Robotics and Navigation as Learning Tools for Fellows Training in Hip Arthroplasty

Technology-Assisted Hip and Knee Arthroplasty in Orthopaedic Residency Training: A National Survey

INTRODUCTION

The adoption of technology-assisted total joint arthroplasty (TA-TJA) is increasing; however, the extent to which TA-TJA is used among orthopaedic trainees is unknown. The purpose of this study was to assess the current use of TA total knee arthroplasty (TKA) and total hip arthroplasty (THA) by orthopaedic residents and to evaluate resident perceptions toward TA-TJA in their surgical training.

METHODS

In this cross-sectional study, an anonymous electronic survey was sent to all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program coordinators to distribute to their PGY-2 to PGY-5 residents. The survey consisted of 24 questions, including resident demographics, utilization of TA-TJA in their training, and perceptions regarding TA-TJA.

RESULTS

A total of 103 orthopaedic residents completed the survey, of whom 68.0% reported using TA-TJA at their institution. Of the residents using TA-TJA, 28.6% used TA for total TKA only, 71.4% used TA for both TKA and THA, and none used TA solely for THA. One-third of residents (33.3%) use TA for more than half of all TKAs conducted, whereas 57.0% use TA for <10% of all THAs conducted. Approximately half of all residents (49.5%) thought that training in TA-TJA should be required during residency, with no significant differences between junior and senior level residents ( P = 0.24). Most (82.0%) thought that trainees should be required to learn conventional TJA before learning TA-TJA. 63.0% thought that technology had a positive effect on their primary TJA training experience; however, 26.0% reported concern that their training conducting conventional TJA may be inadequate.

DISCUSSION

This study demonstrates that most orthopaedic residents currently conduct TA-TJA and highlights notable differences in TJA training experiences. These results provide a platform for future work aimed at further optimizing TJA training in residency, particularly as technology continues to rapidly evolve and utilization of TA-TJA is projected to grow exponentially.

LEVEL OF EVIDENCE

N/A, survey-based study.

Total Hip Arthroplasty with Robotic Arm Assistance for Precise Cup Positioning: A Case-Control Study

OBJECTIVE

To determine whether more precise cup positioning can be achieved with robot-assisted total hip arthroplasty (THA) as compared to conventional THA.

METHODS

In this study, between July 2019 and May 2021, 93 patients aged 23-75 years with osteonecrosis of the femoral head (ONFH) and adult developmental dysplasia of hip who underwent first hip surgery were included in the study. They were randomly assigned to either the robotic-assisted THA group (n = 45) or the conventional THA group (n = 48). After the operation, all patients were given routine rapid rehabilitation guidance. The duration of operation was recorded to estimate the learning curve through cumulative summation analysis. We compared the demographics, duration of operation, cup positioning, leg length discrepancy, hip offset, and Harris Hip Score between robot-assisted THA and manual THA. Precision in the positioning of the acetabular prosthesis using the MAKO system was also compared between the two groups.

RESULTS

The mean duration of operation for the robot-assisted THA group was 91.37 ± 17.34 min (range: 63 to 135 min), which was significantly higher than that for the conventional THA group. When the number of procedures was increased to 13, the duration of operation in the robot-assisted group decreased significantly and gradually became stable. In terms of duration of operation, robot-assisted THA was associated with a learning curve of 13 cases. The mean amount of bleeding in the robot-assisted THA group was not significantly different from that in conventional THA group (328 ± 210 ml vs 315 ± 205 ml) (p = 0.741). There was no significant difference in the proportion of prostheses located within Lewinnek's safe zone between robot-assisted THA group and conventional THA group (69.81% vs 64.41%). The leg length discrepancy (LLD) was significantly smaller in the robot-assisted THA group than in the conventional THA group (p < 0.001), but both were within acceptable limits (10 mm). The inclination and anteversion angles of the acetabular prosthesis planned before operations were correlated with the actual measurement (r = 0.857 p < 0.001, r = 0.830, p < 0.001). After surgery, none of the patients experienced hip dislocation, aseptic loosening, or periprosthetic infection during the 3 months of follow-up.

CONCLUSION

The proportion of acetabular prostheses in the Lewinnek's safety zone was higher and the extent of LLD was significantly lower in the robot-assisted THA group, as compared to the same metrics in the conventional THA group. The MAKO robot improved the accuracy of implant placement in THA.

[The superiority of navigation and robotics in hip arthroplasty: fact or myth?]

Computer-assisted surgery represents a relatively novel treatment option in total hip arthroplasty, which has been supported by the technological progress over the latest decades. Navigation and robotics enable increasing the precision of cup positioning, as well as successful biomechanical restoration of leg length and offset. However, the intended target area is still one of debate in literature. Besides the learning curve, the use of navigation and robotics requires additional time and financial expense, which has not yet been addressed in the German healthcare system. This is one reason why computer-assisted surgery has not fully attained everyday routine. The number of comparative studies is limited, but the results are promising. However, if these surrogate measures will end in reduced revision rates or better outcome is unclear. Further prospective studies and register analysis might illuminate the potential benefit of navigation and robotics.