Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266

https://doi.org/10.1007/s00402-017-2837-1

KNEE ARTHROPLASTY

Combined CT-based and image-free navigation systems in TKA

reduces postoperative outliers of rotational alignment of the tibial
component
Shota Mitsuhashi1 · Yasushi Akamatsu1 · Hideo Kobayashi1 · Yoshihiro Kusayama1 · Ken Kumagai1 · Tomoyuki Saito1

Received: 31 January 2017 / Published online: 25 November 2017

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Abstract
Introduction  Rotational malpositioning of the tibial component can lead to poor functional outcome in TKA. Although vari-
ous surgical techniques have been proposed, precise rotational placement of the tibial component was difficult to accomplish
even with the use of a navigation system. The purpose of this study is to assess whether combined CT-based and image-free
navigation systems replicate accurately the rotational alignment of tibial component that was preoperatively planned on CT,
compared with the conventional method.
Materials and methods  We compared the number of outliers for rotational alignment of the tibial component using combined
CT-based and image-free navigation systems (navigated group) with those of conventional method (conventional group).
Seventy-two TKAs were performed between May 2012 and December 2014. In the navigated group, the anteroposterior axis
was prepared using CT-based navigation system and the tibial component was positioned under control of the navigation.
In the conventional group, the tibial component was placed with reference to the Akagi line that was determined visually.
Fisher’s exact probability test was performed to evaluate the results.
Results  There was a significant difference between the two groups with regard to the number of outliers: 3 outliers in the
navigated group compared with 12 outliers in the conventional group (P < 0.01).
Conclusions  We concluded that combined CT-based and image-free navigation systems decreased the number of rotational
outliers of tibial component, and was helpful for the replication of the accurate rotational alignment of the tibial component
that was preoperatively planned.

Keywords  Total knee arthroplasty (TKA) · Rotational alignment · Tibial component · Image-free navigation · CT-based
navigation

Introduction However, less attention has been paid to establish reliable

Malpositioning of rotational alignment in total knee arthro-
plasty (TKA) results in anterior knee pain [1, 2], instability
[3], polyethylene wear [4], and dislocation of the patella [5,
6]. The rotational alignment of the femoral component has
been extensively recognized, and midtrochlear axis [7, 8],
transepicondylar axis [9, 10], and posterior condylar axis
[11] have been used to determine proper femoral rotation.
* Shota Mitsuhashi
t156069e@yokohama‑cu.ac.jp
1 sulcus of the tibial spine [18], and intermalleolar axis of the
Department of Orthopaedic Surgery, Yokohama City
University School of Medicine, 3‑9 Fukuura, kanazawa‑ku,
Yokohama 236‑0004, Japan
anatomical references for the rotational alignment of the
tibial component. The definition of rotational malalignment
of the tibial component is still debatable. Nicoll et al. [2]
demonstrated that an increase in the postoperative knee pain
occurs at more than 9° of internal rotation. Therefore, the
rotational malalignment of the tibial component was defined
as more than 9°.
The rotational alignment of the tibial component is gener-
ally determined using the range-of-movement (ROM) tech-
nique or the anatomical landmark technique. Tibial tubercle
[12, 13], anterior tibial cortex [14, 15], transcondylar line of
the tibia [16], posterior condylar line of the tibia [17], mid-
ankle were used as anatomical landmarks in the rotational
alignment of the tibial component. These landmarks differ

