Introduction. Stryker computer navigation system has been used for total knee arthroplasty (TKA) procedures since October 2008 at the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics. Material and methods. There have been 126 computer assisted TKA that accounted for 11.5 % of primary TKA within this period (1096 procedures). Arthritis of the knee joints with evident pain syndrome was an indication to TKA surgery. Arthritis of the knee joint of 27 patients (21.4 %) was accompanied by femoral deformity of various etiology with debris found in the medullary canal in several cases. The rest 99 patients (78.6 %) were regular cases of primary TKA. Results. We compared the results of correction of lower limb biomechanical axis with TKA employing navigation and without computer assistance. Regular TKA procedures showed no substantial difference in the correction of biomechanical axis. Complete correction using computer navigation was achieved in 85 % of the cases versus 79 % of the patients without navigation. The deformity up to 3° developed in 14 % of navigated cases and in 17 % of the cases without computer assistance. An error of deformity correction was 3–5° in 4 % of the cases without computer navigation. Those were cases of challenging primary TKA. So the advantages of computer navigation have become evident with greater deformities, and in the cases when intramedullary guide can hardly be used due to severe deformities in the femoral metaphysis and diaphysis, after several operative procedures of osteosynthesis with deformed, obliterating bone marrow canal or presence of debris. Complete correction using computer navigation was achieved in 85.2 % cases versus 42.8 % patients without navigation. Postoperative varus of 2° was observed in 14.8 % cases (valgus or varus deformity of 3° developed in 28.6 % of the cases without computer assistance). Conclusion. What is better: special instrumentation or navigation?. Current instrumentation can provide regular mechanical control of the limb axis and is based on the principles of intramedullary, extramedullary and even double guide placement. Image-free navigation and standard surgical techniques can equally be used for simple cases of primary TKA. Same landmarks are used. These landmarks are determined by a surgeon quite subjectively and can lead to inadequate usage of special instrumentation and computer navigation. However, computer navigation should be used in the cases when intramedullary guide can hardly be used, not desirable or possible. Special instrumentation can fail in setting a valgus angle needed with extraarticular femoral deformity. Navigation allows determining rotation more precisely in the cases when posterior femoral condyles contour (posttraumatic condition, hypoplastic condyles) is distorted. Assessment of ligament balance can be rather subjective when special instrumentation is used. Application of computer navigation is helpful for measurements of flexion and extension gaps sixe and regularity. Computer navigation is contraindicated for contractures and ankyloses of the hip joint. For the rest of the cases the choice of instrumentation is a surgeon's decision

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). While computer-navigation technologies in total knee arthroplasty show survivorship advantages and are widely used, comparable applications within THA show far lower utilisation. Using national registry data, this study compared patient reported outcome measures (PROMs) in patients who underwent THA with and without computer navigation. Data from Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) PROMs program included all primary THA procedures performed for OA up to 31 December 2020. Procedures using the Intellijoint HIP® navigation system were identified and compared to procedures using other computer navigation systems or conventional instrumentation only. Changes in PROM scores between pre-operative and 6-month post-operative time points were analysed using multiple regression model, adjusting for pre-operative score, patient age, gender, ASA score, BMI, surgical approach, and hospital type. There were 65 primary THA procedures that used the Intellijoint HIP® system, 90 procedures used other types of computer navigation, and the remaining 5,284 primary THA procedures used conventional instrumentation. The estimated mean changes in the EuroQol visual analogue scale (EQ VAS) score and Oxford Hip score did not differ significantly when Intellijoint® was compared to conventional instruments (estimated differences of 2.4, 95% CI [-1.7, 6.5], p = 0.245, and −0.5, 95% CI [-2.5, 1.4], p = 0.592, respectively). The proportion of patients who were satisfied with their procedure was also similar when Intellijoint® was compared to conventional instruments (rate ratio 1.06, 95% CI [0.97, 1.16], p = 0.227). The preliminary data demonstrate no significant difference in PROMs when comparing the Intellijoint HIP® THA navigation system with both other navigation systems and conventional instrumentation for primary THAs performed for OA. Level of evidence: III (National registry analysis)

