New technology-based assistive techniques in total knee arthroplasty: A Bayesian network meta-analysis and systematic review

Accuracy of a New Augmented Reality Assisted Technique for Total Knee Arthroplasty: An In Vivo Study

Background

Total knee arthroplasty (TKA) remains the standard of care for treating end-stage osteoarthritis of the knee. Approximately 15%-20% of the patients are dissatisfied following surgery. To improve accuracy and outcomes of TKA, various assistive technologies have been introduced. For this study, an augmented reality (AR) system was explored and tested.

Methods

The Knee + system (Pixee Medical, Besancon, France) was used to guide TKA. It uses a combination of quick response-code labeled instruments and AR glasses to guide tibial and femoral cuts. The primary research goal was to evaluate its accuracy by direct comparing the planned angular values for lateral distal femoral angle, medial proximal tibial angle, hip-knee-ankle axis, and tibial slope to the intraoperative obtained values and the measured angles on postoperative full leg radiographs. The secondary research goal was to assess its feasibility.

Results

This retrospective study evaluated 124 patients, with a follow-up of at least 1 year. The average absolute difference between planned and measured postop values were 1.39° for lateral distal femoral angle, 1.03° for medial proximal tibial angle, 2.16° for tibial slope, and 1.51° for hip-knee-ankle axis. Within the follow-up period, 8 complications were observed. The average surgical time was 83 minutes.

Conclusions

This study has demonstrated a high accuracy, comparable to robotic-assisted total knee arthroplasty, of the Knee + AR system. It has shown to be a safe, cheap and time-efficient assistive technology for patients undergoing medial pivot TKA.

Bayesian meta-analysis of penetrance for cancer risk

Multi-gene panel testing allows many cancer susceptibility genes to be tested quickly at a lower cost making such testing accessible to a broader population. Thus, more patients carrying pathogenic germline mutations in various cancer-susceptibility genes are being identified. This creates a great opportunity, as well as an urgent need, to counsel these patients about appropriate risk-reducing management strategies. Counseling hinges on accurate estimates of age-specific risks of developing various cancers associated with mutations in a specific gene, ie, penetrance estimation. We propose a meta-analysis approach based on a Bayesian hierarchical random-effects model to obtain penetrance estimates by integrating studies reporting different types of risk measures (eg, penetrance, relative risk, odds ratio) while accounting for the associated uncertainties. After estimating posterior distributions of the parameters via a Markov chain Monte Carlo algorithm, we estimate penetrance and credible intervals. We investigate the proposed method and compare with an existing approach via simulations based on studies reporting risks for two moderate-risk breast cancer susceptibility genes, ATM and PALB2. Our proposed method is far superior in terms of coverage probability of credible intervals and mean square error of estimates. Finally, we apply our method to estimate the penetrance of breast cancer among carriers of pathogenic mutations in the ATM gene.

Systematic review and meta-analysis of economic and healthcare resource utilization outcomes for robotic versus manual total knee arthroplasty

The introduction of robotics in orthopedic surgery has led to improved precision and standardization in total knee arthroplasty (TKA). Clinical benefits of robotic versus manual TKA have been well established; however, evidence for economic and healthcare resource utilization outcomes (HRU) is lacking. The primary objective of this study was to compare economic and HRU outcomes for robotic and manual TKA. The secondary objective was to explore comparative robotic and manual TKA pain and opioid consumption outcomes. Multi-database literature searches were performed to identify studies comparing robotic and manual TKA from 2016 to 2022 and meta-analyses were conducted. This review included 50 studies with meta-analyses conducted on 35. Compared with manual TKA, robotic TKA was associated with a: 14% reduction in hospital length of stay (P = 0.022); 74% greater likelihood to be discharged to home (P < 0.001); and 17% lower likelihood to experience a 90-day readmission (P = 0.043). Robotic TKA was associated with longer mean operating times (incision to closure definition: 9.27 min longer, P = 0.030; general operating time definition: 18.05 min longer, P = 0.006). No differences were observed for total procedure cost and 90-day emergency room visits. Most studies reported similar outcomes for robotic and manual TKA regarding pain and opioid use. Coupled with the clinical benefits of robotic TKA, the economic impact of using robotics may contribute to hospitals' quality improvement and financial sustainability. Further research and more randomized controlled trials are needed to effectively quantify the benefits of robotic relative to manual TKA.

