Functional outcomes of SRs that addressed TKA | |

Knee Society Scores (KSS) | |

SR | Results |

Xie, 2012 | Within 6 months: mean standard difference: 4.47; (95% CI 21.05 to 9.99, p=0.36) |

Cheng, 2012 | At 3 months (WMD=1.11, 95% CI −6.33 to 8.56) and 6 months (WMD=2.13, 95% CI −2.53 to 6.79) follow-up |

Rebal, 2014 | 3 months postoperative change: CA TKA had a mean score increase of 68.5 (52.9–75.0), significantly superior to the mean score of 58.1 (47.3–64.0) for knees performed with conventional guides (p=0.03, 95% CI 1.13 to 19.78) Postoperative change at 12–32 months follow-up: knees in the CA TKA groups improved by a mean of 53.1 (37.7–96.6), significantly superior to the mean of 45.8 (32–89.5) for the CONV group (p<0.01, 95% CI 2.87 to 11.90) |

Shin, 2016 | The pooled data showed that the mean difference in the postoperative KSS was 11.15 points higher with the MINA approach than the CONV approach, but this difference was not statistically significant (95 % CI −8.55 to 30.84; N.S.; I 2=98% |

VanderList, 2016 | 6 months: pooled mean difference=5.2 (3.41, 7.00). 1 year: (8.46, 90.65, 16.28). 2 years: 1.97 (−1.91, 5.84). More than 4 years: 2.65 (0.84, 4.46). Total=2.86 (0.96, 4.76) Navigated vs conventional TKA surgery with navigation systems aiming to control for alignment and component position: pooled mean difference=0.66 (−2.06 to 3.38) Navigated vs conventional TKA surgery with navigation systems aiming to control for alignment and component position with controlling for soft tissue balance: pooled mean difference=4.84 (1.61 to 8.07) |

Moskal, 2014 | KSS were slightly larger for NAV, demonstrating some improvement compared with CONV. Knee Society Function Scores: standardized difference in means=−0.341 95% CI (−0.532 to −0.150) p=0.000 Knee Society Knee Scores: standardized difference in means=−0.294 95% CI (−0.489 to −0.100) p=0.003 Knee Society total Scores: standardized difference in means=−0.623 95% CI (−0.940 to −0.307) p=0.000 |

Panjwani, 2019 | Follow-up ≥ 2 years and <5 years postoperatively: no difference (p=0.13; pooled mean difference=−0.86; CI −1.96 to 0.25) Follow-up >5 years and <8 years postoperatively: no significant difference in the two groups (p=0.09) Follow-up >8 years postoperatively: no significant difference in the two groups (p=0.91) |

WOMAC Scores | |

Moskal 2014 | WOMAC Scores (Pain Score, Stiffness Score, and Physical Function Score) were slightly lower for NAV, showing some improvement compared with CONV. WOMAC Pain Scores: standardized difference in means=−0.472; 95% CI (−0.826 to −0.117), p<0.009 WOMAC Stiffness Scores: standardized difference in means=−0.274 95% CI (−0.538 to −0.010), p<0.042 WOMAC Physical Function Scores: standardized difference in means=−0.369 95% CI (−0.619 to −0.173), p<0.001 |

Panjwani, 2019 | Follow-up ≥2 years and <5 years postoperatively: no difference between the two groups (p=0.60; pooled mean difference=0.86; CI −2.32 to 4.04) Follow-up >5 years and <8 years postoperatively: significantly better in the CAS-TKA group (p<0.0001; pooled mean difference=−2.05; CI −2.82 to −1.28) Follow-up >8 years postoperatively: no difference in the two groups (p=0.94; pooled mean difference= −0.08; CI −2.10 to 1.95) |

Karunaratne, 2019 | Low quality of evidence of no difference (mean difference= −0.51; 95% CI −1.95 to 0.94) |

Knee range of motion (ROM) | |

Xie, 2012 | Mean standard difference: 1.38; 95% CI 21.43 to 4.18, p=0.34) |

Shin 2016 | The pooled mean difference in postoperative flexion ROM was 16.64 (95 % CI 14.26 to 19.01, p<0.001; I2=0%) |

Hospital for special surgery (HSS) | |

Karunaratne, 2019 | Medium-term: low quality of evidence of no difference between groups (mean difference=0.04 (−2.94 to 3.01)) Long-term: low quality of evidence of no difference between groups (mean difference=−0.51 (−1.83 to 0.82)) |

Radiological outcomes of SRs that addressed TKA | |

Mechanical axis malalignment | |

Smith, 2012 | No difference |

Hetaimish, 2012 | Malalignment >3°: RR=0.37 (95% CI 0.24 to 0.58, p=0.00001), MAM>2°: 0.54 (95% CI 0.42 to 0.69, p=0.004) |

Thieopont, 2013 | Malalignment >2°, the effect measures (ie, OR and risk ratio) ranged from 0.21 to 0.76 Malalignment >3°, the reduction was comparable, and effect measures ranged from 0.19 to 0.79 |