Introduction. Two aspects are very important for knee joint replacement – restoration of biomechanical limb axis and achieving ligaments balance. Computer navigation allows us to do all this. Material and methods. We analysed 94 knee joint replacement surgeries using computer navigation by “STRYKER”. Results. There is no substantial difference between results of correction of biomechanical axis with computer navigation and without it in case of uncomplicated joint replacement. So, completer correction of axis (varus/valgus zero degrees) with computer navigation was achieved in 84% of cases versus 79% without navigation. There was varus or valgus deformity up to two degrees in 12% after surgery (without navigation −17% of cases). Error in deformity correction without application of navigation was three-five degrees in 4% of cases (all were challenging joint replacement). Advantages of navigation are obvious in case of large deformities, and also when insertion of intramedullary guide is undesirable or impossible. Use of navigation requires good skills of joint replacement, because landmarks should be chosen precisely and possibility of error during determining the center of rotation for the femoral head should be taken into consideration. Duration of surgery without navigation is 82.6±16.4 minutes and is much longer in the beginning of the learning curve (one hour longer or more). After acquiring skills the surgery takes 118±15.6 minutes. Conclusion. We evaluate use of navigation system as a modern and in-demand trend. Use of navigation should be started after getting good skills of joint replacement. Violation of the technology of determining landmarks leads to wrong virtual modeling and serious errors in positioning components. Advantages of navigation are obvious in evident bone deformity, when it is impossible or undesirable to open a medullary canal

Individuals learn to master new motor skills (such as learning a new surgical technique) by evaluating available feedback to alter future performance. Continuous concurrent augmented feedback is supplementary information presented to the learner throughout the performance of a task. An example of this type of feedback is the visual information provided by computer navigation during arthroplasty surgery. This type of feedback is a potentially powerful tool for learning because it theoretically guides the learner to the correct response, reduces errors, and reinforces correct actions. However, motor learning theory suggests that this type of feedback may impair learning because of development of dependence on the additional feedback or distraction from intrinsic feedback. In the current era of reduced number of training hours it is essential to assess the role of computer navigation on trainees. Our objective was to determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty. We conducted a systematic review and critical appraisal of the literature. There is some evidence from randomised controlled trials that navigation use by trainees facilitates accurate placement of arthroplasty components compared to conventional instrumentation. There is no evidence that training with computer navigation impairs performance in retention tests (re-testing on same task after an interval of time) or transfer tests (re-testing in different conditions i.e. without concurrent feedback). We conclude that although there are significant limitations of the published literature on this topic there is no available evidence that supports concerns regarding the theoretical detrimental effects of computer navigation on the learning curve of arthroplasty trainees

Computer navigation in total joint arthroplasty has been shown to be effective in improving the radiographic outcome in patients undergoing both hip and knee arthroplasty. However, critics have argued that the required capital equipment and added time to perform the procedure is cost prohibitive. To test this hypothesis, we compared our hospital discharge experience with computer navigation to national standards published by the Agency for Healthcare Research and Quality for the years 2004 and 2005. In the AHRQ database the average length of stay for DRG 209 in 2004 and 2005 respectively, in the Midwest region was 4.6 days and 4.3 days, with a mean charge of $27,403 and $27,948, with only 40% and 45%, of patients discharged to home with or without home health care. In 2004 and 2005, the senior author performed 125 and 117 Medicare primary hip and knee replacements, respectively, with computer navigation with a mean length of stay of 2.9 days and 2.8 days, with charges of $22,134 and $24,612, and 63% and 71% discharged to home. On a pure charge basis, the senior author experience a decreased overall charge compared to published data. Even if the entire cost of the navigation system in our system $204,000 was spread equally over only the Medicare patients over the two year period, the additional $842/case still results in a case charge below published data. Based on the senior author’s experience with hospitalization cost, length of stay and discharge disposition, computer navigation in total joint replacement is not associated with an increased cost/case and may result in dramatically lower indirect costs due to shorter length of stay and increased number of discharges to home compared to published regional Medicare discharge data

