Can Technology Assistance be Cost Effective in TKA? A Simulation-Based Analysis of a Risk-prioritized, Practice-specific Framework

Navigated Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Prospective Randomized Controlled Trials

Background

Recent evidence on the cost-effectiveness of technology in total knee arthroplasty (TKA) demonstrated that navigated computer-assisted methods (N-TKA) is likely to be most cost-effective in the clinical setting. The aim of the current meta-analysis is to compare radiographic, clinical and functional outcomes between conventional TKA (C-TKA) and N-TKA methods.

Methods

All prospective randomized controlled trials (pRCTs) comparing primary TKA performed using C-TKA and N-TKA techniques were eligible for inclusion. Radiographic outcomes included postoperative coronal, sagittal and axial component alignment. Clinical outcomes included all-cause revision and aseptic revision. Functional outcomes were analyzed when reported. A random-effects meta-analysis of all available cases was performed. This allowed for all missing data.

Results

Normal coronal mechanical alignment of the tibial (p < 0.001) and femoral (p = 0.001) components was achieved more frequently with N-TKA. Normal sagittal mechanical alignment of the tibial component was achieved significantly more with N-TKA (p < 0.010). There was no difference in short-term clinical survivorship (all-cause, p = 0.649; aseptic, p = 0.79) or in functional outcomes reported between groups. There was a clinically significant reduction in the mean C-TKA operative time (87 min, σ = 16.6, 95% CI 76.4-98.8) compared N-TKA (97.6 min, σ = 16.9, 95% CI 86.2-109.1) (p = 0.17).

Conclusion

Navigated TKA achieves superior radiographic alignment for femoral and tibial components in both the coronal and sagittal plane. Operative times are 10 min longer in the N-TKA group. Functional outcomes are similar between navigated and conventional groups. Clinical outcomes reported in Level I studies are limited to short-term follow-up so future prospective studies are required.

Pitfalls with the MAKO Robotic-Arm-Assisted Total Knee Arthroplasty

Robotic-arm-assisted total knee arthroplasty (RATKA) with the MAKO system minimizes deviations in implant alignment and yields superior precision in implant position compared to a manual total knee arthroplasty. In this comprehensive commentary, we present and categorize the limitations and pitfalls of the procedure and we also provide recommendations for avoiding each limitation. The main surgeon-related limitations include prolonged operation duration, loose insertion of the checkpoints and pins, wrong registration and mapping, and damage to soft tissues during bone cutting. The system-related issues include the interruptions of the saw-cutting due to vibrations, specifications for the operating room floor and power supply, the high cost of the system, as well as the cost of each operation due to the extra implants, inability to use the system with various prostheses, wireless connection interruptions between the system's components, and hardware issues with the six joints of the robotic device. In order to circumvent the potential challenges in this surgical procedure, it is essential to possess sufficient experience and undergo comprehensive training. Maintaining continuous awareness of the additional implants throughout the entire operation and prioritizing the preservation of soft tissues are of paramount significance. A profound comprehension of the system and its inherent constraints can also prove to be pivotal in certain situations.

Technology assistance in primary total knee replacement: hype or hope?

INTRODUCTION

Total knee replacement (TKR) reduces pain, it increases quality of life and it generally lasts a long time with revision rates of less than 5% at 10 years. Some authors have suggested that outcomes may be further improved by technology assistance.

AREAS COVERED

Technology assistance in primary TKR includes technologies such as navigated TKR, patient specific instrumentation TKR and robotic TKR.

EXPERT OPINION

In general, technology assistance results in higher accuracy of component positioning and alignment, but this is likely not clinically relevant as no clinically important difference in clinical outcomes, quality of life and complications such as revisions has been demonstrated in meta-analyses of randomized controlled trials. As technology assistance in primary TKR is increasingly used to capture patient and surgeon data, surgeons have an increasingly important role in protecting their patients' data and their own data. Real world evidence of implant registries has shown that TKR without technologically assistance can achieve perfectly acceptable outcomes. Although there is a genuine hope that technology-assisted TKR may further improve these outcomes, this hope is based on promises rather than solid evidence. At the same time, technology assisted TKR is heavily promoted including direct patient marketing, which are aspects of a hype.

