Journal of

Clinical Medicine

Article
Pinless Navigation in Unicompartmental Knee Arthroplasty
Sarah Keuntje-Perka 1,2 , Philipp von Roth 1 , Michael Worlicek 2, *, Matthias Koch 2 , Volker Alt 2
and Moritz Kaiser 1,2

1 Sporthopaedicum Straubing, Medical Care Center, 94135 Straubing, Germany;

sarahperka@googlemail.com (S.K.-P.); roth@sporthopaedicum.de (P.v.R.); moritz.kaiser@ukr.de (M.K.)
2 Department of Trauma Surgery, Regensburg University Medical Center, 93053 Regensburg, Germany;
matthias.koch@ukr.de (M.K.); volker.alt@ukr.de (V.A.)
* Correspondence: michael.worlicek@gmx.de

Abstract: Purpose: In contrast to total knee arthroplasty (TKA), unicompartmental knee arthroplasty
(UKA) is a true resurfacing procedure, as none of the ligaments are replaced or released, and the
pre-arthritic leg alignment is the major goal. As such, the alignment of the tibial component plays a
crucial role in postoperative knee function and long-term survival. Pinless navigation has shown
reliable results in total knee arthroplasty. To the best of our knowledge, the use of pinless navigation
has not been investigated for UKA. Therefore, the present study investigated whether implantation
of the tibial component in 3◦ varus, which is closer to the anatomical axis, is feasible with a pinless
optical navigation system. Methods: 60 patients with the diagnosis of an unicompartmental arthritis,
were eligible for UKA and treated with implantation in 3◦ varus alignment of the tibial component.



Two groups were established. In the treatment group the tibial component was aligned using a


pinless navigation technique. In the control group, a conventional extramedullary alignment guide
Citation: Keuntje-Perka, S.; von
was used. A clinical and radiographic follow up took place within 1 year of operation. Results:
Roth, P.; Worlicek, M.; Koch, M.; Alt,
57 Patients were eligible for analysis. No clinical incidents were noted in the follow up period. The
V.; Kaiser, M. Pinless Navigation in
desired target value, the position of the tibial component, was accurately achieved with an average
Unicompartmental Knee
of 3◦ medial inclination using the pinless navigation as well as using the conventional technique.
Arthroplasty. J. Clin. Med. 2021, 10,
2422. https://doi.org/10.3390/
Mean incision to suture time was negligible between the two techniques. The mean suture time was
jcm10112422 43.2 min with pinless navigation and 42.7 min with the conventional technique. Conclusions: With
pinless navigation in UKA, a method was presented that made it possible to achieve sled prosthesis
Academic Editors: alignment at the level of a high-volume surgeon. These results were achieved with an irrelevant
Victor Valderrabano and increase of surgical time and without placement of pins.
Emmanuel Andrès
Keywords: knee arthroplasty; unicompartmental; navigation; pinless
Received: 15 March 2021
Accepted: 27 May 2021
Published: 30 May 2021

1. Introduction
Publisher’s Note: MDPI stays neutral
Currently, there is an increasing interest in unicondylar knee arthroplasty (UKA).
with regard to jurisdictional claims in
Compared to total knee arthroplasty (TKA), there are fewer postoperative complications
published maps and institutional affil-
iations.
such as wound alterations or periprosthetic infections [1,2]. In some studies it could also
be shown that the early outcome, especially with regard to function, is better than with
TKA [2,3].
However, UKA seems to have a higher long-term revision rate compared to TKA [1,2].
The reasons for this are quite unclear, as there are almost no studies that investigated to
Copyright: © 2021 by the authors.
optimal implant position in UKA.
Licensee MDPI, Basel, Switzerland.
While UKA is the only so-called true surface replacement, since both cruciate ligaments
This article is an open access article
are preserved and the aim of the postoperative alignment is the pre-arthritic status, the
distributed under the terms and
conditions of the Creative Commons
accuracy of implantation is of high relevance for the long-term success.
Attribution (CC BY) license (https://
Up to now, the tibial component has been implanted at a 90◦ angle with respect to the
creativecommons.org/licenses/by/
coronal longitudinal axis, but the native knee joint line has approximately 3◦ varus. Only
4.0/).

