INTRODUCTION. In gap balancing technique, we decided the femoral component rotation according to the ligament balance in flexion. Component and limb alignment are important considerations during TKA. Three-dimensional positioning of TKA implants and exact mechanical axis has an effect on implant loosening, polyethylene stresses, and gait. According to the recent report, the navigation system made it possible to achieve aligned implants more than conventional TKA. Hybrid Navigation technique which is our procedure is combination of navigation system and modified gap technique. In other words, exact mechanical axis is gained by navigation system, stable stability of knee joint is gained by modified gap technique. PURPOSE. The purpose of this study is to carry out clinical evaluation and image evaluation of the patients who underwent hybrid navigation technique TKA. METHODS. We performed TKA using the hybrid navigation technique in 100 knees from April 2012 to April 2015. We evaluated hybrid navigation TKA which we were able to follow up more than five years. 33 knees were available for follow up. We investigated the mid-term results of TKA after a mean follow up period of 5 years and 8 months. We evaluated range of motion(ROM), Japan Orthopaedic Association (JOA)score, complications, revision rate as clinical evaluations. And we evaluated radiolucent line(RLL), loosening in X-ray, implantation accuracy in computed tomography(CT) as image evaluations. Surgical technique was that the knees were exposed using a medial parapatellar approach without patella turnover, and the anterior and posterior cruciate ligaments were resected. And next osteotomy distal femur and proximal tibia using CT-free Navigation, step-wise medial soft tissue release was performed to make the rectangular extension joint gap using gap tensor space (off set balancer) at 40 pounds of distraction force. Flextion gap was made at the same distraction force, thereby we determined external rotation angle of femur osteotomy in a patella reduction position. CT of the whole leg was taken preoperation and postoperation the first postoperative week in all cases. RESULTS. In CT evaluation, coronal and sagittal alignments of femoral componet were mean 90.92° and mean flex 3.02°. These alignment of tibial componet were 90.54° and mean posterior slope 3.0°. Outliers(>3°)of coronal aligment were 6% (2 knees)in femoral componet, and 6%(2 knees) in tibial componet. In clinical evaluation, mean preoperative ROM(flex) was 105 degrees which improved 122 degrees at final follow up. Mean preoperative JOA score was 46.3 which improved 85.8 at final follow up. In image evaluation, there were no incidence of component loosening(RLL>2mm). We experienced two complications(1 deep infection and 1 intraoperative fracture), but there were no postoperative fracture and DVT/PE. The revision arte was 3%(1 knee) due to deep infection. DISCUSSION AND CONCLUSION. Mid-term postoperative results has shown a good prognosis. We will not understand that we do not observe long-term results in future, neverthless we believe that this technique should be considered as an alternative means of conducting TKA

Background. Variability in component alignment continues to be a major in total knee arthroplasty(TKA). In the long term, coronal plane malalignment has been associated with an increased risk of loosening, insatability, and wear. Recently portable navigation system(PNS) in TKA have been introduced. The goal of PNS are to improve the accuracy of post operative alignment and eliminate outlier cases. The aim of this study is to evaluate clinical results and quantify the coronal plane alignment between a group of patients who underwent TKA using PNS versus CT-free large-console navigation system. Patients and Method. An unselected consecutive series of ninety-four patients undergoing primary TKA using the cruciate retaining cemented total knee system between April 2012 and August 2015 were studied. Patients were included only if they were deemed to be candidates for a Cruciate retaining TKA. Patients were excluded if they had a flexion contracture greater than 40°, or severe valgus or varus deformity. Forty eight knees was operated a TKA with CT-free large-console navigation system(The OrthoPilot system; Aesculap, Tuttlingen, Germany). Subsequently forty six knees was received a TKA using portable navigation system (KneeAlign2. TM. ). Postoperatively standing AP hip-to-ankle radiographs were obtained, from which the lower extremity mechanical axis, component angle were measured. The alignment goals were a neutral mechanical axis defined as a hip-to-ankle angle of 0°with the femoral and tibial components aligned perpendicular to the mechanical axis. The total operating time were quantified utilising an operating room database. The total operating time between TKAs performed with CT-free navigation system and those performed with portable navigation system was compared in each group. All patients postoperatively was evaluated of clinical results the Japan Orthopedics Association(JOA) Knee scores. Results. The mechanical axis angle in PNS group was 0.8°, while the CT-free navigation system group was 1.6°and there was no statistical significance. The number of outliers for mechanical axis angle was PNS group 39.1%, the large-console navigation group 22.9%, between the two groups there was statistical significance. The operative time in PNS was 130.0 minutes and significantly less compared to the time of the large-console group 150.4 minutes. The JOA Knee score of navigation group was 83.9 points, and the score of PNS group was 81.0 points., there was no statistical significance between the two groups on the clinical score. Conclusion. portable navigation system improved operative time in TKA, this study demonstrates portable navigation system to obtain same angle of overall mechanical axis angle as large-console group navigation system

