Impact of Image-Derived Instrumentation on Total Knee Arthroplasty Revision Rates

Abstract

Background: Computer navigation and image-derived instrumentation (IDI) are technology-based methods developed to improve outcomes and potentially reduce revision total knee arthroplasty (TKA). IDI refers to the use of manufactured, patient-specific surgical jigs. Conflicting reports exist on IDI-associated improvements in outcomes. The primary aim of the current study was to compare the rates of revision among TKA cases in which components were initially implanted with use of IDI, computer navigation, or neither of these methods (“other” TKA). The secondary aim was to determine whether the outcomes of IDI differed for specific subgroups. Methods: Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for the 3 TKA groups: IDI, computer-navigated, and other TKA. The study period was from the first IDI procedure recorded by the AOANJRR (April 2010) to December 31, 2016. The analysis was restricted to primary TKA cases undertaken for osteoarthritis and involving patellar resurfacing and the use of a cross-linked polyethylene insert. Subanalyses were performed to evaluate the effects of age, sex, implantation method, IDI manufacturer, prosthetic design, and prosthesis type on the rates of revision. Kaplan-Meier estimates of survivorship described the time to first revision. Hazard ratios (HRs, Cox proportional hazards models) with adjustment for age and sex were used to compare revision rates. Results: IDI was used in 5,486 primary TKA procedures. There was no significant difference among the groups in the cumulative percent revision (CPR) at 5 years: 3.3% (95% confidence interval [CI], 2.4% to 4.6%) for IDI, 2.4% (95% CI, 2.2% to 2.7%) for the computer-navigated group, and 2.5% (95% CI, 2.3% to 2.7%) for other TKA. Posterior-stabilized TKA with use of the IDI method had a significantly higher rate of revision at >3 months (HR, 1.45 [95% CI, 1.02 to 2.04]; p = 0.036), as did IDI TKA in the ≤65-year-old patient cohort (HR, 1.52 [95% CI, 1.10 to 2.09]; p = 0.010), compared with computer-navigated TKA. Patellar revision was significantly more likely in the IDI group. Conclusions: IDI TKA demonstrated no overall difference in early to mid-term revision rates compared with standard implantation methods. However, elevated rates of revision were seen with posterior-stabilized TKA, in patients ≤65 years of age, and for patellar revision, meaning that this method should be used with some caution and requires further study. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Decreased patient comorbidities and post-operative complications in technology-assisted compared to conventional total knee arthroplasty

“…This may be a result of surgeons looking at ways of improving the longevity of TKA implants in younger patients by improving component alignment using technology [9, 15, 31]. There is some evidence that technology‐assisted TKA may be most beneficial for individuals younger than age 65 [14, 33, 43], but this is still a highly debatable topic, and long‐term follow‐up is needed [18, 25].…”

Editor’s Spotlight/Take 5: How Large a Study Is Needed to Detect TKA Revision Rate Reductions Attributable to Robotic or Navigated Technologies? A Simulation-based Power Analysis

“…Our specialty's reaction has been otherwise. Despite the fact that no welldesigned study about a new implantalignment tool, navigation system, or surgical robot has been shown to improve patient-reported outcomes or implant durability, and despite the fact that the best studies on those innovationsincluding systematic reviews, network meta-analyses, registry reports, and long-term follow-up studies of randomized trials-have found no differences that a patient might perceive [1,2,8,9,13], the use of expensive, unproven technology in our specialty is growing fast. The global use of robotic-assisted knee arthroplasty, for example, will reach approximately 700,000 procedures per year by 2030, sustaining a compound annual growth rate of 8% from 2021 to 2030 [5].…”

When should we adopt new technology into our practices?

“…As far as we now know, differences in outcomes scores among generally well-performing implants are negligible or nonexistent [2], the odds of a new implant lasting longer than an existing one is hardly better than a coin toss [3,4], and no well-designed study about a novel implant-alignment tool, ligament-balancing approach, or technology-driven innovation has made a dent in patient-reported outcomes or implant durability. The best such studies-systematic reviews, network metaanalyses, registry reports, and long-term follow-up studies of randomized trials-have found no differences at all that a patient might perceive [5][6][7][8][9].…”