This document discusses the use of technology such as robotic guidance systems and navigation in total hip arthroplasty (THA). It finds that while this technology can improve accuracy of cup placement, it has not been proven to improve clinical outcomes such as reducing dislocation rates or loosening. Functional issues like soft tissue tension that can cause instability are not addressed by technology. The document concludes that new technologies for THA have not proven themselves and further large investments in them should be analyzed carefully, as the procedure is already very successful without such technologies when performed through direct anterior approach.

1. DAA-THA—NO TECHNOLOGY
NEEDED
 ANTHONY S UNGER, MD
 WASHINGTON, DC

2. ANTHONY S UNGER, MD
 DISCLOSURES
 INNOMED—ROYALTIES
 BIOMET– ROYALTIES,CONSULTANT
 STRYKER—CONSULTANT, SPEAKER
 CDD-STOCK HOLDER, ROYALTIES
 J OF ARTHROPLASTY-EDITORIAL BOARD

3. THA-TECHNOLOGY
 DORR 2011
 “ROBOTIC GUIDANCE IN
THA:THE SHAPE OFTHINGS
TO COME”

4. DR DORR’S ROBOTS

5. TECHNOLOGY(DEFINE)
 GUIDANCE SYSTEMS
 ROBOTS
 NOT IMPLANT DESIGN OR MATERIALS

6. THA
 “THE MOST SUCCESSFUL
OPERATION OFTHE 21ST
CENTURY”
 2013 ORTHOPAEDIC SURGEON

7. THA—WHY DO THEY FAIL??
 INFECTION
 INSTABILITY
 LOOSENING
 LL DISCREPANCY

8. THA-PROBLEMS THAT TECHNOLOGY
ADDRESSES
 INFECTION---NO
 INSTABILITY—MAYBE
 LOOSENING—NO
 LL DISCREPANCY--MAYBE

9. THA-INSTABILITY
 DISLOCATION RATEAVG 3.9%(US
MEDICARE POPULATION)
 22.5% OF REVISION SURGERY IS FOR
INSTABILITY
 BOZIC JBJS 2009

10. THA-INSTABILITY
 LEWINNEK JBJS 1978
 CLASSIC CUP POSITION: 30-50 ABD, 5-25
ANTEVERSION
 1.5% DISLOCATION RATE IN SAFE ZONE
VERSUS 6.1% OUTSIDE ZONE

11. 50% HIPS NOT IN SAFE ZONE
 The John Charnley Award: Risk Factors for
Cup Malpositioning: Quality Improvement
Through a Joint Registry at aTertiary Hospital
 Mark C. Callanan MA, Bryan Jarrett
BS, Charles R. Bragdon PhD, David
Zurakowski PhD, Harry E. Rubash MD,
AndrewA. Freiberg MD, Henrik Malchau MD,
PhD

12. THA-INSTABILITY
 DIGIOIA 1998
 “IMPROVEMENTS IN ACETABULARCUP
ORIENTATIONWILL IMPROVE OUCOMES
AND REDUCE COSTS”
 IMPROVED CUP POSITION----LESS
INSTABILITY---LESS REVISON---LESS
COSTS
 HASTHIS BEEN PROVEN

13. MORE ACCURATE WITH NAV
 Total Hip Arthroplasty Using Imageless
Computer-Assisted Hip Navigation: A
Prospective Randomized Study
 Richard Lass, MDa, , Bernd Kubista,
MDa, Boris Olischar, MDa, Sophie Frantalb,
Reinhard Windhager, MDa, Alexander Giurea,
MDa

16.  However, in our prospective randomized
study, we could not detect a significant
difference in clinical results and revision rates
comparing the navigation and conventional
implantation-technique, at a short-term
follow-up period (range 0.15–3.5 years).This
is the major limitation of our study

17. ROBOTS IMPROVE ACCURACY
 A comparison between robotic-assisted
and manual implantation of cementless
total hip arthroplasty (Article)
 Nakamura, N.a , Sugano, N.b, Nishii,
T.b, Kakimoto, A.a, Miki, H.b

18. ROBOTS IMPROVE ACCURACY
 Comparison of robotic-assisted and
conventional acetabular cup placement in
THA: A matched-pair controlled study
hip (Article)
 Domb, B.G.abc , El Bitar,Y.F.a, Sadik,
A.Y.a, Stake, C.E.ab, Botser, I.B.a

19. THA INSTABILITY
 BULLE J OF ARTHROPLASTY 2012
 PATIENT SPECIFIC INSTRUMENTATION(PSI)
 PSI HAD SIGNIFICANT IMPROVEMENT IN
PLANNED POSITIONVERSUS FREEHAND
 POSTERIORAPPROACH
 NO DIFF IN OUTCOMES

20. PSI IMPROVES ACCURACY
 Comparison of Acetabular Shell Position
Using Patient Specific Instruments vs.
Standard Surgical Instruments: A
Randomized ClinicalTrial
 Travis Small, DO,Viktor Krebs, MD,
Robert Molloy, MD, Jason Bryan, MS, Alison
K. Klika, MS, ,Wael K. Barsoum, MD

21. THA-INSTABILITY
ALLTHETECHNOLOGIES IMPROVE
ACCURACY
 NO IMPROVEMENT OF OUTCOMES
WHY????

22. THA-INTABILITY
 POSITION OF PROSTHESIS IS A STATIC
MEASUREMENT
 INSTABILITY IS INFLUENCED BY SOFT
TISSUETENSION
 INSTABILITY MAY BE DYNAMIC—
IMPINGEMENT
 TECHNOLOGY DOES NOT EVALUATETHIS!!