Cheng, 2012 | Mechanical axis malalignment >3°: OR=0.4 (95% CI (0.31 to 0.51) |

Fu, 2012 | Malalignment of >3°: a meta-analysis OR of 0.26 (95% CI 0.17 to 0.38) Malalignment at >2°: a meta-analysis OR of 0.33 (95% CI 0.26 to 0.42) |

Rebal, 2014 | The risk difference of alignment within 3° of ideal is 0.14 (CI 0.1 to 1.18) The absolute value of degrees deviation: for the CAS group the mean deviation was 1.3° (1.0° to 1.9°), significantly less than the CONV group deviation of 2.4° (1.8° to 3.2°) (P < .01, 95% CI −1.38 to −0.67 The mean average of the degrees of deviation of the mechanical axis: The CAS group had a mean deviation of 0.3° (−0.6° to 1.0°) while the CONV group had a mean deviation of 0.5° (−2.4° to 1.2) (p=0.33, 95% CI −0.65 to 0.22) Note: positive values for varus deviation and negative values for valgus deviation |

Shi, 2014 | The pooled OR for overall outliers in mechanical axis showed no difference between the two groups; no heterogeneity was observed (p=1.000; I2=0.0%) |

Shin 2016 | No statistical difference is present (95 % CI 1.01 to 0.54; N.S.; I2=64%) |

Zamora, 2013 | OR of postoperative alignment of the mechanical axis in the frontal plane (postoperative deviation of 3° from target angle of 180°=2.32. (95% CI 1.77 to 3.04) |

Cheng, 2011 (A) | RR=0.4; 95% CI 0.31 to 0.5 |

Mason, 2007 | Malalignment >3 °: a meta-analytic mean OR 0.22 (95% CI 0.16 to 0.29) Malalignment >2 °: a meta-analytic mean OR of 0.35 (95% CI 0.28 to 0.43) |

Cheng, 2011 (B) | Malalignment >3° (RR=0.19, 95% CI 0.11 to 0.32, p<0.00001, I2=10% |

Liu, 2014 | Malalignment >3°(OR=0.55; 95% CI 0.44 to 0.68, p<0.001) |

Brin, 2011 | Malalignment >3°: (prospective randomized studies alone): OR=0.03 (95% CI 0.15 to 0.52), (prospective randomized and retrospective studies): OR=0.21 (95% CI 0.12 to 0.33) |

Moskal, 2014 | Femoral flexion angle deviation from neutral: standardized difference in means: −0.606. 95% CI −0.856 to −0.356, p=0.000 Anatomic axis outliers: standardized difference in means: 0.242; 95% CI 0.098 to 0.593, p=0.002 Mechanical axis outliers: OR=0.356; 95% CI 0.237 to 0.536, p=0.000 Tibial component alignment outliers: OR= 0.356; 95% CI 0.237 to 0.536,) p =0.000 Femoral component alignment outliers: OR=0.387; 95% CI 0.254 to 0.589, p=0.000 |

Mannan, 2018 | Weighted mean differences of postoperative alignment to be more accurate in the robotic knee group: mean difference=−0.63; 95% CI −1.18 to 0.08, z=2.25, p=0.02 |

Coronal plane femoral component outliers | |

Fu, 2012 | The OR of malalignment of >3° was estimated at 0.33 (95% CI 0.14 to 0.75) |

Rebal 2014 | Within 3° of ideal (90°): 97.6% (94%–100%) in the CAS groups, significantly more than the 87.4% (81%–97%) in the CONV group (P b .01, 95% CI 0.05 to 0.14) |

Shi 2014 | The pooled data in the random-effects model showed no difference between the two groups. No heterogeneity was observed |

Shin 2016 | The pooled mean difference was similar between the MINA and CONV approaches (95 % CI −0.91 to 2.97; N.S.; I2=95%) |

Cheng 2011 (A) | RR=0.37; 95% CI 0.22 to 0.64 |

Mason 2007 | Malalignment >3°: a meta-analytic mean OR 0.34 (95% CI 0.24 to 0.48) Malalignment >2°: a meta-analytic mean OR 0.29 (95% CI 0.14 to 0.56) |

Brin, 2011 | Femoral angle (prospective randomized and retrospective studies) OR=0.19 (95% CI 0.08 to 0.39) |

Moskal 2014 | Standardized difference in means: −0.663; 95% CI −0.929 to −0.397, p=0.000 |

Coronal plane tibial component outliers | |

Fu, 2012 | Malalignment of >3°: the OR was estimated at 0.29 (95% CI 0.16 to 0.50) |

Rebal 2014 | Within 3° of ideal (90°) demonstrated equivalent results in the CAS group (92.1% (83–100%)) and the CONV group (91.7% (82–97%)) (p=0.73; 95% CI −0.06 to 0.09) |