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in each patient and cannot be easily identified during TKA.
Recently, the Akagi line which connects the middle of the
posterior cruciate ligament (PCL) and the medial border of
the patellar tendon attachment was prepared [19] as a reli-
able and reproducible landmark (Fig. 1). The ROM tech-
nique located the tibial component more internally than the
anatomical landmark technique using the Akagi line [20].
The Akagi line with its higher reliability and reproducibility
for determining the anteroposterior (AP) axis of the tibia
might allow an accurate positioning of the tibial component.
Although the image-free navigation system enables to
acquire the rotational alignment of the tibial component
[21] as well as the femoral component [22], the anatomical
landmarks have to be visually registered to determine the
rotational alignment. The image-free navigation system has
variability in the positioning of the rotational alignment of
the tibial component. In the CT-based navigation system, the
tibial AP axis was registered with reference to the preopera-
tive CT planning [19, 23, 24].
In our series, the image-free navigation system (preci-
sioN Knee Navigation System Ver4.0, Stryker, Mahwah, NJ,
USA) during TKA was mainly used to control the position-
ing of the femoral and tibial components in the coronal and
sagittal views, and the rotation of the femoral component in
the axial view, and the alignment of the lower extremity in
the coronal view. Moreover, the rotational alignment of the
tibial component was controlled using the CT-based naviga-
tion system on one navigation device. The purpose of this
study was to assess whether combined CT-based and image-
free navigation systems accurately replicated the rotational
alignment of the tibial component that was preoperatively
planned on CT. We hypothesized that the combined method
decreased the outlier of the rotational alignment of the tibial
component compared with the conventional method.
Fig. 1  Photograph showing the
Akagi line which connects the
middle of the posterior cruciate
ligament (PCL) and the medial
border of the patellar tendon
attachment
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Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266
Materials and methods
Patient population
Informed consent was obtained from each patient, and the
study was approved by the Ethics Committee of our hospi-
tal (B120906025). A total of 72 knees in 72 patients with
knee osteoarthritis undergoing TKA between May 2012 and
December 2014 were enrolled in this prospective study. The
population consisted of 11 males and 61 females. Subjects
were randomly assigned to the navigated and conventional
groups using the envelope method; each group had 36 knees.
Preoperative planning
Coronal and lateral whole leg radiographs in standing posi-
tion were obtained from patients before TKA. Pre- and
post-operative CT images of patients in supine position
were also obtained. CT scans of the proximal tibia (1.5-mm-
thick slices) were performed using a SOMATOM Sensa-
tion 16 (Siemens, Munich, Germany) at 1 month before and
3 months after surgery (total time period was 4 months).
Data were incorporated into the Orthomap3D (Stryker,
Kalamazoo, MI, USA), which enables the selection of ana-
tomical landmarks. To determine the rotational alignment
of the tibial component in the axial CT images, the medial
border of the patellar tendon attachment was located (Fig. 2a
#1) and axially transposed proximally to the level on the
tibial plateau where the PCL can be identified at the poste-
rior condylar notch (Fig. 2b #2). Then the line connecting
the medial border of the patellar tendon attachment at the
level of tibial plateau and the middle of the posterior cruci-
ate ligament (Fig. 2c #3) was defined as the AP axis of the
proximal tibia (Fig. 2d).
Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266 261

Fig. 2  The Akagi line was

defined as the line connecting
the medial border of the patellar
tendon at the tibial attachment
(#1) to the middle of the tibial
insertion of the posterior cruci-
ate ligament (#3). The medial
border of the patellar tendon at
the tibial attachment was moved
to the same plane of the tibial
insertion of the PCL (#2). Tibial
AP axis was planned as the line
connecting (#2) and (#3)

Surgical procedure

All patients received a cemented posterior cruciate substi-

tute TKA (Scorpio NRG PS, Stryker Mahwah, NJ, USA)
without patellar resurfacing. A midvastus approach was used
with a tibia first bone resection. The tibial bone resection
was made perpendicular to the mechanical axis with a 0°
posterior slope cut of the proximal tibia. These procedures
took place in our hospital and were performed by a single
surgeon (Y.A.) with more than 20 years of experience in
performing TKA and expertise in using the combined navi-
gation systems.
In the navigated group, navigation trackers were attached
Fig. 3  The K-wire was positioned correctly by matching the tibial AP
with anchoring pins to the distal femur and proximal tibia axis using the CT-based navigation system
at the beginning of surgery. After registration, CT-based
navigation system was used to insert a K-wire into the prox-
imal tibia (Fig. 3), which were defined tibial AP axis by
preoperative CT images. Further, the CT-based navigation
system was switched to the image-free navigation system
in the same navigation device. Registration was performed
again in image-free navigation, and the tibial AP axis was
registered with reference to that accurately inserted K-wire
(Fig. 4). The location of the tibial trial baseplate was fitted
under control of the image-free navigation system relative
to the defined tibial AP axis (Fig. 5). After the keel hole of
the tibia was prepared, tibial component was fixed with bone
cement with reference to the location of the keel hole.
In the conventional group, the tibial AP axis was visu-
ally determined with reference to the Akagi line, and the
pins of the tibial extramedial device were inserted parallel Fig. 4  The tibial AP axis was put into the image-free navigation sys-
to the Akagi line. The location of the tibial trial baseplate tem by matching inserted K-wire using a pointer