The aim of this study was to compare the maximum laxity conferred by the cruciate-retaining (CR) and posterior-stabilised (PS) Triathlon single-radius total knee arthroplasty (TKA) for anterior drawer, varus–valgus opening and rotation in eight cadaver knees through a defined arc of flexion (0º to 110º). The null hypothesis was that the limits of laxity of CR- and PS-TKAs are not significantly different. The investigation was undertaken in eight loaded cadaver knees undergoing subjective stress testing using a measurement rig. Firstly the native knee was tested prior to preparation for CR-TKA and subsequently for PS-TKA implantation. Surgical navigation was used to track maximal displacements/rotations at 0º, 30º, 60º, 90º and 110° of flexion. Mixed-effects modelling was used to define the behaviour of the TKAs. . The laxity measured for the CR- and PS-TKAs revealed no statistically significant differences over the studied flexion arc for the two versions of TKA. Compared with the native knee both TKAs exhibited slightly increased anterior drawer and decreased varus-valgus and internal-external roational laxities. We believe further study is required to define the clinical states for which the additional constraint offered by a PS-TKA implant may be beneficial. Cite this article: Bone Joint J 2015; 97-B:642–8

INTRODUCTION. Soft-tissue balancing of the knee is fundamental to the success of total knee arthroplasty(TKA). Preparing rectangular extension and flexion joint gaps in the most important goal in TKA, because it facilitates functional stability of the knee. In gap balancing technique, we decided the femoral component rotation according to the ligament balance in flexion. Component and limb alignment are important considerations during TKA. Three-dimensional positioning of TKA implants and exact mechanical axis has an effect on implant loosening, polyethylene stresses, and gait. According to the recent reports, the navigation system made it possible to achieve aligned implants more than conventional TKA. Hybrid Navigation technique which is our procedure is combination of navigation system and modified gap technique. In other words, exact mechanical axis is gained by navigation system, stable stability of knee joint is gained by modified gap technique. PURPOSE. The purpose of this study is to carry out clinical evaluation and image assenssment using computed tomography (CT) of the patients who underwent hybrid navigation technique TKA. METHODS. We performed TKA using the hybrid navigation technique in 100 knees from April 2012. Surgical technique was that the knees were exposed using a medial parapatellar approach without patella turnover, and the anterior and posterior cruciate ligaments were resected. And next osteotomy distal femur and proximal tibia using CT-free Navigation, step-wise medial soft tissue release was performed to make the rectangular extension joint gap using gap tensor space(off set balancer) at 40 pounds of distraction force. Flextion gap was made at the same distraction force, thereby we determined external rotation angle of femur osteotomy in a patella reduction position. See Figure 1. CT of the whole leg was taken preoperation and postoperation in all cases. RESULTS. Coronal and sagittal alignments of femoral componet angle were mean 91.05° and mean flex anglewere 2.98°. These alignment of tibial componet angle were 91.08° and mean posterior slope angle were 3.38°. Outliers(>3°)of coronal aligment were 9% in femoral componet, and 8% in tibial componet. Mean operation times(skin incision to skin closure) were 108 minutes. We experienced two complications(1 deep infection and 1 peroneal nerve palsy), but there were no intraoperative fracture, postoperative fracture and DVT/PE. DISCUSSION AND CONCLUSION. 100 patients underwent hybrid navigation TKA which has advantage of both navigation and gap technique. CT assessment of components has shown good results. (outlier>3°femoral component: 9%, tibial component 8%) Short-term postoperative results has shown a good prognosis. We will not understand that we do not observe long-term results in future, neverthless we believe that this technique should be considered as an alternative means of conducting TKA

