SURGICAL NAVIGATION

This recommendation has been downgraded due to unique patient populations and associated costs. The advantages of surgical navigation remain unclear with a majority of studies for outcomes, function, and pain showing no difference when compared to conventional TKA. Seven high quality studies for KSS (Yu 2020, Kim 2018, Kim 2017, Todesca 2017, Blyth 2015, Yan 2015, Tsuda 2021), six high quality studies for WOMAC (Hsu 2019, Kim 2018, Kim 2017, Todesca 2017, Cip 2014, Seon 2009), three high quality studies for OKS (Yu 2020, Yan 2015, Tsuda 2021), eight high quality studies for KSS Function (Selvanayagam 2019, Kim 2018, Kim 2017, Todesca 2017, Blyth 2015, Yan 2015, Tsuda 2021, Thiengwittayaporn 2013), six high quality studies for range of motion (Kim 2018, Kim 2017, Blyth 2015, Yan 2015, Cip 2014, Seon 2009), and four high quality studies for pain (Blyth 2015, Kim 2018, Kim 2017, Hsu 2019) showed no difference between surgical navigation and conventional TKA.

The studies comparing blood loss were heterogenous and reporting methods varied, or details were not given. Two high quality studies (Hsu 2019, Ikawa 2017) were in favor of surgical navigation and two high quality studies (Thiengwittayaporn 2013, Kim 2007) showed no difference for blood loss. There were limited studies regarding complications with two high quality studies (Thiengwittayaporn 2013, Blakeney 2011) showing no difference. Lastly, there was one high quality study (Kim 2018) with a 15-year follow up that showed no difference in radiographic parameters, aseptic loosening, or survivorship between surgical navigation and conventional TKA.

As far as operative time, the majority of studies were in favor of conventional TKA. Four high quality studies (Tsuda 2021, Lutzner 2008, Chin 2005, Blakeney 2011) showed longer operative times and one high quality study (Ikawa 2017) showed longer femoral resection time with surgical navigation.

*KSS = Knee Society Score, WOMAC = Western Ontario and McMaster University osteoarthritis Index, OKS = Oxford Knee Score 

Benefits/ Harms of Implementation

Potential benefits for surgical navigation are for specific cases of deformity correction due to trauma or previous retained hardware where conventional instruments cannot be used. Although navigation may result in fewer outliers, increased operative times may lead to increased costs. Furthermore, reliance on computer technology increases the potential to having to abort in the presence of a malfunction.

Outcome Importance

The outcomes between surgical navigation and conventional instruments showed no difference.

Cost Effectiveness / Resource Utilization

Current studies show increased cost to use surgical navigation. However, newer, more cost-effective techniques have been developed and newer studies may change their cost effectiveness and utilization.

Acceptability

The recommendation comes with varying acceptability. Some surgeons may prefer to use surgical navigation even though the outcomes are no different from conventional instruments.

Feasibility

Since there are a number of studies that report no difference in outcomes between surgical navigation and conventional instruments, it may be more feasible to work the downsides of using the technology. Specifically, work on improving efficiency to decrease operating room times and using more cost-effective technology.

Future Research

Since there are multiple studies showing no difference in patient outcomes, the desired benefit would be to show if better alignment reduces loosening and improves survivorship long term with large, randomized studies.