Total knee arthroplasty (TKA) is one of the most successful procedures for treating end-stage osteoarthritis of the knee. However, ~8% of all procedures are revisions, an invasive procedure that removes and re-inserts components due to factors such as loosening or infection. Navigation and robotic systems have been introduced to aid surgeons in accurately resecting bone and balancing the knee;​ however, these innovations have not substantially reduced revision rates.

This thesis proposes a methodology for studying the connections between surgeon-controlled variables and aseptic revision risk and involves five contributions. First, we conducted a simulation study, predicting that comparative studies would need to enroll between 5000 and 8000 patients to have an 80% chance of showing revision rate reductions associated with technology-assisted TKA at 15 years follow-up. Second, we conducted a simulation study that suggested that surgical navigation is most likely to prove cost-effective in reducing revision in the widest range of circumstances compared to robotic surgery which is only likely to be costeffective in large practices containing patients who are on average at an elevated risk of revision. Third, we conducted one final simulation study that determined that a matched case-control methodology paired with survival analysis techniques could be an efficient study design to measure relationships between surgeon-controlled variables and risk of aseptic revision, requiring as little as 300 revision candidates.

Fourth, we propose two techniques, one CT-based and another EOS biplanar X-raybased, for assigning implant coordinate systems in TKA. Each protocol was able to reliably assign coordinate systems with a repeatability on the order of 1 mm and 1⁰. Finally, using data acquired through radiostereometric analysis, we determined that relying on alignment measurements taken at the time of revision as a proxy of alignment at the time of index surgery is likely not reliable.

With yearly TKA procedures expected to surpass 1 million in Canada and the United States by the end of this decade, this work illustrates a plausible pathway for the study of surgeon-controlled variables in connection with aseptic revision in TKA, hopefully spurring new innovations that can extend the lifetime of implanted components and reduce revision rates