Alignment of the femoral component during hip resurfacing has been implicated in the early failure of this device. Techniques to facilitate a more accurate placement of the femoral component may help prevent these early failures. We aim to establish whether the use of imageless computer navigation can improve the accuracy in alignment of the femoral component during hip resurfacing. 6 pairs of cadaveric limbs were randomized to the use of computer navigation or standard instrumentation. All hips had radiographs taken prior to the procedure to facilitate accurate templating. All femoral components were planned to be implanted with a stem shaft angle of 135 degrees. The initial guide wire was placed using either the standard jig with a pin placed in the lateral cortex or with the use of an imageless computer navigation system. The femoral head was then prepared in the same fashion for both groups. Following the procedure radiographs were taken to assess the alignment of the femoral component. The mean stem shaft angle in the computer navigation group was 133.3 degrees compared to 127.7 degrees in the standard instrumentation group (p=0.03). The standard instrumentation group had a range of error of 15 degrees with a standard deviation of 4.2 degrees. The computer navigated group had a range of error of only 8 degrees with a standard deviation of 2.9 degrees. Our results demonstrated that the use of standard alignment instrumentation consistently placed the femoral component in a more varus position when compared to the computer navigation group. The computer navigation was also more consistent in its placement of the femoral component when compared to standard instrumentation. We suggest that imageless computer navigation appears to improve the accuracy of alignment of the femoral component during hip resurfacing

Purpose. This meta-analysis was designed to evaluate the effects of computer navigation on blood conservation after total knee arthroplasty (TKA) by comparing postoperative blood loss and need for allogenic blood transfusion in patients undergoing computer navigation and conventional primary TKAs. Methods. Studies were included in this meta-analysis if they compared change in haemoglobin concentration before and after surgery, postoperative blood loss via drainage or calculated total blood loss, and/or allogenic blood transfusion rate following TKA using computer navigation and conventional methods. For all comparisons, odds ratios and 95 % confidence intervals (CI) were calculated for binary outcomes, while mean difference and 95 % CI were calculated for continuous outcomes. Results. Twelve studies were included in this meta-analysis. The change in haemoglobin concentration was 0.39 g/dl lower with computer navigation than with conventional TKA (P = 0.006). Blood loss via drainage was 83.1 ml (P = 0.03) lower and calculated blood loss was 185.4 ml (P = 0.002) lower with computer navigation than with conventional TKA. However, the need for blood transfusion was similar for the two approaches (n.s.). Conclusions. The primary TKA with computer navigation was effective in reducing haemoglobin loss and blood loss, but had no effect on transfusion requirement, compared with conventional primary TKA. These findings suggest the importance of analysing several blood loss parameters, because each may not always accurately reflect true postsurgical bleeding

Introduction. Restoration of normal hip biomechanics is vital for success of total hip arthroplasty (THA). This requires accurate placement of implants and restoration of limb length and offset. The purpose of this study was to assess the precision and accuracy of computer navigation system in predicting cup placement and restoring limb length and offset. Material and Methods. An analysis of 259 consecutive patients who had THA performed with imageless computer navigation system was carried out. All surgeries were done by single surgeon (KD) using similar technique. Acetabular cup abduction and anteversion, medialisation or lateralisation of offset and limb length change were compared between navigation measurements and follow-up radiographs. Precision, accuracy, sensitivity and specificity were calculated to assess navigation for cup orientation and student t-test used for evaluation of offset and limb length change. A p value of <0.05 was considered significant for evaluation. Results. Mean cup abduction and anteversion was 40.35° (SD, 5.81) and 18.46° (SD, 6.79) in postop radiographs compared to 41° (SD, 5.03) and 14.76° (SD, 6.11) for navigation measurements. Intraoperative navigation measurements had high precision and specificity for determining cup abduction and anteversion (precision >95%, specificity >90%). Accuracy for determining cup abduction was 96.13% compared to 72.2% for cup anteversion. Change in limb length and offset was mean 6.46mm (SD, 5.68) and −1.07mm (SD, 5.75) on radiograph evaluation and 5.41mm (SD, 5.11) and −2.24mm (SD, 5.87) from navigation measurements respectively, the difference being not significant in both (p value > 0.2). Radiograph and navigation had a mean difference of 1.01mm (SD, 2.83) for offset measurements and a mean difference of 1.05mm (SD, 4.37) for postop limb length assessment. Discussion. To the best of our knowledge this is the largest single surgeon study of navigated THA. We found that computer navigation assessment of acetabular cup abduction and anteversion and limb length and offset restoration has high probability of predicting correct placement of implants. To conclude, navigation can serve as an excellent tool for appropriate placement of implants and restoring limb length and offset in THA

