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Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Conventional reconstruction of the anterior cruciate ligament (ACL) has a high success rate. Computer-assisted navigation systems (CANSs) have been developed to further improve the accuracy of tunnel positioning. What is the economic impact from the hospital perspective?

Methods

Patients having a first ACL reconstruction procedure were included in a prospective multicentre open controlled study comparing two groups: CANS versus conventional surgery. The primary clinical efficacy criterion was the objective International Knee Documentation Committee score at 1–2-year follow-up. Costs were collected retrospectively nationwide.

Results

No significant differences were found for the clinical effectiveness between conventional surgery (100 patients) and CANS (114 patients) at follow-up: ORadjusted 1.01 [0.36–2.84] (n.s). Junior surgeons achieved a significant mean decrease in operating time during the study period: 30 % in the CANS group compared with 10 % in the control group (p < 0.01). The average cost of surgery was 704€ for the control group and 1,158€ for the CANS group (p < 0.01). The cost of the operating room accounts for >70 % of the total cost. The surgeon’s status and the technical CANS learning effect influenced this cost. The cost differential between the two groups decreased with ‘CANS’ expertise: 238€ and 271€ in ‘expert’ centres versus 427€ to 731€ in other centres.

Conclusion

While our study demonstrates the feasibility and the potential interest of CANS for training in ACL reconstruction, from a hospital perspective it is not cost efficient at present.

Level of evidence

Economic and decision analysis—developing an economic or decision model, Level II.

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References

  1. Angelini FJ, Albuquerque RF, Sasaki SU, Camanho GL, Hernandez AJ (2010) Comparative study on anterior cruciate ligament reconstruction: determination of isometric points with and without navigation. Clinics (Sao Paulo) 65(7):683–688

    Article  Google Scholar 

  2. Beringer DC, Patel JJ, Bozic KJ (2007) An overview of economic issues in computer-assisted total joint arthroplasty. Clin Orthop Relat Res 463:26–30

    PubMed  Google Scholar 

  3. Briggs AH, O’Brien BJ (2001) The death of cost-minimization analysis? Health Econ 10(2):179–184

    Article  CAS  PubMed  Google Scholar 

  4. Cheng T, Zhao S, Peng X, Zhang X (2012) Does computer-assisted surgery improve postoperative leg alignment and implant positioning following total knee arthroplasty? A meta-analysis of randomized controlled trials? Knee Surg Sports Traumatol Arthrosc 20(7):1307–1322

    Article  PubMed  Google Scholar 

  5. Dessenne V, Lavallee S, Julliard R, Orti R, Martelli S, Cinquin P (1995) Computer-assisted knee anterior cruciate ligament reconstruction: first clinical tests. J Image Guid Surg 1(1):59–64

    Article  CAS  PubMed  Google Scholar 

  6. Eichhorn H (2004) Image-Free Navigation in ACL Replacement with the Orthopilot system. In: Steihl J, Konermann W, Haaker R (eds) Navigation and robotics in Total joint and Spine Surgery. Springer, New York, pp 387–396

    Chapter  Google Scholar 

  7. Endele D, Jung C, Becker U, Bauer G, Mauch F (2009) Anterior cruciate ligament reconstruction with and without computer navigation: a clinical and magnetic resonance imaging evaluation 2 years after surgery. Arthroscopy 25(10):1067–1074

    Article  PubMed  Google Scholar 

  8. Fleute M, Lavallee S, Julliard R (1999) Incorporating a statistically based shape model into a system for computer-assisted anterior cruciate ligament surgery. Med Image Anal 3(3):209–222

    Article  CAS  PubMed  Google Scholar 

  9. French government report: Lucas A, Laborie H, Hingrez E (2012) [Markers of organisation and occupancy of operating rooms from the National Expert commission on hospital audits] MeaH Paris.http://www.anap.fr/detail-dune-publication-ou-dun-outil/recherche/evaluer-et-analyser-la-performance-dun-bloc-operatoire-auto-diag-bloc/

  10. French government report: Tonneau D, Laborie H (2008) [Management and organisation of operating rooms in hospitals and clinics. Final report of in depth survey from the National Expert commission on hospital audits] MeaH, Paris. http://www.anap.fr/detail-dune-publication-ou-dun-outil/recherche/gestion-et-organisation-des-blocs-operatoires-dans-les-hopitaux-et-les-cliniques-rapport-final/

  11. Giffin JR, Harner CD (2001) Failed anterior cruciate ligament surgery: overview of the problem. Am J Knee Surg 14(3):185–192

    CAS  PubMed  Google Scholar 

  12. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474

    CAS  PubMed  Google Scholar 

  13. Hart R, Krejzla J, Svab P, Kocis J, Stipcak V (2008) Outcomes after conventional versus computer-navigated anterior cruciate ligament reconstruction. Arthroscopy 24(5):569–578

    Article  PubMed  Google Scholar 

  14. Hiraoka H, Kuribayashi S, Fukuda A, Fukui N, Nakamura K (2006) Endoscopic anterior cruciate ligament reconstruction using a computer-assisted fluoroscopic navigation system. J Orthop Sci 11(2):159–166

