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

Abstract and Introduction


An orthopaedic surgeon's knowledge of anatomical landmarks is crucial, but other modalities supplement this by providing guidance and feedback to a surgeon. Advances in imaging have enabled three-dimensional visualization of the surgical field and patient anatomy, whereas advances in computer technology have allowed for real-time tracking of instruments and implants. Together, these innovations have given rise to intraoperative navigation systems. The authors review these advances in intraoperative navigation across orthopaedic subspecialties, focusing on the most recent evidence on patient outcomes and complications, the associated learning curve, and the effects on operative time, radiation exposure, and cost. In spine surgery, navigated pedicle screw placement may increase accuracy and safety, especially valuable when treating complex deformities. Improved accuracy of pelvic and peri-articular tumor resection and percutaneous fixation of acetabular and femoral neck fractures has also been achieved using navigation. Early applications in arthroscopy have included surface-based registration for tunnel positioning for anterior cruciate ligament reconstruction and osteochondroplasty for femoro-acetabular impingement. Navigated arthroplasty techniques have addressed knee gap balancing and mechanical axis restoration as well as acetabular cup and glenoid baseplate positioning. Among these orthopaedic subspecialties, significant variation is found in the clinical relevance and dedication to research of navigation techniques.


A surgeon's knowledge of relevant anatomy is critical, but intraoperative imaging and navigation capabilities currently supplement this knowledge to improve the surgeon's orientation. Today's imaging and computer technology allow real-time three-dimensional (3D) reconstruction and tracking of instruments within a surgical field. These technological advancements can potentially minimize risk and improve both accuracy and reproducibility of a surgical procedure.

The earliest concept of surgical navigation dates back to cranial stereotaxy described by Horsely and Clarke in 1908, in which a frame attached to the skull was used to target intracranial lesions based on a coordinate system.[1] Mechanical tools were combined with basic mathematical concepts to increase surgical accuracy. The advent of CT would later modernize this concept, with increasing availability of advanced imaging and complex computer processing. By the late 1990s, techniques for the first image-guided lumbar pedicle screw placement and computer-assisted total knee arthroplasty (TKA) were both published.[2,3]