Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique.

INTRODUCTION: The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA). MATERIALS AND METHODS: A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs. RESULTS: Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID). CONCLUSIONS: Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

Advanced Concepts in Outpatient Joint Arthroplasty.

As the adoption and utilization of outpatient total joint arthroplasty continues to grow, key developments have enabled surgeons to safely and effectively perform these surgeries while increasing patient satisfaction and operating room efficiency. Here, the authors will discuss the evidence-based principles that have guided this paradigm shift in joint arthroplasty surgery, as well as practical methods for selecting appropriate candidates and optimizing perioperative care. There will be 5 core efficiency principles reviewed that can be used to improve organizational management, streamline workflow, and overcome barriers in the ambulatory surgery center. Finally, future directions in outpatient surgery at the ASC, including the merits of implementing robot assistance and computer navigation, as well as expanding indications for revision surgeries, will be debated.

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform.

Robotic-assisted total hip arthroplasty (THA) using a computerized-tomography (CT) based workflow increases surgical time relative to traditional manual technique. The purpose of this investigation was to compare the intra-operative efficiencies of two robotic THA systems: a fluoroscopy-based platform (FL-RTHA) and a contemporary, CT-based (CT-RTHA) platform. A review of 107 consecutive FL-RTHA and 159 CT-RTHA primary, direct anterior approach (DAA) THA procedures was conducted. All cases were performed by one of two surgeons operating at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included averages and consistencies (variances) for surgical times and operating room (OR) times. A secondary outcome was to quantify the duration of robot-active phases in the FL-RTHA workflow. The FL-RTHA cohort experienced shorter surgical times (38.71 min ± 7.00 vs. 75.33 min ± 11.38; p < 0.001) and OR times (101.35 min ± 12.22 vs. 156.74 min ± 17.79; p < 0.001) compared to the CT-RTHA cohort. Surgical times and OR times were both more consistent in the FL-RTHA cohort compared to the CT-RTHA cohort (p < 0.001). Patients who underwent DAA THA with the assistance of a fluoroscopy-based robotic system experienced shorter and more consistent surgical times and OR times compared to patients who underwent similar DAA THA procedures with a contemporary, CT-based robotic platform.

Outpatient Joint Arthroplasty: Practical Guidelines for Success, Effect of COVID--19, and the Roles of Technology and Partnering With Industry.

The COVID-19 pandemic has had a drastic effect on the landscape of outpatient joint arthroplasty. By accelerating the migration to ambulatory surgery centers and hospital outpatient departments, protocols and techniques had to adapt quickly. In addition, the roles of technology and partnering with industry became more appealing in some cases to address specific voids and needs during this transition period. The COVID-19 pandemic abruptly affected the state of outpatient joint arthroplasty in 2020 with long-lasting effects that will continue to shape the practice of outpatient total joint arthroplasty for years to come.

Outpatient Joint Replacement: Practical Guidelines for Your Program Based on Evidence, Success, and Failures.

Joint arthroplasty is increasingly being performed in ambulatory surgery centers (ASCs). Enabled by enhanced recovery protocols and multimodal pain management, and incentivized by the implementation of value-based payment models, this trend is projected to continue, with more than half of total joint replacements predicted to be outpatient by 2026.1 Like any advance in healthcare, this transition offers both new advantages and new challenges. ASCs provide opportunities to improve patient satisfaction and outcomes while lowering costs, but realizing these advantages requires a new level of presurgery preparation for both surgeons and patients. This chapter outlines key considerations for success when transitioning to performing joint arthroplasty at ASCs. Paramount among these are patient selection and preparation. Additional considerations include protocol optimization through data tracking and iterative refinement. A clear understanding of the differences in performing joints at an ASC versus a hospital outpatient setting enables surgeons to make the transition smoothly, maintain a high-quality patient experience, and deliver optimum outcomes.

In Vivo Determination and Comparison of Total Hip Arthroplasty Kinematics for Normal, Preoperative Degenerative, and Postoperative Implanted Hips.

BACKGROUND: The study objective is to analyze subjects having a normal hip and compare in vivo kinematics to subjects before and after receiving a total hip arthroplasty. METHODS: Twenty subjects, 10 with a normal hip and 10 with a preoperative, degenerative hip were analyzed performing normal walking on level ground while under fluoroscopic surveillance. Seven preoperative subjects returned after receiving a total hip arthroplasty using the anterior surgical approach by a single surgeon. Using 3-dimensional to 2-dimensional registration techniques, joint models were overlayed on fluoroscopic images to obtain transformation matrices in the image space. From these images, displacements of the femoral head and acetabulum centers were computed, as well as changes in contact patches between the 2 surfaces throughout the gait cycle. RESULTS: Implanted hips experienced the least amount of separation, compression, and overall sliding throughout the entire gait cycle, but they did show signs of edge loading contact patterns. Conversely, the degenerative hips experienced the most compression, sliding, and separation, with the maximum amount of sliding being 6.9 mm. The normal group ranged in the middle, with the maximum amount of sliding being 1.75 mm. CONCLUSION: Current analysis revealed trends that degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum. None of the implanted hips experienced hip separation.

Outpatient Joint Arthroplasty: Transitioning to the Ambulatory Surgery Center.

The performance of joint arthroplasty in an outpatient setting is expected to rise significantly over the coming decade, with predictions that greater than half of all primary joint arthroplasties will be performed in an outpatient setting by the year 2026. Financial pressures, bundled payment models, and improved understanding of patient recovery have led to discharging patients home the same day as the index procedure. Arthroplasty surgeons are starting to utilize ambulatory surgery centers (ASCs) to perform these outpatient arthroplasty procedures. Our duty as arthroplasty surgeons continues to be to protect our patients' overall care and safety during this transition from a traditional hospital model. Appreciating that postoperative treatment, disposition, physical space, and sterile processing department capabilities are different from traditional hospital models is paramount to success in an ASC. Differences between hospital and ASC models place additional staffing, financial pressure, and time pressure on the arthroplasty surgeon to select and prepare patients before surgery. Adequately preparing patients involves medical optimization, setting patient and family expectations, identifying appropriate caregivers, and establishing effective communication tools after surgery. It is imperative to develop protocols to deal with predictable discharge delays that include blood pressure, oversedation, postoperative urinary retention, postoperative nausea and/or vomiting, pain, and social issues. These protocols are best first developed in a hospital setting where they can be implemented and changed before starting in an ASC. Arthroplasty surgeons will continue to protect patients by developing protocols and preparing patients appropriately for care in an ASC.