Innovations in Total Knee Arthroplasty: Improved Technical Precision, But Unclear Clinical Benefits

Associations of parecoxib and other variables with recovery and safety outcomes in total knee arthroplasty: insights from a retrospective cohort study

Background

Early mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.

Methods

This study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007-2012 and 2013-2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.

Results

Parecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = -0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007-2018, but gender had no significant association with LOS during the period of 2013-2018. The 2013-2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1-2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.

Conclusion

In this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

Identifying Trends and Quantifying Growth for Technological Innovation in Knee Arthroplasty: An Analysis of a Patent Database (1990 to 2020)

Technological innovation is the key for surgical progress in knee arthroplasty and improvement in patient outcomes. Exploring patented technologies can help elucidate trends and growth for numerous innovative technologies. However, patent databases, which contain millions of patents, remain underused in arthroplasty research. Therefore, the present study aimed to: (1) quantify patent activity; (2) group patents related to similar technologies into well-defined clusters; and (3) compare growth between technologies in the field of knee arthroplasty over a 30-year period. An open-source international patent database was queried from January 1990 to January 2020 for all patents related to knee arthroplasty A search strategy identified 70,154 patents, of which 24,425 were unique and included analysis. Patents were grouped into 14 independent technology clusters using Cooperative Patent Classification (CPC) codes. Patent activity was normalized via a validated formula adjusting for exponential growth. Compound annual growth rates (CAGR) were calculated (5-year, 10-year, and 30-year CAGR) and compared for each cluster. Overall yearly patent activity increased by 2,023%, from 104 patents in 1990 to 2,208 patents in 2020. The largest technology clusters were "drugs" (n = 5,347; 23.8%), "components" (n = 4,343; 19.0%), "instruments" (n = 3,130; 13.7%), and "materials" (n = 2,378; 10.4%). The fastest growing technologies with their 5-year CAGR were: "user interfaces for surgical systems" (58.1%); "robotics" (28.6%); "modularity" (21.1%); "navigation" (15.7%); and "computer modeling" (12.5%). Since 1990, overall patent growth rate has been greatest for "computer modeling" (8.4%), "robotics" (8.0%), "navigation" (7.9%), and "patient-specific instrumentation" (6.4%). Most patents in knee arthroplasty for the last 30 years have focused on drugs, components, instruments, and materials. Recent exponential growth was mainly observed for user interfaces for surgical systems, robotics, modularity, navigation, and computer-assisted technologies. Innovation theory would suggest that these rapidly growing technologies are experiencing high innovation output, increased resource investments, growing adoption by providers, and significant clinical impact. Periodic monitoring of technological innovation via patent databases can be useful to establish trends and future directions in the field of knee arthroplasty.

Mapping knowledge landscapes and emerging trends of robotic-assisted knee arthroplasty: A bibliometric analysis

The robotic-assisted knee arthroplasty has gained increasing attention in the research field. To date, no comprehensive bibliometric analysis has been carried out on this topic. The present study aimed to introduce the research status and hotspots and explore the field of robotic-assisted knee arthroplasty from a bibliometric perspective. The Web of Science Core Collection database was utilized to retrieve articles and reviews on robotic-assisted knee arthroplasty published between 1993 and 2023. CiteSpace, VOSviewer, Scimago Graphica, Pajek, and a bibliometric online analysis platform (http://bibliometric.com/) were employed to analyze the regions, institutions, journals, authors, and keywords, aiming to predict the latest trends in research related to robotic-assisted knee arthroplasty. This study encompasses 697 records. The annual publication count pertaining to robotic-assisted knee arthroplasty demonstrates consistent growth. The United States leads with the highest number of studies (298), trailed by the United Kingdom (110) and France (49). The Hospital for Special Surgery emerges as the most prolific institution, while Professor Mont, Michael A holds significant author influence. The Journal of Arthroplasty reigns supreme in this field, boasting the highest publication and citation figures. Funding sources predominantly include Stryker (34), Smith Nephew (19), and the National Natural Science Foundation of China (17). Noteworthy research themes within robotic-assisted knee arthroplasty encompass patient satisfaction, kinematic alignment, and clinical benefits. The landscape of robotic-assisted knee arthroplasty research is thriving. Anticipated trajectories of research will be geared toward refining the precision of robotic technology and enhancing clinical outcomes within the realm of robotic-assisted knee arthroplasty.

