Comparison of Utilization and Short-term Complications Between Technology-assisted and Conventional Total Hip Arthroplasty

Simultaneous Versus Staged Bilateral Total Hip Arthroplasty: A Matched Cohort Analysis of Revenue and Contribution Margin

BACKGROUND

Though previous studies have demonstrated improved cost benefits associated with simultaneous versus staged bilateral total hip arthroplasty (simBTHA and staBTHA), further investigation is needed regarding the revenues and contribution margins (CMs) of these procedures. In this study, we compared revenue, CM, and surgical outcomes between simBTHA and staBTHA.

METHODS

All patients who underwent simBTHA (both procedures completed the same day) and staBTHA (procedures completed on different days within one year) between 2011 and 2021 at a single high-volume orthopedic specialty hospital were identified. Of the 1,517 identified patients (n = 139 simBTHA, n = 1,378 staBTHA), 232 were included in a 1:1 propensity match based on baseline demographics (116 per cohort). Revenue, costs, CM, and surgical outcomes were compared between cohorts.

RESULTS

Compared to staBTHA, simBTHA procedures had significantly lower total costs (P < .001), direct costs (P < .001), and patient revenue. There was no significant difference in CM between groups (P = .361). Additionally, there were no significant differences in length of stay (P = .173), operative time (P = .438), 90-day readmissions (P = .701), 90-day revisions (P = .313), or all-cause revisions (P = .701) between cohorts.

CONCLUSIONS

Though simBTHA procedures have lower revenues than staBTHA, they also have lower costs, resulting in similar CM between procedures. As both procedures have similar postoperative complication rates, further research is required to evaluate specifically which patients may benefit from simBTHA versus staBTHA regarding clinical and patient-reported outcomes.

LEVEL OF EVIDENCE

III.

Lower Intraoperative and Immediate Postoperative Complications in Robotic Versus Conventional Primary Total Hip Arthroplasty: A Retrospective Cohort Analysis of Over 360,000 Patients

PURPOSE

Although a trend of an improved alignment with robotic total hip arthroplasty (THA) over conventional methods has surfaced from recent series, it is unknown whether these results translate into meaningful enhancements in postoperative outcomes. To address this lack in the literature, we compared the perioperative morbidity and mortality with robotic and conventional THA in a large national cohort of 367,894 patients. We hypothesized that no significant differences would exist in the outcomes between the two groups.

METHODS

Records were extracted from 2016-2019 from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project which is the largest in-patient database in the United States. From 367,894 THAs, robotics were employed for 7,863 patients. The remaining 360,031 conventional THAs served as controls. The two groups were compared for demographics, admission, and hospital stay details including costs, and mortality and morbidity data including medical and surgical complications. Descriptive statistics were used for demographic data while analytical statistics including t-tests, chi-squared tests, Fischer exact test, and Pearson chi-squared tests were used for perioperative outcomes. Statistical significance was set at p<0.005.

RESULTS

Demographic distributions between robotic and conventional THA groups displayed similar age and sex characteristics. Shorter mean lengths of stay (1.87 days) were seen in robotic THA versus conventional THA (2.33 days) while higher costs were noted for the former (mean $68,686.71 vs $66,840.39) (p<0.005). Low overall mortality (0.03% robotic, 0.09% conventional) was seen in both groups (p>0.005). Higher comparative incidences of anemia, acute renal failure, and pneumonia were seen in conventional THA (p<0.005) while no significant differences were noted for other complications including myocardial infarction, pulmonary embolism, deep vein thrombosis, and cardiac arrest (p>0.005). Among others, lower dislocation rates, mechanical complications, periprosthetic joint infection, and periprosthetic fractures were seen with robotic THA (p<0.005). Wound complications and superficial infection rates did not differ between the two groups (p>0.005).

CONCLUSIONS

Evidence has emerged from our results to support more routine adaptation of the robotic option of performing a THA. These can be based on lower local, systemic, and mechanical complications as demonstrated by the present study. Further evaluation of these results in follow-up would help establish the foothold of robotic surgery in total hip replacement in the modern context.

Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance

BACKGROUND

While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated.

METHODS

This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores.

RESULTS

No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468).

CONCLUSION

Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.

