmetrical 0.2389 0.1595 Low
Drop in Haematocrit Asymmetrical 0.8167 0.066 Moderate
Knee flexion Symmetrical 0.4694 0.8559 Low
LLMA angle Symmetrical 0.4951 0.4117 Low
CFA angle Asymmetrical >0.9999 0.4313 Moderate
SFA angle Asymmetrical 0.3585 0.3169 Moderate
CTA angle Asymmetrical 0.1513 0.1505 Moderate
STA angle Symmetrical 0.2912 0.6622 Low
LLMA outliers Asymmetrical 0.0152 0.0041 High
CFA outliers Asymmetrical 0.1289 0.0612 Moderate
SFA outliers Symmetrical 0.4454 0.3446 Low
CTA outliers Symmetrical 0.8393 0.5697 Low
STA outliers Symmetrical 0.8618 0.6497 Low
3.4

3.4 Results of syntheses

3.4.1

3.4.1 Comparison of both groups at baseline preoperatively

Both the groups were comparable in terms of female gender (OR = 1.01; 95% CI: 0.85 to 1.20; p = 0.91), age (WMD = 0.12; 95% CI: 0.39 to 0.63, p = 0.65), BMI (WMD = −0.12; 95% CI: 0.42 to 0.18; p = 0.45), distribution of right TKR (OR = 0.96; 95% CI: 0.75 to 1.23; p = 0.76), LLMA (WMD = −0.05; 95% CI: 0.34 to 0.24; p = 0.73), KSKS (SMD = −0.11; 95% CI: 0.24 to 0.01; p = 0.08), KSSf (SMD = −0.05; 95% CI: 0.24 to 0.14; p = 0.6), OKS (SMD = 0.11; 95% CI: 0.26 to 0.48; p = 0.55), KOOS (SMD = −0.05; 95% CI: 0.26 to 0.15; p = 0.62) and the knee range of motion (WMD = 0.03; 95% CI: 0.14 to 0.20; p = 0.71).

3.4.2

3.4.2 Comparison of complications (Figs. 4 and 5)

There was no significant difference in the prevalence of DVT (OR = 0.93; 95% CI: 0.5 to 1.75; p = 0.82; I2 = 0%), PE (OR = 0.65; 95% CI: 0.21 to 1.98; p = 0.45, I2 = 0%), infection (OR = 0.83; 95% CI: 0.25 to 2.76; p = 0.76; I2 = 4%), manipulation under anaesthesia for postoperative knee stiffness (OR = 1.35; 95% CI: 0.48 to 3.76; p = 0.57; I2 = 0%), reoperation rates (OR = 1.42; 95% CI: 0.47 to 4.32; p = 0.54; I2 = 0%) and mortality (OR = 0.16; 95% CI: 0.02 to 1.35; p = 0.09; I2 = 0%).

3.43

3.43 .Comparison of functional outcomes at final follow-up postoperatively (Fig. 6)

There was no difference in the KSKS (SMD = 0.04; 95% CI: 0.09 to 0.17; p = 0.54; I2 = 44%), KSSf (SMD = 0.06; 95% CI: 0.08 to 0.19; p = 0.4; I2 = 0%), OKS (SMD = 0.34, 95% CI = −0.25 to 0.93; p = 0.26; I2 = 89%), KOOS (SMD = 0.07; 95% CI: 0.10 to 0.24; p = 0.4; I2 = 48%) and WOMAC (WMD = −1.82; 95% CI: 3.71 to 0.06; p = 0.06; I2 = 0%) between the APN and CONV techniques.

3.4.4

3.4.4 Comparison of clinically relevant outcomes at final follow-up (Fig. 7)

The operative time was significantly longer in APN (WMD = 4.4; 95% CI: 2.7 to 6.0; p < 0.00001; I2 = 37%). There was no difference in the tourniquet time (WMD = 1.8; 95% CI: 2.8 to 6.3; p = 0.5; I2 = 76%), postoperative blood loss (WMD = −58.4; 95% CI: 116.8 to 0.1; p = 0.05; I2 = 88%), postoperative drop in the haematocrit (SMD = −0.4; 95% CI: 1.3 to 0.4; p = 0.31; I2 = 95%) and knee flexion at final follow-up (SMD = −0.01; 95% CI: 0.15 to 0.24; p = 0.93; I2 = 0%).

