Manual Total Hip Arthroplasty Research Articles

Computerised tomography-based planning with conventional total hip arthroplasty versus robotic-arm assisted total hip arthroplasty: study protocol for a prospective randomised controlled trial

BackgroundRobotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning during total hip arthroplasty. The objective of this study is to compare the accuracy of implant positioning, restoration of hip biomechanics, patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications in conventional manual total hip arthroplasty (CO THA) versus robotic-arm assisted total hip arthroplasty (RO THA). Preoperative pelvic computerised tomography (CT) scans will be used to create patient-specific, virtual, three-dimensional reconstructions for surgical planning in both treatment groups.Methods and analysisThis prospective randomised controlled trial will include 60 patients with symptomatic hip osteoarthritis undergoing primary THA. Following informed consent, patients will be randomised to CO THA (control group) or RO THA (investigation group) at a ratio of 1:1 using an online random number generator. Observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to the accuracy of implant positioning, hip biomechanics, postoperative rehabilitation, clinical progress, functional outcomes, cost-effectiveness, and complications. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. Intention to treat relates to the allocated treatment (CO THA or RO THA), and per-protocol refers to the actual treatment received by the patient. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Bromley Research Ethics Committee, UK. The study is sponsored by University College London, UK.DiscussionThis study compares a comprehensive and robust range of clinical, functional, and radiological outcomes in CT-planned CO THA versus CT-planned RO THA. The findings of this study will enable an improved understanding of the differences in CO THA versus RO THA with respect to patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications.Trial registrationClinicalTrials.gov NCT04095845. Registered on 19 September 2019

Robotic Arm-assisted Total Hip Arthroplasty is More Cost-Effective Than Manual Total Hip Arthroplasty: A Markov Model Analysis.

Total hip arthroplasty (THA) is the benchmark surgical treatment of advanced and symptomatic hip osteoarthritis. Preliminary evidence suggests that the robotic arm-assisted (RAA) technology yields more accurate and reproducible acetabular cup placement, which may improve survival rate and clinical results, but economic considerations are less well-defined. The purpose of this study was to compare the cost effectiveness of the RAA THA with manual THA (mTHA) modalities, considering direct medical costs and utilities from a payer's perspective. A Markov model was constructed to analyze two potential interventions for hip osteoarthritis and degenerative joint disorder: RAA THA and mTHA. Potential outcomes of THA were categorized into the transition states: infection, dislocation, no major complications, or revision. Cumulative costs and utilities were assessed using a cycle length of 1 year over a time horizon of 5 years. RAA THA cohort was cost effective relative to mTHA cohort for cumulative Medicare and cumulative private payer insurance costs over the 5-year period. RAA THA cost saving had an average differential of $945 for Medicare and $1,810 for private insurance relative to mTHA while generating slightly more utility (0.04 quality-adjusted life year). The preferred treatment was sensitive to the utilities generated by successful RAA THA and mTHA. Microsimulations indicated that RAA THA was cost effective in 99.4% of cases. In the Medicare and private payer scenarios, RAA THA is more cost effective than conventional mTHA when considering direct medical costs from a payer's perspective. Economic Level III. Computer simulation model (Markov model).

PMD21 ROBOTIC-ASSISTED TOTAL HIP REPLACEMENT: A 90-DAY EPISODE OF CARE ANALYSIS

Robotic-assisted Total Hip Arthroplasty (RATHA), studies have shown increased accuracy in placing implants and improvements in; patient outcomes, satisfaction scores and post-op complications compared to manual THA (mTHA). The purpose of this study was to compare robotic-assisted vs. manual total hip arthroplasty index and post-discharge utilization and costs in a 90-day episode-of-care (EOC). THA procedures were identified using the Medicare 100% Standard Analytic Files. Members included patients with RATHA or mTHA between 10/1/2015-10/1/2018. Propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual. After PSM, 938 rTHA and 4,670 mTHA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, post-index rehab utilization and costs were assessed. RATHA patients were less likely to have post-index IPR or SNF admissions (0.64% vs. 2.68%; p<0.0001 and 20.79% vs. 24.99%; p=0.0041, respectively). RATHA patients used fewer days in post-index inpatient and SNF care (7.15 vs. 7.91; p=0.8029 and 17.98 vs. 19.64; p=0.5080, respectively) and used fewer HHA visits, (14.06 vs. 15.00; p=0.0006) compared to mTHA. RATHA had lower costs for; IPR ($11,490 vs. $14,674; p=0.0470), SNF ($9,184 vs. $10,408, p=0.0598) and HHA ($3,352 vs. $3,496; p=0.0133) compared to mTHA. Overall, RATHA patients had 12% ($948) lower average post-index costs compared to mTHA patients (p=0.0004). Total 90-day EOC costs for RATHA patients were found to be $785, less than that of mTHA patients ($19,734 vs. $20,519, p=0.0095). Robotic-assisted THA resulted in an overall lower 90-day episode-of-care cost when compared to manual THA. The 90-day EOC cost savings of RATHA were driven by reduced utilization and cost of post-index rehabilitation services including, IPR, SNF and HHA.

