A CLINICAL AND ECONOMIC LITERATURE REVIEW OF THREE MODALITIES IN TECHNOLOGICALLY ASSISTED TKA

Introduction The rate of technological innovation in procedural total knee arthroplasty has left little time for critical evaluation of a new technology before the adoption of even newer modalities. With more drastic financial restrictions being placed on operating room spending, orthopaedic surgeons are now required to provide excellent results on a budget. It is integral that both clinical efficacy and cost-effectiveness of these intraoperative technologies be fully understood in order to provide patients with effectual, economically conscious care. The purpose of this qualitative analysis of literature was to evaluate clinical and economic efficacy of the three most prominent technologies currently used in TKA: computer navigation, patient-specific instrumentation, and kinetic sensors. Methods Three hundred and ninety one publications were collected; 100 were included in final qualitative analysis. Criteria for inclusion in the analysis was defined only insofar as that each piece assessed one of the above listed aspects of the three technologies Literature included in the final evaluation contained background information on each respective technology, clinical outcomes, revision rates, and/or cost analyses. All comparisons were conducted in a strictly qualitative manner, and no attempts were made to conduct interstudy statistical analyses due to the high level of variability in methodology and data collected. Results Navigation Navigation was designed to reduce alignment and component positioning outliers. Many surgeons have argued that its results are no better than that achieved by manual techniques. Some studies have shown that clinical outcomes have improved in navigated TKA patients, but an abundance of research suggests that this is not the case. In consideration of the expense of this technology, coupled with inconclusive results, navigation does not, at this time, seem to fit the schema for significantly reducing the rate of revision and operative cost. PSI Patient-specific instrumentation was designed to reduce the expense of navigation systems, simplify computer-assisted methods, and improve functional outcomes. However, a majority of research has suggested that PSI is either no better, or even worse, at alignment accuracy than manual techniques. Very few publications have been able to attest to any significant increase in functional outcomes scores of PSI patients, over the scores of navigation or manual TKA. Kinetic Sensors Kinetic sensor technology has been engineered to quantify soft-tissue balance, improve rotational alignment, and decrease the risk of post-operative complications. Albeit a young device, the sparse literature that exists shows promising results. The margin of error for detecting loads has been shown to be low, the sensors have successfully measured subtle imbalance that leads to altered gait kinematics, and has shown significant improvement in several patient-reported outcomes measures in balanced patients. Discussion This review shows that not all modalities are created equal, and demonstrates that the cost of some technologies may not yield a clinical or time-saving payoff for the patient and hospital. While kinetic sensor devices seem to be the most promising modality, more research will be necessary to confirm its advantages over time. But, great care must be taken when adopting any novel technology; “new” does not always mean “improved”.