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J Knee Surg 2014; 27(03): 235-248
DOI: 10.1055/s-0033-1360659
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Navigated versus Conventional Total Knee Arthroplasty

Joseph T. Moskal
1   Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
,
Susan G. Capps
2   BENSOL, Warsaw, Indiana
,
John W. Mann
3   Department of Orthopaedic Surgery, Carilion Clinic Orthopaedics, Roanoke, Virginia
,
John A. Scanelli
4   Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
› Author Affiliations
Further Information

Publication History

23 February 2013

23 September 2013

Publication Date:
14 November 2013 (online)

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Abstract

Computer-aided navigation in total knee arthroplasty (TKA) promises improved alignment, performance, and survivorship. Previous meta-analyses demonstrated that navigation yields better component alignment; however, they did not discuss other indicators of performance. This meta-analysis compares navigated (NAV) and conventional (CONV) TKAs and includes clinical outcomes and adverse events. Forty-seven studies (22 randomized trials) of varying methodological quality involving 7,151 TKAs created the sample population. Statistical analyses included analysis of variance of weighted means and random effects modeling. As seen in previous meta-analyses, NAV is favored over CONV TKA. Analysis of surgical characteristics found that length of surgery and tourniquet times were lower for CONV, but not significant. Meta-analysis found that tourniquet times favored CONV but not a strong relationship for length of surgery. Analysis of individual adverse events did not reveal any significant differences. However, when examining adverse events in their totality, the NAV experienced significantly fewer complications. TKA performed with imageless navigation improves component alignment, provides for lower blood loss, improves clinical outcomes as measured by Knee Society and WOMAC scores, and has fewer total adverse events. Published data are insufficient to determine any correlations between component alignment and outcomes.

