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Original Article
Computer assisted surgery. Its usefulness in different levels of pre-operative deformities
Cirugía asistida por ordenador. Su utilidad en distintos grados de deformidades preoperatorias
P. Benavente
Corresponding author
pablo.benavente.rodriguez@gmail.com

Corresponding author.
, C. López Orosa, J.A. Oteo Maldonado, A. Orois Codesal, F.J. García Lázaro
Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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CAS offers intraoperative information in real time about the condition of the ligaments and the kinematic arch of the knee&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> Numerous works have been published so far comparing the results obtained with conventional instrumentation techniques versus those obtained through the use of surgical navigation techniques&#44; mainly regarding postoperative alignment and&#44; more recently&#44; on clinical and functional parameters&#46; The results achieved show considerable variability&#44; ranging from those favorable to navigation<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;15</span></a> to others which found no differences between both methods&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16&#8211;24</span></a> so this is a controversial topic&#46; Some authors have also argued in favor of the potential benefit that these systems could offer in cases with significant intra- and extraarticular deformities&#44; in which restoring a neutral postoperative alignment correctly is much more complex&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> However&#44; the degree of deformity at which the use of these systems would offer an advantage over conventional instrumentation has not been established&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this work is to establish the clinical and functional results&#44; as well as those obtained in terms of radiographic alignment in the coronal plane&#44; obtained with CAS in our medium compared to conventional techniques and to analyze the influence of navigation in different levels of preoperative frontal deformity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We conducted a retrospective cohort study with 100 patients who suffered knee arthrosis and underwent primary total knee arthroplasty at our center between June 2009 and March 2011&#46; Out of this total&#44; 50 had been operated using a conventional technique and the other 50 with the aid of computer-assisted navigation systems&#46; The sample size for a cohort study was calculated based on the results of the most recent metaanalysis&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> according to which 13&#37; of the navigation prostheses were outside the desired interval of &#177;3&#176; of the mechanical axis&#46; Based on a relative risk of detection of 0&#46;35&#44; with an <span class="elsevierStyleItalic">&#945;</span> error of 0&#46;5 and <span class="elsevierStyleItalic">&#946;</span> of 0&#46;8&#44; we established a minimum sample size of 100 cases &#40;50 in each group&#44; upon establishing a ratio of 1 exposed&#47;not exposed&#41;&#46; This calculation was conducted with the software package Epidat version 4&#46;0&#46; Case selection was carried out by reviewing&#44; consecutively and following a chronological order&#44; all those patients intervened for total knee arthroplasty in the given period&#46; We included patients operated for primary total knee prosthesis with a Genesis <span class="elsevierStyleSmallCaps">II</span> model &#40;Smith &#38;Nephew<span class="elsevierStyleSup">&#174;</span>&#44; Memphis&#44; Tennessee&#44; USA&#41; &#8211; both the design with conservation of the posterior cruciate ligament &#40;cruciate retained&#44; CR&#41; and the posterior stabilized&#44; &#40;PS&#41; &#8211;&#44; with an evolution of at least 1 year&#44; regardless of age&#44; presence of extra- or intraarticular deformities&#44; and prior surgical interventions&#46; As exclusion criteria we established not presenting full postoperative monitoring during the first year&#59; reconversion of an initially navigated procedure into conventional during the intervention&#59; existence of a prior indication of the technique to employ&#44; either conventional or navigated surgery&#44; due to the patient presenting specific characteristics that made one of the options preferable to the other&#46; The study was approved by the Ethics Committee of the Biomedical Research Foundation at our hospital&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">All the procedures were conducted by the 5 surgeons of the hip and knee arthroplasty unit&#46; All of them had conducted a minimum of 200 conventional knee arthroplasty interventions previously&#44; and between 10 and 15 navigation-assisted surgeries with the same software employed in every case in the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our service&#44; navigation was available 2 days per week&#59; during the other 3 days we performed conventional techniques&#46; The day of intervention of each patient was established by following the surgery waiting list&#46; As indicated in the exclusion criteria&#44; those patients in whom there was a specific reason that indicated one technique over another were excluded from the revision&#44; so that all the cases finally included were assigned indistinctly to one group or the other&#46; This procedure attempted to minimize a possible selection bias which could have taken place by the fact of having patients undergo one of the techniques for a specific reason&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The surgical procedures were carried out under ischemia&#44; with a pneumatic cuff applied in the base of the thigh and removed at the end of the intervention&#44; once the lower limb had been bandaged&#46; We followed a standard approach in all cases&#44; with incision in the midline and parapatellar medial arthrotomy with patellar eversion&#46; We placed a Genesis <span class="elsevierStyleSmallCaps">II</span> model &#40;Smith &#38; Nephew<span