Evaluation of a computer-assisted navigation system for anterior cruciate ligament reconstruction: prospective non-randomized cohort study versus conventional surgery

Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis

PURPOSE

To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR.

METHODS

CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate.

RESULTS

Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI - 1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups.

CONCLUSION

Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized.

LEVEL OF EVIDENCE

Level III.

Navigation in anterior cruciate ligament reconstruction: State of the art

Computer navigation (CN) for anterior cruciate ligament (ACL) surgery has been used mainly for two purposes: to enhance the accuracy of tunnel position and to evaluate the kinematics of the ACL reconstruction (ACLR) and the stability achieved by different surgical techniques. Many studies have shown that navigation may improve the accuracy of anatomical tunnel orientation and position during ACL reconstructive surgery compared with normal arthroscopic tunnel placement, especially regarding the femoral side. At the same time, it has become the gold-standard method for intraoperative knee kinematic assessment, as it permits a quantitative multidirectional knee joint laxity evaluation. CN in ACL surgery has been associated with diverse problems. First, in most optic systems additional skin incisions and drill holes in the femoral bone are required for fixation of a reference frame to the femur. Second, additional radiation exposure and extra medical cost to the patient for preoperative planning are usually needed. Third, CN, due to additional steps, has more opportunities for error during preoperative planning, intraoperative registration, and operation. Fourth, soft tissues, including the skin and subcutaneous tissues, are usually not considered during the preoperative planning, which can be a problem for kinematic and stability assessment. Many studies have concluded that ACLR using a CN system is more expensive than conventional surgery, it adds extra time to the surgery and it is not mitigated by better clinical outcomes. This, combined with costs and invasiveness, has limited the use of CN to research-related cases. Future technology should prioritize less invasive intra-operative surgical navigation.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Current use of navigation system in ACL surgery: a historical review

PURPOSE

The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years.

METHODS

A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery.

RESULTS

One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined.

CONLUSIONS

Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

Clinical advantages of image-free navigation system using surface-based registration in anatomical anterior cruciate ligament reconstruction

PURPOSE

To evaluate the clinical advantages of a navigation system developed with an emphasis on attaining an appropriate femoral tunnel length and posterior wall margin with no posterior wall blowout, as well as having accurate tunnel positioning, in anatomical anterior cruciate ligament reconstruction (ACLR).

METHODS

Ten freshly frozen human knees were transected at mid-femur and mid-tibia. Each knee specimen underwent arthroscopic single-bundle anterior cruciate ligament reconstruction using the outside-in technique, with two knees by manual ACLR (control group) and another eight knees by only the navigational ACLR without arthroscopic assistance (experimental group). The position/orientation information of tunnel entry point, tunnel length, and posterior wall distance of pre-, intra-, and postoperative tunnel were recorded, and the reliability and errors among them were evaluated.

RESULTS

From comparison of the 3D models for preoperative planning and postoperative reconstruction, the mean differences for navigational femoral tunnelling and arthroscopic-assisted femoral tunnelling were recorded, respectively: (1) tunnel entry position, 1.4 mm (SD 0.3) versus 4.9 mm; (2) tunnel length, 0.7 mm (SD 0.2), similar to 0.6 mm in arthroscopic-assisted femoral tunnelling, and (3) posterior wall distance, 0.5 mm (SD 0.2), much smaller than 4.7 mm for arthroscopic-assisted femoral tunnelling. The intraclass correlation coefficients, calculated to determine the accuracy and reliability of navigational femoral tunnelling, showed excellent internal consistency that ranged from 0.965 to 0.989 for tunnel length and from 0.810 to 0.953 for posterior wall distance.

CONCLUSION

Navigation systems with enhancement of the registration accuracy by the developed system are feasible in anatomical ACLR, in reducing surgical failures such as short tunnel length or posterior wall breakage of distal femur. The present study revealed that computer navigation could aid in avoiding major mistakes in exact positioning and posterior wall blowout and help in attaining appropriate length for femoral tunnelling in anatomical ACLR.

Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient

PURPOSE

Conventional reconstruction of the anterior cruciate ligament (ACL) has a high success rate. Computer-assisted navigation systems (CANSs) have been developed to further improve the accuracy of tunnel positioning. What is the economic impact from the hospital perspective?

METHODS

Patients having a first ACL reconstruction procedure were included in a prospective multicentre open controlled study comparing two groups: CANS versus conventional surgery. The primary clinical efficacy criterion was the objective International Knee Documentation Committee score at 1-2-year follow-up. Costs were collected retrospectively nationwide.

RESULTS

No significant differences were found for the clinical effectiveness between conventional surgery (100 patients) and CANS (114 patients) at follow-up: ORadjusted 1.01 [0.36-2.84] (n.s). Junior surgeons achieved a significant mean decrease in operating time during the study period: 30 % in the CANS group compared with 10 % in the control group (p < 0.01). The average cost of surgery was 704<euro> for the control group and 1,158<euro> for the CANS group (p < 0.01). The cost of the operating room accounts for >70 % of the total cost. The surgeon's status and the technical CANS learning effect influenced this cost. The cost differential between the two groups decreased with 'CANS' expertise: 238<euro> and 271<euro> in 'expert' centres versus 427<euro> to 731<euro> in other centres.

CONCLUSION

While our study demonstrates the feasibility and the potential interest of CANS for training in ACL reconstruction, from a hospital perspective it is not cost efficient at present.

LEVEL OF EVIDENCE

Economic and decision analysis-developing an economic or decision model, Level II.