J. Clin. Med. 2021, 10, 2422. https://doi.org/10.3390/jcm10112422 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2021, 10, 2422 2 of 10

one study investigated slightly varus-aligned tibia implants in UKA and reported a longer
survival rate than neutral alignment [4].
It has also been shown that implantation accuracy and clinical outcome can be im-
proved by using robotic-assisted and computer-navigated systems using pins in TKA and
UKA [5,6], but there is a lack of research for pinless navigation in UKA. In UKA, navigation
with pins is not appropriate, as the procedure would become unnecessarily invasive due to
an extended surgical field.
In this prospective, randomized and controlled single-center trial we investigated
whether pinless navigation in UKA is suitable and whether implantation accuracy of
the tibial implant can be increased by using a pinless navigation system, compared to
conventional alignment with an extramedullary alignment rod. The main target value was
the tibial implant in an alignment with a 3◦ varus.
The hypothesis was that pinless navigation in UKA can provide alignment comparable
to that achieved by a high-volume surgeon using the conventional technique, without
disadvantages regarding surgical time.

2. Materials and Methods

2.1. Study Population
The study was approved by the local Ethics Committee (No. 19-1548-101) and written
informed consent was given by all patients participitating in this study. The trial has been
notifed at the German Clinical Trials Register (ID DRKS00025189). The inclusion criteria in
the study, for the consecutive series of 30 patients with unicompartmental osteoarthritis of
the knee eligible for unicompartmental arthroplasty, were that patients were aged between
40 and 80 years, exhibited intact cruciate and collateral ligaments, had no narrowing of the
contralateral joint space, had no evidence of higher grade patellofemoral disorders or arthri-
tis and an overall operational capability. Exclusion criteria were symptomatic retropatellar
or contralateral arthritis, fixed deformity > 15◦ , inflammatory joint diseases, status after
ligamentary reconstruction (e.g., ACL-reconstruction) and status after osteotomy. The
characteristics of the study population are shown in Table 1. A treatment group and a
control group were formed, each with 30 patients. The treatment group was operated on
using the imageless navigation technique, and the control group using the conventional
surgical technique, in each case with a target value of 3◦ varus of the tibial component.
Two patients, one in each group, denied further participation in the study. In addition, one
patient was indicated for a lateral UKA. This case was excluded after surgery as it would
be misleading for the homogeneity of the study. Therefore, a total of 57 patients were
considered for radiographic analysis. Figure 1 shows a flow diagram illustrating patient
enrolment, allocation, follow-up and analysis.

Table 1. Patient characteristics.

Treatment Control
n 28 29
Gender (male/female) 16/12 14/15
Age (years) 64.0 63.4
Treatment side (left/right) 10/18 14/15
J. Clin. Med. 2021, 10, 2422 3 of 11
J. Clin. Med. 2021, 10, 2422 3 of 10