In the framework of the modiCAS (Modular Interactive Computer Assisted Surgery) Project, which emerged from a collaboration of the University of Siegen and the University of Frankfurt in the fields of mechatronics and medicine, the development of a modular system to assist the surgeon during the whole planning and operation procedure has been started. A completely new realization of a planning system for bone surgery and alloarthroplasty is presented. Characteristics of the new system are generic interfaces for navigation, robotics and real-time data acquisition, graphic interactivity, documentation of each planning-step, a flexible wizard-guided concept and adaptable teaching modes. The system can be configured to any data source such as X-ray, CT, MRI, US with individual calibration. For planning, the data sources can be merged in any user defined way. In contrast to all existing planning systems the presented system can optionally be linked to navigation and robotic systems. The software was realized to run platform-independent on any personal computer surrounding. We used commercially available software libraries for computer graphics and graphical user interface programming. The whole system consists of several modules which are closely linked together and support all major pre- and intraoperative steps of surgery. The user interface remains the same during the planning and the intervention. Preoperative planning is carried out on a totally new planning station comprising an interactive and intuitive graphic interface, while intraoperative features include interactive matching procedures, true real-time-capability and incorporation of navigation and robotics. Initially we realized modules to support total hip allo-arthroplasty. The first application of the system is for a clinical trial on total hip alloarthroplasty. Planning is performed on the basis of radiographs and CT-datasets. Intraoperatively a navigation system and a robotic surgery system are used. Preliminary results show very precise and reproducible plannings that could be achieved in short time without special training of the clinician. Furthermore the unlimited intraoperative access to the whole planning dataset appeared to be very convenient to the surgeon because it allowed immediate response to unforeseen patient specific situations. Future adaptations of the universal planning system will be total knee alloarthroplasty, spine surgery and trauma surgery. The existing system can easily be configured to any surgical procedure because the same basic functionality is used for all applications and only special configurative datasets have to be generated for each application. The open architecture of the system enables easy integration of further input or output devices, an easy adaptation to different interventions, planning styles and operative techniques is possible

Navigation in total hip arthroplasty has been shown to improve acetabular positioning and can decrease the incidence of mal-positioned acetabular components. The aim of this study was to assess two surgical guidance systems by comparing intra-operative measurements of acetabular component inclination and anteversion with a post-operative CT scan. We prospectively collected intra-operative navigation data from 102 hips receiving conventional THA or hip resurfacing arthroplasty through either a direct anterior or posterior approach. Two guidance systems were used simultaneously: an inertial navigation system (INS) and optical navigation system (ONS). Acetabular component anteversion and inclination was measured on a post-operative CT. The average age of the patients was 64 years (range: 24-92) and average BMI was 27 kg/m. 2. (range 19-38). 52% had hip surgery through an anterior approach. 98% of the INS measurements and 88% of the ONS measurements were within 10° of the CT measurements. The mean (and standard deviation) of the absolute difference between the post-operative CT and the intra-operative measurements for inclination and anteversion were 3.0° (2.8) and 4.5° (3.2) respectively for the ONS, along with 2.1° (2.3) and 2.4° (2.1) respectively for the INS. There was significantly lower mean absolute difference to CT for the INS when compared to ONS in both anteversion (p<0.001) and inclination (p=0.02). Both types of navigation produced reliable and reproducible acetabular cup positioning. It is important that patient-specific planning and navigation are used together to ensure that surgeons are targeting the optimal acetabular cup position. This assistance with cup positioning can provide benefits over free-hand techniques, especially in patients with an altered acetabular structure or extensive acetabular bone loss. In conclusion, both ONS and INS allowed for adequate acetabular positioning as measured on postoperative CT, and thus provide reliable intraoperative feedback for optimal acetabular component placement