Shi 2014 | No difference between the two groups. |

Mason 2007 | Malalignment >3°: a meta-analytic mean OR 0.36; 95% CI 0.23 to 0.57 Malalignment >2°: a meta-analytic mean OR 0.26; 95% CI 0.17 to 0.40 |

Brin, 2011 | Tibial angle (prospective randomized and retrospective studies): OR=0.19 (0.07 to 0.41) |

Moskal 2014 | Standardized difference in means: −0.268; 95% CI −0.350 to −0.185, p=0.000 |

Sagittal femoral component malalignment | |

Fu, 2012 | Malalignment of >3°: OR=0.35; 95% CI 0.17 to 0.74 Malalignment at >2°: OR=0.22; 95% CI 0.06 to 0.76 |

Mason, 2007 | Malalignment >3°: a meta-analytic mean OR=0.39; 95% CI 0.11 to 1.34 Malalignment >2°: a meta-analytic mean OR=0.13; 95% CI 0.03 to 0.54 |

Femoral slope | |

FMoskal, 2014 | Femoral slope outliers: OR=0.465; 95% CI 0.303 to 0.712, p=0.000 |

Tibial slope | |

Fu, 2012 | Malalignment of >3°: OR=0.43; 95% CI 0.30 to 0.61 Malalignment at >2°: OR=0.42; 95% CI 0.23 to 0.76 |

Mason 2007 | Malalignment >3°: a meta-analytic mean OR=0.43; 95% CI 0.13 to 1.39 Malalignment >2°: a meta-analytic mean OR=0.31; 95% CI 0.16 to 0.61 |

Moskal 2014 | Standardized difference in means: −0.268; 95% CI −0.350 to −0.185, p=0.000 Tibial slope outliers: OR=0.474; 95% CI 0.309 to 0.729, p=0.001 |

Tibiofemoral mismatch | |

Mejer, 2014 | Standardized mean difference=−0.37 (−1.67 to −0.08) |

Component axial rotation | |

Mejer 2014 | Postoperative rotation of the femoral component: standardized mean difference = −7° (−0.19 to 0.04) Postoperative rotation of the tibial component=0.110.010.24) Number of femoral rotational: pooled OR=1.05 (0.78 to 1.43) Number of tibial rotational: pooled OR=1.12 (0.68 to 1.47) |

Patient safety outcomes of SRs that addressed TKA | |

Allogenic blood transfusion rate | |

Han 2016 | The difference is not statistically significant OR 0.70; 95 % CI 0.49 to 1.01; I 2=0% |

Operative blood loss | |

Xie, 2012 | No significant difference. Mean standard difference=-54.38; 95% CI -119.76 to 11.00; p=0.10) |

Moskal 2014 | No difference |

Change in hemoglobin concentration/hematocrit before and after surgery | |

Han, 2016 | The pooled mean difference in change of hemoglobin was −0.39 g/ dL (95 % CI −0.67 to −0.11, p=0.006; I2=75 %) The pooled mean difference of change of hematocrit was similar in the two groups (0.24%; 95 % CI −0.89% to 0.41%; N.S.; I2=25%) |

Postoperative blood loss via drainage | |

Han, 2016 | The pooled standard mean difference in drainage blood loss was −83.1 mL (95 % CI −159.0 to −7.1, p=0.03; I2=75 %) |

Calculated total blood loss | |

Han, 2016 | The pooled standard mean difference in calculated total blood loss was −185.4 mL (95 % CI −303.3 to −67.5 mL; p=0.002) |

Tourniquet time | |

Moskal 2014 | CONV had significantly lower tourniquet times: standardized difference in means: 0.993; 95% CI 0.567 to 1.419, p=0.000 |

Allogenic blood transfusion rate | |

Han, 2016 | The difference is not statistically significant OR 0.70; 95 % CI 0.49 to 1.01; I2=0% |

Complications/adverse events | |

Alcelik, 2016 | The OR between the MIS CA and the MIS group was 1.31; 95% CI 0.47 to 3.65, p=0.61 |

Cheng, 2011 (B) | No significant difference (RR=1.50; 95% CI 0.44 to 5.11, p=0.51) |

Bauwens 2007 | Risk ratio, 0.69; 95% CI 0.44 to 1.08. There was no evidence of a difference in infection rates (risk ratio, 0.97; 95% CI 0.33 to 2.85) or the onset of thromboembolic events (risk ratio, 0.64; 95% CI 0.31 to 1.34) |

A) 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. doi: 10.1016/j.jss.2010.05.006.B) Cheng T, Zhang G, Zhang X. Clinical and radiographic outcomes of image-based computer-assisted total knee arthroplasty: an evidence-based evaluation.

*Surg Innov*2011;18(1):15–20. doi: 10.1177/1553350610382012.CA, computer assisted; CAS, computer-assisted surgery; CONV, conventional; KSS, Knee Society Score; MIS, Minimally invasive; NAV, navigation; ROM, range of motion; RR, relative risk; SR, systematic review; TKA, total knee arthroplasty; WMD, Weighted mean difference; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.