Figure 1. Flow diagram illustrating patient enrolment, allocation, follow-up and analysis.
Figure 1. Flow diagram illustrating patient enrolment, allocation, follow-up and analysis.
2.2. Surgical Treatment
Table 1. All
Patient characteristics.
procedures were performed between October 2019 and June 2020 by the same
experienced senior surgeon (>200 knee UKA/year). The patient was
Treatment placed in a supine
Control
position under spinal anesthesia and a tourniquet was inflated with 100 mmHg above the
n 28 29
systolic blood pressure at the time of inflation. The quad-sparing-approach was performed
Gender (male/female) 16/12 14/15
in all patients. Subjects received an implant with a fixed bearing platform (Persona Partial
Age (years) 64.0 63.4
Knee, Zimmer Biomet, Warsaw, IN, USA) for medial arthritis in 59 cases and a Physica
Treatment
ZUK (Limaside (left/right)
Corporate, UD, Italy) in one 10/18 14/15However, due
case for lateral arthritis target.
to a different surgical approach and for the purpose of homogeneity in the evaluation,
2.2.this
Surgical Treatment
case was removed for the data analysis. All cases were fully cemented and the same
All procedures
target values and were performed
radiographic between
analysis wereOctober 2019
used. The and component
target June 2020 by thethe
was sametibial
experienced
implant, whichseniorwas surgeon (>200 knee
to be placed in 3◦ UKA/year). Thetopatient
varus. In order achievewasthat,placed in a supine
a computer-assisted,
position
pinlessunder spinal anesthesia
navigation device (Knee and2.6,
a tourniquet
Brainlab AG,was Feldkirchen,
inflated withGermany)
100 mmHgwas above
usedthefor
systolic blood The
30 patients. pressure
accuracyat the timesystem
of this of inflation. The quad-sparing-approach
has already been investigated in several was studies
per-
formed
and wasin allverified
patients. toSubjects received
be a precise an implant
and reliable withnavigation
pinless a fixed bearing
systemplatform
[7–10].(Persona
The setup
Partial Knee,ofZimmer
consisted Biomet,
a stand-alone Warsaw,with
computer IN, infrared
USA) forcameras,
medial arthritis
controlled in by59 acases
touchand a
screen,
Physica
and aZUK (Lima
pointer withCorporate,
reflector UD, Italy)asinwell
spheres one case
as a for lateralarray.
reflector arthritis target.
After bony However,
exposure,
duetheto anatomical
a different surgical
landmarks approach
were and for theby
mapped purpose of homogeneity
the pointer, in particularin thetheevaluation,
medial and
this case was removed for the data analysis. All cases were fully cemented and the same a
lateral malleolus, the tibial anatomic axis and a.p.—direction of the tibia. Subsequently
target valuesextramedullary
standard and radiographic analysisrod
alignment were used.
from theThe target component
Zimmer/Biomet system was wastheattached
tibial
implant, which was
perpendicular to betibia
to the placed
andin 3°reflector
the varus. Inarray
orderwas
to achieve
insertedthat,
intoa the
computer-assisted,
cutting slot. Next,
pinless navigation
the correct device of
alignment (Knee
the 2.6, Brainlab
tibial cut was AG, Feldkirchen,
verified by the Germany)
navigationwas used for
system. For30the
patients. The accuracy of this system has already been investigated in several studies andthe
remaining 30 patients, the standard extramedullary alignment rod was used to align
tibial component at 3◦ varus without computer-assisted guidance.
 was verified to be a precise and reliable pinless navigation system [7–10]. The setup con-
sisted of a stand-alone computer with infrared cameras, controlled by a touch screen, and
a pointer with reflector spheres as well as a reflector array. After bony exposure, the ana-
tomical landmarks were mapped by the pointer, in particular the medial and lateral mal-
J. Clin. Med. 2021, 10, 2422 leolus, the tibial anatomic axis and a.p.—direction of the tibia. Subsequently a standard 4 of 10
extramedullary alignment rod from the Zimmer/Biomet system was attached perpendic-
ular to the tibia and the reflector array was inserted into the cutting slot. Next, the correct
alignment of the tibial cut was verified by the navigation system. For the remaining 30
patients, the standard extramedullary alignment rod was used to align the tibial compo-
Figure 2 shows the surgical setup. Here, the surgeon was referencing the medial
nent at 3° varus without computer-assisted guidance.
malleolus. Light-reflecting
Figure 2 shows spheres
the surgical setup. Here,are attached
the surgeon wastoreferencing
the pointer, which
the medial are detected by the
mal-
leolus. Light-reflecting
infrared spheres areinattached
camera positioned to the pointer,Note
the background. whichthat
are detected
no pinsby the in- to be drilled into
needed
frared
the camera
bone. positioned
Figure in the background.
3 shows the infrared Note that no facing
camera pins needed
the to be drilled
surgical into for detecting the
field
the bone.
above Figure 3 shows
mentioned, the infrared camera
light-reflecting facing the surgical field for detecting the
spheres.
above mentioned, light-reflecting spheres.