Computer aided orthopaedic surgical (CAOS) technology has been around for over 20 years, and while it appears to provide better outcomes compared to conventional jigs, less than 1% of orthopaedic surgeons in USA have adopted it. This study surveyed the arguments against CAOS usage, highlighting those reasons which may continue to prevent CAOS from becoming truly widely accepted. The survey has identified several concerns with navigation systems. For example, the pin tracts from navigation reference frames cause stress risers that increase the risk of bone fracture and soft tissue/muscle damage. Additionally, infrared trackers take footprint space (as they require line of sight access to the tracking camera), increase risk of infection, and present a potential distraction to the surgical team. With current CAOS systems, even more nstrumentation is needed than with non-navigated surgical systems, and it is arguable that navigation makes surgery more complex, requiring a knowledge of anatomic landmarks, an increased number of tasks prior to and during surgery, and an assortment of different and perhaps unfamiliar instruments. These complexities very likely result in a slow learning curve on current CAOS systems, a learning curve that is mostly not started by the majority of surgeons. Other items of concern are the accuracy of morphed/generated bones in imageless systems (and how these models assume non-deformed anatomy), inaccuracies or distortion of the measurements (operating room lighting interfering with infrared trackers or field deformation of electromagnetic systems due to ferromagnetic instruments at the surgical site) and computer reliability. Considering the high cost (or low cost-effectiveness) of integrating CAOS into arthroplasty, and the lack of enough studies documenting truly better long term clinical results or fewer actual complications, it is evident why navigation is not yet a popular option for TKR. As a result of the critical findings from this study, it is our view that any successful new technique/tool in surgery should make the overall procedure easier, faster, cheaper and better (or at least equally as good) as the current techniques. While robotic surgery seems to be re-emerging, we hypothesize that the next real breakthrough will come from newer more utilitarian light weight small foot print technologies actuated by surgeons themselves, with enhanced computer guidance that will allow them to reduce instrumentation, complexity, and surgical time such as navigated free-hand bone cutting. Alternative navigation technologies (e.g. UWB 3D positioning radar) where line of sight becomes less crucial, image based systems (rather than image free), artificial vision, and smart instrumentation are likely to play a major role in achieving widespread future acceptance of CAOS in TKR

Correct alignment of the leg and positioning of the implant has shown to be an important factor in the successful long term outcome of total knee arthroplasty and navigation systems enable an accuracy of corrections and alignment within intervals of 1 mm or 1 degree. This study is to test if there is any discrepancy in accuracy which was sometimes observed in clinical trials between Orthopilot (Aesculap, Tuttlingen, German) and AxiEM (Medtronic Navigation, CoalCreek, Colo., USA). A synthetic bone model (Sawbones, Pacific Laboratories, Vashon, Washington) including pelvis and leg with mobile joint made up of titanium which does not affect the electromagnetic field was constructed. Mechanical axis was checked by ORTHODOC system (Integrated Surgical System, CA, USA) that is a preplanning system for ROBODOC (ISS, CA, USA) assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). The CT images were scanned with 1.25 mm or less slice interval. The CT images were converted to 3-dimensional (3D) volume-rendered model in ORTHODOC. Two orthopaedic surgeons measured it ten times independently. For the measurement of mechanical axis using navigation, 4 orthopaedic surgeons (two experts having more than 100 navigation experiences and two residents) registered anatomical landmarks and kinematic center of bone model ten times using Orthopilot as well as AxiEM. After that, one surgeon intentionally registered the wrong anatomical landmarks (10 mm medial and lateral to the center of distal femur, proximal tibial and ankle, and both malleoli) in both navigation system and observed the change of mechanical axis. True mechanical axis was varus 1.25° using Orthodoc, Orthopilot displayed varus 1.10±0.64° and AxiEM did varus 1.78±0.79°. The difference of mechanical axis between two navigations was not observed (P=0.12) and there were no intra and inter-observer variation in statistical analysis (Correlation=0.934, P=0.00). In the case of erroneous identification of the anatomical landmarks, Orthipilot showed much less variation compared to AxiEM. AxiEM altered the mechanical axis more in palpating center of the distal femur and ankle center and Orthopilot did in palpating the center of ankle. Both navigation systems provide high accuracy and reproducibility of mechanical axis of lower limb in experimental condition. But both were affected by the wrong identification of the anatomical landmarks. AxiEM had more variations. So surgeon should pay attention to register the precise anatomical landmarks

