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CAOS: Dont be too hasty to jump on the bandwagon
Computer-assisted surgery adds time, cost and complexity to surgical procedures.
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Well, you know Dr. Hofmann has enthusiastically demonstrated the potential for computer navigation to improve the precision and accuracy and to optimize your knee replacement alignments.
Although, he did that enthusiastically, I would not jump on that bandwagon at the present time.
What are we really going to improve in our total knee arthroplasty (TKA) by using a computer? Do we have outliers in TKA procedures? Definitely. Our own published works in the orthopedic literature have included these outliers: IB II coronal alignment at an average 6.5 year follow up; femoral average 95° tibial average 88° femoral tibial angle average 5°. Although the averages are great, there are a lot of variability in those coronal plane alignments. However, our revision rate was 0% for all of the studies.
To show improvement in decreasing the revision burden, which is a hard data point, will be difficult. To show improvement in clinical results a soft, multi-factorial data point, as we have shown, will really be difficult.
Computer assisted surgery (CAS) takes longer, adds cost and complexity, it is labor and equipment intensive, there is a long learning curve and it may increase accuracy in the right hands.
Override the system
Surgeons will say how hard it is to determine the landmarks we use in TKA (including the epicondyles). Some experienced surgeons complain about the difficulty of palpating these landmarks. If we were more accurate we wouldn’t need a computer, would we?
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The computer glitch
Do not forget, and all surgeons have to do this on at least an irregular basis, if not a regular basis, you have to be able to manually override the computer if you do not believe the computer.
Many of us have seen presentations on this over the last year and the surgeons are constantly doing that.
How about the computer glitch? It is a constant problem that you have seen in your own ORs. Power outages, computer malfunctions ... then you go from being the great computer-navigator to OR chaos.
The issue of money
Then, there is the issue of the “dollars.” All of these need constant upgrades. I have just seen that recently such an advertisement from one manufacturer.
Software upgrades have made millions of dollars for many people in the past, and the business model in knee replacement surgery just does not make sense to me.
My Iowa Medicare rates keep going down and for me to add 20 to 30 minutes to an operation would be very difficult especially with my high Medicare patient population. In fact, if you do the calculations, 20 minutes would cost us 240,000 hours a year in the United States, a huge burden as far as costs when you look at operative time costs. It would be somewhere around a couple hundred million dollars per year in this country.
Hitting a home run
Also, proponents of computer navigation claim it helps us with our minimally invasive surgery. However, I think we need to question whether that is a marriage that is good or a marriage that is bad. With MIS you can not really see what you are doing, but with computer assisted surgery you could become totally reliant on the computer to position your components, and this is a tremendous risk.
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On any given day, to hit a home run in knee replacement surgery, you need ligamentous balancing, flexion-extension gap balancing and a special feel of the knee as my mentor John Insall used to say. I am not sure a computer can give me this.
Do you use your GPS system when you know where you are going? No, half the time it would take you a route that was not the quickest for you.
I highly recommend navigation for a surgeon who is inexperienced and has poor hand/eye coordination or has problems with depth perception.
So, for right now, I am going to use my own eyes. I am going to use my own on-board computer, and for now, I just do not think computers in knee replacement surgery are ready for “Prime Time.”
I am happy that people like Aaron are really checking computer navigation out because when they get the glitches out of the system, I will be first in line to use it in knee replacement surgery.
For more information:
- John J. Callaghan, MD, can be reached at University of Iowa Hospital, Department of Orthopaedics, 200 Hawkins Drive, Iowa City, IA 52242; 319-356-3110; e-mail: john-callaghan@uiowa.edu.
Reference:
- Callaghan JJ. Navigation: Not ready for prime time — Agree. Part of Symposium K; Controversial issues and hot topics in primary total knee replacement, given at The American Academy of Orthopaedic Surgeons 74th Annual Meeting. February 15, 2007. San Diego.