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Letter to the Editor: Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial
The Journal of Arthroplasty xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Letter to the Editor: Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial To the Editor: We are surprised to read the conclusions of this RCT, which compared the time taken to do a primary TKA using conventional jigs and PSI [1]. The conclusions of this study are not in agreement with the previously published studies or with our experience. Most studies either report significant or non-significant differences in the duration of the surgery between the PSI and traditional groups with decreased duration of surgery in PSI group [2–5]. This seems logical, in our view, since almost one-third of the operative steps are not required in PSI group and hence saving the total operative time. We appreciate the self-confession of the authors, about the shortcomings and weaknesses of their study, like limited experience of the surgeon to use PSI technology. We noticed that the main problem encountered by the surgeon in their PSI group of patients was related to distal femoral cut and AP chamfer cuts. He took almost 78.9% more time in distal femoral cuts and 37.5% in AP chamfer cuts, resulting in overall increase in operative time by 7.5% in PSI group. This may be related to either due to the learning curve of the surgeon or due to some inherent problem in the fitment of femoral blocks (Trumatch, Depuy). The bone re-cuts in PSI group were also significantly higher (103.8%), when compared to traditional instruments (42%), adding to an increased operative time. We do agree with authors, that busy and high volume surgeons trained with traditional instruments have probably higher learning curve with the new technology like PSI. They may find it difficult to accept or apply the newer technology and hence need more readjustment cuts during the surgery, requiring more operative time. One of the major disadvantages of PSI is the steep learning curve associated with the technique and the need for the surgeon to work with the engineer [6]. This would be more pronounced with a high volume surgeon with experience of using traditional jigs. We have the experience of using the PSI using the CT based cutting blocks (Preplan, Stryker) and found that the average reduction of operative time in PSI group is about 30% (under publication). Our requirement to change the bony cuts is very little and the fitment of the femoral block in these blocks is phenomenally accurate and easy. Since the cutting blocks are manufactured locally by the company, the total
time taken from the pre operative CT scan to the shipment of these blocks have been reduced to only 5–6 working days (with only marginal additional cost of about $400). This additional cost can be recovered, in our experience, from the less requirement of blood transfusion, pain relieving drugs and early discharge from the hospital. We therefore, are not in conformity with authors that PSI does not shorten surgical time in primary TKA. Their conclusions cannot be extrapolated to all surgeons and type of cutting blocks. More multicentric and controlled studies are required using various different types of jigs and surgeons to be able to reach to a satisfactory conclusion. Raju Vaishya MBBS, MS, MCh, FRCS Vipul Vijay MBBS, MS (Ortho), DNB (Ortho Surg), Dip. SICOT(Bel) Department of Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospitals Sarita Vihar, New Delhi, India E-mail address: [email protected] Abhishek Vaish MBBS Department of Orthopaedics Sancheti Hospital Shivaji Nagar, Pune, India Available online xxxx References 1. Hamilton WG, Parks NL, Saxena A. Patient-specific instrumentation does not shorten surgical time: a prospective, randomized trial. J Arthroplasty 2013 Sep;28(8):96. 2. Noble Jr JW, Moore CA, Liu N. The value of patient matched instrumentation in total knee arthroplasty. J Arthroplasty 2012;27(1):153. 3. Watters TS, Mather 3rd RC, Browne JA, et al. Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty. J Surg Orthop Adv 2011;20(2):112. 4. Healy WL, Rana AJ, Iorio R. Hospital economics of primary total knee arthroplasty at a teaching hospital. Clin Orthop Relat Res 2011;469(1):87. 5. Tibesku CO, et al. Benefits of using customized instrumentation in total knee arthroplasty: results from an activity-based costing model. Arch Orthop Trauma Surg 2013;133:405. 6. Lachiewicz PF, Henderson RA. Patient-specific instruments for total knee arthroplasty. J Am Acad Orthop Surg 2013;21(9):513.
