Background: Unsatisfactory alignment in unicompartmental knee arthroplasty (UKA) is one potential cause of postoperative failure. Patient-specific instruments (PSIs) are designed to improve the alignment of the prostheses, but the effect of PSIs on the alignment or clinical outcome is controversial and lacks validated evidence. We conducted a meta-analysis and systematic review to determine the effect of PSIs on UKA outcomes for the first time.
Materials and methods: A systematic literature search in MEDLINE, EMBASE, CNKI (Chinese database) and Cochrane Central Register of Controlled Trials (up to June 2019) was performed to collect studies that compared PSIs with conventional instruments. Two reviewers independently screened all the records on the basis of inclusion and exclusion criteria. Quality assessments with Cochrane's quality assessment tool or Newcastle-Ottawa scale (NOS) were conducted, the data were extracted, and statistical analyses were completed.
Results: Ten studies with 444 knees were included. The meta-analysis confirmed that PSIs contributed to reduced errors in the alignment of the femoral compartment in the sagittal plane (mean difference = - 2.53, CI [- 3.14, - 1.99], P < 0.01) and the tibial compartment in both the coronal (mean difference = - 0.97, CI [- 1.44, - 0.49], P < 0.01) and the sagittal plane (mean difference = - 1.29, CI [- 1.81, - 0.76], P < 0.01). One study supported that PSIs reduced outliers in inexperienced surgeons; however, all studies investigating PSIs among experienced surgeons suggested that PSIs cannot reduce the percentage of outliers. There was no significant difference in the postoperative score (mean difference = - 0.06, CI [- 0.36, 0.23], P = 0.68) or rate of complications (RR = 1.02, CI [0.15, 6.79], P = 0.99) between PSIs and conventional instruments.
Conclusion: The findings of this study suggest PSIs could not reduce the percentage of outliers in UKA patients for experts, and postoperative scores and complication rates are not improved by PSIs, compared with conventional instruments. Based on this meta-analysis and systematic review, no practical benefit to UKAs in experts was detected in PSIs. The findings of this study also suggest that PSIs improved alignment of UKA and might be beneficial to inexperienced surgeons, but it is still unclear whether this improvement is clinically significant and the evidence of inexperienced surgeons is limited. Therefore, more high-quality RCTs are need to be carried out in the future.
Keywords: Alignment; PSI; Patient-specific instrument; Total knee arthroplasty; Unicompartmental knee arthroplasty.