The goal of intraoperative navigation is to surgically implement a preoperative computer-generated plan.
The value of this innovation depends on several factors, including (1) whether the plan, if executed, would improve the clinical outcome for patients and (2) how much navigation adds to the time and cost of the procedure.
Thus this study does not provide evidence supporting implementation of a preoperative plan to "correct" preoperative version to 0 degrees. Furthermore, these authors point out that there are complications associated with correction of native retroversion and a lack of consensus on optimal baseplate positioning.
The utilization of preoperative planning, intraoperative navigation, augmented glenoid components, and associated increased operating room time added cost in comparison to 2D planning and standard implants.
Two-year clinical outcomes and complication rates in anatomic and reverse shoulder arthroplasty implanted with Exactech GPS© intraoperative navigation found that for 533 reverse total shoulder arthroplasty using 73% augmented glenoids, the 31-month outcomes were similar to those in a concurrent series of cases in which the surgeon did not elect to use intraoperative navigation and used augmented glenoids in only 26%.
For the group of patients with standard preoperative planning, only 15 augmented glenoid components were utilized while in the group of patients with 3D preoperative planning and navigation 54 augments were used.
The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared to those that did not.
The authors stated, "Since 3D planning and intraoperative navigation is more costly than 2D planning, and augmented glenoid components are more costly than standard glenoid components, the cost-benefit of these changes with respect mid-term and long-term clinical outcomes and implant survival has not been ascertained."
Many studies of navigation evaluate how close the actual baseplate position is to the preoperative plan (accuracy) and the level of consistency or reproducibility of the implant position (precision). Most do not evaluate whether executing the preoperative plan is likely to improve the patients' clinical outcome.
For example The Value of Computer-Assisted Navigation for Glenoid Baseplate Implantation in Reverse Shoulder Arthroplasty A Systematic Review and Meta-Analysis found that a common goal of preoperative planing is to change preoperative retroversion to a postoperative value of 0 degrees.
To determine whether this is, in fact, a goal that is likely to lead to better outcomes for the patient we can look to Baseplate retroversion does not affect postoperative outcomes after reverse shoulder arthroplasty, a study in which the authors sought to preserve glenoid bone stock without aiming for a certain degree of retroversion. Conservative reaming was only carried out only to the extent necessary to create a single concavity to support the baseplate. They compared the two-year outcomes for 161 patients having postoperative component retroversion ≤ 15 degrees to those for 110 patients with postoperative retroversion >15 degrees. There was less than a 5 degree preoperative to postoperative change in version for each group.
There were no significant differences between the groups in American Shoulder and Elbow Surgeons, visual analog scale, or Single Assessment Numeric Evaluation scores. There were also no significant differences in postoperative range of motion or revision rates.
A recent study Intraoperative navigation system use increases accuracy of glenoid component inclination but not functional outcomes in reverse total shoulder arthroplasty: a prospective comparative study evaluated the clinical utility of intraoperative navigation in patients undergoing RSA. 16 patients had navigation and 17 had standard RSA evaluated at a mean follow-up of 16 months. In both groups, planned and postoperative versions were not significantly different. Patient reported outcomes, range of motion and satisfaction did not differ between the navigated and non-navigated patients at final follow-up.
The authors of The Value of Computer-Assisted Navigation for Glenoid Baseplate Implantation in Reverse Shoulder Arthroplasty A Systematic Review and Meta-Analysis found essentially no clinical followup data in the reviewed studies. They concluded that computer-assisted navigation surgery seemed to increase the accuracy and precision of glenoid baseplate inclination in achieving the preoperatively planned position. However, they stated that the clinical value of this technology in terms of improving prosthesis longevity, complications, and patient functional outcomes is unknown.
Interestingly, augmented glenoid components were used in 74% of the cases with navigation in comparison to 32% in cases without navigation. The odds ratio of selecting an augmented glenoid component with the use of planning and navigation was 8.1.
The utilization of preoperative planning, intraoperative navigation, augmented glenoid components, and associated increased operating room time added cost in comparison to 2D planning and standard implants.
The Impact of Preoperative Three-Dimensional Planning and Intraoperative Navigation of Shoulder Arthroplasty on Implant Selection and Operative Time: A Single Surgeon’s Experience assessed the impact of preoperative 3D planning on the surgeon’s selection of the glenoid component (standard versus augmented) and compare duration of surgery with and without intraoperative navigation in 200 patients who underwent shoulder arthroplasty. The first group of 100 patients underwent shoulder arthroplasty utilizing standard 2D preoperative planning based on standard radiographs and CT scans. The second group of 100 patients underwent shoulder arthroplasty utilizing 3D preoperative planning and intraoperative navigation.
For the group of patients with standard preoperative planning, only 15 augmented glenoid components were utilized while in the group of patients with 3D preoperative planning and navigation 54 augments were used.
The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared to those that did not.
The authors stated, "Since 3D planning and intraoperative navigation is more costly than 2D planning, and augmented glenoid components are more costly than standard glenoid components, the cost-benefit of these changes with respect mid-term and long-term clinical outcomes and implant survival has not been ascertained."
Comment: The value of navigation in executing a preoperative plan depends on whether the plan when executed is likely to improve the outcome for the patient. At present, there is a lack of consensus on the best approach to positioning the glenoid baseplate; for example, should glenoid retroversion be "corrected"? (see Glenoid version: acceptors or correctors). The approach used in Baseplate retroversion does not affect postoperative outcomes after reverse shoulder arthroplasty prioritizes bone preservation rather than changing version and can be realized without intraoperative navigation.
Is computer-assisted intraoperative navigation helpful for the patient having reverse shoulder arthroplasty?
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