Keywords

arthroplasty - reconstruction - navigation - survivorship - clinical outcomes
 

  • References

  • 1 Aglietti P, Buzzi R. Posteriorly stabilised total-condylar knee replacement. Three to eight years' follow-up of 85 knees. J Bone Joint Surg Br 1988; 70 (2) 211-216
    PubMedGoogle Scholar
  • 2 Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty 2005; 20 (7) (Suppl. 03) 132-138
    PubMedGoogle Scholar
  • 3 Bargren JH, Blaha JD, Freeman MAR. Alignment in total knee arthroplasty. Correlated biomechanical and clinical observations. Clin Orthop Relat Res 1983; (173) 178-183
    PubMedGoogle Scholar
  • 4 Berend ME, Ritter MA, Meding JB , et al. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 2004; 428 (428) 26-34
    CrossrefPubMedGoogle Scholar
  • 5 Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 1998; (356) 144-153
    PubMedGoogle Scholar
  • 6 Dorr LD, Boiardo RA. Technical considerations in total knee arthroplasty. Clin Orthop Relat Res 1986; (205) 5-11
    PubMedGoogle Scholar
  • 7 Ek ET, Dowsey MM, Tse LF , et al. Comparison of functional and radiological outcomes after computer-assisted versus conventional total knee arthroplasty: a matched-control retrospective study. J Orthop Surg (Hong Kong) 2008; 16 (2) 192-196
    PubMedGoogle Scholar
  • 8 Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clin Orthop Relat Res 1985; (192) 23-33
    PubMedGoogle Scholar
  • 9 Hvid I, Nielsen S. Total condylar knee arthroplasty. Prosthetic component positioning and radiolucent lines. Acta Orthop Scand 1984; 55 (2) 160-165
    Google Scholar
  • 10 Insall J, Tria AJ, Scott WN. The total condylar knee prosthesis: the first 5 years. Clin Orthop Relat Res 1979; (145) 68-77
    PubMedGoogle Scholar
  • 11 Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res 1985; (192) 13-22
    PubMedGoogle Scholar
  • 12 Insall JN. Presidential address to the Knee Society. Choices and compromises in total knee arthroplasty. Clin Orthop Relat Res 1988; (226) 43-48
    PubMedGoogle Scholar
  • 13 Jeffery RS, Morris RW, Denham RA. Coronal alignment after total knee replacement. J Bone Joint Surg Br 1991; 73 (5) 709-714
    PubMedGoogle Scholar
  • 14 Krackow KA, Phillips MJ, Bayers-Thering M, Serpe L, Mihalko WM. Computer-assisted total knee arthroplasty: navigation in TKA. Orthopedics 2003; 26 (10) 1017-1023
    PubMedGoogle Scholar
  • 15 Lotke PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg Am 1977; 59 (1) 77-79
    PubMedGoogle Scholar
  • 16 Moreland JR. Mechanisms of failure in total knee arthroplasty. Clin Orthop Relat Res 1988; (226) 49-64
    PubMedGoogle Scholar
  • 17 Oswald MH, Jakob RP, Schneider E, Hoogewoud H-M. Radiological analysis of normal axial alignment of femur and tibia in view of total knee arthroplasty. J Arthroplasty 1993; 8 (4) 419-426
    CrossrefPubMedGoogle Scholar
  • 18 Ranawat CS, Boachie-Adjei O. Survivorship analysis and results of total condylar knee arthroplasty. Eight- to 11-year follow-up period. Clin Orthop Relat Res 1988; (226) 6-13
    PubMedGoogle Scholar
  • 19 Rand JA, Coventry MB. Ten-year evaluation of geometric total knee arthroplasty. Clin Orthop Relat Res 1988; (232) 168-173
    PubMedGoogle Scholar
  • 20 Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 1994; (299) 153-156
    PubMedGoogle Scholar
  • 21 Stulberg SD, Loan P, Sarin V. Computer-assisted navigation in total knee replacement: results of an initial experience in thirty-five patients. J Bone Joint Surg Am 2002; 84-A (Suppl. 02) 90-98
    PubMedGoogle Scholar
  • 22 Stulberg SD. How accurate is current TKR instrumentation?. Clin Orthop Relat Res 2003; (416) 177-184
    PubMedGoogle Scholar
  • 23 Taylor M, Barrett DS. Explicit finite element simulation of eccentric loading in total knee replacement. Clin Orthop Relat Res 2003; (414) 162-171