Rotational acetabular osteotomy (RAO), one of periacetabular osteotomies, is an effective joint-preserving surgical treatment for developmental dysplasia of the hip. Since 2013, we have been using a CT-based navigation for RAO to perform safe and accurate osteotomy. CT-based navigation allows precise osteotomy during surgery but cannot track the bony fragment after osteotomy. Thus, it is an issue to achieve successful reorientation in accordance with preoperative planning. In this presentation, we introduce a new method to achieve reorientation and evaluate its accuracy. Thirty joints in which CT-based navigated RAO was performed were included in this study. For the first 20 joints, reorientation was confirmed by tracing the lateral aspect of rotated fragment with navigation and checked if it matched with the preoperative planning. For the latter 10 joints, a new method was adopted. Four fiducial points were made on lateral side of the acetabulum in the preoperative 3-dimensional model and intraoperatively, rotation of the osteotomized bone was performed so that the 4 fiducial points match the preoperative plan. To assess the accuracy of position of rotated fragment in each group, preoperative planning and postoperative CT were compared. A total of 24 radial reformat images of postoperative CT were obtained at a half-hour interval following the clockface system around the acetabulum. In every radial image, femoral head coverage of actual postop- and planned were measured to evaluate the accuracy of acetabular fragment repositioning. The 4-fiducial method significantly reduced the reorientation error. Especially in the 12:00 to 1:00 position of the acetabulum, there were significantly fewer errors (p<0.01) and fewer cases with under-correction of the lateral acetabular coverage. With the new method with 4 reference fiducials, reorientation of the acetabulum could be obtained as planned with lesser errors

Introduction. Computer assisted surgery (CAS) systems have been shown to improve alignment accuracy in total knee arthroplasty (TKA), yet concerns regarding increased costs, operative times, pin sites, and the learning curve associated with CAS techniques have limited its widespread acceptance. The purpose of this study was to compare the alignment accuracy of an accelerometer-based, portable navigation device (KneeAlignÒ 2) to a large console, imageless CAS system (AchieveCAS). Our hypothesis is that no significant difference in alignment accuracy will be appreciated between the portable, accelerometer-based system, and the large-console, imageless navigation system. Methods. 62 consecutive patients, and a total of 80 knees, received a posterior cruciate substituting TKA using the Achieve CAS computer navigation system. Subsequently, 65 consecutive patients, and a total of 80 knees, received a posterior cruciate substituting TKA using the KneeAlignÒ 2 to perform both the distal femoral and proximal tibial resections (femoral guide seen in Figure 1, and tibial guide seen in Figure 2). Postoperatively, standing AP hip-to-ankle radiographs were obtained for each patient, from which the lower extremity mechanical axis, tibial component varus/valgus mechanical alignment, and femoral component varus/valgus mechanical alignment were digitally measured. Each measurement was performed by two, blinded independent observers, and interclass correlation for each measurement was calculated. All procedures were performed using a thigh pneumatic tourniquet, and the total tourniquet time for each procedure was recorded. Results. In the KneeAlignÒ 2 cohort, 92.5% of patients had an alignment within 3° of a neutral mechanical axis (vs. 86.3% with AchieveCAS, p<0.01), 96.2% had a tibial component alignment within 2° of perpendicular to the tibial mechanical axis (vs. 97.5% with AchieveCAS, p=0.8), and 94.9% had a femoral component alignment within 2° of perpendicular to the femoral mechanical axis (vs. 92.5% with AchieveCAS, p<0.01). The mean tourniquet time in the KneeAlignÒ 2 cohort was 48.1 + 10.2 minutes, versus 54.1 + 10.5 in the AchieveCAS cohort (p<0.01). The interclass correlation coefficient for measurement of the postoperative tibial alignment was 0.92, for femoral alignment was 0.85, and for overall lower extremity alignment was 0.94. Conclusion. Accelerometer-based, portable navigation can provide the same degree of alignment accuracy as large console, imageless CAS system in TKA, while also decreasing operative times. The KneeAlignÒ 2 successfully combines the benefits and accuracy of large-console, CAS systems, while avoiding the use of extra pin sites, decreasing operative times, and providing a level of familiarity with conventional alignment methods

