The Use of Customized Total Knee Arthroplasty Implants to Increase Efficiency in the Operating Room and Improve Patient Outc
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Operating room efficiency during surgical procedures saves time and money, reduces waste of hospital resources and improves staff morale. Surgical efficiency in orthopaedic surgery can decrease medical complications, such as periprosthetic infection and venous thromboembolic disease, but also must be associated with equivalent or improved longer term patient reported outcomes. In total knee arthroplasty, the instruments used for bone preparation are excessive in number, are frequently redundant, and rely upon achieving average alignment and rotational parameters. As a result, approximately 15-25% of patients report dissatisfaction with their knee reconstructions. Patient specific customized instruments and patient specific implants improve intraoperative efficiency by reducing surgical steps and eliminating redundant steps. Further, because the customized instruments and implants provide anatomic reconstruction of each individual patient, patient reported outcomes have been higher. Additional demonstrated benefits include improved knee alignment and knee kinematics. This paper addresses the various sources of operating room inefficiency, provides suggestions to overcome them, and discusses the first decade of experience with the customized guides for customized implants as a method to improve efficiency.
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2. Willis-Owen CA, Konyves A, Martin DK. Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases. J Bone Joint Surg Br. 2010; 92(8):1128-1133.
3. Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee arthroplasty: an analysis of risk factors. Int Orthop. 2007;31(1):39-44.
4. Ong KL, Lau E, Manley M, Kurtz SM. Effect of procedure duration on total hip arthroplasty and total knee arthroplasty survivorship in the United States Medicare population. J Arthroplasty. 2008;23(6 Suppl 1):127-132.
5. Watters TS, Mather RC 3rd, Browne JA, Berend KR, Lombardi AV Jr, Bolognesi MP. Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty. J Surg Orthop Adv. 2011;20(2):112-116.
6. JFK Memorial Hospital Working Group internal data.
7. Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF. Initial experience with custom-fit total knee replacement: intra-operative events and long-leg coronal alignment. Int Orthop. 2009;33(6):1571-1575
8. Nunley RM, Ellison BS, Zhu J, Ruh EL, Howell SM, Barrack RL. Do patient-specific guides improve coronal alignment in total knee arthroplasty? Clin Orthop Relat Res. 2012; 470(3):895-902.
9. Meier M, Zingde S, Steinert A, Kurtz W, Koeck F, and Beckmann J. What is the possible impact of high variability of distal femoral geometry on TKA? A CT data analysis of 24,042 knees. Clin Orthop Rel. Res 2019; 477(3): 561‐570.
10. Schroeder L, Martin G. In vivo tibial fit and rotational analysis of a customized, patient‐specific TKA versus off‐the‐shelf TKA. J Knee Surgery 2018; 25, https://doi.org10.1055/s‐0038‐1653966).
11. Arbab D, Reimann P, Brucker M, Bouillon B, Lüring C. Alignment in total knee arthroplasty – A comparison of patient‐specific implants with the conventional technique. The Knee 2018; 25(5):882‐887.
12. Ivie, C, Probst P, Bal A, Stannard J, Crist B, and Bal B. Improved radiographic outcomes with patient‐specific total knee replacement. J Arthroplasty 2014; (29): 2100‐2103.
13. Zeller I, Sharma A, Kurtz W, Anderle M, and Komistek R. Customized versus patient‐sized cruciate retaining total knee arthroplasty: an in vivo kinematics study using mobile fluoroscopy. J Arthroplasty 2017;(32): 1344‐1350.
14. Patil S, Bunn A, Bugbee W, Colwell C, and D’Lima D. Patient‐specific implants with custom cutting blocks better approximate natural knee kinematics than standard TKA without custom cutting blocks.” The Knee 2015; 22(6): 624–629.
15. Culler S, Martin G, and Swearingen A. Comparison of adverse events rates and hospital cost between customized individually made implants and standard off‐the‐shelf implants for total knee arthroplasty.” Arthroplasty Today 2017; 3(4): 257–263.
16. O’Connor M and Blau B. The economic value of customized versus off‐the‐shelf knee implants in Medicare fee‐for‐service beneficiaries. Am Health Drug Benefits 2019; 12(2):66-73
17. Reimann P, Brucker M, Arbab D, and Lüring C. Patient satisfaction‐A comparison between patient‐specific implants and conventional total knee arthroplasty. J Orthop 2019; 16(3)273-277.
18. Schroeder L, Neginhal V, and Kurtz W. Patient Satisfaction, Functional Outcomes and Survivorship in Patients with a Customized Posterior‐Stabilized Total Knee Arthroplasty. Orthop Proc, 2019; 101(4):46.
19. Buch R, Schroeder L, Buch R, and Eberle R. Does implant design affect hospital metrics and patient outcomes? TKA Utilizing a “Fast‐Track” Protocol. Recon Rev 2019; 9(1): https://doi.org/10.15438/rr.9.1.203
20. Namin A, Jalali M, Vahdat V, Bedair H, O’Connor M, Kamarthi S, and Isaacs J. The adoption of new medical technologies: The case of customized individually made knee implants. Value Health 2019; 4:423-430.
21. Beyond Compliance. iTotal G2 and iTotal G2 XE.19/10/2020.14:18.2020 Northgate Public Services (UK) Limited
22. American Joint Replacement Registry Annual Report 2020: www.aaos.org
23. Rothstein D and Raval MV. Operating Room Efficiency. Semin Pediatr Surg 2018; 27(2):79-85.
24. Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of Lean Methodology for Improved Quality and Efficiency in Operating Room Instrument availability. J Healthc Qual 2015; 37(5):277-286.
25. Cichos KH, Hyde ZB, Mabry SE, Ghanem ES, Brabston EW, Hayes LW, McGwin G, Ponce BA. Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses. J. Arthopl 2019; 34(12):2834-2840.
26. Zachwieja E, Yayac M , Wills BW, Wilt Z , Austin MS , Courtney PM. Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty. J Arthropl 2020;35(6):1529-1533.
27. Renson L, Poilvache P, Van den Wyngaert H. Improved alignment and operating room efficiency with patient-specific instrumentation for TKA. Knee 2014;21(6):1216-20.
28. Mont MM, McElroy MJ, Johnson AJ, Pivec R, and Single-Use Multicenter Trial Group Writing Group. J Arthropl 2013 28(7):1135-40.
29. Attard A, Fflur Tawy GF, Simons M, Riches P, Rowe P, Biant LC. Health costs and efficiencies of patient-specific and single-use instrumentation in total knee arthroplasty: a randomised controlled trial. BMJ Open Qual 2019 29;8(2)