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Fig. 5  An instrument was designed to achieve the perfect alignment
of the tibial AP axis. The tibial trial baseplate was positioned accu-
rately relative to the AP axis of the tibia with the image-free naviga-
tion system
Fig. 6  An axial CT image showing the tibial component. The tibial
component axis was defined as the line perpendicular to the line
drawn across the posterior condyles of the tibial component. The tib-
ial rotational alignment was recorded as the angle subtended by the
tibial component axis and the tibial AP axis
was fitted and the keel hole was dug with the guidance of
the pins.
Measurements using the CT‑based simulation
software
The preoperative CT images were superimposed on the
postoperative CT images, using the Orthomap software
for measuring the rotational alignment of tibial component
(Fig. 6). The tibial component axis was defined as the line
perpendicular to the transverse axis of the tibial component.
The rotational alignment of the tibial component was deter-
mined relative to the line between the defined AP axis and
the tibial component axis. Internal alignment was noted by
a minus and the external alignment was noted by a plus.
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Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266
The ideal rotational alignment of the tibial component was
defined as ± 3°, and outlier was defined as more than ± 9°.
Each measurement was taken twice by two observers (S.M.
and Y.A.).
Statistical analysis
All data were analyzed using SPSS for windows (version
21.0; IBM Corporation, Chicago, IL, USA). Data were
expressed as means ± standard deviation. Normality of the
data distributions was assessed using the Shapiro–Wilk test.
Differences of the demographic data between groups were
determined by Student’s t test for normal distribution and
the Mann–Whitney U test for those that were not normally
distributed. A Mann–Whitney U test was used to determine
the differences in absolute value of the rotational alignment
of the tibial component between the two groups. Fisher’s
exact probability test was used to compare the number of
ideal rotational alignment or outlier between the two groups.
P values of < 0.05 were considered statistically significant.
The power calculation was performed with a confidence
level of 95% (α = 0.05) and a power (1 − β) of 80%, and 67
knees of each group were suggested. Intraobserver repeat-
ability and interobserver reproducibility were determined
with intra-class correlation coefficients and their kappa val-
ues were 0.82 and 0.75, respectively. The standard devia-
tion for intraobserver measurements was 4.10° and that for
interobserver measurements was 4.98°.
Results
The demographic data of both groups are shown in Table 1.
No significant differences in age, height, weight, body mass
index, and femorotibial angle were apparent between the
groups, but a significant difference was found in gender
(P = 0.05) (Table 1).
The mean rotational alignment of the tibial component
(SD) was − 0.9° (9.3) and ranged from − 11.9° to 7.8° in the
navigated group. In contrast, the mean rotational alignment
of the tibial component (SD) was − 3.1° (4.6) and ranged
from − 19.4° to 16.2° in the conventional group (Fig. 7).
The mean difference of absolute value from 0° to the rota-
tional alignment of the tibial component (SD) was 4.6° (3.2)
in the navigated group and was 7.8° (5.0) in the conventional
group. There was a significant difference in the absolute
values of the rotational alignment of the tibial component
between the two groups (P = 0.01) (Fig. 8).
The rotational alignment within ± 3° were obtained in 14
cases (38.9%) in the navigated group and 8 cases (22.3%)
in the conventional group (P = 0.31). On the other hand, the
rotational alignment within ± 9° were obtained in 33 cases
Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266 263