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. Re-revision due to instability and dislocation can occur in up to 1 in 4 cases following revision total hip arthroplasty (THA). Optimal placement of components during revision surgery is thus critical in avoiding re-revision. Computer-assisted navigation has been shown to improve the accuracy and precision of component placement in primary THA; however, its role in revision surgery is less well documented. The purpose of our study was to evaluate the effect of computer-assisted navigation on component placement in revision total hip arthroplasty, as compared with conventional surgery. Methods. To examine the effect of navigation on acetabular component placement in revision THA, we retrospectively reviewed data from a multi-centre cohort of 128 patients having undergone revision THA between March 2017 and January 2019. An imageless computer navigation device (Intellijoint HIP®, Intellijoint Surgical, Kitchener, ON, Canada) was utilized in 69 surgeries and conventional methods were used in 59 surgeries. Acetabular component placement (anteversion, inclination) and the proportion of acetabular components placed in a functional safe zone (40° inclination/20° anteversion) were compared between navigation assisted and conventional THA groups. Results. Mean inclination decreased post-operatively versus baseline in both the navigation (44.9°±12.1° vs. 43.0°±6.8°, p=0.65) and control (45.8°±19.4° vs. 42.8°±7.1°, p=0.08) groups. Mean anteversion increased in both study groups, with a significant increase noted in the navigation group (18.6°±8.5° vs. 21.6°±7.8°, p=0.04) but not in the control group (19.4°±9.6° vs. 21.2°±9.8°, p=0.33). Post-operatively, a greater proportion of acetabular components were within ±10° of a functional target (40° inclination, 20° anteversion) in the navigation group (inclination: 59/67 (88%), anteversion: 56/67 (84%)) than in the control group (49/59 (83%) and 41/59, (69%), respectively). Acetabular component precision in both study groups improved post-operatively versus baseline. Variance in inclination improved significantly in both control (50.6° vs. 112.4°, p=0.002) and navigation (46.2° vs. 141.1°, p<0.001) groups. Anteversion variance worsened in the control group (96.3° vs. 87.6°, p=0.36) but the navigation group showed improvement (61.2° vs. 72.7°, p=0.25). Post-operative variance amongst cup orientations in the navigation group (IN: 46.2°; AV: 61.2°) indicated significantly better precision than that observed in the control group (IN: 50.6°, p=0.36; AV: 96.3°, p=0.04). Discussion. Re-revision is required in up to 25% of revision THA cases, of which 36% are caused by instability. This places a significant burden on the health care system and highlights the importance of accurate component placement. Our data indicate that the use of imageless navigation in revision THA – by minimizing the likelihood of outliers – may contribute to lower rates of re-revision by improving component orientation in revision THA. Conclusion. Utilizing imageless navigation in revision THAs results in more consistent placement of the acetabular component as compared to non-navigated revision surgeries

The use of intraoperative navigation and robotic surgery for minimally invasive lumbar fusion has been increasing over the past decade. The aim of this study is to evaluate postoperative clinical outcomes, intraoperative parameters, and accuracy of pedicle screw insertion guided by intraoperative navigation in patients undergoing lumbar interbody fusion for spondylolisthesis. Patients who underwent posterior lumbar fusion interbody using intraoperative 3D navigation since December 2021 were included. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey-36 (SF-36) were assessed preoperatively and postoperatively at 1, 3, and 6 months. Screw placement accuracy, measured by Gertzbein and Robbins classification, and facet joint infringement, measured by Yson classification, were assessed by intraoperative Cone Beam CT scans performed at the end of instrumentation. Finally, operation time, intraoperative blood loss, hospital stay, and screw insertion time were evaluated. This study involved 50 patients with a mean age of 63.7 years. VAS decreased from 65.8±23 to 20±22 (p<.01). ODI decreased from 35.4%±15 to 11.8%±14 (p<.01). An increase of SF-36 from 51.5±14 to 76±13 (p<.01) was demonstrated. The accuracy of “perfect” and “clinically acceptable” pedicle screw fixation was 89.5% and 98.4%, respectively. Regarding facet violation, 96.8% of the screws were at grade 0. Finally, the average screw insertion time was 4.3±2 min, hospital stay was 4.2±0.8 days, operation time was 205±53 min, and blood loss was 169±107 ml. Finally, a statistically significant correlation of operation time with hospital stay, blood loss and placement time per screw was found. We demonstrated excellent results for accuracy of pedicle screw fixation and violation of facet joints. VAS, ODI and SF-36 showed statistically significant improvements from the control at one month after surgery. Navigation with intraoperative 3D images represents an effective system to improve operative performance in the surgical treatment of spondylolisthesis