class="elsevierStyleSup">&#174;</span>&#44; Memphis&#44; Tennessee&#44; USA&#41; in all cases&#46; We used both the CR and PS designs&#44; implanting one or the other according to the criteria of each surgeon&#46; The femoral CR component was implanted without cement&#44; with 2 flex-lock anchors&#46; The femoral and tibial PS components were cemented in all cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the conventional surgery group we used intramedullary guides for the placement of the femoral component&#46; Tibial alignment was established through extramedullary and&#47;or intramedullary guides&#46; In cases intervened with navigation&#44; we used the BrainLab Knee Essential software system &#40;BrainLab&#44; Feldkirchen&#44; Germany&#41; for the Genesis <span class="elsevierStyleSmallCaps">II</span> model&#46; This system does not require prior images and is based on optic location &#40;infrared light&#41; with passive emitters&#46; In this group we did not employ intramedullary guides in the femur or tibia&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected demographic data for each patient&#46; As clinical parameters we registered the movement arc and the KSS questionnaire during the preoperative period and after 1 year&#46; We evaluated the preoperative and postoperative mechanical axis in the frontal plane after 1 year evolution in full radiographs of the lower limbs under load&#46; The value was calculated as the angle formed between a line from the center of the femoral head to the center of the knee joint&#44; and another from the center of the knee to the center of the ankle joint&#46; We considered as neutral a value of 180&#176;&#59; lower values represented varus deviations and higher values represented valgus deviations from the axis&#46; We accepted postoperative mechanical angles of 180<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#176; as correct values&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> All the measurements were carried out by the same observer &#40;a resident in the 5th year of service&#41;&#46; With regard to the surgery&#44; we registered the duration of surgery and ischemia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">After the data collection and treatment process we created a database in a Microsoft Excel file&#44; where we recoded the variables&#46; The statistical analysis of the data was carried out using the software package SPSS 20&#46;0 &#40;IBM&#44; Chicago&#44; Illinois&#44; USA&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We used the Chi-squared test for the analysis of the categorized qualitative and quantitative variables&#44; and used the exact Fisher test when the expected frequency was less than 5 in over 20&#37; of the fields&#46; For the quantitative variables we carried out an analysis of normality through the Shapiro&#8211;Wilk test&#46; When these followed a normal distribution we applied parametric tests&#44; like the Student <span class="elsevierStyleItalic">t</span> test&#44; to compare samples &#40;for independent data and paired data&#41;&#46; For variables that did not follow a normal distribution we applied nonparametric tests&#44; like the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#44; to compare means&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The ANOVA test was used for comparison of means of the postoperative mechanical axes between the different preoperative mechanical axis groups and the 2 surgical techniques employed&#46; Next&#44; after verifying the homogeneity of variances&#44; we conducted a posteriori &#40;post hoc&#41; comparisons using the Tukey method&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The size of the response to the clinical variables of &#8220;flexion&#8221; and &#8220;extension&#8221;&#44; as well as the scores of the KSS questionnaires before and after the surgery&#44; were measured according to the statistics of size of the effect and the standardized mean of the response&#46; We could state that this magnitude was clinically relevant with values over 0&#46;8&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the demographic data of the patients included in the study&#46; No statistically significant differences were observed between both groups in terms of age&#44; gender&#44; BMI and laterality of the operated knee&#44; so we assumed that the 2 groups were homogeneous regarding these factors&#46; Neither did we find differences in the preoperative radiographic and clinical data of both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the duration of surgery&#44; both the time of the surgery and of ischemia were significantly higher in the navigation-assisted surgery group&#44; with a mean difference in surgery time of 27&#46;5<span class="elsevierStyleHsp" style=""></span>min &#40;95&#37; CI&#58; 19&#46;2&#8211;35&#46;9<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; and 16&#46;3<span class="elsevierStyleHsp" style=""></span>min in ischemia time &#40;95&#37; CI&#58; 6&#46;4&#8211;26&#46;1<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The distribution of CR and PS implants was similar in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding the postoperative data&#44; when we analyzed the alignment of the lower limb we found significant differences between the mechanical axes&#44; with values that were closer to those accepted as optimal &#40;180&#176; for the mechanical axis&#41; in the navigation group &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The dispersion was less in this group&#44; in both cases showing lower standard deviations than the conventional group&#44; as shown in graphic format by the frequency histograms &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; In addition&#44; the percentage of cases with a correct alignment was significantly higher in the group of patients intervened with navigation&#44; with 62&#37;&#44; whereas this was only true in 36&#37; of cases intervened following the conventional technique &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In order to conduct an in-depth analysis of the alignment data we divided the