Computer-assisted Navigation Surgery Research Articles

Physicians’ perspectives of adopting computer-assisted navigation in orthopedic surgery

ObjectivesUsing Computer-assisted orthopedic navigation surgery system (CAOS) has many advantages but is not mandatory to use during an orthopedic surgery. Therefore, opinions obtained from clinical orthopedists with this system are valuable. This paper integrates technology acceptance model and theory of planned behavior to examine the determinants of continued CAOS use to facilitate user management. MethodsOpinions from orthopedists who had used a CAOS for at least two years were collected through a cross-sectional survey to verify the research framework. Follow-up interviews with an expert panel based on their experiences of CAOS were conducted to reason the impacts of factors of the research framework. ResultsThe results show that factors of “perceived usefulness” and “facilitating condition” determine the intention to continue using CAOS, and “perceived usefulness” was driving by “complexity of task” and “social influence”. Additionally, support in practice from high-level managers had an influence on orthopedists’ satisfaction after using a CAOS. ConclusionsThe aging population is accompanied by the increasing requirements for medical care and medical care attendant expenses, especially in total knee replacement. More precision and improvements on survivorship of patients’ artificial joints are needed. This study facilitates suggestions in user management when encountering an obstacle in implementing a CAOS. Based on these findings, scientific and practical implications are then discussed.

Cervical screw placement using rapid prototyping drill templates for navigation: a literature review.

Due to the high screw malposition rate and the potential risk of neurovascular injury in cervical fixation surgeries, guided tools, mainly computer-assisted surgery navigation systems and rapid prototyping drill templates (RPDTs) have increasingly been developed to help surgeons improve screw placement accuracy. Although RPDTs have been used in cervical surgeries for almost 2 decades, no specific review has been performed detailing the state of this technique. Thus, in the current review, we fully discuss the status of applying RPDTs in cervical surgeries. Studies that tested the accuracy and reliability of RPDTs in guiding cervical screw placements were included in this review. The fabrication workflow and usage of RPDTs, the accuracy and reliability of using RPDTs for screw and plate placement, the advantages and disadvantages of RPDTs and their prospects for future applications as a part of cervical fixation instrumentation are discussed. As the design of RPDTs becomes more rational, the accuracy and reliability of these devices have significantly improved in cervical fixation surgeries. Moreover, RPDTs decrease the intraoperative radiation exposure for surgeons and patients relative to conventional methods. However, some disadvantages also exist. The fabrication of RPDTs is time-consuming, and the time required to learn the related software is long. We believe that because of their merits, the RPDT technique is worth promoting for use in cervical surgeries. However, the time-consuming fabrication workflow and the long period required to learn the related software might limit its widespread use. In the future, the workflow should be simplified to reduce the extra workload for surgeons. Moreover, more clinical studies with high-level evidence are still needed to further test its accuracy and feasibility.

Inferior gluteal artery detection at the greater sciatic notch with a computer-assisted navigation system during pelvic and sacral tumor resection

Background: During pelvic and sacral tumor resection, important vessels, such as the inferior gluteal artery underneath the sciatic notch, are easily injured because of their invisibility. We employed a computer-assisted navigation system to preserve the inferior gluteal artery at the sciatic notch with visualization of the inferior gluteal artery at the sciatic notch, thus maintaining blood flow to the gluteus maximus.Methods: We present the results of seven patients (five men and two women) with a mean age of 64.8 years (58.4–78.8) in whom computer-assisted navigation surgery had been carried out for pelvic and sacral tumor resections.Results: Postoperative enhanced computed tomography (CT) confirmed the preservation of the inferior gluteal artery in all cases. At a mean follow-up of 21.3 months (3–39), the total postoperative complication rate was 25% (n = 2), including hematoma (n = 1) and wound necrosis (n = 1). There were no cases of deep infection.Conclusion: This new application of computer-assisted navigation to pelvic and sacral tumor resection can contribute to reducing postoperative complications related to insufficient flap perfusion.