    PubMedGoogle Scholar
  • 24 Wasielewski RC, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG. Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res 1994; (299) 31-43
    PubMedGoogle Scholar
  • 25 Wasielewski RC, Galat DD, Komistek RD. An intraoperative pressure-measuring device used in total knee arthroplasties and its kinematics correlations. Clin Orthop Relat Res 2004; (427) 171-178
    PubMedGoogle Scholar
  • 26 Windsor RE, Scuderi GR, Moran MC, Insall JN. Mechanisms of failure of the femoral and tibial components in total knee arthroplasty. Clin Orthop Relat Res 1989; (248) 15-19 ; discussion 19–20
    PubMedGoogle Scholar
  • 27 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467 (10) 2606-2612
    CrossrefPubMedGoogle Scholar
  • 28 Bäthis H, Perlick L, Tingart M, Lüring C, Perlick C, Grifka J. Radiological results of image-based and non-image-based computer-assisted total knee arthroplasty. Int Orthop 2004; 28 (2) 87-90
    CrossrefPubMedGoogle Scholar
  • 29 Bäthis H, Perlick L, Tingart M, Lüring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br 2004; 86 (5) 682-687
    CrossrefPubMedGoogle Scholar
  • 30 Bolognesi M, Hofmann A. Computer navigation versus standard instrumentation for TKA: a single-surgeon experience. Clin Orthop Relat Res 2005; 440: 162-169
    CrossrefPubMedGoogle Scholar
  • 31 Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthroplasty versus a conventional jig-based technique. A randomised, prospective trial. J Bone Joint Surg Br 2004; 86 (3) 372-377
    CrossrefPubMedGoogle Scholar
  • 32 Chauhan SK, Clark GW, Lloyd S, Scott RG, Breidahl W, Sikorski JM. Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT Protocol). J Bone Joint Surg Br 2004; 86 (6) 818-823
    Google Scholar
  • 33 Chin PL, Yang KY, Yeo SJ, Lo NN. Randomized control trial comparing radiographic total knee arthroplasty implant placement using computer navigation versus conventional technique. J Arthroplasty 2005; 20 (5) 618-626
    CrossrefPubMedGoogle Scholar
  • 34 Confalonieri N, Manzotti A, Pullen C, Ragone V. Computer-assisted technique versus intramedullary and extramedullary alignment systems in total knee replacement: a radiological comparison. Acta Orthop Belg 2005; 71 (6) 703-709
    PubMedGoogle Scholar
  • 35 Decking R, Markmann Y, Fuchs J, Puhl W, Scharf HP. Leg axis after computer-navigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation. J Arthroplasty 2005; 20 (3) 282-288
    CrossrefPubMedGoogle Scholar
  • 36 Delp SL, Stulberg SD, Davies B, Picard F, Leitner F. Computer assisted knee replacement. Clin Orthop Relat Res 1998; 354 (354) 49-56
    CrossrefPubMedGoogle Scholar
  • 37 Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S. Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res 2007; 457: 156-162
    CrossrefPubMedGoogle Scholar
  • 38 Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A. Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res 2005; 433 (433) 152-159
    PubMedGoogle Scholar
  • 39 Hart R, Janecek M, Chaker A, Bucek P. Total knee arthroplasty implanted with and without kinematic navigation. Int Orthop 2003; 27 (6) 366-369
    CrossrefPubMedGoogle Scholar
  • 40 Jenny JY, Boeri C. Computer-assisted implantation of total knee prostheses: a case-control comparative study with classical instrumentation. Comput Aided Surg 2001; 6 (4) 217-220
    CrossrefPubMedGoogle Scholar
  • 41 Kalairajah Y, Simpson D, Cossey AJ, Verrall GM, Spriggins AJ. Blood loss after total knee replacement: effects of computer-assisted surgery. J Bone Joint Surg Br 2005; 87 (11) 1480-1482
    CrossrefPubMedGoogle Scholar
  • 42 Kalairajah Y, Cossey AJ, Verrall GM, Ludbrook G, Spriggins AJ. Are systemic emboli reduced in computer-assisted knee surgery? A prospective, randomised, clinical trial. J Bone Joint Surg Br 2006; 88 (2) 198-202