patients into 4 subgroups based on the preoperative value of the mechanical axis&#44; taking as cutoff points the values of the 25&#44; 50 and 75 percentiles&#44; and we studied whether preoperative deformity determined postoperative alignment&#44; as well as the influence of the surgical technique employed &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; This was done by means of an ANOVA test&#46; This test found significant differences between the mean values of the postoperative mechanical axis between the different groups of preoperative mechanical axis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#59; but not between the 2 types of surgical techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;127&#41;&#44; and it was not possible to demonstrate the existence of an interaction between both factors &#40;preoperative deformity and surgical technique employed&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;486&#41;&#46; Subsequent comparisons using the Tukey method found that patients with a preoperative deformity greater than 15&#176; had a postoperative alignment which was further from the neutral axis than patients with a deformity smaller than 10&#176;&#44; regardless of the surgical technique employed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Nevertheless&#44; it is notable that within this group patients who underwent navigation-assisted surgery presented a better alignment despite not reaching statistical significance&#44; as previously mentioned &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding the clinical data&#44; when comparing the pre- and postoperative results we observed that patients in both groups presented an improvement in their KSS scores and degree of extension&#46; However&#44; looking at the values of the statistics describing the size of the effect and the standardized mean of the response we can say that the magnitude of the improvement was only clinically significant in terms of the KSS scores for both groups&#46; Nevertheless&#44; we did not find significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;094&#41; when comparing the means of the differences of the total KSS scores between both groups&#44; so we cannot state that the increase in KSS scores was significantly higher in one group compared to the other &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Therefore&#44; we can say that both groups presented a significant and clinically relevant improvement in their KSS scores&#44; albeit without that increase being significantly higher in one group compared to the other&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In our series&#44; optimal alignment of the lower limb was achieved more frequently by using the computer-assisted navigation system &#40;62&#37;&#41; instead of a conventional technique &#40;36&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The first prospective study comparing the conventional technique and navigation in total knee arthroplasty took place in 2001&#46; In it&#44; Mielke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a> reported finding no differences between both techniques in terms of the alignment of the lower limb&#44; using as reference the measurement of the mechanical axis&#46; Since then&#44; there have been numerous works along the same lines which have offered highly variable results&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Several studies have proven that navigation systems contribute to achieve a better positioning of the prosthetic components and a better alignment of the lower limb&#44; whilst also finding&#44; coinciding with our results&#44; a higher percentage of cases with a mechanical axis within an interval considered as optimal &#40;&#177;3&#176; regarding the neutral mechanical axis&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;8&#8211;15&#44;28</span></a> The high percentage of cases within the normal range obtained with both navigation-assisted techniques and conventional surgery are striking compared with our series&#46; In many of these works&#44; optimal postoperative alignment was achieved in around 95&#37; of cases in groups undergoing navigation-assisted surgery&#44; whereas in our study this figure was only 62&#37;&#46; Likewise&#44; the rates of patients with a correct alignment following conventional surgery were very high&#44; around 75&#37;&#44; compared to 38&#37; in our series&#46; Only Macul&#233;-Beneyto et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> in their multicenter work&#44; found results which were lower than ours&#44; with 29&#37; of cases with a correct final alignment after conventional surgery and 48&#37; in the navigation group&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; other authors have not been able to demonstrate significant differences regarding postoperative alignment between these 2 types of surgical techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16&#8211;24</span></a> Likewise&#44; the percentages of patients with a correct postoperative mechanical axis &#40;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#176;&#41; reported by these studies are high&#44; over 80&#37; in the navigation group in most of the works&#59; and between 70&#37; and 80&#37; in the groups where navigation was not employed&#44; even higher than our rate of patients in the navigation-assisted surgery group with a postoperative mechanical axis within the optimal range&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We also found differences between the means of the mechanical axis with values closer to those accepted as optimal in the navigation group&#46; However&#44; the difference of means of the mechanical axis was only of 1&#46;73&#176;&#44; and although statistically significant&#44; the clinical relevance of such a small difference is questionable&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Not only does the difference of means in the mechanical axis favor navigation-assisted surgery&#44; but also the distribution of these variables shows less dispersion in this group&#44; with standard deviations for the postoperative