Image-based navigation improves the positioning of the humeral component in total elbow arthroplasty.

HYPOTHESIS Implant alignment in total elbow arthroplasty (TEA) is a challenging and error-prone process using conventional techniques. Identification of the flexion-extension (FE) axis is further complicated for situations of bone loss. This study evaluated the accuracy of humeral component alignment in TEA. We hypothesized that an image-based navigation system would improve humeral component positioning, with navigational errors less than or approaching 2.0 mm and 2.0 degrees . MATERIALS AND METHODS Implantation of a modified commercial TEA humeral component was performed with and without navigation on 11 cadaveric distal humeri. Navigated alignment was based on positioning the humeral component with the aid of a computed tomography (CT)-based preoperative plan registered to landmarks on the distal humerus. Alignment was performed under 2 scenarios of bone quality: (1) an intact distal humerus, and (2) a distal humerus without articular landmarks. RESULTS Navigation significantly improved implant alignment accuracy (P < .001). Navigated implant alignment was 1.2 +/- 0.3 mm in translation and 1.3 degrees +/- 0.3 degrees in rotation for the intact scenario. For the bone loss scenario, navigated alignment error was 1.1 +/- 0.5 mm and 2.0 degrees +/- 1.3 degrees . Non-navigated alignment was 3.1 +/- 1.3 mm and 5.0 degrees +/- 3.8 degrees for the intact scenario and 3.0 +/- 1.6 mm and 12.2 degrees +/- 3.3 degrees for the bone loss scenario. DISCUSSION Image-based navigation improves the accuracy and reproducibility of humeral component placement in TEA. Implant alignment errors for the navigated alignments were below the target of 2.0 degrees and 2 mm that is considered standard for most navigation systems. Non-navigated implant alignment error was significantly greater for the bone loss scenario compared with the intact scenario. CONCLUSIONS Implant malalignment may increase the likelihood of early implant wear, instability, and loosening. Improved implant positioning will likely lead to fewer complications and greater prosthesis longevity.

[1]  S. Sonne‐Holm,et al.  The GSB III elbow prosthesis in rheumatoid arthritis: A 2- to 9-year follow-up , 2006, Acta orthopaedica.

[2]  R. Ellis,et al.  Computer-assisted distal radius osteotomy. , 2003, The Journal of hand surgery.

[3]  G. King,et al.  Total Elbow Arthroplasty in the Treatment of Posttraumatic Conditions of the Elbow , 2000, Clinical orthopaedics and related research.

[4]  B F Morrey,et al.  The Coonrad-Morrey Total Elbow Arthroplasty in Patients Who Have Rheumatoid Arthritis. A Ten to Fifteen-Year Follow-up Study* , 1998, The Journal of bone and joint surgery. American volume.

[5]  George S Athwal,et al.  Prosthetic replacement for distal humerus fractures. , 2008, The Orthopedic clinics of North America.

[6]  O. Ennis,et al.  ii) Total elbow arthroplasty , 2008 .

[7]  H E Veeger,et al.  Determination of the optimal elbow axis for evaluation of placement of prostheses. , 1999, Clinical biomechanics.

[8]  L. Amiot,et al.  Computed Tomography-Based Navigation for Hip, Knee, and Spine Surgery , 2004, Clinical orthopaedics and related research.

[9]  G L Niebur,et al.  Motion and laxity of the capitellocondylar total elbow prosthesis. , 1994, The Journal of bone and joint surgery. American volume.

[10]  B. Morrey,et al.  Primary Osteoarthritis of the Elbow: Current Treatment Options , 2008, The Journal of the American Academy of Orthopaedic Surgeons.

[11]  A. Carr,et al.  Total elbow arthroplasty: a systematic review of the literature in the English language until the end of 2003. , 2005, The Journal of bone and joint surgery. British volume.

[12]  James A. Johnson,et al.  Design and development of a computer assisted glenoid implantation technique for shoulder replacement surgery , 2007, Computer aided surgery : official journal of the International Society for Computer Aided Surgery.

[13]  L. Holly,et al.  Evaluation of registration techniques for spinal image guidance. , 2006, Journal of neurosurgery. Spine.

[14]  Jay B. West,et al.  Predicting error in rigid-body point-based registration , 1998, IEEE Transactions on Medical Imaging.

[15]  B. Morrey,et al.  Instability of the elbow treated with semiconstrained total elbow arthroplasty. , 1999, The Journal of bone and joint surgery. American volume.

[16]  D. Banzer,et al.  Positioning of total knee arthroplasty with and without navigation support. A prospective, randomised study. , 2003, The Journal of bone and joint surgery. British volume.

[17]  Benoit M. Dawant,et al.  Surface-based registration of CT images to physical space for image-guided surgery of the spine: a sensitivity study , 1998, IEEE Transactions on Medical Imaging.

[18]  Ken Yamaguchi,et al.  Elbow arthroplasty using a convertible implant. , 2005, Techniques in hand & upper extremity surgery.