    Article  PubMed  Google Scholar 

  15. Huang TW, Hsu WH, Peng KT, Hsu RW, Weng YJ, Shen WJ (2011) Total knee arthroplasty with use of computer-assisted navigation compared with conventional guiding systems in the same patient: radiographic results in Asian patients. J Bone Joint Surg Am 93(13):1197–1202

    Article  PubMed  Google Scholar 

  16. Jalliard R, Lavallee S, Dessenne V (1998) Computer assisted reconstruction of the anterior cruciate ligament. Clin Orthop Relat Res 354:57–64

    Article  PubMed  Google Scholar 

  17. Koh JL (2008) The future of computer-assisted surgery (CAS) in sports medicine. Sports Med Arthrosc 16(2):108–110

    Article  PubMed  Google Scholar 

  18. Maniar RN, Johorey AC, Pujary CT, Yadava AN (2011) Margin of error in alignment: a study undertaken when converting from conventional to computer-assisted total knee arthroplasty. J Arthroplasty 26(1):82–87

    Article  PubMed  Google Scholar 

  19. Mauch F, Apic G, Becker U, Bauer G (2007) Differences in the placement of the tibial tunnel during reconstruction of the anterior cruciate ligament with and without computer-assisted navigation. Am J Sports Med 35(11):1824–1832

    Article  PubMed  Google Scholar 

  20. Musahl V, Kopf S, Rabuck S, Becker R, van der Merwe W, Zaffagnini S, Fu FH, Karlsson J (2012) Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surg Sports Traumatol Arthrosc 20(4):793–800

    Article  PubMed  Google Scholar 

  21. Nagda SH, Altobelli GG, Bowdry KA, Brewster CE, Lombardo SJ (2010) Cost analysis of outpatient anterior cruciate ligament reconstruction: autograft versus allograft. Clin Orthop Relat Res 468(5):1418–1422

    Article  PubMed Central  PubMed  Google Scholar 

  22. Nakagawa T, Takeda H, Nakajima K, Nakayama S, Fukai A, Kachi Y et al (2008) Intraoperative 3-dimensional imaging-based navigation-assisted anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 24(10):1161–1167

    Article  PubMed  Google Scholar 

  23. Novak EJ, Silverstein MD, Bozic KJ (2007) The cost-effectiveness of computer-assisted navigation in total knee arthroplasty. J Bone Joint Surg Am 89(11):2389–2397

    Article  PubMed  Google Scholar 

  24. Ohkawa S, Adachi N, Deie M, Nakamae A, Nakasa T, Ochi M (2012) The relationship of anterior and rotatory laxity between surgical navigation and clinical outcome after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 20(4):778–784

    Article  PubMed  Google Scholar 

  25. Ong A, Jung KA, Orozco F, Delasotta L, Lee DW (2011) Total knee arthroplasty using a hybrid navigation technique. J Orthop Surg Res 6:26. doi:10.1186/1749-799X-6-26

    Article  PubMed Central  PubMed  Google Scholar 

  26. Plaweski S, Tchouda SD, Dumas J, Rossi J, Moreau Gaudry A, Cinquin P, Bosson JL, Merloz P (2012) Evaluation of a computer-assisted navigation system for anterior cruciate ligament reconstruction: prospective non-randomized cohort study versus conventional surgery. Orthop Traumatol Surg Res 98(6 Suppl):S91–S97

    Article  CAS  PubMed  Google Scholar 

  27. Plaweski S, Cazal J, Rosell P, Merloz P (2006) Anterior cruciate ligament reconstruction using navigation: a comparative study on 60 patients. Am J Sports Med 34(4):542–552

    Article  PubMed  Google Scholar 

  28. Plaweski S, Rossi J, Merloz P, Julliard R (2011) Analysis of anatomic positioning in computer-assisted and conventional anterior cruciate ligament reconstruction. Orthop Traumatol Surg Res 97(6 Suppl):S80–S85

    CAS  PubMed  Google Scholar 

  29. Plaweski S, Grimaldi M, Courvoisier A, Wimsey S (2011) Intraoperative comparisons of knee kinematics of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1277–1286

    Article  PubMed  Google Scholar 

  30. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC (2013) Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 29(1):98–105

    Article  PubMed  Google Scholar 

  31. Robertsson O, Borgquist L, Knutson K, Lewold S, Lidgren L (1999) Use of unicompartmental instead of tricompartmental prostheses for unicompartmental arthrosis in the knee is a cost-effective alternative. 15,437 primary tricompartmental prostheses were compared with 10,624 primary medial or lateral unicompartmental prostheses. Acta Orthop Scand 70(2):170–175

    Article  CAS  PubMed  Google Scholar 

  32. Saragaglia D (2009)[Computer-assisted total knee arthroplasty: 12 years experience in Grenoble]. Bull Acad Natl Med 193(1):91-104; discussion 104-105

    Google Scholar 

  33. Sati M, Staubli H, Bourquin Y, Kunz M, Nolte LP (2002) Real-time computerized in situ guidance system for ACL graft placement. Comput Aided Surg 7(1):25–40

