Does robotic-assisted computer navigation improve acetabular cup positioning in total hip arthroplasty for Crowe III/IV hip dysplasia? A propensity score case-match analysis

Patient-reported outcome differences for navigated and robot-assisted total hip arthroplasty frequently do not achieve clinically important differences: a systematic review

INTRODUCTION

Total hip arthroplasty (THA) using computer-assisted navigation (N-THA) and robot-assisted surgery (RA-THA) has been increasingly adopted to improve implant positioning and offset/leg-length restoration. Whether clinically meaningful differences in patient-reported outcomes (PROMs) compared to conventional THA (C-THA) are achieved with intraoperative technology has not been established. This systematic review aimed to assess whether published relative PROM improvements with technology use in THA achieved minimal clinically important differences (MCIDs).

METHODS

PubMed/MEDLINE/Cochrane Library were systematically reviewed for studies comparing PROMs for primary N-THA or RA-THA with C-THA as the control group. Relative improvement differences between groups were compared to established MCID values. Reported clinical and radiographic differences were assessed. Review of N-THA and RA-THA literature yielded 6 (n = 2580) and 10 (n = 2786) studies, respectively, for analyses.

RESULTS

Statistically significant improvements in postoperative PROM scores were reported in 2/6 (33.3%) studies comparing N-THA with C-THA, though only 1 (16.7%) reported clinically significant relative improvements. Statistically significant improvements in postoperative PROMs were reported in 6/10 (60.0%) studies comparing RA-THA and C-THA, though none reported clinically significant relative improvements. Improved radiographic outcomes for N-THA and RA-THA were reported in 83.3% and 70.0% of studies, respectively. Only 1 study reported a significant improvement in revision rates with RA-THA as compared to C-THA.

CONCLUSIONS

Reported PROM scores in studies comparing N-THA or RA-THA to C-THA often do not achieve clinically significant relative improvements. Future studies reporting PROMs should be interpreted in the context of validated MCID values to accurately establish the clinical impact of intraoperative technology.

Why robot-assisted total hip arthroplasty aborted: Chinese experience of four hundred and twenty nine consecutive cases

PURPOSE

Robot-assisted total hip arthroplasty (RA-THA) helps with precise orientation of the prosthesis, but some RA-THA procedures are aborted intraoperatively and are converted to manual total hip arthroplasty (THA). This study aimed to analyse why RA-THA is sometimes aborted intraoperatively and to make recommendations accordingly.

METHODS

A total of 429 consecutive Mako THA cases in our prospective database from August 2018 to June 2021 were included in our study. All robotic procedures aborted intraoperatively for any reason were recorded. The patients' demographics, diagnoses, and surgeons' information were included in the statistical analysis to pinpoint the risk factors for intraoperative robot to manual conversion.

RESULTS

Intraoperative RA-THA abortions occurred in 17 cases (3.96%) and the patients had to be converted to manual THA. The adverse events leading to intraoperative abortions included pelvic array loosening or malposition (5, 1.17%), inaccurate bone mapping or construction (6, 1.40%), inaccurate initial registration (4, 0.93%), and other reasons (2, 0.47%).

CONCLUSION

Robot-related adverse events could be found in all perioperative steps of RA-THA, and some of these events might result in intraoperative abortion. Complex hip disease was a statistically significant factor for an increased risk of intraoperative abortion of RA-THA. Standardized surgical procedures and preoperative assessments can be helpful in reducing the rate of RA-THA abortions.

Are robotic-assisted and computer-navigated total hip arthroplasty associated with superior outcomes in patients who have hip dysplasia?

Introduction

Robotic-assisted (RA) and computer-navigated (CN) total hip arthroplasty (THA) have been demonstrated to improve component placement accuracy compared to manual THA (mTHA) for primary osteoarthritis. As hip dysplasia presents several additional challenges in component placement accuracy and leg length discrepancy (LLD) correction during THA, a systematic review was conducted to evaluate whether utilizing these platforms may be associated with superior outcomes over mTHA in patients who have hip dysplasia.

