The cost-effectiveness of computer-assisted navigation in total knee arthroplasty.

BACKGROUND Total knee arthroplasty is one of the most clinically successful and cost-effective interventions in medicine. However, implant malalignment, especially in the coronal plane, is a common cause of early failure following total knee arthroplasty. Computer-assisted surgery has been employed during total knee arthroplasty to improve the precision of component alignment. The purpose of the present study was to evaluate the cost-effectiveness of computer-assisted surgery to determine whether the improved alignment achieved with computer navigation provides a sufficient decrease in failure rates and revisions to justify the added cost. METHODS A decision-analysis model was used to estimate the cost-effectiveness of computer-assisted surgery in total knee arthroplasty. Model inputs, including costs, effectiveness, and clinical outcome probabilities, were obtained from a review of the literature. Sensitivity analyses were performed to evaluate the impact of component-alignment precision with use of computer-assisted and mechanical alignment guides, total knee arthroplasty failure rates secondary to malalignment, and costs of computer-assisted surgery systems on the cost-effectiveness of computer navigation in total knee arthroplasty. RESULTS Computer-assisted surgery is both more effective and more expensive than mechanical alignment systems. Given an additional cost of $1500 per operation, a 14% improvement in coronal alignment precision (within 3 degrees of neutral mechanical axis), and an elevenfold increase in revision rates at fifteen years with coronal malalignment (54% compared with 4.7%), the incremental cost of using computer-assisted surgery is $45,554 per quality-adjusted life-year gained. Cost-savings is achieved if the added cost of computer-assisted surgery is $629 or less per operation. Variability in published clinical outcomes, however, introduces uncertainty in determining the cost-effectiveness. CONCLUSIONS Computer-assisted surgery is potentially a cost-effective or cost-saving addition to total knee arthroplasty. However, the cost-effectiveness is sensitive to variability in the costs of computer navigation systems, the accuracy of alignment achieved with computer navigation, and the probability of revision total knee arthroplasty with malalignment.

[1]  D. Zurakowski,et al.  Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. , 2004, The Journal of bone and joint surgery. British volume.

[2]  J D Reuben,et al.  The effect of femoral component position on the kinematics of total knee arthroplasty. , 1993, Clinical orthopaedics and related research.

[3]  A. Langdown,et al.  Computer-assisted knee arthroplasty versus a conventional jig-based technique. , 2005, The Journal of bone and joint surgery. British volume.

[4]  Jan Victor,et al.  Image-Based Computer-Assisted Total Knee Arthroplasty Leads to Lower Variability in Coronal Alignment , 2004, Clinical orthopaedics and related research.

[5]  M A Freeman,et al.  Alignment in total knee arthroplasty. Correlated biomechanical and clinical observations. , 1983, Clinical orthopaedics and related research.

[6]  Keating Em,et al.  Overview: long-term followup: predicting the success of a total knee arthroplasty. , 2001 .

[7]  K. Buehler,et al.  Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. , 2005, The Journal of arthroplasty.

[8]  K. Shimizu,et al.  The function of posterior tilt of the tibial component following posterior cruciate ligament-retaining total knee arthroplasty. , 1998, Bulletin (Hospital for Joint Diseases (New York, N.Y.)).

[9]  M. Ritter,et al.  Postoperative alignment of total knee replacement. Its effect on survival. , 1994, Clinical orthopaedics and related research.

[10]  Wolfhart Puhl,et al.  Leg axis after computer-navigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation. , 2005, The Journal of arthroplasty.

[11]  R. Morris,et al.  Coronal alignment after total knee replacement. , 1991, The Journal of bone and joint surgery. British volume.

[12]  A. Cossey,et al.  The use of computer-assisted surgical navigation to prevent malalignment in unicompartmental knee arthroplasty. , 2005, The Journal of arthroplasty.

[13]  M. Porter,et al.  Image-guided surgery for total knee replacement. , 2004, The Journal of bone and joint surgery. American volume.

[14]  W. Breidahl,et al.  Computer-assisted knee arthroplasty versus a conventional jig-based technique. A randomised, prospective trial. , 2004, The Journal of bone and joint surgery. British volume.

[15]  Martin Buxton,et al.  Early assessment of the likely cost-effectiveness of a new technology: A Markov model with probabilistic sensitivity analysis of computer-assisted total knee replacement , 2006, International Journal of Technology Assessment in Health Care.

[16]  D. S. Pandher,et al.  Computer-assisted navigation increases precision of component placement in total knee arthroplasty. , 2007, Clinical orthopaedics and related research.

[17]  R. Laskin.  The Genesis Total Knee Prosthesis: A 10-Year Followup Study , 2001, Clinical orthopaedics and related research.

[18]  M. Akagi,et al.  Effect of rotational alignment on patellar tracking in total knee arthroplasty. , 1999, Clinical orthopaedics and related research.

[19]  J. Rand,et al.  Ten-year evaluation of geometric total knee arthroplasty. , 1988, Clinical orthopaedics and related research.

[20]  Olivier Ethgen,et al.  Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. , 2004, The Journal of bone and joint surgery. American volume.

[21]  R Nagamine,et al.  Effect of femoral and tibial component position on patellar tracking following total knee arthroplasty: 10-year follow-up of Miller-Galante I knees. , 2001, The American journal of knee surgery.