Impact of surgeon handedness in manual and robot-assisted total hip arthroplasty

BackgroundThe purpose of this study was to examine whether surgeon handedness could affect cup positioning in manual total hip arthroplasty (THA), and whether robot could diminish or eliminate the impact of surgeon handedness on cup positioning in robot-assisted THA.MethodsFifty-three patients who underwent bilateral robot-assisted THA and sixty-two patients who underwent bilateral manual THA between August 2018 and July 2019 in our institute were respectively analyzed in this study. When the difference between the bilateral anteversion and inclination was greater than 5°, the patient was regarded as having different cup positioning between bilateral THA. Their demographics, orientation of acetabular cup, and postoperative 3 month Harris hip score (HHS) were recorded for analysis.ResultsThere were no significant differences in the gender, age, BMI, diagnosis’s composition, and preoperative and postoperative HHS between the robotic and manual group. Two left hips dislocated in the manual group. The anteversion of left hip was significantly larger than that of right hip (24.77 ± 10.44 vs 22.44 ± 8.67, p = 0.043) in the manual group. There were no significant differences of cup positioning between bilateral robot-assisted THA. The patients in manual group were significantly more likely to have different cup positioning between bilateral hips than those in robotic group (77% vs 45%, p = 0.000). More manual THA were located out of the target zone than robot-assisted THA (70% vs 48%, p = 0.001).ConclusionsSurgeon’s handedness showed a trend towards an impact on cup positioning in manual THA and robot might help surgeon eliminate the adverse impact. However, the impact of handedness on the clinical outcomes still needs further observation.

The learning curve of robotic-arm assisted acetabular cup positioning during total hip arthroplasty.

Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning and orientation during total hip arthroplasty (THA). The objective of this study was to assess the surgical team's learning curve for robotic-arm assisted acetabular cup positioning during THA. This prospective cohort study included 100 patients with symptomatic hip osteoarthritis undergoing primary total THA performed by a single surgeon. This included 50 patients receiving conventional manual THA and 50 patients undergoing robotic-arm assisted acetabular cup positioning during THA. Independent observers recorded surrogate markers of the learning curve including operative times, confidence levels amongst the surgical team using the state-trait anxiety inventory (STAI) questionnaire, accuracy in restoring native hip biomechanics, acetabular cup positioning, leg-length discrepancy, and complications within 90 days of surgery. Cumulative summation (CUSUM) analysis revealed robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for achieving operative times (p < 0.001) and surgical team confidence levels (p < 0.001) comparable to conventional manual THA. There was no learning curve of robotic-arm assisted THA for accuracy of achieving the planned horizontal (p = 0.83) and vertical (p = 0.71) centres of rotation, combined offset (p = 0.67), cup inclination (p = 0.68), cup anteversion (p = 0.72), and correction of leg-length discrepancy (p = 0.61). There was no difference in postoperative complications between the two treatment groups. Integration of robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for operative times and surgical team confidence levels but there was no learning curve effect for accuracy in restoring native hip biomechanics or achieving planned acetabular cup positioning and orientation.

The current role of robotics in total hip arthroplasty.

Robotic total hip arthroplasty (THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA.Robotic THA improves precision and reduces outliers in restoring the planned centre of hip rotation compared to conventional manual THA.Improved accuracy in restoring hip biomechanics and acetabular cup positioning in robotic THA have not translated to any differences in early functional outcomes, correction of leg-length discrepancy, or postoperative complications compared to conventional manual THA.Limitations of robotic THA include substantive installation costs, additional radiation exposure, steep learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.Further higher quality studies are required to compare differences in conventional versus robotic THA in relation to long-term functional outcomes, implant survivorship, time to revision surgery, and cost-effectiveness.Cite this article: EFORT Open Rev 2019;4:618-625. DOI: 10.1302/2058-5241.4.180088

Clinical efficacy of OrthoPilot navigation system versus conventional manual total hip arthroplasty: A systematic review and meta-analysis.

ObjectiveThis study was performed to compare the clinical efficacy between the OrthoPilot navigation system and conventional manual surgery in patients undergoing total hip arthroplasty.MethodsThe Embase, PubMed, CINAHL, and Cochrane databases were searched for clinical trials. The outcome measurements were the anteversion angle, inclination angle, and complications. Review Manager 5.3 statistical software was used for the data analysis.ResultsSignificant differences were found in the femoral offset and overall complication rate between the conventional and navigation groups. Additionally, the conventional group had significantly less anteversion than the navigation group. However, the navigation group had significantly better inclination. The operation time was significantly shorter in the conventional than navigation group.ConclusionBoth the OrthoPilot navigation system and conventional total hip arthroplasty result in significant improvements in patient function with similar overall complication rates and have their own advantages in achieving good cup position. The conventional procedure has a shorter operation time than does use of a navigation system.

Operative Times Have Remained Stable for Total Hip Arthroplasty for >15 Years: Systematic Review of 630,675 Procedures.

