Abstract

This article delves into the ongoing deliberation over the appropriateness of using fixed distal femoral cutting angles in total knee replacement surgery. Based on the latest insights from the ‘Journal of Clinical Orthopaedics and Trauma,’ professionals in the field are prompted to reconsider established surgical techniques. The exploration of alternative methods that could potentially improve patient outcomes represents a significant step forward in orthopaedic surgery.

Contemporary orthopaedic surgery constantly pursues the optimal balance between procedural standardization and individualized patient care. One of the procedures where this balance is critically pertinent is total knee replacement (TKR), a common operation offering pain relief and improved function to patients with severe arthritis or joint damage. Dr. Vikram V. Khanna from Ranjana Hospital in Allahabad, India, has contributed to this discourse with a compelling letter to the editor, published in the Journal of Clinical Orthopaedics and Trauma (DOI: 10.1016/j.jcot.2018.09.016). The letter, titled “Is fixed distal femoral cutting angle still justifiable in total knee replacement?”, invites a critical examination of a long-standing practice in TKR, the fixed distal femoral valgus cutting angle. This article elaborates on this crucial question, drawing on the latest research and expert opinions to shed light on the subject.

Background

The success of a total knee replacement largely depends on the accurate alignment of the prosthetic components in relation to the mechanical axis of the lower limb—a complex task that demands meticulous preoperative planning and intraoperative precision. The distal femoral cut sets the foundation for proper alignment of the femoral component, and typically, a fixed valgus angle, ranging between 5 to 7 degrees, has been the norm. However, this “one-size-fits-all” approach may not cater to the anatomic variances seen in a diverse patient population.

Current Debate

In his letter to the editor, Dr. Khanna questions the fixed nature of the distal femoral cut, emphasizing the importance of taking individual patient anatomy into account. This concept is also supported by other experts, such as Vaishya et al. (DOI: 10.1016/j.jcot.2017.02.007), who recognize that a standardized valgus cutting angle may not be suitable for every patient. The debate hinges on the notion that surgical strategies based on averages might not yield the best outcomes for all, as clinical evidence begins to underscore the importance of personalized surgical angles.

Recent Related Research

Critical insights have been offered by studies such as the analysis of 503 total knee arthroplasties by Mullaji et al. (DOI: 10.1016/j.arth.2012.03.057), which highlighted the impact of preoperative deformity on valgus correction angle. These research outcomes suggest that a tailored approach to setting the valgus angle—based on individual patient’s anatomical landmarks—could potentially improve alignment and the long-term outcomes of TKR surgeries.

Impact on Patient Outcomes

Alignment errors during TKR have been associated with numerous complications, including implant wear and failure, which could necessitate costly and demanding revision surgeries. By challenging the fixed distal femoral valgus cutting angle, surgeons might anticipate reductions in alignment-related postoperative complications, enhanced joint function, and increased longevity of the prosthetic components.

Discussion

The main argument for individualized valgus angles is the recognition of the variability within human anatomy. Some proponents suggest using preoperative imaging to assess each patient’s natural alignment and tailor the surgical procedure accordingly. Yet, opponents of this approach argue for the benefits of standardization, including procedural efficiency and predictability.

Clinical Implications

The orthopedic community shift away from the fixed angle approach to a patient-specific technique, this could translate to new training protocols, updated surgical equipment capable of accommodating variability, and potentially the use of advanced imaging techniques in preoperative planning. Additionally, patient education might need to address the reasons behind selecting a specific angle for their surgery.

Future Research and Technology

Emerging technologies such as robotic-assisted surgery and computer navigation offer promising avenues for enhancing precision in TKR. These tools could help in determining and executing the ideal distal femoral cut for each patient. Ongoing and future studies focused on the integration of these technologies with individualized cutting angles are essential to determine the clinical efficacy and cost-effectiveness of such advancements.

Conclusion

In conclusion, the question posed by Dr. Vikram V. Khanna taps into a fundamental concern within orthopaedic surgery. While the fixed distal femoral valgus cutting angle has served the medical community well, there is growing support for a tailored approach that respects patient-specific anatomic variations. As the dialogue continues, evidence-based practices and technological innovations will shape the future of total knee replacement procedures.

Keywords

1. Total Knee Replacement
2. Distal Femoral Cut
3. Personalized Surgery
4. Knee Prosthesis Alignment
5. Orthopaedic Surgical Technique

References

1. Khanna, V. V. (2019). Is fixed distal femoral cutting angle still justifiable in total knee replacement. Journal of Clinical Orthopaedics and Trauma, 10(3), 634. doi: 10.1016/j.jcot.2018.09.016.
2. Vaishya, R., Vijay, V., Edomwonyi, E.O., & Agarwal, A. (2017). Fixed distal femoral valgus cutting angle is still justifiable in total knee replacement. Journal of Clinical Orthopaedics and Trauma. doi:10.1016/j.jcot.2017.02.007.
3. Mullaji, A.B., Shetty, G.M., Kanna, R., Vadapalli, R.C. (2013). The influence of preoperative deformity on valgus correction angle: an analysis of 503 total knee arthroplasties. Journal of Arthroplasty. doi: 10.1016/j.arth.2012.03.057.
4. PMC6494776
5. PMC5995008