Purpose. Patient-matched instrumentation is advocated as the latest development in arthroplasty surgery. Custom-made cutting blocks created from preoperative MRI scans have been proposed to achieve perfect alignment of the lower limb in total knee arthroplasty (TKA). The aim of this study was to determine the efficacy of patient-specific cutting blocks by comparing them to navigation, the current gold standard. Methods. 60 TKA patients were recruited to undergo their surgery guided by Smith & Nephew Visionaire Patient-Matched cutting blocks. Continuous computer navigation was used during the surgery to evaluate the accuracy of the cutting blocks. The blocks were assessed for the fit to the articular surface, as well as alignment in the coronal, sagittal and rotational planes, sizing, and resection depth. Results. All patient-matched cutting blocks were a good fit intra-operatively. Significant differences (p<0.05) in the resection depths of the distal femur and tibial plateau were observed between the cutting blocks and computer navigation for the medial compartment. Cutting block alignment of the femur and tibia in the coronal and sagittal planes also differed significantly (p<0.05) to navigation measurements. The PSCB would have placed 79.3% of the sample within +3° of neutral in the coronal plane, while the rotational and sagittal alignment results within +3° were 77.2% and 54.5% respectively. In addition, intraoperative assessment of sagittal femoral alignment differed to planned alignment by an average of 4.0 degrees (+/−2.3). Conclusion. This study suggests the use of patient-matched cutting blocks is not accurate, particularly in the guidance of the sagittal alignment in total knee arthroplasty. Despite this technique creating well fitting cutting blocks, intraoperative monitoring revealed an unacceptable degree of potential limb mal-alignment, resulting in increased outliers particularly when compared with standard computer navigation. Caution is recommended before PSCB are used routinely without objective verification of alignment

Patient-matched instrumentation is advocated as the latest development in arthroplasty surgery. Custom-made cutting blocks created from preoperative MRI scans have been proposed to achieve perfect alignment of the lower limb in total knee arthroplasty (TKA). The aim of this study was to determine the efficacy of patient-specific cutting blocks by comparing them to navigation, the current gold standard. 25 TKA patients were recruited to undergo their surgery guided by Smith & Nephew Visionaire Patient-Matched cutting blocks. Continuous computer navigation was used during the surgery to evaluate the accuracy of the cutting blocks. The blocks were assessed for the fit to the articular surface, as well as alignment in the coronal and sagittal planes, sizing, and resection depth. Actual postoperative alignment was then assessed by detailed CT scans following the Perth protocol, comparing the results with intraoperative measurements. All patient-matched cutting blocks were a good fit intra-operatively. Significant differences (p<0.05) in the resection depths of the distal femur and tibial plateau were observed between the cutting blocks and computer navigation for the medial compartment. Cutting block alignment of the femur and tibia in the coronal and sagittal planes also differed significantly (p<0.05) to navigation measurements. In addition, intraoperative assessment of sagittal femoral alignment differed to planned alignment by an average of 4.0 degrees (+/−2.3). This study suggests the use of patient-matched cutting blocks is not accurate, particularly in the guidance of the sagittal alignment in total knee arthroplasty. Despite this technique creating well fitting cutting blocks, intraoperative monitoring, validated by postoperative CT scans, revealed an unacceptable degree of potential limb mal-alignment, resulting in increased outliers particularly when compared with standard computer navigation

