The Role of Intraoperative Navigation in Orthopaedic Surgery

Alexa J. Karkenny, MD; Joseph R. Mendelis, MD; David S. Geller, MD; Jaime A. Gomez, MD


J Am Acad Orthop Surg. 2019;27(19):e849-e858. 

In This Article

Barriers to Widespread Acceptance of Intraoperative Navigation

Current navigation technology can provide substantial benefits including real-time feedback, increased accuracy, and improved visualization, but systems are still in their infancy. In an era of rising healthcare expenditures, the potential for increased cost, setup, surgical time, and staffing needs as well as the learning curve of navigated surgery must be considered by surgeons and hospital administrators alike. As with any evolving technology, using navigation in a clinical setting can often involve a degree of trouble-shooting on the part of the surgeon, circulating nurse, surgical technician, or manufacturer representative. Regardless of the technique, the surgeon is ultimately responsible for the patient and thus must recognize navigation as a supplemental tool, such that a procedure could continue within the standard of care in a conventional manner should the system fail.

In terms of direct costs, hospitals must consider the initial acquisition of navigation platforms and intraoperative imaging modalities as well as maintenance expenses. Navigation platforms that have broader applications may be a more fiscally responsible choice in a lower-volume setting (Table 1). Hospitals must also consider that some systems rely on reusable components (ie, reference arrays) whereas others rely on disposable, patient-specific guides (ie, screw trajectory jigs). Indirect costs dependent on total operative time and length of stay are likely variable and, as shown in the aforementioned studies, may decrease over time as surgical teams become familiar with the setup.[20] In terms of surgeon training, the real-time visual feedback may allow residents to become more technically involved without sacrificing patient safety.[38] Additionally, a current lack of long-term outcome data on this new technology is a barrier to surgeon acceptance, but this may be ameliorated with increasing availability of literature over time. In terms of patient acceptance, one study examining patient perception of robotic and navigated surgery in the United Kingdom in 2014 reported that half of the patients believed that this type of surgery was more accurate, faster, and easier for the surgeon whereas about 20% believed that it provided no benefit over conventional surgery.[40] Technological advancements in health care have provided tools that can improve clinical practice, but it is critical that surgeons and hospital administrations embrace navigation responsibly, recognizing its limitations and avoiding its use solely for the sake of marketing.