Economic Analyses in Anterior Cruciate Ligament Reconstruction

Background: As the health care system in the United States (US) transitions toward value-based care, there is an increased emphasis on understanding the cost drivers and high-value procedures within orthopaedics. To date, there has been no systematic review of the economic literature on anterior cruciate ligament reconstruction (ACLR). Purpose: To evaluate the overall evidence base for economic studies published on ACLR in the orthopaedic literature. Data available on the economics of ACLR are summarized and cost drivers associated with the procedure are identified. Study Design: Systematic review. Methods: All economic studies (including US-based and non–US-based) published between inception of the MEDLINE database and October 3, 2014, were identified. Given the heterogeneity of the existing evidence base, a qualitative, descriptive approach was used to assess the collective results from the economic studies on ACLR. When applicable, comparisons were made for the following cost-related variables associated with the procedure for economic implications: outpatient versus inpatient surgery (or outpatient vs overnight hospital stay vs >1-night stay); bone–patellar tendon–bone (BPTB) graft versus hamstring (HS) graft source; autograft versus allograft source; staged unilateral ACLR versus bilateral ACLR in a single setting; single- versus double-bundle technique; ACLR versus nonoperative treatment; and other unique comparisons reported in single studies, including computer-assisted navigation surgery (CANS) versus traditional surgery, early versus delayed ACLR, single- versus double-incision technique, and finally the costs of ACLR without comparison of variables. Results: A total of 24 studies were identified and included; of these, 17 included studies were cost identification studies. The remaining 7 studies were cost utility analyses that used economic models to investigate the effect of variables such as the cost of allograft tissue, fixation devices, and physical therapy, the percentage and timing of revision surgery, and the cost of revision surgery. Of the 24 studies, there were 3 studies with level 1 evidence, 8 with level 2 evidence, 6 with level 3 evidence, and 7 with level 4 evidence. The following economic comparisons were demonstrated: (1) ACLR is more cost-effective than nonoperative treatment with rehabilitation only (per 3 cost utility analyses); (2) autograft use had lower total costs than allograft use, with operating room supply costs and allograft costs most significant (per 5 cost identification studies and 1 cost utility analysis); (3) results on hamstring versus BPTB graft source are conflicting (per 2 cost identification studies); (4) there is significant cost reduction with an outpatient versus inpatient setting (per 5 studies using cost identification analyses); (5) bilateral ACLR is more cost efficient than 2 unilateral ACLRs in separate settings (per 2 cost identification studies); (6) there are lower costs with similarly successful outcomes between single- and double-bundle technique (per 3 cost identification studies and 2 cost utility analyses). Conclusion: Results from this review suggest that early single-bundle, single (endoscopic)-incision outpatient ACLR using either BPTB or HS autograft provides the most value. In the setting of bilateral ACL rupture, single-setting bilateral ACLR is more cost-effective than staged unilateral ACLR. Procedures using CANS technology do not yet yield results that are superior to the results of a standard surgical procedure, and CANS has substantially greater costs.

A comparison of alignment using patient specific guides, computer navigation and conventional instrumentation in total knee arthroplasty

BackgroundPatient specific guides (PSG) have been introduced as a tool in total knee arthroplasty (TKA) in an attempt to improve limb alignment and reduce operative time compared to other established surgical techniques. The purpose of this study was to compare the post-operative radiographic alignment and operative time in patients who underwent TKA surgery with PSG, conventional instrumentation or computer-assisted navigation surgery using fully cemented components. MethodsA cohort of 260 patients who underwent TKA surgery using PSG (PSG group, n=115) was compared to patients who underwent TKA using either conventional instrumentation (CON group, n=92) or computer-assisted navigation (CAS group, n=53). Post-operative CT imaging using the Perth CT protocol was used to compare alignment between the three groups. ResultsIn the PSG and CAS groups, the post-operative hip–knee angle (HKA) was within 3° of neutral alignment in 91.3% and 90.7% of patients, respectively. This compared to 80.4% of patients in the CON group (p=0.02). There were no significant differences with respect to alignment when comparing individual component positioning between the PSG and CAS groups apart from tibial slope (Table 3). Total operative time was found to be significantly reduced in the PSG group (80.2min) compared to both the CON group (86min, p=0.002) and the CAS group (110.2min, p<0.0001). ConclusionsThe use of PSG resulted in similar alignment accuracy to CAS and superior alignment to CON with significantly shorter operative times.