0883-5403/0000-0000$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2014.01.027
Please cite this article as: Vaishya R, et al, Letter to the Editor: Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.01.027
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Letter to the Editor: Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial To the Editor: We are surprised to read the conclusions of this RCT, which compared the time taken to do a primary TKA using conventional jigs and PSI [1]. The conclusions of this study are not in agreement with the previously published studies or with our experience. Most studies either report significant or non-significant differences in the duration of the surgery between the PSI and traditional groups with decreased duration of surgery in PSI group [2–5]. This seems logical, in our view, since almost one-third of the operative steps are not required in PSI group and hence saving the total operative time. We appreciate the self-confession of the authors, about the shortcomings and weaknesses of their study, like limited experience of the surgeon to use PSI technology. We noticed that the main problem encountered by the surgeon in their PSI group of patients was related to distal femoral cut and AP chamfer cuts. He took almost 78.9% more time in distal femoral cuts and 37.5% in AP chamfer cuts, resulting in overall increase in operative time by 7.5% in PSI group. This may be related to either due to the learning curve of the surgeon or due to some inherent problem in the fitment of femoral blocks (Trumatch, Depuy). The bone re-cuts in PSI group were also significantly higher (103.8%), when compared to traditional instruments (42%), adding to an increased operative time. We do agree with authors, that busy and high volume surgeons trained with traditional instruments have probably higher learning curve with the new technology like PSI. They may find it difficult to accept or apply the newer technology and hence need more readjustment cuts during the surgery, requiring more operative time. One of the major disadvantages of PSI is the steep learning curve associated with the technique and the need for the surgeon to work with the engineer [6]. This would be more pronounced with a high volume surgeon with experience of using traditional jigs. We have the experience of using the PSI using the CT based cutting blocks (Preplan, Stryker) and found that the average reduction of operative time in PSI group is about 30% (under publication). Our requirement to change the bony cuts is very little and the fitment of the femoral block in these blocks is phenomenally accurate and easy. Since the cutting blocks are manufactured locally by the company, the total
time taken from the pre operative CT scan to the shipment of these blocks have been reduced to only 5–6 working days (with only marginal additional cost of about $400). This additional cost can be recovered, in our experience, from the less requirement of blood transfusion, pain relieving drugs and early discharge from the hospital. We therefore, are not in conformity with authors that PSI does not shorten surgical time in primary TKA. Their conclusions cannot be extrapolated to all surgeons and type of cutting blocks. More multicentric and controlled studies are required using various different types of jigs and surgeons to be able to reach to a satisfactory conclusion. Raju Vaishya MBBS, MS, MCh, FRCS Vipul Vijay MBBS, MS (Ortho), DNB (Ortho Surg), Dip. SICOT(Bel) Department of Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospitals Sarita Vihar, New Delhi, India E-mail address: [email protected] Abhishek Vaish MBBS Department of Orthopaedics Sancheti Hospital Shivaji Nagar, Pune, India Available online xxxx References 1. Hamilton WG, Parks NL, Saxena A. Patient-specific instrumentation does not shorten surgical time: a prospective, randomized trial. J Arthroplasty 2013 Sep;28(8):96. 2. Noble Jr JW, Moore CA, Liu N. The value of patient matched instrumentation in total knee arthroplasty. J Arthroplasty 2012;27(1):153. 3. Watters TS, Mather 3rd RC, Browne JA, et al. Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty. J Surg Orthop Adv 2011;20(2):112. 4. Healy WL, Rana AJ, Iorio R. Hospital economics of primary total knee arthroplasty at a teaching hospital. Clin Orthop Relat Res 2011;469(1):87. 5. Tibesku CO, et al. Benefits of using customized instrumentation in total knee arthroplasty: results from an activity-based costing model. Arch Orthop Trauma Surg 2013;133:405. 6. Lachiewicz PF, Henderson RA. Patient-specific instruments for total knee arthroplasty. J Am Acad Orthop Surg 2013;21(9):513.
0883-5403/0000-0000$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2014.01.027
Please cite this article as: Vaishya R, et al, Letter to the Editor: Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.01.027