Short-Term Benefits of Robotic Assisted Total Knee Arthroplasty Over Computer Navigated Total Knee Arthroplasty Are Not Sustained With No Difference in Postoperative Patient-Reported Outcome Measures

Recovery Time and Success: A Comparative Study of Robotic and Manual Total Hip Arthroplasty Outcomes

BACKGROUND

Despite the growing utilization of robotic-assisted total hip arthroplasty (rTHA), major debate remains regarding its comparative effectiveness in achieving optimal patient outcomes compared to manual total hip arthroplasty (mTHA). This study aimed to compare both the rate and time to achieve minimal clinically important difference (MCID) between rTHA and mTHA.

METHODS

We conducted a retrospective analysis comparing 341 rTHAs with a 1:3 propensity score-matched cohort of 1,023 mTHAs performed from 2016 to 2022. Propensity scores were generated based on age, sex, body mass index, and Charlson comorbidity index. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function-10a (PF-10a), and Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS). The time to achieve MCID was assessed using survival curves with and without interval censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

RESULTS

Manual total hip arthroplasty demonstrated a significantly higher rate of achieving MCID for PROMIS Global Physical (84.1 versus 79.8%, P = 0.003) and HOOS-PS (60.0 versus 44.9%, P < 0.001), while rates for PROMIS PF-10a were similar (58.6 versus 56.0%, P = 0.085). In the interval-censored analysis, rTHA achieved MCID for HOOS-PS significantly faster than mTHA (0.67 versus 1.0 months, P < 0.001). However, no significant differences were found for PROMIS Global Physical (0.24 versus 0.70 months, P = 0.18) and PROMIS PF-10a (1.60 versus 3.03 months, P = 0.73) when compared to mTHA.

CONCLUSIONS

We conducted a propensity score-matched analysis of rTHA and mTHA, accounting for baseline characteristics, but not factors such as case difficulty and anatomic complexity. We found that rTHA achieved MCID faster, while mTHA had a higher overall proportion of MCID achievement. Robotic-assisted surgery may expedite initial recovery, while manual techniques may lead to better long-term outcomes.

Evidence Versus Frenzy in Robotic Total Knee Arthroplasty: A Systematic Review Comparing News Media Claims to Randomized Controlled Trial Evidence

BACKGROUND

Robotic total knee arthroplasty (rTKA) has garnered increasing attention in recent years, both clinically and in the media. The purpose of this study was to compare the volume of and messaging in published randomized controlled trials (RCTs) versus media reports on the topic of rTKA.

METHODS

This was a systematic review of RCTs and media articles on rTKA. PubMed, Embase, and MEDLINE were searched for RCTs; Factiva was searched for media articles. The number of publications of each type per year was recorded. Media articles were classified on the basis of their primary information source, their general tone toward rTKA, and the benefits and drawbacks of rTKA discussed. The volume, tone, and specific messaging around rTKA were compared between media articles and RCTs.

RESULTS

Fifteen RCTs and 460 media articles, published between 1991 and 2023, were included. The rates of both publication types increased over time, with more rapid increases in recent years. Ninety-five percent of media publications highlighted at least 1 benefit of rTKA. The most commonly cited benefits were more precise implant positioning (82.6%) and faster recovery (28.7%). Fewer than 7% of media publications (n = 30) mentioned downsides to rTKA. Overall, 89.3% of media articles presented a favorable view of rTKA. Ninety percent of RCTs reported that rTKA significantly outperformed manual TKA in terms of component positioning. Four of 6 RCTs reported significantly longer operative times with rTKA. Most RCTs found no significant differences in functional outcomes, opioid use, or complication rates.

CONCLUSIONS

The rate of publications on rTKA has increased substantially in media sources and peer-reviewed journals, with the volume of media articles far outpacing RCTs on the topic. More precise component positioning was the most consistently reported benefit of rTKA in RCTs. However, media sources also reported a range of other, less well-supported benefits, and employed overwhelmingly positive tones regarding rTKA, more so than is supported by mixed clinical results. Efforts to ensure that patients and health-care providers receive accurate and evidence-based information about new health technologies are critical.

CLINICAL RELEVANCE

This study demonstrates a clear disparity between news media coverage of rTKA and the best clinical evidence available. This information can help to guide discussions between patients and surgeons regarding the use of rTKA.

Considerations of morphometry and phenotypes in modern knee arthroplasty

As advancements in total knee arthroplasty progress at an exciting pace, two areas are of special interest, as they directly impact implant design and surgical decision making. Knee morphometry considers the three-dimensional shape of the articulating surfaces within the knee joint, and knee phenotyping provides the ability to categorize alignment into practical groupings that can be used in both clinical and research settings. This annotation discusses the details of these concepts, and the ways in which they are helping us better understand the individual subtleties of each patient's knee.