Detection of the hip center in computer-assisted surgery: An in vitro assessment study

The HKA i.e. the angle between the hip, knee and ankle centers is a clinical parameter widely used in orthopedic surgery. It can be intraoperatively assessed with computer-assisted surgery navigation systems by computing the 3D location of these joint centers. The hip center is computed using functional methods but is defined by the experts as the anatomical center of the femoral head. The aim of this in vitro study is therefore to assess, first, the accuracy of these functional methods for the determination of the HKA and, second, their reproducibility. We have analyzed on six cadaveric lower limbs the accuracy and the reproducibility of functional methods and their impact on the HKA values. The anatomical hip center has been used as the reference value. The reproducibility is 5.2mm for the determination of the functional hip centers. The average impact on the HKA is 1.2° (4° max). Despite a lack of reproducibility of the functional methods, the impact on the HKA is limited. The accuracy of the functional methods on the HKA can therefore be enough for some clinical applications.

Correction of Orbital Wall Fracture Close to the Optic Canal Using Computer-Assisted Navigation Surgery

Repairing orbital wall fractures can result in serious complications, including enophthalmos, diplopia, or even blindness. Especially, surgeons worry about damaging the optic nerve while dissecting the optic canal area. We avoid these complications by using a navigation system that was adapted to stereotactic concept based on three-dimensional imaging of the patient's anatomy. Here, we report 5 cases of orbital wall fracture that were repaired using a navigation system. The Navigation System II (Stryker, Freiburg, Germany) and the iNtellect Cranial Navigation (version 1.1) platform were used for each operation. A computer-assisted navigation surgery was performed according to the following procedures: (1) image set, (2) planning, (3) apparatus setup, (4) registration, and (5) intraoperative navigation. Operations were performed under general anesthesia. Dissection was performed up to the periosteum immediately anterior to the optic canal, near the fracture. Vulnerable surrounding structures were identified with the intraoperative pointer. After navigation, we inserted an implant into the defect, successfully, avoiding damage to the optic canal and optic nerve. None of the patients had any surgical complications. Postoperative computed tomography scans demonstrated that the fractures were corrected, and continuity was maintained without displacement. The three-dimensional image allowed us to easily visualize intraoperative anatomical structure, allowing us to avoid unnecessary procedures and to correct the orbital wall. The mean volume of fractured orbital cavity was 29.2 cm(3) (range, 28.3-30.4 cm(3)) preoperatively and 27.0 cm(3) (range, 25.9-28.5 cm(3)) postoperatively; thus, the defects were corrected by 2.2 cm(3) (range, 1.3-2.8 cm(3)) on average. We used a navigation system to perform accurate and safe surgery in patients with extensive orbital wall fracture, including around the optic canal. By using the functions to visualize the locations indicated by the pointer, we were able to perform successful dissections and implantations in areas adjacent to the optic canal. The good outcomes obtained here provide evidence that surgical correction of the orbital wall using a navigation system is useful in cases of deep, extensive orbital wall fracture.