3.4.5

3.4.5 Comparison of absolute values of component alignment (Figs. 8 and 9)

APN was better for the restoration of the postoperative lower limb mechanical axis (WMD = −0.6; 95% CI: 1.0 to −0.2; p = 0.003; I2 = 75%) and the CFA (WMD = −0.44; 95% CI: 0.68 to −0.21; p = 0.0002; I2 = 61%). There was no difference in the restoration of SFA (WMD = −0.37; 95% CI: 0.76 to 0.03; p = 0.07; I2 = 54%), CTA (WMD = −0.19; 95% CI: 0.43 to 0.06; p = 0.13; I2 = 70%) and STA (WMD = 0.22; 95% CI: 0.49 to 0.93; p = 0.54; I2 = 88%).

3.4.6

3.4.6 Comparison of outliers of component alignment (Figs. 10 and 11)

APN significantly reduced the odds of LLMA outliers (OR = 0.44; 95% CI: 0.30 to 0.66; p < 0.0001; I2 = 51%), reduced the odds of CFA outliers (OR = 0.55; 95% CI: 0.33 to 0.94; p = 0.03; I2 = 49%), reduced the odds of outliers of CTA(OR = 0.49; 95% CI: 0.35 to 0.69; p < 0.0001; I2 = 27%) and reduced the odds of outliers of STA(OR = 0.44; 95% CI: 0.29 to 0.67; p = 0.0001; I2 = 42%). There was no difference in the number of SFA outliers (OR = 0.65; 95% CI: 0.32 to 1.32; p = 0.24; I2 = 68%).

3.4.7

3.4.7 Publication bias (Table 8)

The asymmetrical shape of the Funnel plots for LLMA outliers and CFA outliers is presented in Fig. 12. Publication bias could not be evaluated for several parameters due to fewer comparative studies for those parameters since it was not possible to draw the Funnel plots and not possible to determine theBeggMazumdar test and the Egger test.

Funnel plot showing asymmetrical distribution suggesting presence of publication bias.
Fig. 12 Funnel plot showing asymmetrical distribution suggesting presence of publication bias.
4

4 Discussion

4.1

4.1 Our findings

The main finding of our study was no difference in the prevalence of various complications between APN and CONV-TKA. The present MA reported the comparison of separate complications such as DVT, PE, infection, MUA for stiffness, re-operation and mortality instead of reporting overall pooled complication rate. The present meta-analysis included 12 studies that compared the prevalence of venous thrombo-embolism events, postoperative infection and mortality. Thirteen studies in the present meta-analysis compared the prevalence of MUA for postoperative knee stiffness and 14 studies compared re-operation rates after the index procedures. Our sample size was much larger than previous systematic review and meta-analyses. The systematic review3 included four studies and reported no complications in three studies and venous thrombo-embolism events in one study. Since there was no pooling of data, quantitative comparative data was not available from the systematic review.3 The meta-analysis by Shihab et al.7 compared seven studies for operative complications and reported no difference in overall pooled complication rate. The meta-analysis by Li et al.8 compared four studies for operative complications and reported significantly lower overall pooled complication with APN. Possible explanation for this discordant result could be the fewer studies and consequent lower power of the study of Li et al.8 compared to our study. One can also argue that Li et al. included only RCTs whereas our meta-analysis compared complications of both RCTs and non-RCT comparative studies with overall good methodology and hence higher power of study would be a major strength. Furthermore, the comparison of different complications had no heterogeneity.

There was no difference in the functional outcomes between APN and CONV-TKA. This finding concurs with previous systematic reviews (SR) and meta-analyses (MA).4–8 The present MA included a large cohort of 25 studies and hence, the authors can confidently state that the functional outcomes are similar with either technique. Tsuda et al.14 described an unconventional scoring pattern of KSKS score wherein the postoperative scores were much higher than the usually reported upper limit value of 100 points. One study24 reported the use of Knee Injury and Osteoarthritis Outcome Score for joint replacement (KOOS JR). In another study,44 the KOOS were modified by excluding the questions on sports and recreational activities. Though the Oxford Knee Score was reported in four studies, the scoring was done in the opposite direction in two studies. In two studies, the OKS increased postoperatively14,43 whereas in two studies, the OKS decreased postoperatively 33, 40due to reversal of the scoring pattern used. Since the included studies used different versions of KSKS, KSS function and KOOS, the SMD was used to evaluate the difference. The justification for the use of SMD for OKS was due to the reporting of different scoring patterns.