INTRODUCTION. The restoration of physiological kinematics is one of the goals of a total knee arthroplasty (TKA). Navigation systems have been developed to allow an accurate and precise placement of the implants. But its application to the intraoperative measurement of knee kinematics has not been validated. The hypothesis of this study was that the measurement of the knee axis, femoral rotation, femoral translation with respect to the tibia, and medial and lateral femorotibial gaps during continuous passive knee flexion by the navigation system would be different from that by fluoroscopy taken as reference. MATERIAL – METHODS. Five pairs of knees of preserved specimens were used. The e.Motion FP ® TKA (B-Braun Aesculap, Tuttlingen, Germany) was implanted using the OrthoPilot TKA 4.3 version and Kobe version navigation system (B-Braun Aesculap, Tuttlingen, Germany). Kinematic recording by the navigation system was performed simultaneously with fluoroscopic recording during a continuous passive flexion-extension movement of the prosthetic knee. Kinematic parameters were extracted from the fluoroscopic recordings by image processing using JointTrack Auto ® software (University of Florida, Gainesville, USA). The main criteria were the axis of the knee measured by the angle between the center of the femoral head, the center of the knee and the center of the ankle (HKA), femoral rotation, femoral translation with respect to the tibia, and medial and lateral femorotibial gaps. The data analysis was performed by a Kappa correlation test. The agreement of the measurements was assessed using the intraclass correlation coefficient (ICC) and its 95% confidence interval. RESULTS. The respective CCIs were as follows: HKA angle 0.839 [0.820; 0.856]; femoral translation 0.560 [0.517; 0.600]; femoral rotation 0.652 [0.616; 0.686]; medial femorotibial gap 0.905 [0.894; 0.916]; lateral femorotibial gap 0.767 [0.740; 0.791]. DISCUSSION. Measurements of TKA kinematics by the navigation system and by fluoroscopy were consistent for HKA angle and medial and lateral femorotibial gaps, but not for femoral translation and femoral rotation. These differences can be explained by a methodological bias. At the end of this work, the specific navigation system cannot be considered as a reliable instrument for measuring the kinematics of a TKA

Aims. Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error. Methods. A total of 356 patients undergoing primary THA were prospectively enrolled from November 2016 to March 2018. Clinically relevant error using the CAS system was defined as a difference of > 5° between CAS and 3D radiological reconstruction measurements for acetabular component inclination and anteversion. Univariate and multiple logistic regression analyses were conducted to determine whether hypermobile (. Δ. sacral slope(SS). stand-sit. > 30°), or stiff (. ∆. SS. stand-sit. < 10°) spinopelvic mobility contributed to increased error rates. Results. The paired absolute difference between CAS and postoperative imaging measurements was 2.3° (standard deviation (SD) 2.6°) for inclination and 3.1° (SD 4.2°) for anteversion. Using a target zone of 40° (± 10°) (inclination) and 20° (± 10°) (anteversion), postoperative standing radiographs measured 96% of acetabular components within the target zone for both inclination and anteversion. Multiple logistic regression analysis controlling for BMI and sex revealed that hypermobile spinopelvic mobility significantly increased error rates for anteversion (odds ratio (OR) 2.48, p = 0.009) and inclination (OR 2.44, p = 0.016), whereas stiff spinopelvic mobility increased error rates for anteversion (OR 1.97, p = 0.028). There were no dislocations at a minimum three-year follow-up. Conclusion. Despite high reliability in acetabular positioning for inclination in a large patient cohort using an optical CAS system, hypermobile and stiff spinopelvic mobility significantly increased the risk of clinically relevant errors. In patients with abnormal spinopelvic mobility, CAS systems should be adjusted for use to avoid acetabular component misalignment and subsequent risk for long-term dislocation. Cite this article: Bone Jt Open 2022;3(6):475–484

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA). Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position. For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods. A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired

Introduction. This study aimed to evaluate the effectiveness of a novel intraoperative navigation platform for total knee arthroplasty (TKA) in restoring native knee joint kinematics and strains in the medial collateral ligament (MCL) and lateral collateral ligament (LCL) during squatting motions. Method. Six cadaver lower limbs underwent computed tomography scans to design patient-specific guides. Using these scans, bony landmarks and virtual single-line collateral ligaments were identified to provide intraoperative real-time feedback, aided in bone resection, implant alignment, tibiofemoral kinematics, and collateral ligament elongations, using the navigation platform. The specimens were subjected to squatting (35°-100°) motions on a physiological ex vivo knee simulator, maintaining a constant 110N vertical ankle load regulated by active quadriceps and bilateral hamstring actuators. Subsequently, each knee underwent a medially-stabilized TKA using the mechanical alignment technique, followed by a retest under the same conditions used preoperatively. Using a dedicated wand, MCL and LCL insertions—anterior, middle, and posterior bundles—were identified in relation to bone-pin markers. The knee kinematics and collateral ligament strains were analyzed from 3D marker trajectories captured by a six-camera optical system. Result. Both native and TKA conditions demonstrated similar patterns in tibial valgus orientation (Root Mean Square Error (RMSE=1.7°), patellar flexion (RMSE=1.2°), abduction (RMSE=0.5°), and rotation (RMSE=0.4°) during squatting (p>0.13). However, a significant difference was found in tibial internal rotation between 35° and 61° (p<0.045, RMSE=3.3°). MCL strains in anterior (RMSE=1.5%), middle (RMSE=0.8%), and posterior (RMSE=0.8%) bundles closely matched in both conditions, showing no statistical differences (p>0.05). Conversely, LCL strain across all bundles (RMSE<4.6%) exhibited significant differences from mid to deep flexion (p<0.048). Conclusion. The novel intraoperative navigation platform not only aims to achieve planned knee alignment but also assists in restoring native knee kinematics and collateral ligament behavior through real-time feedback. Acknowledgment. This study was funded by Medacta International (Castel San Pietro, Switzerland)

