635 C OPYRIGHT Ó 2015
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
commentarybyby Gwo-Chin Gwo-Chin Lee, Lee, MD, MD, is A Acommentary to the onlineofversion of this at linked to linked the online version this article atarticle jbjs.org. jbjs.org.
Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age Richard N. de Steiger, MBBS, FRACS, FAOrthA, Yen-Liang Liu, MAppStats, and Stephen E. Graves, MBBS, DPhil, FAOrthA Investigation performed at the Australian Orthopaedic Association National Joint Replacement Registry, School of Population Health and Clinical Practice, University of Adelaide, Adelaide, South Australia, Australia
Background: Computer navigation for total knee arthroplasty has improved alignment compared with that resulting from non-navigated total knee arthroplasty. This study analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry to examine the effect of computer navigation on the rate of revision of primary total knee arthroplasty. Methods: The cumulative percent revision following all non-navigated and navigated primary total knee arthroplasties performed in Australia from January 1, 2003, to December 31, 2012, was assessed. In addition, the type of and reason for revision as well as the effect of age, surgeon volume, and use of cement for the prosthesis were examined. KaplanMeier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazards models, with adjustment for age and sex, were used to compare revision rates. Results: Computer navigation was used in 44,573 (14.1% of all) primary total knee arthroplasties, and the rate of its use increased from 2.4% in 2003 to 22.8% in 2012. Overall, the cumulative percent revision following non-navigated total knee arthroplasty at nine years was 5.2% (95% confidence interval [CI] = 5.1 to 5.4) compared with 4.6% (95% CI = 4.2 to 5.1) for computer-navigated total knee arthroplasty (HR = 1.05 [95% CI = 0.98 to 1.12], p = 0.15). There was a significant difference in the rate of revision following non-navigated total knee arthroplasty compared with that following navigated total knee arthroplasty for younger patients (HR = 1.13 [95% CI = 1.03 to 1.25], p = 0.011). Patients less than sixty-five years of age who had undergone non-navigated total knee arthroplasty had a cumulative percent revision of 7.8% (95% CI = 7.5 to 8.2) at nine years compared with 6.3% (95% CI = 5.5 to 7.3) for those who had undergone navigated total knee arthroplasty. Computer navigation led to a significant reduction in the rate of revision due to loosening/lysis (HR = 1.38 [95% CI = 1.13 to 1.67], p = 0.001), which is the most common reason for revision of total knee arthroplasty. Conclusions: Computer navigation reduced the overall rate of revision and the rate revision for loosening/lysis following total knee arthroplasty in patients less than sixty-five years of age. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution (s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. One or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2015;97:635-42
d
http://dx.doi.org/10.2106/JBJS.M.01496
636 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 97-A N U M B E R 8 A P R I L 15, 2 015 d
d
d
T
otal knee arthroplasty is a successful operation for patients with severe arthritis for whom nonoperative treatment has failed. Many studies have shown good long-term implant survivorship1,2 although there are age-related differences3. Prosthetic design, surgical technique, surgeon experience, and overall alignment can all have a bearing on the success of the procedure. Computer navigation for total knee arthroplasty was first introduced in Europe in the 1990s, and there has been a widespread increase in its use throughout the world in the last decade. The proposed benefits of computer navigation for total knee arthroplasty include improved accuracy of both tibial and femoral component positioning and overall mechanical alignment. Most studies comparing computer navigation with standard total knee arthroplasty have demonstrated a greater number of patients with coronal mechanical axis alignment within 3° of neutral in the navigation group4-9. Whether this improved alignment leads to a reduction in the long-term rate of revision is yet to be determined. Most of the early studies investigating the use of computer navigation for knee arthroplasty have been performed in specialist orthopaedic centers, where the procedures were often
N AV I G AT E D K N E E A R T H R O P L A S T Y R E D U C E S R E V I S I O N R AT E P AT I E N T S L E S S T H A N S I X T Y - F I V E Y E A R S O F A G E
done by highly experienced surgeons10-12. Orthopaedic surgeons tend to be early adopters of new technology, and it is important to determine the outcome of this technology in a broader population. Joint replacement registries collect and report data on patients who have undergone joint arthroplasty, and analyses can be performed on device and non-device-related characteristics13. Joint replacement registries also provide the ideal platform for monitoring the introduction of new technology at a population level. Computer navigation was introduced into Australia in 2001, and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) began collecting data on its use for knee arthroplasty in 2003. The aim of this study was to determine if there was a difference in the rate of revision after navigated total knee arthroplasty compared with that after non-navigated total knee arthroplasty. Materials and Methods
T
his prospective study was designed to evaluate the rate of revision of computer-navigated total knee arthroplasty with use of registry data on the Australian population of patients who underwent total knee arthroplasty. The AOANJRR began data collection on September 1, 1999, and includes data on almost 100% of the arthroplasty procedures performed in Australia since 2002.