mechanical axis of 4&#46;5&#176; in the conventional surgery group and of 3&#46;1&#176; in the navigation group&#44; thus indicating that we achieved greater precision with navigation than with conventional techniques&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">However&#44; the difference between one technique and the other is of just a few degrees&#44; which is within the range of imprecision of the measurements caused by intra- and interobserver variability&#44; as well as projection errors of the radiographs&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">29</span></a> Huang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">30</span></a> found that the measurement of the mechanical axis has a variability of between 1&#176; and 3&#176;&#46; However&#44; this error may be greater in situations in which it is difficult to position patients correctly at the time of obtaining the radiograph&#44; as in the case of obese patients and those with severe deformities in flexion&#46; According to Krackow et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">29</span></a> the artifact produced with a rotation and flexion under 10&#176; is lower than 2&#176;&#46; However&#44; the changes become relevant with values between 10&#176; and 20&#176;&#44; with variations around 7&#176; in the alignment of the lower limb&#46; In 2007&#44; Brouwer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a> validated the results published by Krackow et al&#46; in cadaver studies&#44; in which they found that both rotation without flexion and flexion without rotation caused minimal changes in the angles projected on a radiograph&#46; However&#44; the combination of 15&#176; external rotation and 15&#176; flexion produces an apparent varus deformity of 4&#176;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">On one hand&#44; some authors have supported that navigation is especially interesting for patients with significant intra-<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> and extraarticular<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a> deformities&#44; in whom bone loss and ligamentous lesions hinder the restoration of correct alignment and stability using conventional techniques and instruments&#46; In particular&#44; Sorrells et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> found that those cases with a preoperative alignment with more than 10&#176; varus or valgus had a higher probability of presenting postoperative alignment outside the ranges considered as optimal&#46; For this reason&#44; we studied the relationship between preoperative alignment and the type of technique employed in surgery with postoperative alignment&#44; and observed that patients with preoperative deformities lower than 10&#176; varus presented a mean postoperative alignment within the correct interval regardless of the technique used&#44; whereas patients with a preoperative varus of 15&#176; or more presented an alignment outside the mean range&#44; also regardless of the technique employed&#46; However&#44; we did notice a trend toward presenting better postoperative alignment among those patients with preoperative varus between 10&#176; and 15&#176; who were intervened with a navigation-assisted technique versus those who underwent a conventional technique &#40;178&#46;7 versus 175&#46;5&#41;&#44; although the differences did not reach statistical significance&#46; If this trend were confirmed&#44; these results could indicate that perhaps navigation would be able to &#8220;rescue&#8221; those patients with a preoperative varus alignment within 10&#176; and 15&#176;&#46; This group would be the one that could benefit the most from the use of navigation systems&#46; In their study&#44; Hern&#225;ndez Vaquero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> compared both surgical techniques in patients with a mechanical axis over 10&#176; and in patients with an axis under 10&#176;&#44; and in both cases obtained a better final alignment with the use of navigation&#46; These authors argued that perhaps the most important role that surgical navigation could have in arthroplasty would be in cases of complex knees which presented significant deformities or when mechanical alignment could not be used&#44; thus representing an alternative to traditional instrumentation in trying to achieve an effective treatment of these patients&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The clinical and functional evaluation was based on the scores obtained in the KSS questionnaire&#44; as well as the degree of flexion and extension of the knee&#46; As far as we could discern&#44; none of the works published to date has reported the size of the effect or the standardized mean response&#44; so we were unable to compare the magnitude of the improvement observed in our study with that obtained by these works&#46; Our results coincide with the majority of those published in the sense that all find an improvement in the scores of the different questionnaires used&#44; and specifically of the KSS&#44; but this improvement was similar in both groups&#44; with no significant differences being found in the final scores between the conventional surgery and navigation groups&#46; Only Hoffart et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> found better postoperative scores in the navigation group&#44; both in the total KSS and in the clinical and functional sections&#46; Unlike them&#44; Schmitt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">34</span></a> not only did not find differences&#44; but in fact found that the conventional surgery group had a higher score in the postoperative functional KSS &#40;94&#46;1&#41; than the 2 groups of navigation-assisted surgery with which it was compared &#40;85&#46;6 and 76&#46;3&#41;&#44; based upon similar preoperative scores&#46; Likewise&#44; different metaanalyses have concluded that the use of CAS does not help to improve postoperative function in total knee arthroplasties&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">25&#44;35</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">We