Cup orientation of total hip arthroplasty (THA) is critical for dislocation, range of motion, polyethylene wear, pelvic osteolysis, and component migration. But, substantial error under manual technique has been reported. Therefore, various navigation systems were introduced to reduce outliers. CT based navigation (CTN) was reported to reduce outliers in cup orientation. Recently, a noble technique, fluoroscopy-CT-based navigation (FCTN), has recently been developed using 2D-3D matching technique. Because of much less registration points, FCTN might be friendly to MIS THA and cases with sever bone deformity. Between October 2006 and April 2008, 33 THAs were performed through MIS approach with navigations. We prospectively randomized those into two groups, CTN and FCTN groups. We implanted cementless hemispherical cups in 18 hips using CTN (VectorVision CT Hip 3.1) and in 15 hips using FCTN (VectorVision CT Hip 3.5). For all the patients, volumetric post-operative CT scan was performed to measure 3D cup orientation. using 3D image-processing software (JMM, Japan). The difference from target angles of anteversion was 2.7 ± 2.4 degrees in FCTN group, and 12.1 ± 5.7 degrees in CTN group (p < 0.001). The absolute value of difference from target angles of inclination was 2.7 ± 2.4 degrees in FCTN group, and 6.5 ± 4.5 degrees in CTN group (p = 0.006). FCTN does not need surface registration around acetabulum, which is great advantage to MIS THA. Our study clearly showed that FCTN significantly improved a cup orientation to CTN

Problem. Total hip replacement (THA) is among the most common and highest total spend elective operations in the United States. However, up to 7% of patients have 90-day complications after surgery, most frequently joint dislocation that is related to poor acetabular component positioning. These complications lead to patient morbidity and mortality, as well as significant cost to the health system. As such, surgeons and hospitals value navigation technology, but existing solutions including robotics and optical navigation are costly, time-consuming, and complex to learn, resulting in limited uptake globally. Solution. Augmented reality represents a navigation solution that is rapid, accurate, intuitive, easy to learn, and does not require large and costly equipment in the operating room. In addition to providing cutting edge technology to specialty orthopedic centers, augmented reality is a very attractive solution for lower volume and smaller operative settings such as ambulatory surgery centers that cannot justify purchases of large capital equipment navigation systems. Product. HipInsight™ is an augmented reality solution for navigation of the acetabular component in THA. HipInsight is a navigation solution that includes preoperative, cloud based surgical planning based on patient imaging and surgeon preference of implants as well as intraoperative guidance for placement of the acetabular component. Once the patient specific surgical plan is generated on the cloud-based planning system, holograms showing the optimal planned position of the acetabular component are exported in holographic format to a Microsoft HoloLens 2™, which the surgeon wears during placement of the acetabular component in total hip arthroplasty. The pelvis is registered using the HipXpert™ mechanical registration device, which takes 2–3 minutes to dock in the operating room. The surgeon then is able to view the patient's anatomy and optimal placement of the acetabular component under the skin in augmented reality. The surgeon then aligns the real cup impactor with the augmented reality projection of the cup impactor resulting in precise placement of the cup. Timescales. HipInsight was FDA cleared on January 28, 2021 for intraoperative use for placement of the acetabular component in total hip arthroplasty. The first case was performed in February 2021, and the product was launched to a select group of orthopedic surgeons in March 2021. Funding. HipInsight has been self-funded to date, and is beginning to engage in discussions to raise capital for a rapidly scaling commercial launch

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