Background:Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period.Methods:The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were “operative,” “time,” and “total hip arthroplasty.” An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria.Results:The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee.Conclusions:The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost.

Robotics and navigation – Delivering the patient-specific plan

Accurate implant positioning and restoration of native hip biomechanics are important technical objectives in total hip arthroplasty (THA). Evolution in surgical technology for THA has led to the development of individualised components and computer-assisted surgery, which aim to improve the accuracy and reproducibility of achieving these objectives compared to conventional manual THA. This chapter discusses the role of robotics, navigation, and patient-specific implants for delivering a patient-specific surgical plan, and explores how this technology may be adapted to execute individualised plans for optimal implant positioning based on dynamic changes in spinopelvic relations.

Adoption of Robotic vs Fluoroscopic Guidance in Total Hip Arthroplasty: Is Acetabular Positioning Improved in the Learning Curve?

BackgroundAcetabulum positioning affects dislocation rates, component impingement, bearing surface wear rates, and need for revision surgery. Novel techniques purport to improve the accuracy and precision of acetabular component position, but may have a significant learning curve. Our aim was to assess whether adopting robotic or fluoroscopic techniques improve acetabulum positioning compared to manual total hip arthroplasty (THA) during the learning curve. MethodsThree types of THAs were compared in this retrospective cohort: (1) the first 100 fluoroscopically guided direct anterior THAs (fluoroscopic anterior [FA]) done by a surgeon learning the anterior approach, (2) the first 100 robotic-assisted posterior THAs done by a surgeon learning robotic-assisted surgery (robotic posterior [RP]), and (3) the last 100 manual posterior (MP) THAs done by each surgeon (200 THAs) before adoption of novel techniques. Component position was measured on plain radiographs. Radiographic measurements were taken by 2 blinded observers. The percentage of hips within the surgeons’ “target zone” (inclination, 30°-50°; anteversion, 10°-30°) was calculated, along with the percentage within the “safe zone” of Lewinnek (inclination, 30°-50°; anteversion, 5°-25°) and Callanan (inclination, 30°-45°; anteversion, 5°-25°). Relative risk (RR) and absolute risk reduction (ARR) were calculated. Variances (square of the standard deviations) were used to describe the variability of cup position. ResultsSeventy-six percentage of MP THAs were within the surgeons’ target zone compared with 84% of FA THAs and 97% of RP THAs. This difference was statistically significant, associated with a RR reduction of 87% (RR, 0.13 [0.04-0.40]; P < .01; ARR, 21%; number needed to treat, 5) for RP compared to MP THAs. Compared to FA THAs, RP THAs were associated with a RR reduction of 81% (RR, 0.19 [0.06-0.62]; P < .01; ARR, 13%; number needed to treat, 8). Variances were lower for acetabulum inclination and anteversion in RP THAs (14.0 and 19.5) as compared to the MP (37.5 and 56.3) and FA (24.5 and 54.6) groups. These differences were statistically significant (P < .01). ConclusionAdoption of robotic techniques delivers significant and immediate improvement in the precision of acetabular component positioning during the learning curve. While fluoroscopy has been shown to be beneficial with experience, a learning curve exists before precision improves significantly.

Effect of robotic milling on periprosthetic bone remodeling

The ROBODOC system has provided better fit and fill of the stem and less destruction of the bony architecture than with manual surgery. These benefits might affect femoral periprosthetic bone remodeling. We evaluated the effects of robotic milling in cementless total hip arthroplasty (THA) in a longitudinal 24-month follow-up study using dual energy X-ray absorptiometry (DEXA) and plain radiographs of 29 patients (31 hips) after ROBODOC THA and 24 patients (27 hips) after manual THA with the same stem design. To minimize the influence of other factors on bone remodeling, only female osteoarthritis patients, who had no drugs that might affect bone metabolism were enrolled. Significantly less bone loss occurred at the proximal periprosthetic areas in the ROBODOC group. In zone 1, the decrease was 15.5 versus 29.9% using conventional rasping; in zone 7, the loss was 17.0% with ROBODOC compared to 30.5% with conventional rasping (p < 0.05). On radiographs, endosteal spot welds in the proximal medial portion were more pronounced in the ROBODOC group (48 vs. 11% in the conventional group, p < 0.05). Our results suggest that robotic milling is effective in facilitating proximal load transfer around the femoral component and minimizing bone loss after cementless THA.

Robotic systems in total hip arthroplasty – is the time ripe for a new approach?

The technical aspects of manual total hip arthroplasty are briefly described. The development, technique and technical problems of previous robotic systems in total hip arthroplasty are described with special details of the Robodoc--System. Recent advances regarding the minimally invasive technique of total-hip implantation and navigation are described. The current development of a robotic assisted system for total hip arthroplasty is presented. This project aims to combine the advantages of minimally invasive techniques and navigational systems with the accuracy that robotic assisted bone milling can provide. The project-name is RomEo (Robotic minimally invasive Endoprosthetics), the main project partners are the Helmut-Schmidt-University/Hamburg and the Department of Trauma and Orthopaedics of the BG Trauma Hospital Hamburg.