Robotic-assisted total knee arthroplasty in clinical practice: protocol for a randomised controlled trial

Between 2 and 20% of patients who undergo total knee arthroplasty (TKA) report restricted motion and anterior knee pain. Non-optimal alignment of the implant components is a common cause of such complaints. Robotic-assisted TKA has been advocated to improve the accuracy of component positioning to match patients' anatomy and biomechanics. However, the advantages of robotic surgery over conventional freehand TKA are still unclear. The present study is a protocol for a single-blind clinical trial in which patients will be randomly allocated to undergo either robotic-assisted TKA or conventional freehand TKA. A restricted kinematic alignment with medial para-stellar approach shall be made in all patients. The present study follows the SPIRIT guidelines. The primary outcome of interest is to compare robotic TKA versus traditional freehand TKA in terms of patient-reported outcome measures (PROMs), length of hospitalisation, blood values, blood transfusion units, and range of motion. The second outcome of interest is to evaluate the accuracy of component positioning of robotic-assisted TKA compared to the conventional freehand TKA.Level of evidence Level I, randomised controlled trial.Registration German Registry of Clinical Trials (ID: DRKS00030614).

The Role of 3D-Printed Patient-Specific Instrumentation in Total Knee Arthroplasty: A Literature Review

Total knee arthroplasty (TKA) is currently one of the most common orthopedic surgeries due to the ever-increasing average life expectancy. The constant need for effective and accurate techniques was contributed to the development of three-dimensional (3D) printing in that field, especially for patient-specific instrumentation (PSI) and custom-made implants fabrication. PSI may offer numerous benefits, such as resection accuracy, mechanical axis alignment, cost-effectiveness, and time economy. Nonetheless, the results of existing studies are controversial. For this purpose, a review article of the published articles was conducted to summarize the role of 3D-printed PSI in TKA.

Global research status and trends in orthopaedic surgical robotics: a bibliometric and visualisation analysis study

This study aimed to investigate and summarise the current state of research and trends in orthopaedic surgical robots. Data on publicly available publications related to orthopaedic surgical robots were extracted by abstract searches of the Web of Science Core Collection database. A bibliometric analysis and detailed reading of the publications were then carried out and the information was visualised using co-authorship analysis, coupling analysis, co-citation analysis and co-occurrence analysis in VOSviewer. With 436 publications included in the study from 1993 to 2022, the overall contribution of publications to the world showed an increasing trend year by year, with a particularly pronounced after 2017, and a geographical trend of predominantly East Asia, North America, and Western Europe. Of these, China was the largest contributor (n = 128). Overall, the UK affiliates and their scholars were leaders in the field, with a high number of publications, total citations, average citations per article and H-index. The most published institutions and authors were Imperial College London (n = 21) and Professor Fares Sahi Haddad of University College London (n = 12), respectively. Journals with a high overall impact on robotic orthopaedic surgery were the Journal of Arthroplasty, Bone Joint Journal, International Journal of Medical Robotics and Computer Assisted Surgery. Keyword co-occurrence network analysis revealed four main clusters: robot-assisted knee, hip arthroplasty, spine surgery, and robotic technology research and development. The top three most common sites for robot-assisted surgery use were the knee, hip and spine. The most used robot types were the knee and spine, with Mako and Arobot being the most used robots for the knee and TiRobot for the spine. This study comprehensively reveals the current status and trends of global research on orthopaedic surgical robots, covering countries, institutions, authors, journals, research hotspots, robot types and surgical sites, providing directional guidance and research ideas for further research on the technological development and clinical evaluation of orthopaedic surgical robots.

Augmented reality in the operating room: a clinical feasibility study

Background

Augmented Reality (AR) is a rapidly emerging technology finding growing acceptance and application in different fields of surgery. Various studies have been performed evaluating the precision and accuracy of AR guided navigation. This study investigates the feasibility of a commercially available AR head mounted device during orthopedic surgery.

Methods

Thirteen orthopedic surgeons from a Swiss university clinic performed 25 orthopedic surgical procedures wearing a holographic AR headset (HoloLens, Microsoft, Redmond, WA, USA) providing complementary three-dimensional, patient specific anatomic information. The surgeon’s experience of using the device during surgery was recorded using a standardized 58-item questionnaire grading different aspects on a 100-point scale with anchor statements.