    CAS  PubMed  Google Scholar 

  34. Schep NW, Stavenuiter MH, Diekerhof CH, Martens EP, van Haeff CM, Broeders IA et al (2005) Intersurgeon variance in computer-assisted planning of anterior cruciate ligament reconstruction. Arthroscopy 21(8):942–947

    Article  PubMed  Google Scholar 

  35. Schnurr C, Eysel P, Konig DP (2011) Displays mounted on cutting blocks reduce the learning curve in navigated total knee arthroplasty. Comput Aided Surg 16(5):249–256

    Article  PubMed  Google Scholar 

  36. Slover J, Hoffman MV, Malchau H, Tosteson AN, Koval KJ (2009) A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in the active, healthy, elderly population. J Arthroplasty 24(6):854–860

    Article  PubMed Central  PubMed  Google Scholar 

  37. Smith BR, Deakin AH, Baines J, Picard F (2010) Computer navigated total knee arthroplasty: the learning curve. Comput Aided Surg 15(1–3):40–48

    Article  PubMed  Google Scholar 

  38. Sudan R, Bennett KM, Jacobs DO, Sudan DL (2012) Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 255(5):940–945

    Article  PubMed  Google Scholar 

  39. Swank ML, Alkire M, Conditt M, Lonner JH (2009) Technology and cost-effectiveness in knee arthroplasty: computer navigation and robotics. Am J Orthop (Belle Mead NJ) 38(2 Suppl):32–36

    Google Scholar 

  40. Valentin P, Hofbauer M, Aldrian S (2005) Clinical results of computer-navigated anterior cruciate ligament reconstructions. Orthopedics 28(10 Suppl):S1289–S1291

    PubMed  Google Scholar 

  41. Willcox NM, Clarke JV, Smith BR, Deakin AH, Deep K (2012) A comparison of radiological and computer navigation measurements of lower limb coronal alignment before and after total knee replacement. J Bone Joint Surg Br 94(9):1234–1240

    Article  CAS  PubMed  Google Scholar 

  42. Zaffagnini S, Klos TV, Bignozzi S (2010) Computer-assisted anterior cruciate ligament reconstruction: an evidence-based approach of the first 15 years. Arthroscopy 26(4):546–554

    Article  PubMed  Google Scholar 

  43. Zaffagnini S, Bignozzi S, Martelli S, Imakiire N, Lopomo N, Marcacci M (2006) New intraoperative protocol for kinematic evaluation of ACL reconstruction: preliminary results. Knee Surg Sports Traumatol Arthrosc 14(9):811–816

    Article  CAS  PubMed  Google Scholar 

  44. Zhang GQ, Chen JY, Chai W, Liu M, Wang Y (2011) Comparison between computer-assisted-navigation and conventional total knee arthroplasties in patients undergoing simultaneous bilateral procedures: a randomized clinical trial. J Bone Joint Surg Am 93(13):1190–1196

    Article  PubMed  Google Scholar 

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Acknowledgments

This study was supported by the clinical research program of the French Ministry of Health (Programme de soutien aux techniques innovantes et coûteuses, STIC/Ministère de la Santé/DHOS). We are indebted to the other members of the CANS ‘STIC’ group: B Schlaterrer, F De Peretti, F Dubrana, N Pujol, N Bellot, N Graveleau, P Hardy, F Farizon, S Paratte, JN Argenson, J Pernin, P Massin, O Touchard, and D Molé; and to Alison Foote for critically reading and editing the manuscript. The study was funded by the French Ministry of Health (National Health Program: Programme National de Soutien aux Innovations Techniques Coûteuses, STIC 2005).

Conflict of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Cellule d’évaluation médico-économique des innovations, Pavillon Taillefer, CHU de Grenoble, 38043, Grenoble, France

    Jennifer Margier & Sandra David Tchouda

  2. Laboratoire TIMC-IMAG-CNRS, UMR CNRS Université Alpes-Grenoble UMR 5525, CHU Grenoble, 38043, Grenoble, France

    Sandra David Tchouda, Jean-Jacques Banihachemi & Jean-Luc Bosson

  3. Clinique Universitaire de Chirurgie Orthopédique et de Traumatologie du Sport, Urgences Hôpital Sud, CHU de Grenoble, Grenoble, France

    Jean-Jacques Banihachemi & Stéphane Plaweski

  4. Centre d’Investigation Clinique (CIC), Pavillon Taillefer, CHU de Grenoble, 38043, Grenoble, France

    Jean-Luc Bosson

Authors
  1. Jennifer Margier
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  2. Sandra David Tchouda
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  5. Stéphane Plaweski
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Correspondence to Jennifer Margier.

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Margier, J., Tchouda, S.D., Banihachemi, JJ. et al. Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient. Knee Surg Sports Traumatol Arthrosc 23, 1026–1034 (2015). https://doi.org/10.1007/s00167-013-2831-2

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  • DOI: https://doi.org/10.1007/s00167-013-2831-2

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