    CrossrefPubMedGoogle Scholar
  • 43 Kim SJ, MacDonald M, Hernandez J, Wixson RL. Computer assisted navigation in total knee arthroplasty: improved coronal alignment. J Arthroplasty 2005; 20 (7) (Suppl. 03) 123-131
    CrossrefPubMedGoogle Scholar
  • 44 Nabeyama R, Matsuda S, Miura H, Mawatari T, Kawano T, Iwamoto Y. The accuracy of image-guided knee replacement based on computed tomography. J Bone Joint Surg Br 2004; 86 (3) 366-371
    CrossrefPubMedGoogle Scholar
  • 45 Seon JK, Song EK. Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial. J Arthroplasty 2006; 21 (6) 777-782
    CrossrefPubMedGoogle Scholar
  • 46 Sikorski JM, Blythe MC. Learning the vagaries of computer-assisted total knee replacement. J Bone Joint Surg Br 2005; 87 (7) 903-910
    CrossrefPubMedGoogle Scholar
  • 47 Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A. Positioning of total knee arthroplasty with and without navigation support. A prospective, randomised study. J Bone Joint Surg Br 2003; 85 (6) 830-835
    PubMedGoogle Scholar
  • 48 Stöckl B, Nogler M, Rosiek R, Fischer M, Krismer M, Kessler O. Navigation improves accuracy of rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 2004; (426) 180-186
    PubMedGoogle Scholar
  • 49 Victor J, Hoste D. Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment. Clin Orthop Relat Res 2004; (428) 131-139
    PubMedGoogle Scholar
  • 50 Bauwens K, Matthes G, Wich M , et al. Navigated total knee replacement. A meta-analysis. J Bone Joint Surg Am 2007; 89 (2) 261-269
    CrossrefPubMedGoogle Scholar
  • 51 Brin YS, Nikolaou VS, Joseph L, Zukor DJ, Antoniou J. Imageless computer assisted versus conventional total knee replacement. A Bayesian meta-analysis of 23 comparative studies. Int Orthop 2011; 35 (3) 331-339
    CrossrefPubMedGoogle Scholar
  • 52 Cheng T, Zhang G, Zhang X. Imageless navigation system does not improve component rotational alignment in total knee arthroplasty. J Surg Res 2011; 171 (2) 590-600
    CrossrefPubMedGoogle Scholar
  • 53 Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty 2007; 22 (8) 1097-1106
    CrossrefPubMedGoogle Scholar
  • 54 Decking R, Markmann Y, Mattes T, Puhl W, Scharf HP. On the outcome of computer-assisted total knee replacement. Acta Chir Orthop Traumatol Cech 2007; 74 (3) 171-174
    PubMedGoogle Scholar
  • 55 Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am 2003; 85-A (1) 1-3
    PubMedGoogle Scholar
  • 56 Borenstein M. Introduction to Meta-Analysis. Chichester, UK: John Wiley & Sons; 2009
    CrossrefGoogle Scholar
  • 57 Benjamin J. Component alignment in total knee arthroplasty. Instr Course Lect 2006; 55: 405-412
    PubMedGoogle Scholar
  • 58 Cooke TD, Sled EA, Scudamore RA. Frontal plane knee alignment: a call for standardized measurement. J Rheumatol 2007; 34 (9) 1796-1801
    PubMedGoogle Scholar
  • 59 Bejek Z, Sólyom L, Szendrõi M. Experiences with computer navigated total knee arthroplasty. Int Orthop 2007; 31 (5) 617-622
    CrossrefPubMedGoogle Scholar
  • 60 Berry DJ. Computer-assisted knee arthroplasty is better than a conventional jig-based technique in terms of component alignment. J Bone Joint Surg Am 2004; 86-A (11) 2573
    PubMedGoogle Scholar
  • 61 Bonutti PM, Dethmers DA, McGrath MS, Ulrich SD, Mont MA. Navigation did not improve the precision of minimally invasive knee arthroplasty. Clin Orthop Relat Res 2008; 466 (11) 2730-2735
    CrossrefPubMedGoogle Scholar
  • 62 Carter III RE, Rush PF, Smid JA, Smith WL. Experience with computer-assisted navigation for total knee arthroplasty in a community setting. J Arthroplasty 2008; 23 (5) 707-713
    CrossrefPubMedGoogle Scholar