Figure 2. The surgical setup is shown. Here, the surgeon was referencing the medial malleolus.
Figure 2. The surgical setup is shown. Here, the surgeon was referencing the medial malleolus.
Light-reflecting spheres, attached to the pointer, were detected by an infrared camera positioned
in the background. spheres, attached to the pointer, were detected by an infrared camera positioned in
Light-reflecting
J. Clin. Med. 2021, 10, 2422 5 of 11
the background.

Figure 3. Shows the infrared camera facing the surgical field for detecting the light-reflecting
Figure Shows
3. the
spheres of the infrared camera facing the surgical field for detecting the light-reflecting spheres
pointer.
of the pointer.
2.3. Radiographic Analysis and Clinical Follow up
Within one year postoperatively, the clinical and radiological follow-up of the pa-
tients took place. Patients were routinely examined and surgery sites were controlled.
Standard weight bearing radiographs in lateral projection as well as long-leg radiographs
were taken. Subsequently, the inclination of the tibial component was determined. Radi-
ographic analysis was performed in Horos for Mac, Version 3.3.6 [11]. First, the anatomi-
J. Clin. Med. 2021, 10, 2422 5 of 10

2.3. Radiographic Analysis and Clinical Follow up

Within one year postoperatively, the clinical and radiological follow-up of the patients
took place. Patients were routinely examined and surgery sites were controlled. Standard
weight bearing radiographs in lateral projection as well as long-leg radiographs were
taken. Subsequently, the inclination of the tibial component was determined. Radiographic
analysis was performed in Horos for Mac, Version 3.3.6 [11]. First, the anatomical axis of the
tibia was determined in the a.p. long-leg radiographs according to Paley [12]. Four points
of the two cortices were marked, two in the proximal and two in the distal metaphysis,
each with one on the lateral and one on the medial corticalis, resulting in a rectangle shape.
Based on this, the software automatically calculated the center of the four landmarks and
thus the longitudinal axis. Following that, the angle of the tibia component was calculated
from the previously determined axis and the lower edge of the tibial implant. Figure 4
represents the measurement process. Two points on the medial and two on the lateral cortex
were marked and thus the longitudinal axis was calculated. Next a tangent was drawn
J. Clin. Med. 2021, 10, 2422 to the lower border of the tibial component and thus the medial inclination calculated 6 of 11
between tangent and longitudinal axis.

Figure4.4.Illustration
Figure Illustrationof
ofthe
themeasurement
measurementprocess.
process.Two
Twopoints
pointson
onthe
themedial
medialandandtwo
twoon
onthe
thelateral
lateral
cortex were marked and thus the longitudinal axis was calculated. Next a tangent was drawn toto
cortex were marked and thus the longitudinal axis was calculated. Next a tangent was drawn the
the lower border of the tibial component and thus the medial inclination calculated between tan-
lower border of the tibial component and thus the medial inclination calculated between tangent and
gent and longitudinal axis. In this case of group 1 the angle was 87.4° varus (R = right side).
longitudinal axis. In this case of group 1 the angle was 87.4◦ varus (R = right side).

Theposterior
The posteriorinclination
inclinationofofthe
thetibial
tibialcomponent
componentwas wasdetermined
determinedfrom
fromthethelateral
lateral
radiographs according to Faschingbauer et al. [13]. One tangent was applied to
radiographs according to Faschingbauer et al. [13]. One tangent was applied to the posteriorthe poste-
rior cortex,
cortex, another
another to the caudal
to the caudal endcomponent.
end of the of the component.
Thus, theThus,
anglethe
wasangle was calculated
calculated between
between the two lines. This process of measurement is
the two lines. This process of measurement is shown in Figure 5. shown in Figure 5.
J. Clin. Med. 2021, 10, 2422 6 of 10
J. Clin. Med. 2021, 10, 2422 7 of 11

Figure5.5.Illustration
Figure Illustrationofofthe
themeasurement
measurement process.
process. For
For determining
determining thethe posterior
posterior slope,
slope, a tangent
a tangent was
was drawn next to the posterior cortical axis, another one next to the lower border of the tibial
drawn next to the posterior cortical axis, another one next to the lower border of the tibial component.
component. In this case the posterior inclination was 87.5°.
In this case the posterior inclination was 87.5◦ .