Is robotic assistance more eye-catching than computer navigation in joint arthroplasty? A Google trends analysis from the point of public interest

Computer-assisted navigation system (CAS) and robotic assisted surgery (RAS) have been widely used in joint arthroplasty, but few studies focused on public interest. We aimed to evaluate current trend and seasonality of public interest in CAS and RAS arthroplasty over the past 10 years, and forecast the future development. All data related to CAS or RAS arthroplasty from January 2012 to December 2021 were collected through Google Trends. Public interest was described by relative search volume (RSV). Pre-existing trend was evaluated by linear and exponential models. Time series analysis and ARIMA model were utilized to analyze the seasonality and future trend. R software 3.5.0 was for statistics analysis. Public interest in RAS arthroplasty has been continuously increasing (P < 0.001) and exponential model (R2 = 0.83, MAE = 7.35, MAPE = 34%, RSME = 9.58) fitted better than linear one (R2 = 0.78, MAE = 8.44, MAPE = 42%, RSME = 10.67). CAS arthroplasty showed a downtrend (P < 0.01) with equivalent R2 (0.04) and accuracy measures (MAE = 3.92, MAPE = 31%, RSME = 4.95). The greatest popularity of RAS was observed in July and October, while the lowest was in March and December. For CAS, a rise of public interest was in May and October, but lower values were observed in January and November. Based on ARIMA models, the popularity of RAS might continuously increase and nearly double in 2030, along with a stability with slight downtrend for CAS. Public interest in RAS arthroplasty has been continuously increasing and seems to maintain this uptrend in the next 10 years, whereas popularity of CAS arthroplasty will likely remain stable.

Robot-assisted knee arthroplasty improves component positioning and alignment, but results are inconclusive on whether it improves clinical scores or reduces complications and revisions: a systematic overview of meta-analyses

PURPOSE

The purpose of this systematic overview was to identify, synthesise and critically appraise findings of meta-analyses on robot-assisted versus conventional unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The hypothesis was that robotic assistance would reduce complications and revision rates, yield better clinical scores, and improve component positioning and alignment.

METHODS

Two researchers independently conducted a literature search using Embase^®, MEDLINE^®, Web of Science, Allied and Complementary Medicine™ and Cochrane Database of Systematic Reviews on 2 November 2020 for meta-analyses (Level I-IV) on robotic assistance in UKA and/or TKA. Outcomes were tabulated and reported as weighted mean difference (WMD), risk ratio (RR) or weighted odds ratio (WOR), and were considered statistically significant when p < 0.05.

RESULTS

A total of ten meta-analyses were identified; four on robot-assisted UKA (n, 1880 robot-assisted vs. 2352 conventional UKA; follow-up, 0 to 60 months), seven on robot-assisted TKA (n, 4567 robot-assisted vs. 5966 conventional TKA; follow-up, 0 to 132 months). Of the meta-analyses on UKA, one found that robotic assistance reduced complication rates (relative risk (RR), 0.62), one found that it improved clinical scores (weighted mean difference (WMD), 19.67), three found that it extended operation times (WMD, 15.7 to 17.1 min), and three found that it improved component positioning and alignment (WMD, - 1.30 to - 3.02 degrees). Of the meta-analyses on TKA, two found that robotic assistance improved clinical scores (WMD, 1.62-1.71), two found that that it extended surgery times (WMD, 21.5-24.26 min), and five found that it improved component positioning and alignment (WMD, - 0.50 to - 10.07 degrees). None of the meta-analyses reported differences in survivorship between robot-assisted versus conventional knee arthroplasty.