  • 63 Chang CW, Yang CY. Kinematic navigation in total knee replacement—experience from the first 50 cases. J Formos Med Assoc 2006; 105 (6) 468-474
    CrossrefPubMedGoogle Scholar
  • 64 Cheung KW, Chiu KH. Imageless computer navigation in total knee arthroplasty. Hong Kong Med J 2009; 15 (5) 353-358
    PubMedGoogle Scholar
  • 65 Confalonieri N, Manzotti A, Pullen C, Ragone V. Mini-incision versus mini-incision and computer-assisted surgery in total knee replacement: a radiological prospective randomised study. Knee 2007; 14 (6) 443-447
    CrossrefPubMedGoogle Scholar
  • 66 Daubresse F, Vajeu C, Loquet J. Total knee arthroplasty with conventional or navigated technique: comparison of the learning curves in a community hospital. Acta Orthop Belg 2005; 71 (6) 710-713
    PubMedGoogle Scholar
  • 67 Dutton AQ, Yeo S-J, Yang K-Y, Lo N-N, Chia K-U, Chong H-C. Computer-assisted minimally invasive total knee arthroplasty compared with standard total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am 2008; 90 (1) 2-9
    PubMedGoogle Scholar
  • 68 Hasegawa M, Yoshida K, Wakabayashi H, Sudo A. Minimally invasive total knee arthroplasty: comparison of jig-based technique versus computer navigation for clinical and alignment outcome. Knee Surg Sports Traumatol Arthrosc 2011; 19 (6) 904-910
    CrossrefPubMedGoogle Scholar
  • 69 Jenny JY, Clemens U, Kohler S, Kiefer H, Konermann W, Miehlke RK. Consistency of implantation of a total knee arthroplasty with a non-image-based navigation system: a case-control study of 235 cases compared with 235 conventionally implanted prostheses. J Arthroplasty 2005; 20 (7) 832-839
    CrossrefPubMedGoogle Scholar
  • 70 Johnson DR, Dennis DA, Kindsfater K, Kim RH. Evaluation of TKA performed with and without computer navigation: A bilateral TKA study. J Arthroplasty 2010; 25 (3) e7
    CrossrefPubMedGoogle Scholar
  • 71 Kamat YD, Aurakzai KM, Adhikari AR, Matthews D, Kalairajah Y, Field RE. Does computer navigation in total knee arthroplasty improve patient outcome at midterm follow-up?. Int Orthop 2009; 33 (6) 1567-1570
    CrossrefPubMedGoogle Scholar
  • 72 Kim Y-H, Kim J-S, Choi Y, Kwon O-R. Computer-assisted surgical navigation does not improve the alignment and orientation of the components in total knee arthroplasty. J Bone Joint Surg Am 2009; 91 (1) 14-19
    CrossrefPubMedGoogle Scholar
  • 73 Kim YH, Kim JS, Yoon SH. Alignment and orientation of the components in total knee replacement with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br 2007; 89 (4) 471-476
    CrossrefPubMedGoogle Scholar
  • 74 Lee DH, Park JH, Song DI, Padhy D, Jeong WK, Han SB. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection. Knee Surg Sports Traumatol Arthrosc 2010; 18 (3) 381-387
    CrossrefPubMedGoogle Scholar
  • 75 Lehnen K, Giesinger K, Warschkow R, Porter M, Koch E, Kuster MS. Clinical outcome using a ligament referencing technique in CAS versus conventional technique. Knee Surg Sports Traumatol Arthrosc 2011; 19 (6) 887-892
    CrossrefPubMedGoogle Scholar
  • 76 Lützner J, Krummenauer F, Wolf C, Günther KP, Kirschner S. Computer-assisted and conventional total knee replacement: a comparative, prospective, randomised study with radiological and CT evaluation. J Bone Joint Surg Br 2008; 90 (8) 1039-1044
    PubMedGoogle Scholar
  • 77 Martin A, Wohlgenannt O, Prenn M, Oelsch C, von Strempel A. Imageless navigation for TKA increases implantation accuracy. Clin Orthop Relat Res 2007; 460: 178-184
    CrossrefPubMedGoogle Scholar
  • 78 Matsumoto T, Tsumura N, Kurosaka M, Muratsu H, Yoshiya S, Kuroda R. Clinical values in computer-assisted total knee arthroplasty. Orthopedics 2006; 29 (12) 1115-1120
    PubMedGoogle Scholar
  • 79 Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C. A prospective, randomized study of computer-assisted and conventional total knee arthroplasty. Three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am 2007; 89 (2) 236-243