Methods

PubMed, Medline, EBSCOhost, and Google Scholar were searched on September 13, 2023 to identify comparative studies published after January 1, 2000 that evaluated outcomes of RA-THA or CN-THA in patients who have hip dysplasia. The query yielded 197 unique articles, which were screened for alignment with the study aims. After screening, 10 studies fulfilled all inclusion criteria, comprising 946 patients. Risk of bias was evaluated via the Methodological Index for Nonrandomized Studies tool, and the mean score was 21.2 ± 1.5.

Results

Both RA-THA and CN-THA were not associated with improved acetabular anteversion and inclination when evaluating Crowe I-IV types altogether compared to mTHA, but studies reported improved accuracy for each Crowe I and II cases when assessed individually. While studies reporting acetabular cup placement within the Lewinnek and Callanan safe zones consistently found higher odds of accurate positioning for RA-THA versus mTHA, accuracy in achieving targeted center of rotation was mixed. Also, studies reported no difference in LLD restoration for RA-THA and CN-THA compared to mTHA. While operative time may be increased when utilizing these platforms, they may also expedite specific sequences, offsetting most of the increase in operative time.

Conclusion

This review highlights the advantages of RA-THA and CN-THA for patients who have DDH, particularly when treating Crowe I and II types as superior radiographic outcomes were achieved with these intraoperative technologies. However, there remains a need for studies to investigate whether this results in patient-reported outcome measures.

Robotic-assisted total hip arthroplasty in patients with developmental dysplasia of the hip

PURPOSES

Due to the morphological diversity of deformities, technical difficulties, improperly designed components, and so on, THA remains a challenging task in dysplastic hips, especially in highly dislocated hips. The purpose of this study was to comprehensively evaluate the clinical outcomes of robot-assisted THA in patients with DDH through a large cohort study, including the precision of acetabular cup positioning, indicators of inflammatory response, indicators of muscle damage, and complications.

METHODS

We retrospectively analyzed patients with DDH who underwent THA in our prospectively constructed joint registry between August 2018 and August 2022. Finally, 147 manual THAs and 147 robotic-assisted THAs were included in the final analysis. Patient demographics, indicators of inflammation, indicators of muscle damage, operative time, Harris hip scores (HHS), and forgotten joint score (FJS) were recorded for analysis. The precision of the positioning of the acetabular component was assessed with plain radiographs.

RESULTS

In the Crowe II/III groups, the reconstructed center of rotation (COR) in the robotic-assisted group was closer to the anatomical COR with less variation than the manual group (absolute horizontal distances of COR 3.5 ± 2.8 vs. 5.4 ± 4.9 mm, p < 0.05; absolute vertical distances of COR 6.4 ± 4.1 vs. 11.7 ± 8.2 mm, p = 0.001). For all Crowe subtypes, the robotic-assisted THA significantly increased the proportion of acetabular cups located in the safety zone within 5° (all p < 0.05). Interleukin-6 and creatine kinase levels were slightly lower and significantly different in the robotic-assisted group at three days postoperatively (all p < 0.05).

CONCLUSIONS

Compared to the manual technique, the robot-assisted technique improved the precision and reproducibility of acetabular component positioning, particularly in DDH patients with Crowe types II/III. The robotic-assisted technique did not increase operative time, bleeding, complications, or revision rates, and had a slighter early inflammatory response and muscle damage.