2.4.Statistical
2.4. StatisticalAnalysis
Analysis
Forstatistical
For statisticalanalysis,
analysis,continuous
continuousdatadataare
arepresented
presentedas asmeans
meansandandstandard
standarderror
error
ofofthe
themean.
mean.Group
Groupcomparisons
comparisonswere wereperformed
performedby bytwo-sided
two-sidedt-tests
t-testsfor
forindependent
independent
variables.Absolute
variables. Absoluteandandrelative
relative frequencies
frequencies were
were given
given forfor categorical
categorical data.
data. Differences
Differences of
of p < 0.05 were considered statistically significant. IBM SPSS Statistics 26 (SPSS
p < 0.05 were considered statistically significant. IBM SPSS Statistics 26 (SPSS Inc, Chicago, Inc, Chi-
cago,
IL, USA)IL,was
USA) wasfor
used used for analysis.
analysis. Post hocPost hoc power
power analysisanalysis was performed
was performed for the nav-
for the navigation
igation
data. Thedata. The in
analysis analysis
G*Powerin G*Power
3.1 for Mac3.1 for Mac
resulted inresulted in asample
a calculated calculated
size sample size of
of 28 subjects
28 both
for subjects for both
groups groups
to achieve to achievepower
a statistical a statistical
of 1-betapower
= 0.9of 1-beta
and = 0.9 of
an alpha and an alpha of
0.05.
0.05.
3. Results
3. Results
Within one year postoperatively, no surgery site infections were noted, all wounds
healedWithin one year
per primam andpostoperatively,
no revision wasno surgery site
necessary. infectionsbecause
No dropouts were noted, all wounds
of failure of the
navigation or intraoperative decision to switch to TKA were noted.
healed per primam and no revision was necessary. No dropouts because of failure of the
◦ ◦
In the treatment
navigation group, the
or intraoperative mean position
decision to switchoftothe
TKAtibial noted. was 87.6 +/− 1.0 .
component
were
Minimum ◦ ◦
In theand maximum
treatment medial
group, the inclination
mean positionwasof86.1the and
tibial89.7 , respectively,
component resulting
was 87.6°
◦ . The 25th percentile was 86.9◦ and the 75th percentile was 88.3◦ . The mean
in
+/− 1.0°.
aMinimum
range of 3.6
and maximum medial inclination was 86.1° and 89.7°, respectively, resulting in
posterior inclination ◦ +/− 1.9◦ . Minimum and maximum
a range of 3.6°. The of thepercentile
25th tibial component
was was
86.9° 86.8
and the 75th percentile was 88.3°. The mean
◦ and 90.0◦ , resulting in a range of 6◦ .
posterior inclination was 84.0
posterior inclination of the tibial component was 86.8° +/− 1.9°. Minimum and◦ maximum
In the control group, the mean position of the tibial component was 87.3 +/− 1.2◦ .
posterior inclination was 84.0° and 90.0°, resulting in◦ a range of 6°.
Minimum and maximum medial inclination was 84.1 and 89.3◦ , respectively, resulting in
In the control group, the mean position of the tibial component was 87.3° +/− 1.2°.
a range of 5.2◦ . The difference between the two groups was not significant, p = 0.3. The
Minimum and maximum medial inclination was 84.1° and 89.3°, respectively, resulting in
mean posterior inclination of the tibial component was 86.9◦ +/− 1.6◦ . Minimum and
a range of 5.2°. The difference between◦ the two groups was not significant, p = 0.3. The
maximum posterior inclination was 83.9 and 89.7◦ , resulting in a range of 5.8◦ .
mean posterior inclination of the tibial component was 86.9° +/− 1.6°. Minimum and max-
Figure 6 presents boxplots, which show the range of medial inclination for navigation
imum posterior inclination was 83.9° and 89.7°, resulting in a range of 5.8°.
and conventional groups.
Figure 6 presents boxplots, which show the range of medial inclination for navigation
and conventional groups.
Mean incision to suture time in the navigation group was 44.2 min +/− 4.4 and 42.7
min +/− 5.1 in the control group. The difference was statistically not significant, p = 0.13.
Boxplots showing the range of incision to suture time are illustrated in Figure 7.
J. Clin. Med. 2021, 10, 2422 7 of 10
J. Clin. Med. 2021, 10, 2422 8 of 11