identified a series of limitations in the present work&#46; Firstly&#44; we should bear in mind that this was a retrospective study in which the patients were included after being intervened and were chosen among a group of patients based on the criteria described previously&#46; In this type of studies it is common to have some selection bias which affects the inclusion or exclusion of patients&#44; thus there is a risk that the sample selected is not representative of the population extracted&#46; We attempted to diminish that error insofar as possible by including patients consecutively in the dates indicated until the desired sample size was reached&#44; as long as the relevant complementary tests were obtained&#44; essentially teleradiographs&#46; However&#44; not all surgeons in the team request this test during the preoperative study&#44; as is the case in routine monitoring&#44; so some patients who did not have it could not be included in the study&#46; Neither did we include those in whom some specific reason indicated a specific technique&#44; thus attempting to avoid selecting patients in whom one technique was more advantageous than the other given their specific conditions&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Another limitation was that the selected sample size was calculated in order to adjust to the comparative analysis of the alignment of the postoperative mechanical axis between the 2 surgical technique groups&#46; However&#44; when delving into an analysis by subgroups&#44; the number of cases was reduced and so the statistical analysis lost some power&#46; In addition&#44; since cases presenting preoperative varus deformity were predominant&#44; we were not able to analyze the results of navigation in different subgroups of valgus deviation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">On the other hand&#44; since all radiographic measurements were conducted by a single observer&#44; it was not possible to compare intra- and interobserver variability&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">We can conclude that navigation has led to better results in terms of postoperative alignment&#44; with a lower percentage of cases outside the range and better precision in the placement of implants&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Overall&#44; patients with preoperative deformities greater than 10&#176; had a better postoperative alignment than those with deformities greater than 15&#176; regardless of the technique employed&#46; However&#44; among those cases with a preoperative mechanical axis within 10&#176; and 15&#176; varus&#44; the use of navigation systems seemed to produce a better postoperative alignment&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0185" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">II</span>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that this investigation adhered to the ethical guidelines of the Committee on Responsible Human Experimentation&#44; as well as the World Medical Association and the Declaration of Helsinki&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and&#47;or subjects referred to in the work&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Conflict of interests"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-07-20"
    "fechaAceptado" => "2014-10-03"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec542234"
          "palabras" => array:4 [
            0 => "Total knee replacement"
            1 => "Navigation"
            2 => "Computer assisted surgery"
            3 => "Post-operative alignment"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec542235"
          "palabras" => array:4 [
            0 => "Artroplastia total de rodilla"
            1 => "Navegaci&#243;n"
            2 => "Cirug&#237;a asistida por ordenador"
            3 => "Alineaci&#243;n postoperatoria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare the results obtained with computer assisted surgery with conventional techniques and evaluate the influence of navigation at different levels of preoperative deformity&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 100 cases with primary total knee arthroplasty performed with conventional or computer assisted surgery&#46; A comparison was made of the post-operative mechanical axis of the lower limb between both groups and in terms of pre-operative deformity&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Optimal alignment is most often obtained by using the navigation system &#40;62&#37;&#41; than by a conventional technique &#40;36&#37;&#41;&#46; Patients with deformities under 10&#176; varus showed a mean post-operative alignment within the optimal range &#40;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#176; deviation from the neutral mechanical axis&#41;&#44; while those with more than 15&#176; of varus show an alignment out of range&#44; regardless of the technique used &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#46; In those with a deformity of between 10&#176; and 15&#176; of pre-operative varus alignment&#44; values were found closer to the neutral axis in the navigation group &#40;178&#46;7&#176;&#41; than in the conventional technique &#40;175&#46;5&#176;&#41;&#44; although these differences are not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;127&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Post-operative alignment obtained with navigation is better than with the conventional technique&#44; with a smaller percentage of cases out of range&#44; and greater accuracy in placing implants&#46; A potential benefit was observed in navigation for cases with deformities of between 10&#176; and 15&#176; of varus&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Conocer los resultados obtenidos con cirug&#237;a asistida por ordenador en nuestro medio en comparaci&#243;n con las t&#233;cnicas convencionales y analizar la influencia de la navegaci&#243;n ante distintos grados de deformidad preoperatoria&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo con 100 pacientes intervenidos de artroplastia total de rodilla mediante