The invasiveness of robot-assisted total hip replacement is similar to that of conventional surgery

Robot-assisted total hip arthroplasty (R-THA) is increasingly being performed throughout the world. The invasiveness of this operation is unknown. We retrospectively reviewed the cohort of consecutive osteonecrosis of the femoral head (ONFH) patients who received primary R-THA or manual THA (M-THA) from January 2020 to January 2022 in our institution. One experienced surgeon performed all procedures. We calculated the propensity score to match similar patients in different groups by multivariate logistic regression analysis for each patient. We included confounders consisting of age, sex, body mass index (BMI), and operation time. Preoperative serum markers and Harris hip scores (HHS), postoperative serum markers at first day and third day, complications rate, postoperative HHS and Forgotten Joint Score (FJS) at 6 months after surgery of different cohorts were compared. We analyzed 218 ONFH patients treated with THA (98 R-THA patients, and 120 M-THA patients). After propensity score matching, we generated cohorts of 95 patients in R-THA and M-THA groups. We found no significant difference in preoperative serum markers and HHS. In the R-THA cohort, the PLT count was significantly lower on the postoperative day 1 (192.36 ± 41.72 × 109/L Vs 210.47 ± 72.85 × 109/L, p < 0.05). The Hb level was significantly lower on the postoperative third day in the R-THA cohort (98.52 ± 12.99 g/L Vs 104.74 ± 13.15 g/L, p < 0.05). There was no significant difference in the other serum markers between the cohorts on postoperative day 1 and 3 (p > 0.05). The FJS was significantly higher in the R-THA than M-THA group (p = 0.01). There was no significant difference in the postoperative HHS or complication rate between the groups (p > 0.05). The R-THA is not associated with a serious invasiveness compared to M-THA. Patients who underwent R-THA had a better early function compared to those who underwent M-THA.

Correcting Hip Dysplasia in Young Adults: Intraoperative Navigation and Outcomes

Developmental dysplasia of the hip (DDH) often leads to characteristic acetabular dysplasia and typical femoral anomalies. There are numerous treatments for skeletally mature patients with DDH including hip arthroscopy, pelvic and femoral osteotomies, as well as total hip arthroplasty. Before proceeding to an arthroplasty procedure, it can be helpful to obtain an opinion of a hip preservation specialist to ascertain if alternative surgical treatments could contribute to the patient's care. In general, the use of robotic navigation has been associated with a higher proportion of cups placed in the Lewinnek safe zone, larger improvements in Harris Hip Scores, and no difference in overall complication rates in comparison to manual total hip arthroplasty. The use of robotic navigation allows for both 2-dimensional and 3-dimensional preoperative templating, enabling the surgeon to plan the position of the construct such that it achieves maximum bony purchase and hip stability. In complex DDH cases, surgeons can work with a biomechanics department to complete a fit check assessment, which utilizes 3-dimensional templating software to ascertain the appropriateness of the implant's geometry with the patient's anatomy. Furthermore, a 3-dimensional printed plastic model of the pelvis and/or femur can be constructed in order to complete a rehearsal procedure, which may be particularly helpful for those cases involving osteotomies. The literature on the use of robotic-assisted total hip arthroplasty in patients with DDH demonstrates improved component positioning in comparison to navigated as well as manual methods; however, studies with long-term follow-up in this patient population are lacking.

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

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

Effect of hip flexion contracture on the pelvic sagittal tilt in the supine position: A retrospective case-series study

OBJECTIVES

The functional pelvic plane, which adopts the natural pelvic sagittal tilt in the supine position, is a good reference for determining the cup angle in total hip arthroplasty. However, hip flexion contracture may change pelvic tilt postoperatively by the release of contracture. This study investigated the influence of hip flexion contracture on pelvic sagittal tilt in the supine position.

METHODS

This study included 300 patients who underwent primary unilateral total hip arthroplasty. We divided the participants into two groups: with a preoperative hip extension angle of <0° (hip flexion contracture group) and without (non-contracture group). The pelvic sagittal tilt and femoral flexion angle were investigated using computed tomography or pelvic radiographs performed preoperatively and postoperatively.

RESULTS

The femoral flexion angle had significantly reduced postoperatively in the hip flexion contracture group but remained unchanged in the non-contracture group. The preoperative and postoperative pelvic sagittal tilt showed no significant differences between the two groups up to 1 year postoperatively.