Arthrodesis is used most commonly as a salvage procedure for failed total knee arthroplasty (TKA). For successful arthrodesis, a stable fusion technique and acceptable limb mechanical alignment are needed. Although the use of intramedullary alignment rods might be helpful in terms of achieving an acceptable limb mechanical axis, fat embolism and intramedullary dissemination of an infection or reactivation of latent infection might occur in failed TKA cases. However, computer-assisted surgery allows precise cuts to be made without breaching medullary cavities. Here, the authors describe a case of knee arthrodesis performed by computer navigation and the Ilizarov method in a patient with a past history of infection. A 45-year-old man visited our hospital with failed total knee arthroplasy. Fortunately, even though infection was treated by debridement with component retention, mild heating was present over the knee, but ESR(erythrocyte sedimentation rate) and CRP(C-reactive protein) were within normal ranges. X-ray showed subsidence of the femoral component and a radiolucent line around the femoral component. Arthrodesis was planned for this patient due to disabling pain, a long-lasting severe functional deficit, failure of the primary TKA for ankylosed knee, and the patient’s poor economic status and his strong desire for arthrodesis. The computer navigation surgery system and the Ilizarov method were used for two reasons. The first reason was that the patient had a past history of infection. At pre-operative evaluation, even though ESR and CRP levels were within normal range, we could not completely rule out the possibility of latent infection due to suspicious findings such as long lasting disabling knee pain, mild heating over the knee, severe osteolytic radiographic changes around the femoral component. In that situation, inserting an IM rod to achieve acceptable mechanical alignment might have reactivated and disseminated a possible latent infection to the femoral or tibial medullary canals. The second reason was that we wanted to reduce the possibility of fat embolism by using computer navigation without instrumentation within the medullary canal. A CT-free, wireless computer navigation system was applied, with trackers fixed to the femur and tibia and no requirement for the use of an IM rod with component retention. Navigated femoral and tibial bone resections were then performed using Stryker software. The femoral resection was conducted at 0° of flexion to the sagittal axis, and the tibial resection at 7 ° of flexion to the sagittal axis. Arthrodesis was held in proper axial and rotational alignment with bone surfaces compressed together. Finally, knee arthrodesis was completed using the Ilizarov method. Based on our experience of the described case, we believe that arthrodesis for failed TKR, especially failure secondary to intraarticular infection, can be considered as another indication for computer navigation

Introduction:. Restoration of normal hip biomechanics is vital for success of total hip arthroplasty (THA). This requires accurate placement of implants and restoration of limb length and offset. The purpose of this study was to assess the accuracy of computer navigation system in predicting cup placement and restoring limb length and offset. Material and Methods:. An analysis of 259 consecutive patients who had THA performed with imageless computer navigation system was carried out. Acetabular cup abduction and anteversion, medialisation or lateralisation of offset and limb length change were compared between navigation measurements and follow-up radiographs. Sensitivity, specificity, accuracy and PPV were calculated to assess navigation for cup orientation and student t-test used for evaluation of offset and limb length change. Results:. Mean cup abduction and anteversion was 40.35° (SD, 5.81) and 18.46° (SD, 6.79) in postop radiographs compared to 41° (SD, 5.03) and 14.76°(SD, 6.11) for navigation measurements. Intraoperative navigation measurements had high PPV and specificity for determining cup abduction and anteversion (PPV >95%, specificity >90%). Accuracy for determining cup abduction was 96.13% compared to 72.2% for cup anteversion. Change in limb length and offset was mean 6.46 mm (SD, 5.68) and −1.07 mm (SD, 5.75) on radiograph evaluation and 5.41 mm (SD, 5.11) and −2.24 mm (SD, 5.87) from navigation measurements respectively, the difference being not significant in both (p value >0.2). Radiograph and navigation had a mean difference of 1.01 mm (SD, 2.83) for offset measurements and a mean difference of 1.05 mm (SD, 4.37) for postop limb length assessment. Discussion:. To conclude, navigation can serve as an excellent tool for appropriate placement of implants and restoring limb length and offset in THA

Hip Resurfacing is now an established treatment option for young active patients with osteoarthritis. However, there is slow uptake of hip resurfacing by some surgeons, with concern regarding failure from femoral neck fracture, a small but significant risk. Femoral neck fracture may follow notching of the neck, which occurs upon preparing the femoral head after inserting the femoral head/neck guide-wire. The placement of the femoral head/neck guide-wire is a concern for even experienced surgeons routinely, and in difficult cases of femoral head/neck deformity this is especially so. For the first time a preliminary series of Durom hip resurfacings, based on the successful Metasul bearing, were implanted using a computer image guidance system. The aim of computer navigation is to optimally place the femoral prosthesis in the correct degree of valgus with good underlying bone coverage, without notching the femoral neck or over-sizing the femoral component. Preoperative CT scanning was not required. A standard posterior approach to the hip was utilised, and a navigation reference frame was applied to the proximal femur. Then using an image intensifier and the computer navigation system, a guide-wire was passed quickly and easily into the femoral head/neck with a navigated drill guide. The femoral head was then prepared safely for the femoral component of the resurfacing, with minimal risk of femoral neck fracture. Computer navigation systems have an important role to play in hip resurfacing with respect to femoral head/neck preparation, as demonstrated from our preliminary study. This series shows the use of computer navigation in hip resurfacing to be both SAFE and SIMPLE with a quick learning curve. It was shown to be FASTER and MORE ACCURATE in the process of guide-wire placement in the femoral head/neck as compared to conventional jigs. Crucially, femoral neck fractures may even be potentially ELIMINATED using this technique. In the future, hip resurfacing in conjunction with computer navigation systems may allow;. - SAFER hip resurfacing, with reduced rates of femoral neck fractures. - Improved TRAINING to include junior surgeons in hip resurfacing. - Surgeons to operate INDEPENDENTLY initially. - Surgeons to operate on DIFFICULT cases subsequently. - The development of MINIMALLY INVASIVE hip resurfacing. - The development of SPECIALIST centres for teaching and difficult cases