Minimized Soft Tissue Release in Robotic-Assisted Total Knee Arthroplasty: A Retrospective Review of 100 Cases

Aim For a successful total knee arthroplasty (TKA), bone cuts and soft tissue envelope must be balanced to ensure equal flexion and extension gaps. The study aims to assess if preoperative computed tomography (CT) scans and planning software reduce soft tissue release. Methodology A retrospective analysis was conducted for the first 100 consecutive robotic-assisted (RA) TKA (RA-TKA) patients between March 2022 and May 2023. All patients underwent preoperative leg CT scans utilizing a fully automated Cuvis Joint robot. Planning software determined implant sizes and bone resections to achieve a 180° hip-knee-ankle axis. A posterior-stabilized knee design was implanted during surgery by the same surgical team using a medial parapatellar approach. The study hypothesis was, that RA-TKA with preoperative CT scans and planning does not reduce soft tissue release incidence, comparing it with the historical control cohort using chi-square tests (P < 0.05 considered significant). Results The study consisted of 89 women and 11 males, with an average age of 65.3 ± 12 years. The average body mass index of the patients was 27.4 ± 5.2 kg/m2. Ninety-four individuals had varus knees, while six had valgus knee deformity. Varus deformity ranged between 7° and 18°, and valgus knee deformity ranged from 6° to 14° preoperatively. Twelve patients (12.77%) of 94 varus knees (versus historic control 29%, P-value = 0.0047) and one out of 6 (16.67%) valgus knees (versus historic control 84%, P < 0.0001) required posteromedial and posterolateral release for appropriate knee balance. Conclusions The study negates the null hypothesis and indicates that RA-TKA with preoperative CT scans and planning reduces the incidence of soft tissue releases to achieve a well-balanced knee.

Robotics in total knee replacement: Current use and future implications

Robotic total knee replacement (TKR) surgery has evolved over the years with the aim of improving the overall 80% satisfaction rate associated with TKR surgery. Proponents claim higher precision in executing the pre-operative plan which results in improved alignment and possibly better clinical outcomes. Opponents suggest longer operative times with potentially higher complications and no superiority in clinical outcomes alongside increased costs. This editorial will summarize where we currently stand and the future implications of using robotics in knee replacement surgery.

Robotic Arm-Assisted Total Knee Arthroplasty: Anatomical Alignment and Mid-Term Outcomes from the First Cohort Originating in Greece

Robotic arm-assisted total knee arthroplasty (RATKA) represents a haptic assistive robotic arm used for bone preparation. The purpose of this study was to present implant survivorship, complications and evaluate patients' satisfaction, clinical and functional outcome of RATKA with a minimum of 1-year follow-up. The Oxford Knee Score was recorded preoperatively and at last follow-up. Patients' satisfaction rates, as well as complications and re-operations were studied. Anatomical alignment including varus, valgus deformities and flexion, extension, pre-and postoperatively were evaluated. A total of 156 patients with mean age = 71.9 years were included in the study. The mean follow-up was 35.7 months, while one revision was performed due to infection. Statistically significant improvement of the Oxford Knee Score, as well as of the knee alignment deformities were recorded, while 99.4% of patients reported to be "very satisfied" or "satisfied" with the procedure. RATKA seems to be a safe, as well as reproductible procedure at short-and mid-term follow-up, while the accurate implant positioning may lead to favorable long-term outcomes.

Multicenter, prospective cohort study: immediate postoperative gains in active range of motion following robotic-assisted total knee replacement compared to a propensity-matched control using manual instrumentation

BACKGROUND

Range of motion (ROM) following total knee replacement (TKR) has been associated with patient satisfaction and knee function, and is also an early indicator of a successful procedure. Robotic-assisted TKR (raTKR) is considered to reproduce more precise resections, and, as a result, may be associated with improved early patient satisfaction compared to manual TKR (mTKR). The purpose of this study was to evaluate the early postoperative active ROM (aROM) between raTKR and mTKR.

METHODS

A total of 216 mTKR patients were propensity-matched, in terms of age, gender, comorbidities, and BMI, to 216 raTKR cases. Intraoperative and immediate postoperative adverse events were collected. Knee flexion and extension aROM were measured preoperatively and at one- and three months after operation.

RESULTS

Changes in flexion aROM were significantly greater in raTKR vs. mTKR at one- (6.9°, 95% CI: 3.5, 10.4°) and three months (4.9°, 95% CI: 2.1, 7.7°). Flexion aROM was greater at three postoperative months compared to preoperative aROM only in the raTKR group, and raTKR patients had higher odds of achieving ≥ 90° of flexion at one month after operation (OR: 2.15, 95% CI: 1.16, 3.99). There were no significant differences between groups in intraoperative (P > 0.999) or postoperative adverse events.