TABLE I Primary Total Knee Arthroplasties Performed with and without Navigation by Year of Procedure Computer-Navigated Procedure Year
No.
FOR
Non-Navigated
Total
%*
No.
%*
No.
%*
Patients of all ages 2003 2004
526 727
2.4 3.1
21,205 22,875
97.6 96.9
21,731 23,602
100.0 100.0
2005
1291
4.9
25,038
95.1
26,329
100.0
2006
2201
8.0
25,182
92.0
27,383
100.0
2007
2960
10.1
26,323
89.9
29,283
100.0
2008
4099
12.6
28,512
87.4
32,611
100.0
2009
6156
17.9
28,142
82.1
34,298
100.0
2010
7906
20.9
29,994
79.1
37,900
100.0
2011 2012
9176 9531
22.8 22.8
30,995 32,279
77.2 77.2
40,171 41,810
100.0 100.0
Total
44,573
14.1
270,545
85.9
315,118
100.0
2003
150
2.3
6247
97.7
6397
100.0
2004
255
3.6
6760
96.4
7015
100.0
2005
407
5.1
7543
94.9
7950
100.0
2006
755
8.9
7758
91.1
8513
100.0
2007
1009
10.7
8417
89.3
9426
100.0
2008 2009
1482 2240
13.4 19.0
9582 9531
86.6 81.0
11,064 11,771
100.0 100.0
2010
2862
21.6
10,386
78.4
13,248
100.0
2011
3463
24.2
10,863
75.8
14,326
100.0
2012
3397
23.8
10,897
76.2
14,294
100.0
Total
16,020
15.4
87,984
84.6
104,004
100.0
Patients
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
commentarybyby Gwo-Chin Gwo-Chin Lee, Lee, MD, MD, is A Acommentary to the onlineofversion of this at linked to linked the online version this article atarticle jbjs.org. jbjs.org.
Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age Richard N. de Steiger, MBBS, FRACS, FAOrthA, Yen-Liang Liu, MAppStats, and Stephen E. Graves, MBBS, DPhil, FAOrthA Investigation performed at the Australian Orthopaedic Association National Joint Replacement Registry, School of Population Health and Clinical Practice, University of Adelaide, Adelaide, South Australia, Australia
Background: Computer navigation for total knee arthroplasty has improved alignment compared with that resulting from non-navigated total knee arthroplasty. This study analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry to examine the effect of computer navigation on the rate of revision of primary total knee arthroplasty. Methods: The cumulative percent revision following all non-navigated and navigated primary total knee arthroplasties performed in Australia from January 1, 2003, to December 31, 2012, was assessed. In addition, the type of and reason for revision as well as the effect of age, surgeon volume, and use of cement for the prosthesis were examined. KaplanMeier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazards models, with adjustment for age and sex, were used to compare revision rates. Results: Computer navigation was used in 44,573 (14.1% of all) primary total knee arthroplasties, and the rate of its use increased from 2.4% in 2003 to 22.8% in 2012. Overall, the cumulative percent revision following non-navigated total knee arthroplasty at nine years was 5.2% (95% confidence interval [CI] = 5.1 to 5.4) compared with 4.6% (95% CI = 4.2 to 5.1) for computer-navigated total knee arthroplasty (HR = 1.05 [95% CI = 0.98 to 1.12], p = 0.15). There was a significant difference in the rate of revision following non-navigated total knee arthroplasty compared with that following navigated total knee arthroplasty for younger patients (HR = 1.13 [95% CI = 1.03 to 1.25], p = 0.011). Patients less than sixty-five years of age who had undergone non-navigated total knee arthroplasty had a cumulative percent revision of 7.8% (95% CI = 7.5 to 8.2) at nine years compared with 6.3% (95% CI = 5.5 to 7.3) for those who had undergone navigated total knee arthroplasty. Computer navigation led to a significant reduction in the rate of revision due to loosening/lysis (HR = 1.38 [95% CI = 1.13 to 1.67], p = 0.001), which is the most common reason for revision of total knee arthroplasty. Conclusions: Computer navigation reduced the overall rate of revision and the rate revision for loosening/lysis following total knee arthroplasty in patients less than sixty-five years of age. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution (s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. One or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2015;97:635-42