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). Computer-navigation technologies in total knee arthroplasty show evidence-supported survivorship advantages and are used widely. The aim of this study was to determine the revision outcome of hip commercially available navigation technologies. Data from the Australian Orthopaedic Association National Joint Replacement Registry from January 2016 to December 2020 included all primary THA procedures performed for osteoarthritis (OA). Procedures using the Intellijoint HIP® navigation were identified and compared to procedures inserted using ‘other’ computer navigation systems and to all non-navigated procedures. The cumulative percent revision (CPR) was compared between the three groups using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazards models, adjusted for age and gender. A prosthesis specific analysis was also performed. There were 1911 procedures that used the Intellijoint® system, 4081 used ‘other’ computer navigation, and 160,661 were non-navigated. The all-cause 2-year CPR rate for the Intellijoint HIP® system was 1.8% (95% CI 1.2, 2.6), compared to 2.2% (95% CI 1.8, 2.8) for other navigated and 2.2% (95% CI 2.1, 2.3) for non-navigated cases. A prosthesis specific analysis identified the Paragon/Acetabular Shell THAs combined with the Intellijoint HIP® system as having a higher (3.4%) rate of revision than non-navigated THAs (HR = 2.00 (1.01, 4.00), p=0.048). When this outlier combination was excluded, the Intellijoint® system group demonstrated a two-year CPR of 1.3%. There was no statistical difference in the CPR between the three groups before or after excluding Paragon/Acetabular Shell system. The preliminary data presented demonstrate no statistical difference in all cause revision rates when comparing the Intellijoint HIP® THA navigation system with ‘other’ navigation systems and ‘non-navigated’ approaches for primary THAs performed for OA. The current sample size remains too small to permit meaningful subgroup statistical comparisons

Background: The rates of primary and revision knee arthroplasty in the United States have been increasing. Simultaneously, several studies have reported increased complication rates when these procedures are performed at low-volume centers. One innovation designed to improve knee arthroplasty outcomes is computer navigation, which aims to reduce revision rates by improving the alignment achieved at surgery. The purpose of this study was to examine the impact of hospital volume on the costeffectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption. Methods: A Markov decision model was used to evaluate the cost-effectiveness of computer-assisted knee arthroplasty, in relation to hospital volume. Transition probabilities were estimated from the arthroplasty literature, and costs were based on the average reimbursement for primary and revision knee arthroplasty at out institution. Outcomes were measured in quality adjusted life years. Results: The results demonstrate that computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of navigation increases, and as the impact on revision rates decreases. If a center performs 250 cases per year, computer navigation will be cost-effective if the annual revision rate is reduced by 2% per year over a twenty-year period. If a center performs 150 cases per year, computer navigation is cost-effective if it results in a 2.5% reduction in the annual revision rate over a twenty-year period. If a center performs only 25 cases per year, the annual reduction in revision rates must be 13% for computer navigation to be cost-effective. Conclusion: This analysis demonstrates that computer navigation is not likely to be a cost-effective investment in health care improvement in low volume joint replacement centers, where its benefit is most likely to be realized. However, it may be a cost-effective technology for higher volume joint replacement centers, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revisions rates with the use of this technology can be realized. This illustrates that hospital volume can have a substantial impact on the cost-effectiveness of new technology in surgery, and this should be carefully considered by any center considering such a large capital investment

