Sunday, July 12, 2015

Computer assisted shoulder surgery - why do we keep on talking about it?

Comparing conventional and computer-assisted surgery baseplate and screw placement in reverse shoulder arthroplasty.

These authors used a custom-designed system allowing computed tomography (CT)-based preoperative planning, intraoperative navigation, and postoperative evaluation. Five orthopedic surgeons defined common preoperative plans on 3-dimensional CT reconstructed cadaveric scapulae. Each surgeon performed 3 computer-assisted and 3 conventional simulated procedures. The 3-dimensional CT reconstructed postoperative units were digitally matched to the preoperative model for evaluation of entry points, end points, and angulations of screws and baseplate.

Comparison of the groups revealed no difference in accuracy or precision of screws or baseplate entry points. The accuracy and precision of the screw angulation was 5 to 10 degrees closer to the preoperative plan for the navigated system. 

Comment: Several facts regarding computer assisted shoulder surgery are self-evident:
(1) it requires a preoperative CT scan, which is often otherwise unnecessary
(2) it requires expensive software to simulate the procedure
(3) the technique requires special training and has its own learning curve
(4) it is unlikely to be affordable in the community hospitals where most reconstructive shoulder surgery is done
(5) the value (incremental improvement in clinical outcomes / incremental cost) has yet to be determined
(6) most of the studies claiming to show an advantage are, like this one, performed in laboratory scapular models that do not replicate the challenges in exposure encountered in actual surgery.
(7) the evidence that reverse total shoulders fail because of poor glenoid component placement is slim at best

See related posts here and here and here and here.

Our purpose should be to define techniques that all arthroplasty surgeons can use and that do not result in additional expenditure for no or minimal gain for the patient. If the goal is to find the 'best bone' for a central fixation screw, this can be done by the simple means of sliding a finger down the anterior border of the scapula while making the drill hole for the screw. If sufficient bone engagement is not achieved, the drill position can be easily altered. This method uses a computer all surgeons have between our own ears. 


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