t&#233;cnica convencional y cirug&#237;a asistida por ordenador&#46; Se compar&#243; el eje mec&#225;nico postoperatorio del miembro inferior en carga entre ambos grupos y en funci&#243;n de la deformidad preoperatoria de cada caso&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtiene una alineaci&#243;n &#243;ptima con mayor frecuencia al utilizar el sistema de navegaci&#243;n &#40;62&#37;&#41; que mediante una t&#233;cnica convencional &#40;36&#37;&#41;&#46; Los pacientes con deformidades menores de 10&#176; de varo presentaron una media de alineaci&#243;n postoperatoria dentro del intervalo &#243;ptimo &#40;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#176; de desviaci&#243;n del eje mec&#225;nico neutro&#41; mientras que aquellos con m&#225;s de 15&#176; de varo muestran una alineaci&#243;n fuera de rango&#44; independientemente de la t&#233;cnica empleada &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; En aquellos con una deformidad de entre 10 y 15&#176; de varo preoperatoria los valores de alineaci&#243;n se encontraron m&#225;s pr&#243;ximos al eje neutro en el grupo de la navegaci&#243;n &#40;178&#44;7&#176;&#41; que en el de t&#233;cnica convencional &#40;175&#44;5&#176;&#41;&#44; aunque estas diferencias no son estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;127&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La alineaci&#243;n postoperatoria obtenida con la navegaci&#243;n es mejor que con la t&#233;cnica convencional&#44; con un menor porcentaje de casos fuera de rango y una mayor precisi&#243;n en la colocaci&#243;n de los implantes&#46; Se observa un potencial beneficio de la navegaci&#243;n para aquellos casos con deformidades de entre 10 y 15&#176; de varo&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Please cite this article as&#58; Benavente P&#44; L&#243;pez Orosa C&#44; Oteo Maldonado JA&#44; Orois Codesal A&#44; Garc&#237;a L&#225;zaro FL&#46; Cirug&#237;a asistida por ordenador&#46; Su utilidad en distintos grados de deformidades preoperatorias&#46; Rev Esp Cir Ortop Traumatol&#46; 2015&#59;59&#58;245&#8211;253&#46;</p>"
      ]
    ]
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      0 => array:7 [
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Histogram of frequencies of the postoperative mechanical axis in the conventional surgery group&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Histogram of frequencies of the postoperative mechanical axis in the navigation surgery group&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bar chart representing the means of the postoperative mechanical axis in each subgroup of preoperative mechanical axis according to the surgical technique employed&#46;</p>"
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      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; L&#58; left&#59; R&#58; right&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Values are given as mean and standard deviation&#44; with the interval in brackets&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conventional &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Navigation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 &#40;46&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 &#40;44&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;805<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;<span class="elsevierStyleItalic">n</span>&#41; male&#47;female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#47;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#47;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;529<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;82 &#40;21&#46;90&#8211;44&#46;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;63&#177;5&#46;48 &#40;21&#46;50&#8211;47&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;698<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Knee &#40;<span class="elsevierStyleItalic">n</span>&#41; <span class="elsevierStyleSmallCaps">L</span>&#47;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#47;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#47;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Student <span class="elsevierStyleItalic">t</span> test for independent samples&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Chi-squared test&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Descriptive analysis of the variables age&#44; gender&#44; BMI and operated side&#46;</p>"
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        "etiqueta" => "Table 2"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Values are given as mean and standard deviation&#44; with the interval in brackets&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conventional &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Navigation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative KSS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;9 &#40;56&#8211;155&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;56 &#40;21&#8211;165&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;052<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Flexion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5 &#40;0&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;0 &#40;0&#8211;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;491<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Maximum flexion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;42 &#40;45&#8211;125&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;2 &#40;50&#8211;125&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;579<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mechanical axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">171&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;47 &#40;160&#8211;194&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;1 &#40;157&#8211;200&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;412<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Descriptive analysis of the preoperative variables&#58; KSS score&#44; flexion and maximum flexion&#44; and mechanical axis&#46;</p>"