23. CAN YOUR ROBOT/NAV DO THIS??

24. DAA(w Xray) VS NAV(POST)
 AcetabularComponent Positioning in PrimaryTHA via an
Anterior, Posterolateral, or Posterolateral-navigated Surgical
Technique
 Denis Nam, MD; Peter K. Sculco, MD; Edwin P. Su, MD; Michael M.
Alexiades, MD; Mark P. Figgie, MD; David J. Mayman, MD
 NAV(POST) better than DAA(w xray)
 DAA did not have as much anteversion as
NAV ???

25.  Matta et al---0.61%
 Siguier et al----0.96%
 Unger 2006-2014 0.3%, none
in last 500 cases
DAA- LESS DISLOCATION

26. THA-NO TECHNOLOGY NEEDED
 PAGANO: 2009
 RECENT META-ANALYSIS:IMPROVED CUP
POSITION BUT NO IMPROVEMENT IN
OUTCOMES
 “IN 2008THE OBJECTIVE DATA FOR COMPUTER
NAV IS LACKING,THE CONSENSUS IS ALSO
LACKINGAS FEW SURGEONSACTUALLY USE
NAV FORTHA”

27. THA-NO TECHNOLOGY NEEDED
 “WE ARE NOW ENTERINGTHE 2ND DECADE
OF CLINICAL USE OFTHE NAV SYSTEMS
ANDWE STILL HAVE NOT FOUNDTHE
EVIDENCE OF A CLINICAL BENEFIT”
 “NAV ALSO DEMONSTRATESA NUMBER OF
UNFAVORABLE ISSUES, INCREASED SURG
TIME(INFECTION??), HIGHER COSTS ,
SPECIFIC COMPLICATIONS”

28. THA-LL
 “PARAMONT GOAL OFTHA IS IMPLANT
FIXATION AND HIP STABILITY”
 BUT AVOID LL DISCREPANCY

29. THA--LL
 LL DISCREP COMMON AFTERTHA
 MINIMIZE LL DISCREPANCY CRUCIALTO
THA SUCCESS
 LL DISCREP IS 2ND MOST COMMON
SOURCE OF LITIGATION

30. THA—LL
 MOST PTSWITH LL DISCREP IMPROVE
WITHTIME
 PT AND CHIROPRACTORS DRAW
ATTENTIONAND NEEDTO BE EDUCATED
 HIP SOCIETY STUDY; 0.5%TO 7% LL
PERSIST
 TX SHOE LIFT(UPTO 9.5MM) PT AND IN SEVERE
CASES REVISION

31. THA--LL
 ¾ OF PREOP PTS HAVE SHORTEN LIMB
 THA LENGTHENS LIMB AVG 2.5-6.2 MM
 GENERALLY < 1CM LL DISCREP IS
ACCEPTABLE
 CANTECHNOLOGY IMPROVE LL
DISCREPANCYAFTERTHA???

32. THA--LL
 CANTECHNOLGY HELP??
 LL DISCREPANCY DIVIDED INTOTWO
CATAGORIES
 A. STRUCTURAL
 B. FUNCTIONAL

33. THA-LL
 STRUCTURAL;ACTUAL DIFFERENCE IN
OSSEOUS STRUCTURES
 FUNCTIONAL; POSTORALASSYMETRY
RESULTING FROM SOFTTISSUE
CONTRACTURES----PELVICOBLIQUITY

34. THA--LL
 TECHNOLOGY
 MAY IMPROVE STRUCURAL ASPECT OF LL
 ITWILL NOTASSESS FUNCTIONAL ASPECTS OF
LL

35. THA—LL
 INTRAOPERATIVEASSESSMENTS
 STRUCTURAL(TECHNOLOGY) IMAGING,
COMPUTERS, ROBOTS
 FUNCTIONAL(NOTECHNOLOGY NEEDED)
SHUCKTEST, DROPKICKTEST, LEGTO LEG
COMPARISION

36. DAA REDUCES LL DISCREPANCY
 PT is SUPINE—”FEELTHE MALLEOLI “
 LL CAN BE EASILY ASSESSED
 FUNCTIONALASSESSMENT EASY
 XRAY CONFIRMATION IF NECESSARY

37. THA-NO TECHNOLOGY NEEDED
 IAN LEARMONTH “THA ANDTHE LAW OF
DIMINISHING RETURNS” JBJS 2006
 THA ADVANCES:FIXATION,BEARINGS,MIS
 LAW OF DIMINISHING RETURNS APPLIES: AS
PRODUCT IMPROVESA EXPONENTIALLY
GREATER INVESTMENT IS NEEDEDTO IMPROVE
TECHNOLOGY

38. THA—NO TECHNOLOGY NEEDED
 LEARMONTH 2006
 “CANWE AFFORD A SUBSTANCIAL
INVESTMENT FOR AN ALREADYVERY
SUCCESSFUL PROCEDURE”
 “A GREATER BENEFIT MAY ACCRUE FROM
RESEARCH IN ORTHOBIOLOGIS,TISSUE
ENGINEERING AND GENETHERAPY”

39. THA-NO TECHNOLOGY NEEDED
 PROFESSION IS BEING PUSHED BY
OUTSIDE FORCES
 MEDIA
 PATIENTS
 INDUSTRY
 SURGEON DESIGNERS

40. THA—NO TECHNOLOGY NEEDED
 CONCLUSIONS:
 NEWTECHNOLOGY HAS NOT PROVEN ITSELF
TO IMPROVE OUTCOMES, FURTHER
INVESTMENT MUST BE ANALYSED IN LIEU OF
THIS FACT ASWELLASTHE OPPORTUNITYTO
ENHANCE OUTCOMESTHROUGH OTHER
MEANS.
 NEWTECHONOLGY SHOULD BE ADVOCATED
CAREFULLY ATTHISTIME

41. THANK YOU