An anatomo-functional implant positioning technique with robotic assistance for primary TKA allows the restoration of the native knee alignment and a natural functional ligament pattern, with a faster recovery at 6 months compared to an adjusted mechanical technique

• Parratte Sébastien
• van Overschelde Philippe
• Bandi Marc
• Ozturk Burak Yagmur
• Batailler Cécile

• Total knee arthroplasty
• ROSA
• Robotic-assisted surgery
• Anatomo-functional implant positioning
• Patellar tracking
• Ligament balancing
• Lateral gap laxity

Purpose An anatomo-functional implant positioning (AFIP) technique in total knee arthroplasty (TKA) could restore physiological ligament balance (symmetric gap in extension, asymmetric gap in flexion). The purposes were to compare (1) ligament balancing in extension and flexion after TKA in the AFIP group, (2) TKA alignment, implant positioning and patellar tracking between AFIP and adjusted mechanical alignment (aMA) techniques, (3) clinical outcomes between both groups at 12 months. Methods All robotic-assisted TKA with an AFIP technique were included (n = 40). Exclusion criteria were genu valgum (HKA angle > 183°), extra-articular deformity more than 10°, and patellar maltracking (high-grade J-sign). One control patient with a TKA implanted by an aMA technique was matched for each case, based on age, body mass index, sex, and knee alignment. Ligament balancing (medial and lateral gaps in millimeters) in full extension and at 90° of flexion after TKA in the AFIP group was assessed with the robotic system. TKA alignment (HKA angle), implants positioning (femoral and tibial coronal axis, tibial slope, joint-line orientation), patellar tracking (patellar tilt and translation) and the Knee Society Score (KSS) at 6 and 12 months were compared between both groups. The ligament balancing was compared using a t test for paired samples in the AFIP group. The radiographic measurements and KSS scores were compared between groups using a t test for independent samples. Results In the AFIP group, there was no significant difference between the medial and lateral gap laxity in extension (NS). A significant opening of the lateral gap was observed in flexion compared to extension (mean: + 2.9 mm; p < 0.0001). The mean postoperative HKA angle was comparable between both groups (177.3° ± 2.1 in the AFIP group vs 176.8° ± 3.2; NS). In the AFIP group, the femoral anatomy was restored (90.9° ± 1.6) and the tibial varus was partially corrected (87.4° ± 1.8). The improvement of Knee and Function KSS at 6 months was better in the AFIP group (59.3 ± 11.9 and 51.7 ± 20, respectively, versus 49.3 ± 9.7 and 20.8 ± 13; p < 0.001). Conclusion The AFIP concept allowed the restoration of the native knee alignment and a natural functional ligament pattern. With a more physiological target for ligament balancing, the AFIP technique had equivalent clinical outcomes at 12 months compared to aMA, with a faster recovery. Level of evidence III retrospective therapeutic case control series. Keywords Total knee arthroplasty • ROSA • Robotic-assisted surgery • Anatomo-functional implant positioning • Patellar tracking • Ligament balancing • Lateral gap laxity Abbreviations AFIP Anatomo-functional implant positioning BMI Body mass index HKA Hip-knee angle JLCA Joint-line convergence angle JLO Joint-line orientation KA Kinematic alignment KSS Knee Society Score MA Mechanical alignment MCL Medial collateral ligament * Cécile Batailler