Background. The literature quotes up to 20% dissatisfaction rates for total knee replacements (TKR). Swedish registry and national joint registry of England and Wales confirm this with high volumes of patients included. This dissatisfaction rate is used as a basis for improving/changing/modernising knee implant designs by major companies across the world. Aim. We aimed to compare post TKR satisfaction rates for navigated and non navigated knees. Methods. This was a retrospective analysis of prospectively collected data. All patients undergo comprehensive preoperative evaluation and comprehensive consent process and same rehabilitation protocols are followed as standard practice. Two groups were established depending on whether surgery was performed with or without computer navigation. We included 229 patients in each group. There were nine bilateral cases in the navigated group giving a total of 238 knees. Both groups were similar at the time of surgery (navigated: 68 years (sd9);; BMI 32.46;; (sd5.19);; OKS: 42.2 (sd7.5);; non-navigated: 70 years (sd9);; BMI 32.36;; (sd5.26);; OKS: 42.4 (sd7.3)). The satisfaction rates are recorded as very satisfied, satisfied, unsure or dissatisfied. Results. Of the 238 navigated knees 227 (95.4%) were very satisfied or satisfied;; while of the 229 non-navigated knees 205 (89.5%) were very satisfied or satisfied. Only 3 (1.3%) navigated knees and 9 (3.9%) non-navigated knees were dissatisfied. Seven (2.9%) navigated knees and fifteen (6.6%) non-navigated knees were unsure. The navigated group showed better satisfaction (p=0.049) compared to the non-navigated group and better satisfaction than previously published satisfaction rates [3]. When combining dissatisfaction and unsure responses the navigated group again performed significantly better than the non-navigated group (p=0.021). Satisfaction rates were also compared with published literature, which suggest that 82–89% of TKA patients are satisfied and that navigation has no effect on satisfaction [3]. Our data for the non-navigated knees are similar to high end of the published data. This goes to show that comprehensive education of patients, high volume surgeons and elective arthroplasty unit along with comprehensive consent process can achieve best results. We have also shown that navigation influences satisfaction rates. There were no differences in 6 week OKS data with scores of 28.1 (sd= 8.0) and 28.8 (sd=7.8) for navigated and non-navigated groups(p=0.623), The same was also true for range of flexion/extension (92.1° [sd=13.4°& 91.3° [sd=14.1°, p=0.360) and length of hospital stay in days (median=5 [min=2, max=37], median=5 [min=2, max=19], p=0.959);; for navigated and non-navigated groups respectively. Of those navigated knees reported as ‘dissatisfied’ and ‘unsure’, 50.0% (5 knees) were due to pain in the knee. For non-navigated knees, 66.7% (16 knees) stated knee pain as the reason for being ‘dissatisfied’ or ‘unsure’. Conclusion. A modern elective arthroplasty service can deliver high satisfaction rates. Use of computer navigation further improves even the best conventional satisfaction rates. Industry should promote better surgical techniques rather than bringing out new implants to improve satisfaction rates in total knee replacements

The Gpsystem Medacta vision system is composed of an infrared camera that produces and receives infrared rays reflected by almost 3 reflectors mounted on different rigid body devices (F=femoral, T=tibial, G=guide), in order to determine its position with an error lower than 0.35mm. Data received from this vision system are than elaborated by the Cinetique Gpsystem Version 1.0 system in order to determine the correct cutting guide positioning both for the femur and the tibia. The cutting guide is moved on different planes by 5 electric engines applied on 5 no ending screws. The first step of this system is determining, with the F and the T rigid bodies, patient’s lower limb kinematic in order to evaluate its mechanical axis, its flexion-extension range of movement and its pathological deviations. The second step is evaluating anatomical landmarks to find out the correct degrees of tibial and femoral cuts: these landmarks are the medial and lateral tibial glena, the distal femoral condyles, the posterior femoral condyles, the anterior femoral cortex, the tibial tuberosity, the Whiteside line and the epycondilar axis (each anatomical landmark is identified by multiple points in order to decrease possible errors). The third step is applying the cutting guide and the Grigid body on the femoral clamp in order to estimate the correct level for the tibial cut than, once the tibial osteotomy is done the vision system controls its correct execution and the soft tissue balancing of the knee. The fourth step is calculating with the Gpsystem the correct orientation of the femoral cutting guide and checking its positioning and cutting execution. The last step is applying the test-prosthesis verifying the mechanical axis of the knee and than assembling the definitive prosthesis. Since now we have applied 10 Cinetique knee prosthesis with the Medacta computer navigation system with good results and good positioning of the prosthesis. Medacta computer navigation system for Cinetique knee arthroplasty is innovative for its simple cutting guide and movement device both in their hardware than in their way of using and for a simpler software interface; these characteristics allows faster surgeon technique learning, shortening of surgical time and a better prosthesis positioning