[22]  D. Banzer,et al.  Positioning of total knee arthroplasty with and without navigation support. A prospective, randomised study. , 2003, The Journal of bone and joint surgery. British volume.

[23]  M. Weinstein,et al.  Theoretical Foundations of Cost-Effectiveness Analysis , 1996 .

[24]  R. Grimer,et al.  INFECTION AFTER TOTAL HIP ARTHROPLASTY , 2009 .

[25]  J. J. Jacobs,et al.  Malrotation Causing Patellofemoral Complications After Total Knee Arthroplasty , 1998, Clinical orthopaedics and related research.

[26]  M. Tingart,et al.  Radiological results of image-based and non-image-based computer-assisted total knee arthroplasty , 2004, International Orthopaedics.

[27]  M. Ritter,et al.  Tibial Component Failure Mechanisms in Total Knee Arthroplasty , 2004, Clinical orthopaedics and related research.

[28]  P. Lotke,et al.  Influence of positioning of prosthesis in total knee replacement. , 1977, The Journal of bone and joint surgery. American volume.

[29]  S. Cannon,et al.  The effect of component malalignment on the clinical and radiological outcome of the Kinemax total knee replacement. , 2003, The Knee.

[30]  I. Hvid,et al.  Total condylar knee arthroplasty. Prosthetic component positioning and radiolucent lines. , 1984, Acta orthopaedica Scandinavica.

[31]  J. Stoker,et al.  The Department of Health and Human Services. , 1999, Home healthcare nurse.

[32]  R. Buzzi,et al.  Posteriorly stabilised total-condylar knee replacement. Three to eight years' follow-up of 85 knees. , 1988, The Journal of bone and joint surgery. British volume.

[33]  Richard L Wixson,et al.  Computer assisted navigation in total knee arthroplasty: improved coronal alignment. , 2005, The Journal of arthroplasty.

[34]  W Waugh,et al.  Tibiofemoral alignment and the results of knee replacement. , 1985, The Journal of bone and joint surgery. British volume.

[35]  A S Detsky,et al.  How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. , 1992, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[36]  M. Janeček,et al.  Total knee arthroplasty implanted with and without kinematic navigation , 2003, International Orthopaedics.

[37]  M. Tingart,et al.  Navigation in total-knee arthroplastyCT-based implantation compared with the conventional technique , 2004, Acta orthopaedica Scandinavica.

[38]  S. Stulberg.  S.D. Stulberg replies , 2004 .

[39]  J. Moreland.  Mechanisms of failure in total knee arthroplasty. , 1988, Clinical orthopaedics and related research.

[40]  J D Reuben,et al.  The effect of femoral component position on patellar tracking after total knee arthroplasty. , 1990, Clinical orthopaedics and related research.

[41]  T. Sculco,et al.  Total Condylar Knee Arthroplasty: A Long-Term Followup , 2001, Clinical orthopaedics and related research.

[42]  C. Ranawat,et al.  Total Condylar Knee Replacement: A 20-Year Followup Study , 2001, Clinical orthopaedics and related research.

[43]  M. Swank.  Computer-assisted surgery in total knee arthroplasty:recent advances. , 2004, Surgical technology international.

[44]  D. Shakespeare,et al.  Varus/valgus alignment of the tibial component in total knee arthroplasty. , 2003, The Knee.

[45]  E. M. Keating,et al.  Overview: long-term followup: predicting the success of a total knee arthroplasty. , 2001, Clinical orthopaedics and related research.

[46]  P. Nicolai,et al.  The effect of surgeon experience on component positioning in 673 Press Fit Condylar posterior cruciate-sacrificing total knee arthroplasties. , 2001, The Journal of arthroplasty.

[47]  S. Delp,et al.  Computer assisted knee replacement. , 1998, Clinical orthopaedics and related research.

[48]  J M Sikorski,et al.  Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT Protocol). , 2004, The Journal of bone and joint surgery. British volume.

[49]  Markus Tingart,et al.  Revision total knee arthroplasty: a comparison of postoperative leg alignment after computer-assisted implantation versus the conventional technique , 2005, Knee Surgery, Sports Traumatology, Arthroscopy.

[50]  G. Engh,et al.  Radiographic assessment of knee alignment after total knee arthroplasty. , 1988, The Journal of arthroplasty.

[51]  N. Olchanski,et al.  Cost-utility analyses in orthopaedic surgery. , 2005, The Journal of bone and joint surgery. American volume.

[52]  D. Shakespeare,et al.  Varus/valgus alignment of the femoral component in total knee arthroplasty. , 2003, Knee (Oxford).

[53]  Peter Loan,et al.  Computer-Assisted Navigation in Total Knee Replacement: Results of an Initial Experience in Thirty-five Patients , 2002, The Journal of bone and joint surgery. American volume.

[54]  J. Jenny,et al.  Unicompartmental knee prosthesis implantation with a non-image-based navigation system: rationale, technique, case-control comparative study with a conventional instrumented implantation , 2002, Knee Surgery, Sports Traumatology, Arthroscopy.

[55]  Michael Nogler,et al.  Navigation Improves Accuracy of Rotational Alignment in Total Knee Arthroplasty , 2004, Clinical orthopaedics and related research.