Real-Time Navigation-Assisted Orthognathic Surgery

One limitation of orthognathic surgery is the narrow surgical field, which makes it difficult to view the operative site directly. Thus, many perioperative complications can occur. In this study, we evaluated the usefulness of computer-aided navigation techniques in orthognathic surgery. We enrolled 10 patients (3 men and 7 women) with facial deformities who were treated between July 2010 and February 2011. A Le Fort I osteotomy, sagittal split ramus osteotomy, and reduction malarplasty were performed with guided navigation. All 10 patients were treated successfully using the computer-assisted navigation surgery. Using the navigation system, instruments were visualized on a monitor in real time and all maneuvers were performed safely. Orthognathic surgery, such as a Le Fort 1 osteotomy, sagittal split ramus osteotomy, and reduction malarplasty, can be performed safely under the guidance of a surgical navigation system. Navigation systems enable surgeons to carry out preoperative plans accurately without injuring important anatomic structures because the positions of the instruments can be visualized on site in real time.

Computer-Assisted Navigational Surgery Improves Outcomes in Orbital Reconstructive Surgery

Orbital reconstruction is a difficult procedure, success of which is dependent on the surgeon's experience. The lack of objective methods requires a fair amount of estimation is its execution. This study evaluates the efficacy of Kolibri (BrainLab, Munich, Germany), an intraoperative navigation device, in improving outcomes. From 2004 to 2009, 58 patients with orbital trauma who underwent surgery at the National University Hospital, Singapore, were included in this prospective matched control trial. Twenty-nine consecutive patients underwent surgery with Kolibri. The control group underwent surgery without the device. Both groups were matched for age, sex, orbital wall fracture, preoperative ophthalmologic features, etiology and severity of trauma, surgical approach, and types of implant used. The postoperative follow-up was at 1, 3, 6, and 12 months. For subjective assessment, the postoperative ophthalmologic features, including diplopia, infraorbital hypoesthesia, ophthalmoplegia, and enophthalmos, were compared. At 1, 3, 6, and 12 months, respectively, there were fewer patients with postoperative ophthalmologic complications in the study group (italicized; n = 29) compared with the control group (n = 29; P < 0.05): 12/29 (41%) versus 21/29 (72%), 8/29 (28%) versus 19/29 (66%), 5/29 (17%) versus 15/29 (52%), and 2/29 (7%) versus 12/29 (41%). For objective assessment, using the Kolibri workstation, operative plans were created and fused with postoperative computed tomographic scans. Vertical distances between the actual reconstructed and planned orbital floors were measured. On average, the vertical distance measured from the boundaries of floor defects for patients in the study group was 3.24 mm (95% confidence interval, 1.56-4.91) lower than the control group (P = 0.001). In conclusion, navigation minimizes postoperative complications, reduces the need for repeat procedures, and helps surgeons with planning, execution, and postoperative assessment.

Computer-assisted navigation in total knee arthroplasty: a review of literature

Computer-assisted navigation surgery (CAS) has been performed in total knee arthroplasty (TKA) for approximately 10 years. This technique offers experienced and inexperienced surgeons improved control and reproducible results. Currently, 30% of primary total knee replacements are performed using the CAS technique in Germany. The main problems after total knee replacement are generally aseptic loosening, instability and infection. According to various authors, the main reason for aseptic loosening is an inadequate alignment of the mechanical limb axis. Several level I and II studies have demonstrated that CAS leads to significantly less axial deviation. Nevertheless, there are critical arguments against CAS for routine use, such as longer operation times and higher costs. Additionally, there are still no long-term results available that post a definitive statement about lower revision rates, declining numbers of aseptic loosening, cost-effectiveness and clinical outcomes following CAS.

Knee arthroplasty: growing trends and future problems

Total knee arthroplasty, as practiced in the early 21st century, is a product of almost 150 years of understanding the biomechanics of the knee as well as the development of prosthetic materials and surgical techniques, with good long-term results. Patient expectations after total knee arthroplasty have changed; patients undergo total knee arthroplasty hoping to restore their quality of life, which sometimes includes activities requiring high physical demand. Both cemented and uncemented knees provide long-lasting fixation. Minimally invasive surgery limits soft-tissue damage and may facilitate faster rehabilitation. Better materials and implant designs have increased the range of motion and decreased wear. Computer-assisted navigation surgery will render more accurate placement of implants. This article discusses developments in selected topics related to adult knee reconstruction to provide stable and durable implants. Finally, health economics will dictate what is affordable and cost effective in any healthcare system.