CONCLUSION

Robot-assisted knee arthroplasty enabled more accurate component positioning and placement within target zones, but extended operation time considerably. Although robotic assistance improved component positioning, its benefits regarding clinical scores, patient satisfaction and implant survivorship remains to be confirmed. Finally, this overview revealed that six of the ten meta-analyses were of 'critically low quality', calling for caution when interpreting results.

LEVEL OF EVIDENCE

IV.

Assistive technologies in knee arthroplasty: fashion or evolution? Rate of publications and national registries prove the Scott Parabola wrong

PURPOSE

Most opponents of assistive technologies in orthopedic surgery consider them as a marketing ruse or fashion. Our hypothesis was that many innovations in modern knee arthroplasty are not following the Scott Parabola. This parabola represents the visual curve of a procedure or therapy showing great promise at the beginning, becoming the standard treatment after reports of encouraging results, only to fall into disuse due to adverse outcome reports. This study aimed to assess the interest in these assistive technologies by (1) their number of publications/year and (2) their actual surgical use reported in the National Joint Registries.

METHODS

The search was performed through PubMed, EMBASE, and MEDLINE databases from 1997 to 2021 inclusive to identify all available literature that described the use and results of assistive technologies or new surgical techniques in knee arthroplasty. In the Australian and Norwegian registries, the number of cases performed with these techniques in knee arthroplasty has been quantified year by year.

RESULTS

Following the initial online search, a total of 4085 articles was found. After the assessment mentioned above, 2106 articles were included in the study. The orthopedic techniques assessed in this study are not following the "Scott's parabola" in the literature. Computer-assisted knee arthroplasty and patient-specific instrumentation have increased quickly to have reached a plateau, with a stable number of publications over the last 6 years. The number of publications concerning robotic surgery, accelerometers and sensors continue to rise. In the Australian registry, the proportion of primary TKA performed by computer-assisted systems increased from 2.4% in 2003 to 32% in 2019. In the Norwegian registry, the proportion of computer-assisted TKA remained between 8 and 12% of primary TKA since 2007.

CONCLUSION

Most of the innovations in modern knee arthroplasty are not following the Scott Parabola. After a fast rise, these techniques do not disappear but continue to evolve. Their evolution is synergistic, and techniques appeared to be linked to each other's. Despite persisting concerns about the cost-efficiency of assisting technologies in knee arthroplasties, the interest and use do not decrease and seems to be directly linked to an exponential increase in interest for a better understanding of alignment targets and improved functional recovery.

Patient-Specific Instrumentation Accuracy Evaluated with 3D Virtual Models

There have been remarkable advances in knee replacement surgery over the last few decades. One of the concerns continues to be the accuracy in achieving the desired alignment. Patient-specific instrumentation (PSI) was developed to increase component placement accuracy, but the available evidence is not conclusive. Our study aimed to determine a PSI system’s three-dimensional accuracy on 3D virtual models obtained by post-operative computed tomography. We compared the angular placement values of 35 total knee arthroplasties (TKAs) operated within a year obtained with the planned ones, and we analyzed the possible relationships between alignment and patient-reported outcomes. The mean (SD) discrepancies measured by two experienced engineers to the planned values observed were 1.64° (1.3°) for the hip–knee–ankle angle, 1.45° (1.06°) for the supplementary angle of the femoral lateral distal angle, 1.44° (0.97°) for the proximal medial tibial angle, 2.28° (1.78°) for tibial slope, 0.64° (1.09°) for femoral sagittal flexion, and 1.42° (1.06°) for femoral rotation. Neither variables related to post-operative alignment nor the proportion of change between pre-and post-operative alignment influenced the patient-reported outcomes. The evaluated PSI system’s three-dimensional alignment analysis showed a statistically significant difference between the angular values planned and those obtained. However, we did not find a relevant effect size, and this slight discrepancy did not impact the clinical outcome.