CONCLUSIONS

Compared with mTKR, raTKR resulted  in less loss of aROM immediately after operation and a faster recovery of aROM within three months after operation.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT# 03737149).

Improving alignment in total knee arthroplasty: a cadaveric assessment of a surgical navigation tool with computed tomography imaging

PURPOSE

To investigate the accuracy of an imageless, optical surgical navigation tool to assist with femoral and tibial bone cuts performed during TKA.

PATIENTS AND METHODS

Six board-certified orthopedic surgeons participated in a laboratory cadaver investigation, performing femoral and tibial bone cuts with the assistance of a computer navigation tool. Femoral and tibial varus/valgus, tibial slope, femoral flexion, and both femoral and tibial rotation measurements from the device were compared with angular measurements calculated from computed tomography (CT) images of the knees.

RESULTS

Measurements with the navigation tool were highly correlated with those obtained from CT scans in all three axes. For the distal femoral cut, the absolute mean difference in varus/valgus was 0.83° (SD 0.46°, r = 0.76), femoral flexion was 1.91° (SD 1.16°, r = 0.85), and femoral rotation was 1.29° (SD 1.01°, r = 0.88) relative to Whiteside's line and 0.97° (SD 0.56°, r = 0.81) relative to the posterior condylar axis. For the tibia, the absolute mean difference in varus/valgus was 1.08° (SD 0.64°, r = 0.85), posterior slope was 2.78° (SD 1.40°, r = 0.60), and rotation relative to the anteroposterior axis (posterior cruciate ligament to the medial third of the tibial tuberosity) was 2.98° (SD 2.54°, r = 0.79).

CONCLUSION

Utilization of an imageless navigation tool may aid surgeons in accurately performing and monitoring femoral and tibial bone cuts, and implant rotation in TKA and thus, more accurately align TKA components.

Technological innovations in shoulder replacement: current concepts and the future of robotics in total shoulder arthroplasty

BACKGROUND

Total shoulder arthroplasty (TSA) has been rapidly evolving over the last several decades, with innovative technological strategies being investigated and developed in order to achieve optimal component precision and joint alignment and stability, preserve implant longevity, and improve patient outcomes. Future advancements such as robotic-assisted surgeries, augmented reality, artificial intelligence, patient-specific instrumentation (PSI) and other peri- and preoperative planning tools will continue to revolutionize TSA. Robotic-assisted arthroplasty is a novel and increasingly popular alternative to the conventional arthroplasty procedure in the hip and knee but has not yet been investigated in the shoulder. Therefore, the purpose of this study was to conduct a narrative review of the literature on the evolution and projected trends of technological advances and robotic assistance in total shoulder arthroplasty.

METHODS

A narrative synthesis method was employed for this review, rather than a meta-analysis or systematic review of the literature. This decision was based on 2 primary factors: (1) the lack of eligible, peer-reviewed studies with high-quality level of evidence available for review on robotic-assisted shoulder arthroplasty, and (2) a narrative review allows for a broader scope of content analysis, including a comprehensive review of all technological advances-including robotics-within the field of TSA. A general literature search was performed using PubMed, Embase, and Cochrane Library databases. These databases were queried by 2 independent reviewers from database inception through November 11, 2022, for all articles investigating the role of robotics and technology assistance in total shoulder arthroplasty. Inclusion criteria included studies describing "shoulder arthroplasty" and "robotics."

RESULTS

After exclusion criteria were applied, 4 studies on robotic-assisted TSA were described in the review. Given the novelty of this technology and limited data on robotics in TSA, these studies consisted of a literature review, nonvalidated experimental biomechanical studies in sawbones models, and preclinical proof-of-concept cadaveric studies using prototype robotic technology primarily in conjunction with PSI. The remaining studies described the technological advancements in TSA, including PSI, computer-assisted navigation, artificial intelligence, machine learning, and virtual, augmented, and mixed reality. Although not yet commercially available, robotic-assisted TSA confers the theoretical advantages of precise humeral head cuts for restoration of proximal humerus anatomy, more accurate glenoid preparation, and improved soft-tissue assessment in limited early studies.

CONCLUSION

The evidence for the use of robotics in total hip arthroplasty and total knee arthroplasty demonstrates improved component accuracy, more precise radiographic measurements, and improved early/mid-term patient-reported and functional outcomes. Although no such data currently exist for shoulder arthroplasty given that the technology has not yet been commercialized, the lessons learned from robotic hip and knee surgery in conjunction with its rapid adoption suggests robotic-assisted TSA is on the horizon of innovation. By achieving a better understanding of the past, present, and future innovations in TSA through this narrative review, orthopedic surgeons can be better prepared for future applications.