    CrossrefPubMedGoogle Scholar
  • 80 Molfetta L, Caldo D. Computer navigation versus conventional implantation for varus knee total arthroplasty: a case-control study at 5 years follow-up. Knee 2008; 15 (2) 75-79
    CrossrefPubMedGoogle Scholar
  • 81 Mombert M, Van Den Daelen L, Gunst P, Missinne L. Navigated total knee arthroplasty: a radiological analysis of 42 randomised cases. Acta Orthop Belg 2007; 73 (1) 49-54
    PubMedGoogle Scholar
  • 82 Mullaji A, Kanna R, Marawar S, Kohli A, Sharma A. Comparison of limb and component alignment using computer-assisted navigation versus image intensifier-guided conventional total knee arthroplasty: a prospective, randomized, single-surgeon study of 467 knees. J Arthroplasty 2007; 22 (7) 953-959
    CrossrefPubMedGoogle Scholar
  • 83 Pang CH, Chan WL, Yen CH , et al. Comparison of total knee arthroplasty using computer-assisted navigation versus conventional guiding systems: a prospective study. J Orthop Surg (Hong Kong) 2009; 17 (2) 170-173
    PubMedGoogle Scholar
  • 84 Rosenberger RE, Hoser C, Quirbach S, Attal R, Hennerbichler A, Fink C. Improved accuracy of component alignment with the implementation of image-free navigation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2008; 16 (3) 249-257
    CrossrefPubMedGoogle Scholar
  • 85 Seon JK, Song EK. Functional impact of navigation-assisted minimally invasive total knee arthroplasty. Orthopedics 2005; 28 (10, Suppl): s1251-s1254
    PubMedGoogle Scholar
  • 86 Seon JK, Song EK, Yoon TR, Park SJ, Bae BH, Cho SG. Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty. Comput Aided Surg 2007; 12 (3) 189-193
    CrossrefPubMedGoogle Scholar
  • 87 Seon JK, Park SJ, Lee KB, Li G, Kozanek M, Song EK. Functional comparison of total knee arthroplasty performed with and without a navigation system. Int Orthop 2009; 33 (4) 987-990
    CrossrefPubMedGoogle Scholar
  • 88 Song EK, Seon JK, Yoon TR, Park SJ, Cho SG, Yim JH. Comparative study of stability after total knee arthroplasties between navigation system and conventional techniques. J Arthroplasty 2007; 22 (8) 1107-1111
    CrossrefPubMedGoogle Scholar
  • 89 Stulberg SD, Yaffe MA, Koo SS. Computer-assisted surgery versus manual total knee arthroplasty: a case-controlled study. J Bone Joint Surg Am 2006; 88 (Suppl. 04) 47-54
    PubMedGoogle Scholar
  • 90 Tingart M, Lüring C, Bäthis H, Beckmann J, Grifka J, Perlick L. Computer-assisted total knee arthroplasty versus the conventional technique: how precise is navigation in clinical routine?. Knee Surg Sports Traumatol Arthrosc 2008; 16 (1) 44-50
    CrossrefPubMedGoogle Scholar
  • 91 Tyagi V, Kim TH, Hwang JH, Oh KJ. Imageless navigation assisted total knee arthroplasty with comprehensive gap balancing in medial osteoarthritic varus knees with anatomic variations. Comput Aided Surg 2010; 15 (4–6) 90-97
    CrossrefPubMedGoogle Scholar
  • 92 van Strien T, van der Linden-van der Zwaag E, Kaptein B, van Erkel A, Valstar E, Nelissen R. Computer assisted versus conventional cemented total knee prostheses alignment accuracy and micromotion of the tibial component. Int Orthop 2009; 33 (5) 1255-1261
    CrossrefPubMedGoogle Scholar
  • 93 Weng YJ, Hsu RW, Hsu WH. Comparison of computer-assisted navigation and conventional instrumentation for bilateral total knee arthroplasty. J Arthroplasty 2009; 24 (5) 668-673
    CrossrefPubMedGoogle Scholar
  • 94 Zhang GQ, Chen JY, Chai W, Liu M, Wang Y. Comparison between computer-assisted-navigation and conventional total knee arthroplasties in patients undergoing simultaneous bilateral procedures: a randomized clinical trial. J Bone Joint Surg Am 2011; 93 (13) 1190-1196
    PubMedGoogle Scholar