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Computer assisted knee replacement surgery- a mere marketing gimmick?

Just like any other industry, computers have invaded orthopedic surgeons’ territory as well. Outpatient clinics, wards, ICU’s , operation theaters etc. Although the first computer assisted knee replacement surgery was performed in 1997, it has not yet become standard of care (routine) anywhere in the world.Many countries have yet to adopt this technology in daily surgical practice. In the UK and USA this figure is less than 3%. No more than 6% of the practicing surgeons in France are using computer assisted knee replacement surgery. There is a concern that in emerging countries like India and Brazil, private hospitals have been using computers more as a marketing gimmick, as it could potentially attract increasingly richer patients.

What is computer assisted knee replacement surgery?

Computer assisted knee replacement surgery is a surgical technology that assist surgeons through creation and display of images showing replacement components and their relationship to the bones and the ligaments of the joints being replaced. It has two basic components:

A special camera designed to see the surgical joint and limb, to create image of the same.

A computer program which integrates these images with surgical information and assists the surgeon during the operation.

The computer can use actual images of the joints like X-ray, CT Scan or can create virtual images of the damaged joints. The camera and computer are given information by the surgeon about the normal and abnormal anatomic landmarks of the joint and the limb. The surgeon uses the computer generated information and the images to accurately and reproducibly reconstruct the damaged joint and the limb.

What are the advantages of computer assisted knee replacement surgery?

Appropriate assessment of the patients anatomy, deformity and pathology.

Proper sized and better fitted prosthesis.

Surgeries performed by minimally invasive approach.

Better component positioning and better restoration of limb mechanics.

Decreased dislocation rates.

Decreased surgical trauma.

These listed advantages are being questioned repeatedly by several publications in the recent past. However, surgeons who use computer technology for surgery continue to claim better alignment of total knee replacement implants compared to conventional surgery. The jury still seems to be out regarding this issue.

Why are surgeons not using the technology routinely in most parts of the world?

Despite, the obvious advantages, most surgeons are yet to adapt this technology – some of the reasons are as follows:

Increased risk of infection: Use of supplemental screws or pins, presence of additional personnel and equipment in the operating theater raises the risk of infection.

Increased operation time : The operating time increases anywhere between 10 to 30 minutes if computers are used to do the knee replacement surgery, depending on the surgeon’s familiarity and frequency of usage of computers for performing knee replacement surgeries.

Cost factor: Cost of the surgery is certainly a factor especially in countries like India. At present, cost of computer knee placement surgery is about 20-25% higher.

Surgeon’s Age: Older surgeons who are a bit unfamiliar with computer as a technology are less likely to use this technology and younger surgeons are more likely to use it. In most countries the mean age of orthopedic surgeons are at their peak of practice is about 45-50 years. These surgeons typically graduated in the 1990s before the wide spread use of computers and the internet who may not have familiarized themselves with this kind of technologies.

Disruptive Innovation: In medical field any disruptive innovation will take longer time for penetration. Computer assisted knee replacement surgery took approximately 15 years to go from the first step, so called innovators categories, to the second, so called early adopters category. In the field of computer assisted knee replacement surgery the electronic instrumentation technology may represent disruptive compared to conventional instrumentation. Hence, it may still be in the hands of innovators and early adopters.

What is the future of computer assisted knee replacement surgery?

Although computer assisted knee replacement surgery is not yet main stream, it may not be able to escape technological progress. The current concerns of cost, duration of surgery, concern about increased risk of infection and the surgeon’s willingness to learn will certainly change in the near future as more advances occur in the technology itself. Mahatma Gandhi said “First they ignore you, then they laugh at you, then they fight you, then you win!” You like it or not computers will continue to invade the orthopedic surgeon’s territory. Tomorrow if not today, a routine knee replacement surgery will be performed using the computers.

 

The writer is Dr. Chandrasekar Chikkamuniyappa, Senior Joint Replacement Surgeon and CEO, People Tree Hospitals. Recently awarded with “India’s Most Promising Orthopedic Surgeon – 2014”.

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1 Comment

  1. Dr Basavaraj C.M
    December 1, 2014 at 2:21 pm — Reply

    IS IT A MERE MARKETING GIMMICK?

