Computer navigation, robotic assistance may not increase PJI risk in TJA
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Key takeaways:
- Conventional, robotic-assisted and computer-navigated total joint arthroplasties had similar rates of infection.
- But robotic-assisted and computer-navigated TJAs had longer operative times than conventional TJA.
Although the use of computer navigation and robotic assistance yielded longer operative times in total joint arthroplasty, published results showed these methods had no association with increased risk of periprosthetic joint infection.
“All of these things are useful to know subsequently for cost analyses and patient benefits, but we can at least say with some confidence that [computer navigation and robotic assistance] do not put the patient at risk of having a higher risk for surgical site infections,” Alberto V. Carli, MD, hip and knee surgeon at Hospital for Special Surgery, told Healio.
Computer navigation, robotic assistance
Carli and colleagues retrospectively reviewed data for patients who underwent either primary total hip (n = 12,726) or knee (n = 11,727) arthroplasty between 2018 and 2021 at Hospital for Special Surgery. Researchers stratified patients into groups based on whether they underwent conventional THA (n = 8,022) or TKA (n = 6,599), computer-navigated THA (n = 2,678) or TKA (n = 5,673), or robotic-assisted THA (n=2,026) or TKA (n = 743).
Researchers matched patients who underwent conventional TJA 1:1 to patients who underwent computer-navigated and robotic-assisted TJAs, accounting for age, sex, BMI, Charlson Comorbidity Index score, components and smoking status. Researchers compared surgical time and rates of PJI within 90 days after surgery between the conventional, computer navigation and robotic-assisted groups.
Results showed computer-navigated and robotic-assisted THAs had longer operative times by 3 and 11 minutes, respectively, compared with conventional THA. Researchers found this difference to be significant. Although robotic-assisted TKA had a significantly longer operative time by 14 minutes compared with conventional TKA, researchers found surgical times were similar between the computer navigation and conventional TKA groups.
Patients who underwent conventional THA and TKA had similar rates of PJI compared with patients who underwent computer-navigated and robotic-assisted THA and TKA, according to results. Logistic regression models showed no association for the development of PJI with use of computer navigation for THA and no association for increased risk of PJI with use of either robotic-assisted or computer-navigated TKA.
“Apart from the increase in time, fortunately, we did not find a significant increase in infections at all,” Carli said. “This was an important finding, especially as we are trying to improve an operation, we do not want to make this improvement come at a different cost. This is relevant in terms of giving some justification to the utilization of this technology, and we are not putting patients at higher risk. But it is still, at the same time, an important indicator that this does take more time.”
Future research
Carli said more research needs to be done on the use of robotics and computer navigation in longer and more technically challenging procedures to see if the technologies contribute to an increase in complications. In addition, he said more work needs to be done to see if robotics and computer navigation lead to meaningful reductions in hip dislocations, dissatisfaction and residual pain after TKA.
“It is hard to do because we do not have a good understanding about how all those complications occur. We still see patients who have robotic-assisted knees who are unhappy for a variety of reasons, but that is where I think the field has to go,” Carli said. “If we do have conclusive data that show that, then there will be a robot in every OR in the world. That is where we are probably going to be heading, but we need to have convincing peer-reviewed data for that.”
References:
- LaValva SM, et al. J Arthroplasty. 2024;doi:10.1016/j.arth.2023.08.007.
- LaValva SM, et al. J Bone Joint Surg Am. 2024;doi:10.2106/JBJS.23.00289.
For more information:
Alberto V. Carli, MD, can be reached at 523 East 72nd St., 7th Fl., New York, NY 10021. He can be contacted through Noelle Caccia at caccian@hss.edu.
Perspective
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The use of robotics and navigation in THA has grown exponentially in the last 5 years as surgeons understand more about the hip-spine relationship and accuracy of implant placement to avoid instability and impingement. The added personnel, instrument trays and consoles required for enabling technology add to the particle burden in the OR and may have implications for infection risk.
The authors retrospectively evaluated patients who were propensity-score matched and underwent hip replacement using conventional instrumentation, computer navigation or robotics. Despite longer operative times, they showed no differences in rates of prosthetic joint infection at 90 days following surgery.
The authors should be commended on a well-done study with a large sample size. Infection research is inherently challenging in that the rate is low, so studies require tens of thousands of patients to draw conclusions about true associations. With an average infection rate of between 0.2% to 0.4%, one would likely need more than 10,000 patients to realize any significant differences. Other interesting variables to collect include the number of people in the OR during the surgery, and how many trays and consoles are opened. Air quality is an emerging area of research, and increased turbulent airflow may affect particle counts especially for longer cases.
Perspective
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Alberto V. Carli, MD, and his team retrospectively reviewed data on 13,015 knees in 11,727 patients who underwent TKA from 2018 to 2021. They propensity-matched conventional, computer navigation and robotic TKA and found that robotic-assisted TKA took longer (on average 14 minutes) than conventional TKA. Still, there was no statistical difference in periprosthetic joint infection rates when comparing computer-navigated TKA (0.3%) and robotic-assisted TKA (0.3%) to conventional TKA (0.5%) at 90 days postoperatively.
This article is important as it adds to the growing literature of support for the use of robotic or computer navigation in TKA. As insurance companies attempt to deny the use of technology in TKA, more data in support of its safe use are essential. This article appeases fears of having more foreign objects in the OR, such as robotic arms, image display screens, more instrumentation/trays and more personnel who are needed to operate the equipment. Furthermore, it was interesting that increases in surgical time did not lead to increased infection rates; in fact, they found that patients with PJI had shorter surgical times than those without infection. No matter which technique you choose for your TKA, we should be grateful to know that the tools themselves are safe for our patients.
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