Incidence of soft tissue releases in robotic assisted cementless TKA with mechanical alignment and flexion gap balancing

BACKGROUND

To ensure the success of total knee arthroplasty (TKA), precise bone cuts and a well-balanced soft tissue envelope are crucial. Soft tissue release may be necessary, subject to various factors. Therefore, documenting the type, frequency, and necessity of soft tissue releases can establish a benchmark for comparing different alignment techniques and philosophies and evaluating their outcomes. The purpose of this study was to demonstrate that robotic-assisted knee surgery requires minimal soft tissue release.

METHODS

We prospectively documented and retrospectively reviewed the soft tissue releases employed in securing ligament balance in the first 175 patients who received robotic-assisted TKAs at Nepean Hospital. ROSA was utilized in all surgeries with the aim of restoring mechanical coronal alignment, with a flexion gap balancing technique. Surgeries were performed between December 2019 to August 2021 by a single surgeon who used a standard medial parapatellar approach without a tourniquet, and the cementless persona prosthesis. All patients were followed up for a minimum of 6 months post-surgery. Soft tissue releases included any form of medial release for varus knee, posterolateral release for valgus knee and PCL fenestration or sacrifice.

RESULTS

There were 131 female and 44 male patients, aged between 48 to 89 years (average 60 years). The preoperative HKA ranged from 22 degrees varus to 28 degrees valgus, with 71% of patients presenting with a varus deformity. For the whole group, the no need for soft tissue release was documented in 123 patients (70.3%), small fenestrated releases of PCL in 27 (15.4%), sacrifice of PCL in 8 (4.5%), medial releases in 4 (2.3%) and posterolateral releases in 13 (7.4%). In 29.7% of patients in whom a soft tissue release was necessary for balance, over half were/received minor fenestrations of the PCL. Outcomes to date included no revisions or impending revisions, 2 MUAs (1%), and Oxford knee scores averaged 40 at 6 months.

CONCLUSION

We concluded that Robot technology enhanced the precision of bone cuts and allowed for titration of required soft tissue releases to achieve optimal balance.

The Impact of Robotic-Assisted Total Knee Arthroplasty on Resident Training

BACKGROUND

As robotic-assisted total knee replacement (rTKA) continues to gain popularity, the impact of this technology on resident education remains unknown. The purpose of this study was to describe trainee experience and perceptions of rTKA and its effect on surgical training.

METHODS

Two hundred and twenty two senior orthopaedic residents attending a national board review course completed a 17-question survey regarding their experience and perceptions regarding rTKA. Mean and standard deviations were calculated for Likert scale questions, and bivariate analyses were utilized to compare answer groups.

RESULTS

Seventy percent of respondents reported exposure to rTKA during their training. Of those with robotic exposure, 20% reported that greater than half of their TKA experience involved robotics. Only 29% percent agreed that robotics improved outcomes, whereas 21% disagreed and the remainder were unsure. Over half of respondents agreed that robotics are used primarily for marketing purposes. Of those who trained with rTKA, 45% percent believed that robotics improved their understanding of the surgical procedure; however, 25% felt robotics negatively compromised their training with traditional instrumentation. Higher robotic case exposure (P = .001) and attending an industry-sponsored course (P = .02) was associated with the belief that robotics improved outcomes. Robotic case volume and percentage was associated with the belief that robotics improved understanding of the surgical procedure, however, it also was associated with reduced comfort performing traditional knee arthroplasty (P = .001).

CONCLUSION

Current resident training experience varies greatly within the United States with regards to rTKA. While exposure to rTKA may be beneficial for a well-rounded surgical education, over-exposure likely results in decreased comfort with traditional instrumentation.

Robotic-assisted revision total knee arthroplasty: a novel surgical technique

BACKGROUND

Revision total knee arthroplasty is a challenging procedure. The robotic-assisted system has been shown to enhance the accuracy of preoperative planning and improve reproducibility in primary arthroplasty surgeries. The aim of this paper was to describe the surgical technique for robotic-assisted revision total knee arthroplasty and the potential benefits of this technique.

METHOD

This single-centre retrospective study included a total of 19 patients recruited from April 1, 2021 to April 30, 2022. Inclusion criteria were patients who had Mako™ robotic-assisted revision total knee arthroplasty done within the study period with a more than 6 months follow-up. Statistical analysis was done using Microsoft Excel 16.0.

RESULTS

All 19 patients were followed up for 6 to 18 months. All patients in this study had uneventful recoveries without needing any re-revision surgery when reviewed to date.

CONCLUSION

With the development of dedicated revision total knee software, robot-assisted revision TKA can be a promising technique that may improve surgical outcomes by increasing the accuracy of implant placement, and soft tissue protection and achieving a better well-balanced knee.