Does Computer Navigation or Robotic Assistance Affect the Risk of Periprosthetic Joint Infection in Primary Total Knee Arthroplasty? A Propensity Score-Matched Cohort Analysis

BACKGROUND

The use of technology during total knee arthroplasty (TKA) has been associated with more accurate component position and less blood loss. Yet to date, the risk of developing prosthetic joint infection (PJI) associated with computer navigation (CN) or robotic assistance (RA) has not been thoroughly evaluated. This study used propensity score-matching (PSM) in a large cohort of primary TKA patients to compare the rate of PJI following conventional TKA (TKA) versus CN-TKA and RA-TKA.

METHODS

We retrospectively reviewed 13,015 knees in 11,727 patients who underwent primary TKA at a single institution from 2018 to 2021. The cohort was stratified into TKA, CN-TKA, and RA-TKA groups. 1:1 PSM was applied to 11,834 patients. Propensity score-matching was performed using logistic regression accounting for age, sex, body mass index, Charlson Comorbidity Index (CCI) score, CCI components, and smoking status. Univariate and multivariable analyses were performed to evaluate differences in surgical time and PJI rate.

RESULTS

Significantly longer median operating times were noted in the RA-TKA group (14 minutes) compared to TKA (P < .001). The PJI rates among matched cohorts were similar among RA-TKA (0.3%), CN-TKA (0.3%), and conventional TKA (0.5%). Multivariable logistic regressions demonstrated that the use of robotic assistance (odds ratio (OR) = 0.5, P = .423) or computer navigation (OR = 0.61, P = .128) was not associated with increased risk of PJI when compared to conventional TKA.

CONCLUSIONS

Use of computer navigation and robotic assistance during primary TKA are associated with longer surgical times, but no difference in PJI frequency within 90 days of surgery.

Total Hip Arthroplasty: An Update on Navigation, Robotics, and Contemporary Advancements

While total hip arthroplasty (THA) remains effective for improvement of pain and function in patients with osteoarthritis and avascular necrosis, there remain areas of continued pursuit of excellence, including decreasing rates of dislocation, leg length discrepancy, implant loosening, and infection. This review article covers several bearing surfaces and articulations, computer-assisted navigation and robotic technology, and minimally invasive surgical approaches that have sought to improve such outcomes. Perhaps the most significant improvement to THA implant longevity has been the broad adoption of highly cross-linked polyethylene, with low wear rates. Similarly, navigation and robotic technology has proven to more reproducibly achieve intraoperative component positioning, which has demonstrated clinical benefit with decreased risk of dislocation in a number of studies. Given the projected increase in THA over the coming decades, continued investigation of effective incorporation of technology, soft tissue-sparing approaches, and durable implants is imperative to continued pursuit of improved outcomes in THA.

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 Imageless Navigation Does Not Reduce 90-Day Adverse Events or Five-Year Revisions in a Large National Cohort

BACKGROUND

Computer navigation is an increasingly utilized technology that is considered with total hip arthroplasty (THA). However, the evidence to support this practice is mixed. The current study leveraged a large national administrative database to compare 90-day adverse events as well as 5-year all-cause revision and dislocation rates following THA performed with and without imageless navigation.

METHODS

From 2010 to 2020, a large national database was queried for THA cases performed for osteoarthritis. Cases with or without imageless navigation were matched at 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI) score. Ninety-day adverse events were assessed and compared with multivariate analyses. Five-year incidence of revision and dislocation were also assessed between cohorts.

RESULTS

Use of THA imageless navigation increased from 2010 (2.5% of cases) to 2020 (5.5% of cases; P < .001). After matching, 11,990 THA patients with navigation and 47,948 without navigation were identified. Overall, 90-day adverse events were observed in 7.0% of the population. Multivariate analysis controlling for age, sex, and ECI demonstrated a difference in only one 90-day adverse event; wound dehiscence, which had higher odds in the navigation group (odds ratio, 1.60, P < .001). At 5 years, revisions for the navigated group were higher (4.4 versus 3.6%: P = .006), while dislocations were not significantly different.

CONCLUSION

THA imageless navigation was not found to be associated with improved 90-day postoperative adverse events or differences in the 5-year rates of revision or dislocation. The current data were unable to identify clear advantages of this evolving technology for primary THA.