Comparison of Computer-Assisted Navigation and Conventional Instrumentation for Bilateral Total Knee Arthroplasty

This prospective study analyzed computer-assisted surgery (CAS) navigation and conventional instrumentation in bilateral total knee arthroplasty. Sixty patients underwent CAS navigation in 1 knee and conventional instrumentation in the contralateral knee randomly. The target zone resided in the reconstructed mechanical axis within a range of 3° varus or valgus. The reconstructed mechanical axes in the CAS navigation group were significantly closer to planned axes than those in the conventional group. Average blood loss in the CAS navigation group was lower, whereas mean tourniquet time was longer than in the conventional group. No surgery-related complications existed in either group. The results indicate that, despite longer operative time, CAS navigation total knee arthroplasty is a safe procedure and outperforms conventional technique in accuracy of leg axes.

Transient Myopia as a Complication after Complex Orbital Reconstructions with Computer-Assisted Navigation Surgery

Transient Myopia as a Complication after Complex Orbital Reconstructions with Computer-Assisted Navigation Surgery

Efficacy of Computer Assisted Surgery in Revision Total Knee Arthroplasty

Purpose : The purpose of this study was to analyze the accuracy of the mechanical axis and implant positions postoperatively and to evaluate the radiology results of computer assisted navigation surgery for bone cutting and ligament balancing in revision TKA. Materials and Methods : 13 consecutive revision TKAs were performed by a single surgeon with use of computer assisted surgery (CAS) from July 2004 to August 2005. At the revision, the mean age was 64.7 years. The mean interval from the index arthroplasty was 9.8 years. The cause of the revision included 11 cases of polyethylene wear and 2 cases of loosening. Two observers measured the mechanical axis, position of the implants, and level of joint lines. Results : By observer I, the mechanical axis improved from varus 11.9˚ to valgus 1.5˚, and the mean α, β, γ and δ angles were 95.3, 90.8, 3.9 and 87.6˚ respectively. From observer II, the mechanical axis improved from varus 11.6˚ to valgus 1.6˚, and mean α, β, γ and δ angles were 95.5, 90.5, 4.1 and 87.9˚ respectively. The measured angles from observers I and II showed a good correlation. Conclusion : Accurate bone cutting and verification in each step are possible using real time information provided by the CAS. The mechanical axis, component positions, joint line could be checked and adjusted with feedback of navigation system. Information about flexion and extension gap and ligament balancing could be verified during revision surgery.

Total Hip Arthroplasty Through a Minimal Posterior Approach Using Imageless Computer-Assisted Hip Navigation

With decreased exposure in a minimal posterior hip incision, navigation with computer assistance provides an alternative method to accurately place the components. This study compares the results of a series of 82 navigated total hips to a retrospective cohort of 50 hips done with conventional instruments. The surgical incision split the gluteus maximus but did not extend distally into the fascia. The goal of cup placement was 40° to 45° of abduction (ABD) and 17° to 23° of flexion (FLX). Postoperative radiographs were digitized and analyzed. In the study group, 82 hips were done with computer assistance and compared with 50 done with conventional methods (manual) through the same incision. Radiographic analysis showed that there were significantly fewer cases inside the desired range of ABD and FLX in the manual group (6%) compared with the navigation group (30%), P = .001, with significant differences in the variances of ABD and FLX ( P = .011 and .028). Improved accuracy of cup placement was found with increased experience in the use of navigation by the surgeon over the time of the series. The use of a computer-assisted surgery navigation system with a minimal posterior incision for a total hip arthroplasty results in significantly more reproducible acetabular component placement.

Stereotactic computer-assisted navigational sinus surgery: historical perspective and review of the available systems.

Stereotactic computer-assisted navigational sinus surgery: historical perspective and review of the available systems.