J. Clin. Med. 2021, 10, 2422 8 of 11

Figure 6. Mean position of the tibial component in coronar plane. Boxplots show range of medial inclination for navigation
and conventional group. With the navigation technique, outliers could be reduced as well as range of medial inclination.
Figure 6. Mean position of the tibial component in coronar plane. Boxplots show range of medial inclination for navigation
One outlier in the conventional aligned group was marked with “o”.
and conventional group. With the navigation technique, outliers could be reduced as well as range of medial inclination.
One outlier in the conventional aligned
Mean group wastomarked
incision suturewith "o".in the navigation group was 44.2 min +/− 4.4 and
time
Figure 6. Mean position of the tibial component in coronar plane. Boxplots show range of medial inclination for navigation
and conventional group. With42.7the
min +/− 5.1technique,
navigation in the control
outliersgroup.
could beThe difference
reduced as well was statistically
as range of medial not significant,
inclination.
p = aligned
One outlier in the conventional 0.13. Boxplots
group wasshowing
markedthe
withrange
"o". of incision to suture time are illustrated in Figure 7.

Figure 7. Mean incision to suture time. Boxplots show range of incision to suture time. In the navigation technique, the
range and
Figure meanincision
7. Mean time wastoslightly higher.
suture time. One outlier
Boxplots showwith 62 of
range min in the navigation
incision group
to suture time. In was noticed. technique, the
the navigation
range and mean time was slightly higher. One outlier with 62 min in the navigation group was noticed.
Figure 7. Mean incision to suture time. Boxplots show range of incision to suture time. In the navigation technique, the
range and mean time was slightly higher. One outlier with 62 min in the navigation group was noticed.
J. Clin. Med. 2021, 10, 2422 8 of 10