    Dr Chandrashekar Chickamuniyappa you have clearly advertised in your People tree hospital website that you are using this technology regularly and extensively

    Quote (“ The institute of Orthopaedics, People Tree Hospitals this cutting edge technique of Joint Replacement is practiced regularly and extensively. The Availability of this state of the art technology combined with the presence of experts who knows how to use this technology makes our centre a truly unique one”)
    Do You Still Want To Call It A Marketing Gimmick?

    This becomes a marketing gimmick, if the hospital advertises about this technology and for some reason it is not offering it to its patients.

    But if a hospital is offering this technology I don’t think it is inappropriate in advertising it because, there are obvious advantages of using this technology, which is backed by strong evidences to support it.

    I think the title of this article should have been “computer-assisted joint replacement where do we stand now” rather than “mere marketing gimmick”.

    Some of the aspects covered in your article are not current concepts I would like to highlight some of them for your information.

    1. You mentioned

    “The computer can use actual images of the joints like X-ray, CT Scan or can create virtual images of the damaged joints.”,

    Dr Chandrashekar Chickamuniyappa this technology does not exist now and is outdated.

    The current technology is image less navigation it does not use any information from the patient’s x-rays or the CT scans.
    Current technology is simple and straight forward it is just another tool to know the exact mechanical axis of the lower limb very accurately. It is not rocket science.
    One of the most important data, which the computer lets the operating surgeon know, is the precise point of the mechanical axis of the hip joint.

    2. You mentioned

    “What are the advantages of computer assisted knee replacement surgery?
    Appropriate assessment of the patients anatomy, deformity and pathology.—————————————————————-
    Decreased dislocation rates.
    Decreased surgical trauma.”

    Amongst the advantages you have mentioned the only advantage, which has a strong level 1 evidence in favour of computer assistance, is the restoration of limb mechanical axis.
    The rest are not evidence-based.
    I wonder what you mean by decreased dislocation rates in knee replacement!
    Do you mean to say that in non-navigated surgeries the dislocation/ subluxation rate is higher?

    Common sense says the surgical trauma, whether it is navigation or non-navigated is the same.

    Please refer my article, which clearly mentions the actual advantages of Navigation backed with evidences.

    3. You mentioned

    Why are surgeons not using the technology routinely in most parts of the world?
    Despite, the obvious advantages, most surgeons are yet to adapt this technology – some of the reasons are as follows:
    Increased risk of infection: Use of supplemental screws or pins, presence of additional personnel and equipment in the operating theater raises the risk of infection.

    This is baseless where is the evidence for this?
    The reason why the surgeons are not routinely using this is because the initial investment for the equipment is high (it ranges from 40-60 lacs). And also there is learning curve to it.

    Surgeons who are confident in using this technology the operating time is comparable and hence the risk of infection is not the cause for surgeons not using this technology.

    Even if surgeon spends another 10 or 15 minutes extra it is worth that extra time because from evidences we know that the chances of restoration of mechanical axis is higher.
    Hence this translates to better long-term survival of the implant, which is what one needs.

    4. You mentioned

    “At present, cost of computer knee replacement surgery is about 20-25% higher”.

    Does it cost 20 to 25% higher in your Hospital??? As you have mentioned that you use it regularly and extensively.
    In this respect one would like to know the exact details for this extra cost. Is it not an extra burden to your patient?

    You must be knowing that when one uses active wired arrays the only extra expenditure would be a set of the reflective sphere balls, which would cost meager amount, so when we compare it to the average cost for the surgery this would be .01%.

    At BGS global Hospital there is no extra charge for navigated TKR. Which I think you are aware since you were working in this hospital.

    I appreciate your last paragraph where in you have mentioned that eventually the number of surgeons using this technology would increase.
    This definitely is true and it is reflected in the Australian joint registry, which shows that gradually the number of surgeons using the computer assistance is increasing.

    Dr Basavaraj C.M.
    D’Ortho, DNB(ortho),FRCS (ortho),
    Lower limb arthroplasty Fellowship( UK)
    Consultant Orthopaedics and joint replacement surgeon, BGS global hospitals, Bangalore,India

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