Does Imageless Computer-assisted TKA Lead to Improved Rotational Alignment or Fewer Outliers?: A Systematic Review

Computer-assisted surgery (CAS) has been developed to enhance prosthetic alignment during primary TKAs. Imageless CAS improves coronal and sagittal alignment compared with conventional TKA. However, the effect of imageless CAS on rotational alignment remains unclear. We conducted a systematic and qualitative review of the current literature regarding the effectiveness of imageless CAS during TKA on (1) rotational alignment of the femoral and tibial components and tibiofemoral mismatch in terms of deviation from neutral rotation, and (2) the number of femoral and tibial rotational outliers. Data sources included PubMed, MEDLINE, and EMBASE. Study selection, data extraction, and methodologic quality assessment were conducted independently by two reviewers. Standardized mean difference with 95% CI was calculated for continuous variables (rotational alignment of the femoral or tibial component and tibiofemoral mismatch). To compare the number of outliers for femoral and tibial component rotation, the odds ratio and 95% CI were calculated. The literature search produced 657 potentially relevant studies, 17 of which met the inclusion criteria. One study was considered as having high methodologic quality, 15 studies had medium, and one study had low quality. Conflicting evidence was found for all outcome measures except for tibiofemoral mismatch. Moderate evidence was found that imageless CAS had no influence on postoperative tibiofemoral mismatch. The measurement protocol for measuring tibial rotation varied among the studies and in only one of the studies was the sample size calculation based on one of the outcome measures used in our systematic review. More studies of high methodologic quality and with a sample size calculation based on the outcome measures will be helpful to assess whether an imageless CAS TKA improves femoral and tibial rotational alignment and tibiofemoral mismatch or decreases the number of femoral and tibial rotational outliers. To statistically analyze the results of different studies, the same measurement protocol should be used among the studies