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        "etiqueta" => "Table 3"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">For the variables of duration of surgery and duration of ischemia&#44; values are given as mean and standard deviation&#44; with the interval in brackets&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conventional &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Navigation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Type of implant CR&#47;PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#47;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#47;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;687<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of surgery&#44; min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;8 &#40;68&#8211;175&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">130&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;7 &#40;78&#8211;192&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;000</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of ischemia&#44; min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">104&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;5 &#40;75&#8211;145&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;7 &#40;80&#8211;180&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;001</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab842421.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Student <span class="elsevierStyleItalic">t</span> test for independent samples&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Chi-squared test&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Comparative analysis between the type of implant&#44; duration of surgery and duration of ischemia&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Values are given as mean and standard deviation&#44; with the interval in brackets&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Mechanical axis&#58; values over 180&#176; indicate valgus&#44; whilst values under 180&#176; indicate varus&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Difference in means&#44; with 95&#37; confidence interval in brackets&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Conventional &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Navigation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Difference in means&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mechanical axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">176&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5 &#40;165&#46;6&#8211;184&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">177&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;1 &#40;170&#46;4&#8211;186&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;73 &#40;0&#46;21&#8211;3&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">0&#46;027</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab842423.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Student <span class="elsevierStyleItalic">t</span> test for independent samples&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Analysis of the postoperative mechanical axis&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Values are given as mean and standard deviation &#40;in brackets&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subgroups mechanical axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postoperative mechanical axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">&#8804;165</td><td class="td" title="table-entry  " align="left" valign="top">Conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">174&#46;3 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">174&#46;6 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">174&#46;4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">165&#8211;170</td><td class="td" title="table-entry  " align="left" valign="top">Conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">175&#46;5 &#40;4&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&#46;7 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;1 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">170&#8211;175</td><td class="td" title="table-entry  " align="left" valign="top">Conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;3 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;9 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;7 &#40;2&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">&#62;175</td><td class="td" title="table-entry  " align="left" valign="top">Conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&#46;5 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&#46;9 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&#46;7 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Total</td><td class="td" title="table-entry  " align="left" valign="top">Conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">176&#46;2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;9 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177&#46;1 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab842425.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Descriptive analysis of the variable postoperative mechanical axis in the different subgroups of preoperative mechanical axis&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; SE&#58; size of the effect&#59; SMR&#58; standardized mean of the response&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Values are given as mean and standard deviation &#40;in brackets&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preop&#46;Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postop&#46;Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-Preop&#46; Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SMR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">KSS conventional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">148&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">KSS navigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;56&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 19888856
Original language: English
DOI:10.1016/j.recote.2015.04.002
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