Accurate implant alignment, prolonged operative times, array pin site infection and intra-operative fracture risk with computer assisted knee arthroplasty is well documented. This study compares the accuracy and cost-effectiveness of the pre- operative MRI based Signature custom made guides (Biomet) to intra-operative computer navigation (BrainLab Knee Unlimited). Twenty patients from a single surgeon's orthopaedic waiting list awaiting primary knee arthroplasty were identified. Patients were contacted and consented for the study and their suitability for MRI examination assessed. An MRI scan of the hip, knee and ankle was performed of the operative side following a set scanning protocol. Following MRI, patient specific femoral and tibial positioning cutting guides were manufactured. Patients then underwent arthroplasty and intra-operative computer navigation was used to measure the accuracy of the custom made, patient specific cutting guides. A cost analysis of the signature system compared with computer navigation was made. Our provisional results show that the accuracy of the pre-operative MRI patient specific femoral and tibial positioning guides was comparable to computer navigation. Pre-operative, patient specific implant positioning cutting guides were as accurate as computer navigation from analysis of our preliminary results. The potential advantages of the MRI based system are accurate pre-operative planning, reduced operating times and avoidance of pin site sepsis. However, further larger studies are required to examine this technique

Purpose:. The use of computer navigation has been shown to improve the accuracy of femoral component placement compared to conventional instrumentation in hip resurfacing. Whether exposure to computer navigation improves accuracy when the procedure is subsequently performed with conventional instrumentation without navigation has not been explored. We examinedwhether femoral component alignment utilizing a conventional jig improves following experience with the use of imageless computer navigation for hip resurfacing. Methods:. Between December 2004 and December 2008, 213 consecutive hip resurfacings were performed by a single surgeon. The first 17 (Cohort 1) and the last 9 (Cohort 2) hip resurfacings were performed using a conventional guidewire alignment jig. In 187 cases the femoral component was implanted using the imageless computer navigation. Cohorts 1 and 2 were compared for femoral component alignment accuracy. Results:. All components in Cohort 2 achieved the position determined by the pre-operative plan. The mean deviation of the stem-shaft angle (SSA) from the pre-operatively planned target position was 2.2 degrees (SD, 2.2°, 95% CI, 0.8°, 3.7°) in Cohort 2 and 5.6 degrees (SD, 4.3°, 95% CI, 3.6°, 7.6°) in Cohort 1 (p = 0.01). Four implants in Cohort 1 were positioned at least 10 degrees varus compared to the target SSA position and another four were retroverted. Conclusions:. Femoral component placement utilizing conventional instrumentation may be more accurate following experience using imageless computer navigation

The presence of retained metalwork, previou fractures or osteotomies makes TKA surgery challenging. Obstructed intramedually canals can produce difficulty with the use of IM instrumentation whilst the altered alignment can result in problematic soft tissue balancing. We present a series of 35 patients with deformity who underwent a successful TKA. Between July 2003 and January 2006 35 patients were operated on between 3 centres. All had extraarticular deformities in either the femur or tibia due to previous fractures or exposure to surgery. All underwent TKA surgery using an image free computer navigation system and extramedullary TKA instrumentation. All patients underwent pre-op and post-operative long eg alignment films. The pre-operative long eg films showed an alignment of 16 degrees varus to 18 degrees of valgus. Post-operative alignment ranged from 3 degrees varus to 4 degrees valgus. The femoral component position ranged from 88-91 degrees from the mechanical axis whilst the tibial component position ranged from 89-92 degrees from the mechanical axis of the limb. Total knee arthroplasty in the presence of extraarticular deformity is fraught with problems in regaining limb alignment and soft tissue balancing. This is the largest combined series of patients in which the same navigation system has been used to provide extramedullary alignment and cuts resulting in excellent component positioning and post-operative alignment. We recommend the routine use of computer navigation in these difficult cases