Tracing the evolution of robotic-assisted total knee arthroplasty: a bibliometric analysis of the top 100 highly cited articles

Robotic-assisted surgical systems hold promise in enhancing total knee arthroplasty (TKA) outcomes and patients' quality of life. This study aims to comprehensively analyze the literature on robot-assisted total knee arthroplasty (r-TKA), providing insights into its current development, clinical application, and research trends. A systematic search was conducted in the Web of Science Core Collection (WOSCC) to identify relevant articles. Data were collected from the top 100 highly cited articles. Article evidence levels were assessed following established guidelines. Statistical analyses and visualizations were performed to reveal publication trends, citations, research hotspots, and collaborative networks. The analysis covered 100 highly cited articles meeting the research criteria, with a focus on the last five years. The United States emerged as a major contributor, with most publications and citations in the Journal of Knee Surgery and Knee Surgery Sports Traumatology Arthroscopy. Research priorities revolved around clinical outcomes, accuracy, and alignment of r-TKA. Notably, higher evidence levels correlated with more citations, indicating greater attention. Interest in and research on r-TKA is steadily increasing, with a few countries at the forefront of these endeavors. While numerous studies have already reported short- to medium-term follow-up results, it is crucial to conduct longer-term investigations to gain a more comprehensive understanding of the clinical benefits that r-TKA offers compared to conventional techniques. Through ongoing research and a greater embrace of robotic technology, we can continue to improve the quality of life for patients undergoing knee arthroplasty.

Projected Savings Associated with Lowering the Risk of Total Hip Arthroplasty Revision Due to Dislocation in Patients with Spinopelvic Pathology

Purpose

In the United States (US), total hip arthroplasty (THA) is the most common hospital inpatient operation among Medicare beneficiaries and is ranked fourth when considering all payers. Spinopelvic pathology (SPP) is associated with an increased risk of THA revision (rTHA) due to dislocation. Several strategies have been proposed to mitigate the risk of instability in this population, including use of dual-mobility implants, anterior-based surgical approaches, and technology-assistance (digital 2D/3D pre-surgical planning, computer navigation, and robotic assistance). For primary THA (pTHA) patients with SPP who subsequently undergo rTHA due to dislocation, we aimed to estimate (1) target population size; (2) economic burden; and (3) 10-year projected savings to the US payer of lowering the risk of rTHA due to dislocation among pTHA patients with SPP.

Methods

A budget impact analysis from the US payer perspective was undertaken using published literature; American Academy of Orthopaedic Surgeons American Joint Replacement Registry 2021 Annual Report; Centers for Medicare & Medicaid Services MEDPAR 2019; and National (Nationwide) Inpatient Sample (NIS) 2019. Expenditures were inflation-adjusted to 2021 US dollars using the Medical Care component of the Consumer Price Index. Sensitivity analyses were performed.

Results

The target population size in 2021 was estimated at 5040 (range, 4830-6309) for Medicare (fee-for-service plus Medicare Advantage) and 8003 (range, 7669-10,018) for all-payer. Annual rTHA episode-of-care (through 90 days) expenditures for Medicare and all-payer were $185 million and $314 million, respectively. Using a 4.14% compound annual growth rate from NIS, the estimated number of applicable rTHA procedures that will be performed from 2022-2031 was 63,419 Medicare and 100,697 all-payer. With each 10% reduction in relative risk of rTHA due to dislocation, Medicare and all-payer could save $233 million and $395 million, respectively, over a 10-year period.

Conclusion

Among pTHA patients with spinopelvic pathology, a modest reduction in the risk of rTHA due to dislocation could achieve substantial cumulative savings to payers while improving healthcare quality.