Table 1  The demographic Navigation group Conventional group P value

data for the navigation and the
conventional group Knee (n) 36 36 n.s.
Gender (male/female) 7/29 4/32 < 0.05
Mean ­agea (years) 69.1 ± 9.6 75.0 ± 8.3 n.s.
Heighta (cm) 155.1 ± 8.9 150.1 ± 7.3 n.s.
Weighta (kg) 64.7 ± 14.6 61.8 ± 12.2 n.s.
Body mass i­ndexa (kg/m2) 26.8 ± 5.4 27.3 ± 4.1 n.s.
Preoperative ­FTAa (°) 185.2 ± 7.4 186.2 ± 6.2 n.s.

FTA femorotibial angle

a
 The values are given as the mean and the standard deviation

Fig. 8  A box plot of the difference of absolute value from 0° in both

Fig. 7  A box plot of the rotational alignment of the tibial component groups. Box plot horizontals indicate medians and quartiles, verticals
in both the groups. Box plot horizontals indicate medians and quar- indicate minimum and maximum observations
tiles, verticals indicate minimum and maximum observations. Nega-
tive values indicate internal rotation, positive value indicates external
rotation Table 2  Details of the rotational alignment of the tibial component
for both groups
(91%) in the navigated group and 24 cases (66.7%) in the Navigated Conventional P value
conventional group (P < 0.01) (Table 2). group group
The mean posterior tibial slope (SD) was 88.6 (2.3) and
Number of ideal rota- 14 8 n.s.
ranged from 82.9° to 92.7° in the navigated group. In con- tional alignments
trast, the mean posterior tibial slope (SD) was 88.5 (2.6) Number of outliers 3 12 < 0.01
and ranged from 82.5° to 93.0° in the conventional group
(P = 0.85).
Previous studies have shown that the malrotation of the
tibial component induces the risk of postoperative compli-
Discussion cations, such as anterior knee pain [1, 2], instability, poly-
ethylene wear [3], and dislocation of the patella [5, 6] due
The important finding of the present study was that the com- to the lack of homogeneous stress distribution and unbal-
bined CT-based and image-free navigation systems signifi- anced patellofemoral joint kinematics. It is difficult to deter-
cantly decreased the variability of the rotational alignment mine the ideal rotational alignment of the tibial component
of the tibial component compared with the conventional because there are many anatomical landmarks. In addition,
method. none of landmarks have been universally accepted because

