Comparison of Utilization and Short-Term Complications Between Technology-Assisted and Conventional Total Hip Arthroplasty

Trevor Simcox, MD; Vivek Singh, MD, MPH; Christian T. Oakley, BS; Jan A. Koenig, MD; Ran Schwarzkopf, MD, MSc; Joshua C. Rozell, MD


J Am Acad Orthop Surg. 2022;30(8):e673-e682. 

In This Article

Abstract and Introduction


Introduction: Although technology-assisted total hip arthroplasty (TA-THA) may improve implant positioning, it remains unknown whether TA-THA confers improved clinical outcomes. We sought to examine national TA-THA utilization trends and compare clinical outcomes between TA-THA and unassisted THA (U-THA).

Methods: Patients who underwent primary, elective THA from 2010 to 2018 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographic, perioperative, and 30-day outcomes were queried and collected. Patients were stratified based on whether they underwent TA-THA, which included computer navigation or robotics, and U-THA. Propensity score matching paired patients undergoing TA-THA or U-THA on a 1:1 basis.

Results: Of the 238,755 THA patients, 3,149 cases (1.3%) were done using TA-THA. Comparing the unmatched TA-THA and U-THA groups, race distribution (P < 0.001) and baseline functional status (P < 0.001) differed. Propensity score matching yielded 2,335 TA-THA and U-THA pairs. Perioperatively, the TA-THA cohort had longer mean surgical times (101.0 ± 34.0 versus 91.9 ± 38.8 minutes, P < 0.001), but lower transfusion rates (5.7% versus 7.8%, P = 0.005). As compared with the U-THA group, the TA-THA group had a shorter mean hospital length of stay (2.0 ± 1.1 versus 2.5 ± 2.0 days, P < 0.001) and a higher proportion of patients discharged home (85.8% versus 75.7%, P < 0.001). Notably, the TA-THA cohort had higher readmission rates (3.8% versus 2.4%, P < 0.001). Major complication and revision surgery rates did not markedly differ between groups.

Discussion: TA-THA utilization rates remain low among orthopaedic surgeons. As compared with U-THA, TA-THA yield mixed perioperative and 30-day outcomes. Surgeons must consider the clinical benefits and drawbacks of TA-THA when determining the proper surgical technique and technology for each patient. Clinical trials assessing long-term functional and clinical outcomes between U-THA and TA-THA are required to further elucidate the utility of assistive technologies in THA.

Level III Evidence: Retrospective Cohort Study


Total hip arthroplasty (THA) is one of the most commonly performed elective operations in the United States with over 500,000 cases done per year.[1] It has been described as one of the most successful elective operations for quality of life and patient satisfaction.[2] With the advent of technology-assisted THA (TA-THA), orthopaedic surgeons may now achieve increased accuracy and precision in the placement of THA implants.[3–5] Despite the obvious advantages of TA-THA, there is no consensus in the literature as to whether TA-THA confers short-term or long-term clinical improvements in outcomes over unassisted techniques.[6–13] Thus, longer-term studies are required to detect any substantial and meaningful clinical benefits of the use of advanced technology.

TA-THA encompasses both computer navigation and robotic THA and relies on some combination of handheld sensors, robotic arms, intraoperative imaging, and/or specialized cameras to detect the orientation of the femur and pelvis for bone preparation and implant positioning. Surgical navigation provides orthopaedic surgeons with intraoperative real-time positioning information. However, it does not actively perform bone resection and may be further categorized into image-based or imageless systems. Robotic systems may offer both three-dimensional intraoperative data and aid in performing bony resection. These systems are categorized into active and semiactive systems depending on whether the robot performs bone preparation independently or in conjunction with the operator.[14]

Despite being available for several decades, TA-THA has not been universally adopted for a variety of reasons[15] and accounts for only 3% to 5% of THAs done within the United States.[16,17] This low proportion of TA-THA may be secondary to costly capital investment for hospital systems, a potentially steep learning curve, and skepticism by orthopaedic surgeons who have already achieved good outcomes using conventional methods.[12,17,18] In addition, many facilities may have not optimized operating room workflow or trained support staff to incorporate TA-THA into the operating room.[19]

Certain surgeons, geographic regions, hospital systems, or populations may use technology at different rates. The most recent study to examine national trends in computer navigation and robotic THA within a validated national database reviewed data through 2014, [16] showing that the utilization of technology for THA steadily increased from 0.1% to 3.0% of cases between 2005 and 2014. However, there are still limited data on early postoperative complications and surgical recovery from TA-THA versus unassisted THA (U-THA).[16,20] Additional evaluation of utilization trends will help elucidate how these technologies are being implemented on a national level.

Therefore, the purpose of this study was to investigate the national trends in the utilization of TA-THA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database; compare short-term major complication, readmission, and revision surgery rates; and examine differences in hospitalization and discharge trends between patients undergoing conventional THA and TA-THA. We expect to observe an increase in intraoperative technology utilization over the years of the study and anticipate that patients undergoing TA-THA would have longer surgical times but no notable differences in complication, readmission, and revision surgery rate compared with those undergoing U-TKA.