The present MA observed significantly shorter operative time with CONV and this concurs with previous SR and MA 5−7and differs from those of a recent MA 8that reported no difference in operative time. Our MA included nine RCTs and included studies published in the English language. The MA by Li et al.8 included 10 RCTs and included studies published in a non-English language. Furthermore, the difference of 4.4 min in the operative time reported in the present MA, though statistically significant, is of doubtful clinical significance. Two SR and MA6,7 reported no difference in blood loss between APN and CONV and our findings concur with them. Our findings do not concur with the observations of Li et al.8 who reported lesser blood loss with APN. A possible explanation could be the present MA included seven studies whereas the MA of Li et al.8 included three studies for comparison of blood loss. Since the drop in haematocrit was determined using different methods in the included studies, the SMD was a more appropriate method. Furthermore, the present MA is the only analysis to have compared the drop in haematocrit postoperatively; and there was no difference between groups. This finding also supports our finding of minimal difference in blood loss with APN and CONV. Since some studies reported knee range of motion instead of knee flexion, the SMD was used to determine the statistical significance of the difference. The present MA is the first analysis to have reported knee flexion postoperatively and there was no difference between the two techniques.

The finding of better restoration of the lower limb mechanical axis by APN concurred with two SR and MA.5,8 APN improved LLMA restoration by 0.6°, which is lower than previously reported values that are in the range of 0.8°–0.9°.5,8 Previous SR and MA used pooled data from six5 and eight studies8 whereas the present MA used pooled data from 15 studies and this could be a possible reason for the lower estimation of LLMA restoration in the present MA. The improvement by 0.6° in LLMA with APN, though statistically significant seems to be of questionable clinical significance since the value is too small and could be due to measurement error. APN improved CFA alignment by 0.4°, which is slightly lower than previously reported values that are in the range of 0.5°–0.9°.5,6 Previous SR and MA used pooled data from five5 and 11 studies6 whereas the present MA used pooled data from 18 studies and this could be a possible reason for the modest estimation of CFA alignment in the present MA. The improvement by 0.4° in CFA with APN, though statistically significant seems to be of doubtful clinical significance since the value is too small and could be due to measurement error.

The findings of APN reducing the number of outliers of LLMA and CFA observed in the present study concurred with previous SR and MA.4,6–8 The findings of APN reducing the number of outliers of CTA observed in the present study concurred with similar findings of previous SR and MA.6,8 The findings of APN leading to fewer outliers of STA did not concur with previous studies.7,8 Probable reasons for this divergent result could be due to fewer comparative studies in previous MA and SR compared to the present study.

4.2

4.2 Comparison with other studies

The present meta-analysis included more studies that reported functional outcomes compared to the previously published systematic reviews and meta-analyses. Our analysis included nine studies that reported KSKS whereas the previous systematic reviews and meta-analyses5–8 included 3–4 studies that reported KSKS. Nine studies reporting KSSf were included in the present meta-analysis but two meta-analyses6,7 have included four studies that reported KSSf. The present meta-analysis included four studies that reported the OKS whereas the previous analysis7 included two studies reporting the OKS. One previous systematic review8 included one study on KOOS whereas the present meta-analysis included three studies reporting the KOOS. None of the previous systematic reviews reported the WOMAC; but our analysis included two studies that reported the WOMAC. Furthermore, Shihab et al.7 combined the Knee Society Knee Score (three studies) and the Knee Injury and Osteoarthritis Outcome Score (one study) into a single composite score for statistical pooling of data.