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264
of their low reliability [25]. Nicoll et al. [2] compared the
rotational errors in 39 painful and 26 painless TKAs and
concluded that the internal rotation of more than 9° of the
tibial component was a significant cut-off value associated
with pain. Therefore, an angle within ± 9° was chosen as the
ideal rotational alignment of the tibial component.
Although the accuracy for the placement of tibial com-
ponents in the coronal and sagittal views has been improved
by navigation and other forms of computer-assisted TKA
compared with conventional TKA [26–32], its usefulness
on rotational alignment remains unclear [3, 33–39]. Her-
nandez et al. [3] referenced the tibial and fibular malleoli
in the image-free navigation system, but stated that these
landmarks were susceptible to deformities with knee osteo-
arthritis, resulting in reduced reproducibility. To compen-
sate for this weak point in the image-free navigation system,
decision-making was added for the accurate rotational align-
ment of the tibial component by combining the CT-based
navigation system and the image-free navigation system into
a single navigation device.
Kuriyama et al. [23] reported that an ideal rotational
alignment of the tibial component within ± 3° was obtained
in 50% (34 of 68) cases when it was manually positioned,
after the keel hole of the tibia was prepared using CT-based
navigation system. The ideal rotational alignment of the
tibial component within ± 3° was obtained in approximately
40% (14 of 36) in our study, when the keel hole of tibia was
prepared using combined image-free navigation systems.
This result was slightly inferior to the previous study [23].
The difference between Kuriyama’s finding and our finding
might be related to switching CT-based navigation to image-
free navigation. Our results showed a reduction in the num-
ber of outliers (malalignment of > 9° in 9% cases), but there
were still three internal outliers in the navigated group. Pos-
sible reasons for malrotation of the tibial component is that
the lateral femoral condyle can deflect the tibial component
positioning into internal or impingement of the popliteus
tendon can affect the positioning of the tibial component into
internal during the cementing procedure [2, 23]. To address
this internal malrotation, the navigation system should have
been used during the cementing procedure.
This study has some limitations. First, the measurement
error of the Akagi line was not included in our study. Akagi
et  al. [19] reported that a maximum intraobserver error
of measurement in the Akagi line was 4% and the largest
standard deviation was 1.1%. Second, bias may have been
introduced because a single surgeon based his intraoperative
judgment on the correct rotational positioning of the tibial
component by referencing the Akagi line. Third, this study
included a limited number of patients and lacked sample size
calculations and statistical analysis that would strengthen
the investigation. Our findings should be further verified
in a larger cohort of patients for confirmation. Fourth, the
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Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266
relationships between the degree of rotational alignment
of the tibial component and postoperative knee function,
patient satisfaction, or long-term durability were not evalu-
ated. Singisetti et al. [40] reported that navigation TKA did
not result in improvements in clinical outcomes compared
with conventional TKA. However, the radiological outcome
of component alignment was not investigated in their study.
Therefore, a direct correlation between component align-
ment and clinical outcome should have been investigated in
our study. Fifth, there might have been a measurement error
due to the 2-dimensional (2D) CT analysis. CT slices are
affected by the orientation of the patient’s legs while taking
the images, and the width of CT slices affects the determina-
tion of anatomical landmarks [41]. Finally, there was con-
siderable concern regarding radiation exposure during CT to
measure the postoperative rotational alignment of the tibial
component. However, the reliability of long-leg radiographs
was inadequate for the assessment of postoperative implant
alignment [42]. Therefore, low-dose CT was necessary to
improve the accuracy of the measurements.
Conclusion
In conclusion, our study suggests that combined CT-based
and image-free navigation systems in TKA decreased the