[19]  D. Zurakowski,et al.  Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. , 2004, The Journal of bone and joint surgery. British volume.

[20]  J. London.  Kinematics of the elbow. , 1981, The Journal of bone and joint surgery. American volume.

[21]  Bernard F. Morrey,et al.  The Elbow and Its Disorders , 2000 .

[22]  Georg Matziolis,et al.  A prospective, randomized study of computer-assisted and conventional total knee arthroplasty. Three-dimensional evaluation of implant alignment and rotation. , 2007, The Journal of bone and joint surgery. American volume.

[23]  James A. Johnson,et al.  Early experience with computer-assisted shoulder hemiarthroplasty for fractures of the proximal humerus: development of a novel technique and an in vitro comparison with traditional methods. , 2007, Journal of shoulder and elbow surgery.

[24]  B F Morrey,et al.  Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow. , 2005, The Journal of bone and joint surgery. British volume.

[25]  P. Rozing,et al.  Systematic review of primary total elbow prostheses used for the rheumatoid elbow , 2004, Clinical Rheumatology.

[26]  P. D. Di Cesare,et al.  Surgical Management of the Rheumatoid Elbow , 2003, The Journal of the American Academy of Orthopaedic Surgeons.

[27]  J. Argenson,et al.  Validation and usefulness of a computer-assisted cup-positioning system in total hip arthroplasty. A prospective, randomized, controlled study. , 2007, The Journal of bone and joint surgery. American volume.

[28]  James A. Johnson,et al.  Surgeon accuracy in the selection of the flexion-extension axis of the elbow: an in vitro study. , 2006, Journal of shoulder and elbow surgery.

[29]  F Langlotz,et al.  Computer Assistance for Pelvic Osteotomies , 1998, Clinical orthopaedics and related research.

[30]  Hani Haider,et al.  Minimally invasive total knee arthroplasty surgery through navigated freehand bone cutting: winner of the 2005 "HAP" PAUL AWARD. , 2007, The Journal of arthroplasty.

[31]  Paul J. Besl,et al.  A Method for Registration of 3-D Shapes , 1992, IEEE Trans. Pattern Anal. Mach. Intell..

[32]  Colin P McDonald,et al.  The effect of anatomic landmark selection of the distal humerus on registration accuracy in computer-assisted elbow surgery. , 2008, Journal of shoulder and elbow surgery.

[33]  E. W. Kelly,et al.  Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty. , 2004, Journal of shoulder and elbow surgery.

[34]  D. Vandevelde,et al.  Reduction in Variability of Acetabular Cup Abduction Using Computer Assisted Surgery: A Prospective and Randomized Study , 2002, Computer aided surgery : official journal of the International Society for Computer Aided Surgery.

[35]  N. Blewitt,et al.  An anatomic study of the axis of elbow movement in the coronal plane: Relevance to component alignment in elbow arthroplasty. , 1994, Journal of shoulder and elbow surgery.

[36]  B F Morrey,et al.  Loose-hinge total elbow arthroplasty. An experimental study of the effects of implant alignment on three-dimensional elbow kinematics. , 1995, The Journal of arthroplasty.

[37]  Hideki Yoshikawa,et al.  Surface-based registration accuracy of CT-based image-guided spine surgery , 2005, European Spine Journal.

[38]  P Mansat,et al.  Semiconstrained Total Elbow Arthroplasty for Ankylosed and Stiff Elbows* , 2000, The Journal of bone and joint surgery. American volume.

[39]  Daniel B. Russakoff,et al.  Intensity-based 2D-3D spine image registration incorporating a single fiducial marker. , 2005, Academic radiology.

[40]  William J. Schroeder,et al.  The Visualization Toolkit , 2005, The Visualization Handbook.

[41]  J T Bryant,et al.  Geometry of the humeroulnar joint , 1988, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[42]  R. Emery,et al.  Total elbow replacement in the treatment of rheumatoid disease. , 1999, Clinical orthopaedics and related research.

[43]  C. Sinopidis,et al.  Unlinked elbow arthroplasty as primary treatment for fractures of the distal humerus. , 2008, Journal of shoulder and elbow surgery.

[44]  D. Baksi.  Sloppy hinge prosthetic elbow replacement for post-traumatic ankylosis or instability. , 1998, The Journal of bone and joint surgery. British volume.

[45]  Kai-Nan An.  Kinematics and constraint of total elbow arthroplasty. , 2005, Journal of shoulder and elbow surgery.

[46]  B F Morrey,et al.  Total elbow arthroplasty in primary osteoarthritis of the elbow. , 1998, The Journal of arthroplasty.

[47]  Brigitte M Jolles,et al.  Computer-assisted Cup Placement Techniques in Total Hip Arthroplasty Improve Accuracy of Placement , 2004, Clinical orthopaedics and related research.

[48]  T D Brown,et al.  Radiographic determinants of the elbow rotation axis: Experimental identification and quantitative validation , 2000, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[49]  A. Carr,et al.  Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants. , 2005, The Journal of bone and joint surgery. American volume.