Editor's Spotlight/Take 5: No Benefit After THA Performed With Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study

Abstract

Orthopaedic surgery is arguably the most successful specialty in the 20th century in terms of the amount of suffering it has relieved. The claim becomes even more legitimate if we focus on the second half of the 20th century. Total joint replacement, more-modern approaches to skeletal trauma (particularly intramedullary nailing of long-bone fractures), and arthroscopic surgery all transformed not just their respective sub-subspecialties, but the lives of hundreds of millions of patients with common and disabling problems.Figure: Jean-Noel A. Argenson MD, PhDIt seems, though, that the last 30 years have been less transformative. Companies introduced “me-too” implants that showed only substantial equivalence to less-expensive devices, rather than superiority [8]. Surgeons deployed procedures before reasonable standards of efficacy were met [2, 9]. Physicians injected millions of patients with products that demonstrated little benefit in rigorous trials [3, 6]. All of these interventions exposed patients to risks and increased costs to healthcare systems. The fact that we need concepts like the minimum clinically important difference and the minimum detectable change to characterize our treatment outcomes are poignant signs of how little we sometimes require of novel interventions, which expose patients to risk and healthcare systems to cost. The intellectually rigorous orthopaedic surgeon must remain agnostic on the subject of computer-assisted surgery, based on the data we now have. Numerous short-term followup studies suggest navigation can improve surgical accuracy [7, 10], though not all do [5]. Improved alignment in knee arthroplasty might improve implant longevity; improved alignment in hip arthroplasty might reduce the likelihood of dislocation. Both are laudable goals, but they are as-yet unproven [1, 4] despite widespread usage and considerable expense. Prior to this month's issue of Clinical Orthopaedics and Related Research® we have had no robust, long-term studies comparing computer-navigated arthroplasty to freehand surgical techniques. We therefore are proud to share a 10-year followup from a randomized trial performed by Professor Jean-Noel A. Argenson's group in Marseille, France, which found no advantage to computer-assisted acetabular component placement compared to standard surgical techniques. This study is special because it does so much more than merely compare implant alignment. It focuses on the outcomes that matter to patients—hip scores, implant wear, and reconstructive survivorship. Surgeons do not treat radiographs, they treat other human beings. Our studies need to reflect this, particularly before we incorporate expensive new approaches into practice. This study sets an aspirational standard for other studies of new technologies by asking the right questions, by assessing outcomes at long-term followup, and by accounting for all the patients it enrolled. It probably does not close the door on computer navigation, but it certainly puts the ball deep in the court of navigation's proponents; they now need to demonstrate both accuracy and clinical relevance. Join me in the Take-5 interview that follows with Professor Argenson, as we discuss the standards that ought to apply to new technologies before they see widespread use in practice. Take Five Interview with Jean-Noel A. Argenson MD, PhD, Senior Author of “No Benefit After THA Performed With Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study” Seth S. Leopold MD:It seems as though everything today is improved by the use of computers; why do you think it has been so hard to develop computer-navigation systems that offer clear advantages to surgeons and patients? Jean-Noel A. Argenson MD, PhD: My partners and I are convinced that computer technology may indeed improve our ability to perform THA. The kinds of technology already in use (or that are on the near-term horizon) include templating software for precise preoperativ