outlier of the rotational alignment of the tibial component
compared with the conventional method. A combined navi-
gation system was helpful for the replication of the accurate
rotational alignment of the tibial component that was pre-
operatively planned.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no conflict of
interest.
Funding  There is no funding source.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
References
1. Barrack RL, Schrader T, Bertot AJ, Wolfe MW, Myers L (2001)
Component rotation and anterior knee pain after total knee arthro-
plasty. Clin Orthop Relat Res 392:46–55
2. Nicoll D, Rowley DI (2010) Internal rotational error of the tibial
component is a major cause of pain after total knee replacement.
J Bone Jt Surg Br 92(9):1238–1244
Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266 265
3. Hernandez-Vaquero D, Noriega-Fernandez A, Fernandez-Carreira
JM, Fernandez-Simon JM, Llorens de los Rios J (2014) Computer-
assisted surgery improves rotational positioning of the femoral
component but not the tibial component in total knee arthroplasty.
Knee Surg Sports Traumatol Arthrosc 22(12):3127–3134
4. Nagamine R, Whiteside LA, Otani T, White SE, McCarthy DS
(1996) Effect of medial displacement of the tibial tubercle on
patellar position after rotational malposition of the femoral com-
ponent in total knee arthroplasty. J Arthroplasty 11(1):104–110
5. Berger RA, Crossett L, Jacobs JJ (1998) Malrotation causing
patellofemoral complications after total knee arthroplasty. Clin
Orthop Relat Res 356:144–153
6. Chin KR, Bae DS, Lonner JH, Scott RD (2004) Revision surgery
for patellar dislocation after primary total knee arthroplasty. J
Arthroplasty 19(8):956–961
7. Whiteside LA, Arima J (1995) The anteroposterior axis for femo-
ral rotational alignment in valgus total knee arthroplasty. Clin
Orthop Relat Res 321:168–172
8. Vanin N, Panzica M, Dikos G, Krettek C, Hankemeier S (2011)
Rotational alignment in total knee arthroplasty: intraoperative
inter- and intraobserver reliability of Whiteside’s line. Arch
Orthop Trauma Surg 131(11):1477–1480
9. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS
(1993) Determining the rotational alignment of the femoral com-
ponent in total knee arthroplasty using the epicondylar axis. Clin
Orthop Relat Res 286:40–47
10. Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE (2001)
Optimizing femoral component rotation in total knee arthroplasty.
Clin Orthop Relat Res 392:38–45
11. Hungerford DS, Krackow KA (1985) Total joint arthroplasty of
the knee. Clin Orthop Relat Res 192:23–33
12. Huddleston JI, Scott RD, Wimberley DW (2005) Determination
of neutral tibial rotational alignment in rotating platform TKA.
Clin Orthop Relat Res 440:101–106
13. Cobb JP, Dixon H, Dandachli W, Iranpour F (2008) The anatomi-
cal tibial axis: reliable rotational orientation in knee replacement.
J Bone Jt Surg Br 90(8):1032–1038
14. Baldini A, Indelli PF, L DEL, Mariani PC, Marcucci M (2013)
Rotational alignment of the tibial component in total knee arthro-
plasty: the anterior tibial cortex is a reliable landmark. Joints
1(4):155–160
15. Kim CW, Seo SS, Kim JH, Roh SM, Lee CR (2014) The anter-
oposterior axis of the tibia in Korean patients undergoing total
knee replacement. Bone Jt J 96-b(11):1485–1490
16. Eckhoff DG, Johnston RJ, Stamm ER, Kilcoyne RF, Wiedel
JD (1994) Version of the osteoarthritic knee. J Arthroplasty
9(1):73–79
17. Moreland JR (1988) Mechanisms of failure in total knee arthro-
plasty. Clin Orthop Relat Res 226:49–64
18. Sahin N, Atici T, Kurtoglu U, Turgut A, Ozkaya G, Ozkan Y
(2013) Centre of the posterior cruciate ligament and the sul-
cus between tubercle spines are reliable landmarks for tibial
component placement. Knee Surg Sports Traumatol Arthrosc
21(10):2384–2391
19. Akagi M, Oh M, Nonaka T, Tsujimoto H, Asano T, Hamanishi C
(2004) An anteroposterior axis of the tibia for total knee arthro-
plasty. Clin Orthop Relat Res 420:213–219
20. Ikeuchi M, Yamanaka N, Okanoue Y, Ueta E, Tani T (2007)
Determining the rotational alignment of the tibial component at
total knee replacement: a comparison of two techniques. J Bone
Jt Surg Br 89(1):45–49
21. Lutzner J, Krummenauer F, Gunther KP, Kirschner S (2010) Rota-
tional alignment of the tibial component in total knee arthroplasty
is better at the medial third of tibial tuberosity than at the medial
border. BMC Musculoskelet Disord 11:57
22. Inui H, Taketomi S, Nakamura K, Sanada T, Tanaka S, Nakagawa
T (2013) An additional reference axis improves femoral rotation