Results

Surgeons were generally satisfied with image quality (85 ± 17 points) and accuracy of the virtual objects (84 ± 19 point). Wearing the AR device was rated as fairly comfortable (79 ± 13 points). Functionality of voice commands (68 ± 20 points) and gestures (66 ± 20 points) provided less favorable results. The greatest potential in the use of the AR device was found for surgical correction of deformities (87 ± 15 points). Overall, surgeons were satisfied with the application of this novel technology (78 ± 20 points) and future access to it was demanded (75 ± 22 points).

Conclusion

AR is a rapidly evolving technology with large potential in different surgical settings, offering the opportunity to provide a compact, low cost alternative requiring a minimum of infrastructure compared to conventional navigation systems. While surgeons where generally satisfied with image quality of the here tested head mounted AR device, some technical and ergonomic shortcomings were pointed out. This study serves as a proof of concept for the use of an AR head mounted device in a real-world sterile setting in orthopedic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04339-w.

Preoperative Predictors of Same-Day Discharge After Total Knee Arthroplasty

Background

In January 2020, The Centers for Medicare and Medicaid Services approved total knee arthroplasty (TKA) to be performed in ambulatory surgery centers (ASCs). This study aims to develop a predictive model for targeting appropriate patients for ASC-based TKA.

Methods

A retrospective review of 2266 patients (205 same-day discharge [SDD; 9.0%] and 2061 one-day length of stay [91.0%]) undergoing TKA at a regional medical center between July 2016 and September 2020 was conducted. Multiple logistic regression was used to evaluate predictors of SDD, as these patients represent those most likely to safely undergo TKA in an ASC.

Results

Controlling for other demographics and comorbidities, patients with the following characteristics were at reduced odds of SDD: increased age (odds ratio [OR] = 0.935, P < .001), body mass index ≥35 (OR = 0.491, P = .002), female (OR = 0.535, P < .001), nonwhite race (OR = 0.456, P = .003), primary hypertension (OR = 0.710, P = .032), ≥3 comorbidities (OR = 0.507, P = .002), American Society of Anesthesiologists score ≥3 (OR = 0.378, P < .001). The model was deemed to be of adequate fit using the Hosmer and Lemeshow test (χ² = 12.437, P = .112), and the area under the curve was found to be 0.773 indicating acceptable discrimination.

Conclusion

For patients undergoing primary TKA, increased age, body mass index ≥35, female gender, nonwhite race, primary hypertension, ≥3 comorbidities, and American Society of Anesthesiologists score ≥3 decrease the likelihood of SDD. A predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in identifying patients that are candidates for SDD or ASC-based TKA.

What Factors Influence Operative Time in Total Knee Arthroplasty? A 10-Year Analysis in a National Sample

BACKGROUND

Changes in reimbursement in total knee arthroplasty (TKA) by Centers for Medicare and Medicaid Services (CMS) have been tied to a perceived decrease in the total surgical time required to perform these operations. However, little information is available to CMS about recorded surgical times for TKA across the United States and the variables that drive these values. Therefore, the purpose of our study, is to evaluate (1) changes in operative time over time and (2) factors associated with variations in operative time.

METHODS

The National Surgical Quality Improvement Program database was queried to identify all primary TKAs conducted between January 1, 2008, and December 31, 2017. All TKAs conducted within our study period that had operative time data available were included. Multivariable linear models were created to assess factors that influence operative time over the study period.

RESULTS

Our final analysis included 140,890 TKAs. The mean operative time across the study period was found to be 92.60 minutes. Examining quarterly values, operative time stayed within 5 minutes of this mean (range, 89.80-97.51 minutes). Age, sex, functional status, anesthesia type, body mass index, operative year, transfusion requirements, and preoperative laboratory findings significantly influenced operative time (P < .05 for all).

CONCLUSION

Our analysis indicates that while there are numerous factors that influence procedure duration, operative times have remained stable. This information should be heavily considered in regard to physician reimbursement, because providers are maintaining operative times and work effort while mitigating factors that influence outcomes in the perioperative period.