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F. Picard, F. Leitner, A. Gregori, D. Saragaglia
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knee technology users [17]. Numerous reasons
explain why this technology is still not used
more routinely and widely in orthopaedics. In a
recent publication, we identified two obvious
explanations: one is the lack of optimal
ergonomic systems for most of them and the
second is economical [18].
Regarding the ergonomic of CAS systems,
most of them have been developed through
engineering cycles of improvements with little
input from surgeons, which have produced
sometimes very sophisticated but also very
complex solutions to navigate straightforward
surgery such as TKA. On the other hand,
orthopaedic companies and furthermore the
“majors” have not been much interested in
developing tools in this field (i.e. camera,
electronics devices, software…) which are out
of their domain of competencies (i.e. prosthetic
design, metallurgy or mechanical ancillary
instrumentations…). Therefore, the lack of
input from orthopaedic surgeons combined
with cautious investments from orthopaedic
companies [19] have slow down attraction to
the field. Moreover, a sluggish marketing
compared to Minimally Invasive Surgery
(MIS) for example made the introduction of
this technology very timid. It is also true that
MIS was an easier concept to sell to surgeons
and patients than CAS !
However, two recent key events have changed
the perception of this technology from all
players in the field and may have allowed CAS
to pass the chasm between early adopters and
mainstream orthopaedic users. The first is the
acquisition of an autonomous robotic haptic
assistive tool, named MAKO (Fort Lauderdale,
Florida US) by a major orthopaedic company
(Stryker, Kalamazoo, US) [20]. Stryker is the
number one world company in orthopaedics
and they bought MAKO for 16.2 billion dollars
(!), which clearly suggests a dramatic change
towards the technology in the field of
orthopaedic surgery. The second event is the
publication of the 2013 Australian Registry
outcomes showing a statistical difference
reduction of knee revision after 6 to 9 years
follow-up, in young navigated TKA patients
(less 65years old) incomparison toconventional
TKA [21]. These results would require
confirmations from other sources, albeit being
striking. Although navigation is hence a mature
technology, it still needs to go through usual
phases of adoption [22]. On the other hand,
computers are everywhere and it is unlikely
that orthopaedic surgical theatres will escape
the changes.
In this article, we would like to describe the
phases we went through over the last fifty years
with this technology and describe the benefits,
as well as the drawbacks that have been raised
all along the way using navigation on knee
arthroplasty.
Looking back, we can categorise five
identifiable phases in my practice with CAS
(Computer assisted Surgery/Computer assisted
navigation) for TKA:
1.
Prototypal phase
2.
Measured resection technique
3.
Gap management software development
4.
Refinement of the technique and intelligent
use of data collection
5.
New tools in the surgical tool box.
Prototypal phase
In the 1990s, most of the teams who were
working on computer-assisted technology in
the field of orthopaedics were strongly focused
on robotics and image-guided technology [23,
24, 25]. Therefore, the concept of CT-free
navigation using only intraoperative anatomical
and kinematical data straight from the patient’s
anatomy was a little bit disruptive. Patient’s
frame of reference was built from immediate
data collection and did not require to establish
any complex registration or matching process
imposing convoluted mathematical computa
tion. The concept was quite odd and provocative
because it was deescalating the natural
evolution of complex technology and software
engineering process. It took a long time to
develop technical and software tools to become
a usable and reliable system, which could then
be used in routine practice. Once the system
was available, a few teams in the world started
to evaluate the principles in view to reproduce