alignment in image-free computer navigation assisted total knee
arthroplasty. J Arthroplasty 28(5):766–771
23. Kuriyama S, Hyakuna K, Inoue S, Tamaki Y, Ito H, Matsuda S
(2014) Tibial rotational alignment was significantly improved by
use of a CT-navigated control device in total knee arthroplasty. J
Arthroplasty 29(12):2352–2356
24. Mizu-uchi H, Matsuda S, Miura H, Okazaki K, Akasaki Y, Iwa-
moto Y (2008) The evaluation of post-operative alignment in total
knee replacement using a CT-based navigation system. J Bone Jt
Surg Br 90(8):1025–1031
25. Heyse TJ, Stiehl JB, Tibesku CO (2015). Measuring tibial com-
ponent rotation of TKA in MRI: what is reproducible? Knee
22(6):604–608
26. Zhang GQ, Chen JY, Chai W, Liu M, Wang Y (2011) Compari-
son between computer-assisted-navigation and conventional total
knee arthroplasties in patients undergoing simultaneous bilat-
eral procedures: a randomized clinical trial. J Bone Jt Surg Am
93(13):1190–1196
27. Jenny JY, Boeri C (2001) Computer-assisted implantation of total
knee prostheses: a case-control comparative study with classical
instrumentation. Comput Aided Surg 6(4):217–220
28. Blakeney WG, Khan RJ, Wall SJ (2011) Computer-assisted tech-
niques versus conventional guides for component alignment in
total knee arthroplasty: a randomized controlled trial. J Bone Jt
Surg Am 93(15):1377–1384
29. Burnett RS, Barrack RL (2013) Computer-assisted total knee
arthroplasty is currently of no proven clinical benefit: a systematic
review. Clin Orthop Relat Res 471(1):264–276
30. Cheng T, Zhao S, Peng X, Zhang X (2012) Does computer-
assisted surgery improve postoperative leg alignment and implant
positioning following total knee arthroplasty? A meta-analysis
of randomized controlled trials? Knee Surg Sports Traumatol
Arthrosc 20(7):1307–1322
31. Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari
M, Zalzal PK (2012) Meta-analysis of navigation vs conventional
total knee arthroplasty. J Arthroplasty 27(6):1177–1182
32. Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C (2007) A pro-
spective, randomized study of computer-assisted and conventional
total knee arthroplasty. Three-dimensional evaluation of implant
alignment and rotation. J Bone Jt Surg Am 89(2):236–243
33. Kim YH, Kim JS, Yoon SH (2007) Alignment and orientation
of the components in total knee replacement with and without
navigation support: a prospective, randomised study. J Bone Jt
Surg Br 89(4):471–476
34. Meijer MF, Reininga IH, Boerboom AL, Bulstra SK, Stevens M
(2014) Does imageless computer-assisted TKA lead to improved
rotational alignment or fewer outliers? A systematic review. Clin
Orthop Relat Res 472(10):3124–3133
35. Cheng T, Zhang G, Zhang X (2011) Imageless navigation system
does not improve component rotational alignment in total knee
arthroplasty. J Surg Res 171(2):590–600
36. Zhang XL, Zhang W, Shao JJ (2012) Rotational alignment in total
knee arthroplasty: nonimage-based navigation system versus con-
ventional technique. Chin Med J (Engl) 125(2):236–243
37. Liow MH, Goh GS, Pang HN, Tay DK, Lo NN, Yeo SJ (2016)
Computer-assisted stereotaxic navigation improves the accuracy
of mechanical alignment and component positioning in total knee
arthroplasty. Arch Orthop Trauma Surg 136(8):1173–1180
38. Heyse TJ, Tibesku CO (2015) Improved tibial component rota-
tion in TKA using patient-specific instrumentation. Arch Orthop
Trauma Surg 135(5):697–701
39. Wada K, Mikami H, Hamada D, Yonezu H, Oba K, Sairyo K
(2016) Measurement of rotational and coronal alignment in total
13

266
knee arthroplasty using a navigation system is reproducible. Arch
Orthop Trauma Surg 136(2):271–276
40. Singisetti K, Muthumayandi K, Abual-Rub Z, Weir D (2015)
Navigation-assisted versus conventional total knee replacement:
no difference in patient-reported outcome measures (PROMs) at
1 and 2 years. Arch Orthop Trauma Surg 135(11):1595–1601
4 1. Hirschmann MT, Konala P, Amsler F, Iranpour F, Friederich
NF, Cobb JP (2011) The position and orientation of total knee
13
Archives of Orthopaedic and Trauma Surgery (2018) 138:259–266
replacement components: a comparison of conventional radio-
graphs, transverse 2D-CT slices and 3D-CT reconstruction. J
Bone Jt Surg Br 93(5):629–633
42. Maderbacher G, Baier C, Benditz A, Wagner F, Greimel F, Grifka
J et al (2017) Presence of rotational errors in long leg radiographs
after total knee arthroplasty and impact on measured lower limb
and component alignment. Int Orthop. https://doi.org/10.1007/
s00264-017-3408-3