CONCLUSIONS

The influence of hip flexion contracture on the pelvic sagittal tilt in the supine position was minimal. The functional pelvic plane in the supine position could be a good reference to ascertain the cup orientation, even in hip flexion contracture cases.

Is Robotic-Assisted Technology Still Accurate in Total Hip Arthroplasty for Fibrous-Fused Hips?

BACKGROUND

Total hip arthroplasty (THA) for fibrous-fused hips is technically demanding. This study aimed to evaluate the precision and accuracy, as well as the rate of conversion of robotic-assisted THA in such difficult patients.

METHODS

We retrospectively analyzed 67 patients (84 hips) who underwent THA with fibrous-fused hips between August 2018 and June 2021 at our institution. Demographics, acetabular cup positioning, leg-length discrepancies, and postoperative Harris hip scores were recorded for all patients. Thirty-six patients (44 hips) who underwent robotic-assisted THA and 31 patients (40 hips) who underwent manual THA were enrolled in this study.

RESULTS

The robot accurately executed the preoperative plan, and there were no statistically significant differences between the preoperative planned anteversion, inclination, and postoperative measurements. In the robotic group, the percentage of acetabular cups in the safe zone was significantly higher than in the manual group (87.2 versus 55%, respectively, P = .042). The rate of conversion to manual THA for various reasons in the robotic-assisted THA group was 11.4% (5/44). Compared with manual THA, the mean increase in operative time for conversion from robotic-assisted to manual THA was 24 min (P < .001).

CONCLUSION

In patients who have fibrous-fused hips, preoperative planning can be accurately executed by robotic-assisted technology. Compared with manual THA, robotic-assisted THA had a remarkable advantage in improving the frequency of achieving cup positioning within the target zone. Overall, robotic-assisted technology was helpful in such difficult cases, and the approximately 11.4% of cases converted to manual THA are reminders that surgeons should be thoroughly prepared preoperatively.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic-assisted versus manual total hip arthroplasty in obese patients: a retrospective case-control study

Aims

The objective of this study was to evaluate the accuracy of acetabular cup positioning in the obese patients when using robotic-assisted technology during total hip arthroplasty (THA).

Methods

Data were retrospectively collected from patients who underwent primary (THA) with a body mass index (BMI) ≥ 28 kg/m² and ≥ 1 year of follow-up between January 2018 and December 2019. Their demographics, diagnosis, acetabular cup positioning, American Society of Anesthesiologists (ASA) score, Harris Hip Score (HHS), and Forgotten Joint Score (FJS) at the final follow-up were recorded for analysis.

Results

There were no statistically significant differences between the two groups in height, weight, BMI, ASA score, or preoperative Harris Hip Score (HHS). Also, there was no difference in inclination angle between the two groups (R-THA: 41.29° ± 3.04°; manual THA (M-THA): 40.47° ± 5.46°; P = 0.312). However, the mean anteversion angle was greater in the R-THA group (20.71° ± 1.98° vs. 19.08° ± 4.04°; P < 0.001). Compared to M-THA, R-THA more frequently achieved an acetabular cup angle within 5° of the target (anteversion, 98.1% vs. 78.1% P = 0.001; inclination, 88.5% vs. 53.1%, P < 0.001). The R-THA group was more advantageous in restoring the hip center of rotation (COR) and leg length difference (LLD). There was no statistical difference in postoperative HHS (P = 0.404) or FJS (P = 0.497) between the two groups.

Conclusions

Compared to manual technique, robotic-assisted technique provided more precise acetabular cup positioning and better leg length restoration for obese patients. The robotic-assisted technique was more advantageous in recovering the center of rotation position and achieved a higher proportion of the acetabular cup placed in the target safety zone. Further studies are needed to confirm the clinical outcomes of surgeries in obese patients using robotic-assisted technology.