d
http://dx.doi.org/10.2106/JBJS.M.01496
636 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 97-A N U M B E R 8 A P R I L 15, 2 015 d
d
d
T
otal knee arthroplasty is a successful operation for patients with severe arthritis for whom nonoperative treatment has failed. Many studies have shown good long-term implant survivorship1,2 although there are age-related differences3. Prosthetic design, surgical technique, surgeon experience, and overall alignment can all have a bearing on the success of the procedure. Computer navigation for total knee arthroplasty was first introduced in Europe in the 1990s, and there has been a widespread increase in its use throughout the world in the last decade. The proposed benefits of computer navigation for total knee arthroplasty include improved accuracy of both tibial and femoral component positioning and overall mechanical alignment. Most studies comparing computer navigation with standard total knee arthroplasty have demonstrated a greater number of patients with coronal mechanical axis alignment within 3° of neutral in the navigation group4-9. Whether this improved alignment leads to a reduction in the long-term rate of revision is yet to be determined. Most of the early studies investigating the use of computer navigation for knee arthroplasty have been performed in specialist orthopaedic centers, where the procedures were often
N AV I G AT E D K N E E A R T H R O P L A S T Y R E D U C E S R E V I S I O N R AT E P AT I E N T S L E S S T H A N S I X T Y - F I V E Y E A R S O F A G E
done by highly experienced surgeons10-12. Orthopaedic surgeons tend to be early adopters of new technology, and it is important to determine the outcome of this technology in a broader population. Joint replacement registries collect and report data on patients who have undergone joint arthroplasty, and analyses can be performed on device and non-device-related characteristics13. Joint replacement registries also provide the ideal platform for monitoring the introduction of new technology at a population level. Computer navigation was introduced into Australia in 2001, and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) began collecting data on its use for knee arthroplasty in 2003. The aim of this study was to determine if there was a difference in the rate of revision after navigated total knee arthroplasty compared with that after non-navigated total knee arthroplasty. Materials and Methods
T
his prospective study was designed to evaluate the rate of revision of computer-navigated total knee arthroplasty with use of registry data on the Australian population of patients who underwent total knee arthroplasty. The AOANJRR began data collection on September 1, 1999, and includes data on almost 100% of the arthroplasty procedures performed in Australia since 2002.
TABLE I Primary Total Knee Arthroplasties Performed with and without Navigation by Year of Procedure Computer-Navigated Procedure Year
No.
FOR
Non-Navigated
Total
%*
No.
%*
No.
%*
Patients of all ages 2003 2004
526 727
2.4 3.1
21,205 22,875
97.6 96.9
21,731 23,602
100.0 100.0
2005
1291
4.9
25,038
95.1
26,329
100.0
2006
2201
8.0
25,182
92.0
27,383
100.0
2007
2960
10.1
26,323
89.9
29,283
100.0
2008
4099
12.6
28,512
87.4
32,611
100.0
2009
6156
17.9
28,142
82.1
34,298
100.0
2010
7906
20.9
29,994
79.1
37,900
100.0
2011 2012
9176 9531
22.8 22.8
30,995 32,279
77.2 77.2
40,171 41,810
100.0 100.0
Total
44,573
14.1
270,545
85.9
315,118
100.0
2003
150
2.3
6247
97.7
6397
100.0
2004
255
3.6
6760
96.4
7015
100.0
2005
407
5.1
7543
94.9
7950
100.0
2006
755
8.9
7758
91.1
8513
100.0
2007
1009
10.7
8417
89.3
9426
100.0
2008 2009
1482 2240
13.4 19.0
9582 9531
86.6 81.0
11,064 11,771
100.0 100.0
2010
2862
21.6
10,386
78.4
13,248
100.0
2011
3463
24.2
10,863
75.8
14,326
100.0
2012
3397
23.8
10,897
76.2
14,294
100.0
Total
16,020
15.4
87,984
84.6
104,004
100.0
Patients