4. Discussion
The accuracy of the implantation and the correct three-dimensional alignment of
the unicondylar knee replacement are essentially responsible for the clinical outcome.
This requires a considerable amount of extensive clinical experience by the surgeon to
achieve the required precision. Registry data show that experienced surgeons increase the
survivorship of unicompartmental knee arthroplasty in contrast to surgeons who present
only a low annual volume of UKA [14].
In the present study, we demonstrated that pinless navigation can achieve equivalent
implantation accuracy like an experienced surgeon. Furthermore, the number of outliers
could be reduced compared to an experienced surgeon. The previously documented
minimum number of operations per surgeon per year for a good surgical result could thus
be significantly lower when a navigation technique is used for implantation. A previously
study defined a threshold of 12 UKAs per year. Below this, surgeons cause a revision rate
twice as high as surgeons with more than 12 implantations per year. However, this is only
valid for the conventional alignment technique [15].
Additionally, the formerly documented proportion of 40–60% unicondylar prostheses
in the number of surgeries performed annually by a single surgeon, as a prerequisite for a
satisfying outcome, could; therefore, be re-discussed [16].
It can be assumed that the deviation in three-dimensional alignment, which often
results when conventional instruments are used, is the cause of the increased failure rate.
The rationale for desired positioning of a unicondylar partial knee prosthesis is that the
alignment should be according to the anatomy, since the lateral and patellofemoral portions
are not replaced.
In recent years, this consideration has led to the belief that a slight varus alignment
provides better results because it is more consistent with anatomic conditions [4]. Although
the optimal positioning is still unclear, observations show that, on the one hand, excellent
results can be achieved with this technique, but the degree of maximum deviation is even
lower. Thus, a deviation of 5◦ from the mechanical tibial axis appears to be the threshold
for a then strongly increasing probability of loosening and a worse outcome [17].
So far, it has been shown that computer-assisted navigation could implant UKAs
as accurately or even more accurately in terms of clinical outcome than when using the
conventional technique [18,19]. The application of pins has several disadvantages as there
is the risk of fracture development, the possibility of local infection, and additional damage
to the soft tissue [20,21]. Moreover, a lower amount of additional time was involved [22].
To the best of our knowledge, the presented study is the first investigating pinless nav-
igation in UKA. The results showed that, with this type of navigation, even an experienced
surgeon could achieve target values with lower outliers regarding component placement
than with the conventional technique. The range for pinless navigation was 3.6◦ , which
was significantly less than the range of 5.2◦ for conventional alignment technique.
The fact that pinless navigation can reduce outliers compared to conventional implan-
tation has already been shown in total knee arthroplasty [7,10]. In the study presented here,
outliers could also be avoided with the navigated technique in comparison to conventional
alignment technique, with which also one outlier of 84.1◦ was produced, even in a high
volume surgeon.
The reduced range of the degree of medial inclination of the tibial component com-
pensates for the minimally extended incision to suture time. It was 43.2 min for the
implantation with the pinless navigation and 42.7 min without navigation.
In addition, our data showed an increased range of operation times in pinless naviga-
tion compared to conventional instrumentation. This could be due to the fact that the use of
the navigation unit can cause delays for technical reasons (e.g., registration of landmarks).
Our study has several limitations. First, radiographs were taken from a clinical
routine. These sufficiently met the clinical requirements, but for scientific purposes, it must
be mentioned that sometimes the prosthesis was not completely orthograde by the central
beam, so that there was a certain tilting, which made the measurement more difficult.
J. Clin. Med. 2021, 10, 2422 9 of 10

Second, all operations and measurements were performed by one single surgeon, so
that no intra- or inter-rater reliability values were available.
Third, the determination of the position of the tibial component was performed after
cementing, consequently a different thickness of the cement mantle may have influenced
the result.

5. Conclusions
For the first time, it could be shown that pinless navigation can significantly reduce
the percentage of outliers with similar implantation accuracy. The clinical relevance is
that even an inexperienced surgeon can achieve accuracy comparable to that of a highly
experienced surgeon using pinless navigation. The disadvantages of pin-based navigation
can; thus, be completely avoided. The extension of the operation time can be estimated as
not relevant.
Besides the advantages, of course, the learning curve and the acquisition costs must
be considered.

Author Contributions: Conceptualization, P.v.R. and M.W.; methodology, P.v.R., M.W., M.K. (Moritz Kaiser);
software, M.K. (Moritz Kaiser) and P.v.R.; validation, S.K.-P., M.K. (Moritz Kaiser) and P.v.R.; formal
analysis; resources, M.W., P.v.R.; writing—original draft preparation, M.K. (Moritz Kaiser), S.K.-P.;
writing—review and editing, P.v.R., M.K. (Matthias Koch); supervision, V.A.; funding acquisition,
M.W. All authors have read and agreed to the published version of the manuscript.
Funding: Funding for this study was received by the DKG—Deutsche Kniegesellschaft.
Institutional Review Board Statement: The study was approved by the local Ethics Committee
(No. 19-1548-101) and written informed consent was given by all patients participitating in this study.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data sharing is not applicable to this article.
Acknowledgments: We would like to thank Brainlab, Feldkirchen for providing the optical naviga-
tion system free of charge and the DKG—Deutsche Kniegesellschaft for the funding of this study.
Conflicts of Interest: The authors declare that they have no conflict of interest.

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