Three tests were used to stringently assess publication bias in the present study, in contrast to the use of the singular Funnel plot in previous SR and MA.4,6,7 Three SR and MA did not assess publication bias.3,5,8

4.3

4.3 Strengths of the study

A large sample size compared to previous SR and MA, comparison of baseline demographic characteristics, reporting of various complications, functional outcome, clinically relevant outcomes, and radiographic assessment of absolute values and outliers of component alignment in coronal and sagittal planes, assessment and reporting of publication bias using three different methods are strengths of the study. The present MA is an updated analysis on a subject of debate and the study presents new robust evidence. To avoid missing data, we used scientifically accepted methods to compute the values of missing data and this adds to the robustness of our conclusion.

4.4

4.4 Limitations of the study

Large heterogeneity was observed for 42% of the comparisons in the present MA. The learning curve effect was taken into consideration in a few studies.14,28–30,40,42 Even in those studies where the learning curve effect was described, there was significant variation in the number of cases operated using APN. One study reported performing five cases of APN-TKAsbefore inclusion14 whereas another study required the performance of 30 cases28 and another study required performing 100 cases29 of APN-TKAs before participating in the study as an operating surgeon. There were multiple operating surgeons in some studies15,25,39 whereas other studies were single surgeon series.13,16,24,26,34 The APN was used solely for the insertion of the tibial component in one study,41 whereas it was used solely for the insertion of the femoral component in five studies26,30,31,37,38 and other studies it was used for insertion of both femoral and tibial components. There was variation in the assessment of the alignment of components with some studies using CT scans14,15,30,36 whereas other studies used plain radiographs. The AP view of the long-leg radiograph was weight bearing view in most studies whereas in two studies it was not specified.38,43 The standard lateral view of the knee was reported in most studies whereas the long-leg standing lateral radiograph of the knee was used in two studies.26,29 While most studies that reported the assessment of SFA chose 87° or 3° as the target value, two studies chose 90° or 0° as the target value.38,39 The target value of the STA for the posterior stabilized knee (PS) would be 3° and that for the cruciate retaining (CR) knee would be 7°. Tsuda et al.14 used both PS and CR knees in their study and this led to heterogeneity in the target values for STA. Gharaibeh et al.36 used fixed-bearing TKA and mobile-bearing TKA in their study; and the target values for STA were 97° and 90° respectively. This was based on surgeon preference and hence a source of heterogeneity in the study. Most studies used >3° deviation from the target value as the criterion for defining outliers whereas three studies41–43 used >2° deviation as the criterion for determining outliers. There was variation in the duration of follow-up in studies reporting clinical outcomes with most studies having atleast twelve months of follow-up whereas few studies had six months of follow-up.14,40,42 The present meta-analysis included only studies published in English language and this could be a source of selection bias. Furthermore, all the included studies reported short to medium term follow-up. There is dearth of good quality studies reporting on the survivorship of the prosthesis due to variation in the alignment of various prosthetic components due to APN and CONV-TKA.

5

5 Conclusion

Though an accelerometer-based portable navigation system helps in mitigating the surgical outliers of acceptable limits of component alignment, it does not essentially translate to lesser complications and significant improvement in the functional and clinically relevant outcomes.

Funding

No funding for the project.

Ethical approval

Not required as this was analysis of information that is already available in the public domain.

Informed consent

Not required as this study involved analysis of information that is already available in the public domain.

Funding/sponsorship

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical statement

Since this was a meta-analysis and includes review of previously published work in the public domain, this study does not require approval of the Ethical Committee.

Funding statement

This study was not funded by any Government or private organizations/entities.

Statement of guardian/patient consent

This is not applicable to the present study since this meta-analysis included review of already published studies that are in the public domain. This study did not involve review of any patient.

Authors’ contribution

All authors [KV, VKJ, MKP, VKV] contributed to the study conception and design. Literature search and identification of suitable studies was done by VKJ and MKP. Data compilation, statistical analysis and the initial interpretation was performed by KV. The checking of the interpretation of the analysis was performed by VKJ, MKP and VKV. The first draft of the manuscript was written by KV and all authors [VKJ, MKP, VKV] reviewed the manuscript critically and revised it for intellectual content. All authors [KV, VKJ, MKP, VKV] have read and approved the final manuscript are willing to be accountable for all contents of the manuscript.

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