Cost-Effectiveness of Robot-Assisted Total Knee Arthroplasty: A Markov Decision Analysis

Cost-effectiveness analysis of robotic-arm assisted versus manual total knee arthroplasty in the UK

Aims

The aim of this study was to estimate the additional cost per quality-adjusted life-year (QALY) of robotic-assisted total knee arthroplasty (rTKA) compared to manually performed total knee arthroplasty (mTKA).

Methods

An economic evaluation was undertaken from the UK NHS and personal social services perspective, alongside a randomized controlled trial comparing rTKA and mTKA. Costs were estimated individually using a top-down approach and included all healthcare resources incurred during the trial. Costs were presented in 2021 GBP sterling (£). Responses to the EuroQol five-dimension three-level questionnaire were used to estimate QALYs for each participant. The incremental cost-effectiveness ratio (ICER) was evaluated against the current willingness-to-pay threshold recommended by the National Institute for Health and Care Excellence. Stochastic sensitivity analysis was performed using bootstrapping techniques, and results were shown through the cost-effectiveness acceptability curve and cost-effectiveness plane. Cost-effectiveness over one- and ten-year time horizons were explored using a decision model.

Results

There were 100 participants randomized: 50 rTKA and 50 mTKA. Overall, 37 participants (39.4%) had some missing data on either costs or utilities, or on both. Multiple imputation was used for the base case results. The intervention was associated with incremental mean per-patient costs of £1,829 (95% CI 421 to 3,238) and an incremental QALY gain of 0.015 (95% CI -0.05 to 0.0796) at one year. The ICER at one year was £123,770. However, rTKA was likely to be cost-effective over a ten-year time horizon, with an ICER of £11,109. All except one of the scenarios (QALY gain reduction to 0.005) explored supported the cost-effectiveness of rTKA over a ten-year time horizon with an ICER below a £20,000 threshold.

Conclusion

Over a short one-year time horizon, rTKA was not a cost-effective procedure compared to mTKA. However, when results were extrapolated out to a ten-year time horizon, which would need to be confirmed in future research, rTKA was likely to be cost-effective.

Redefining Knee Arthroplasty: Does Robotic Assistance Improve Outcomes Beyond Alignment? An Evidence-Based Umbrella Review

Background: Robotic-assisted total knee arthroplasty (rTKA) has been introduced to improve surgical precision and alignment in knee replacement procedures. However, its impact on clinical outcomes, pain relief, and cost-effectiveness remains debated. This umbrella review synthesizes evidence from systematic reviews and meta-analyses comparing rTKA to conventional TKA. Methods: An umbrella review was conducted in PubMed, Scopus, Web of Science, Embase, and the Cochrane Database of Systematic Reviews. Systematic reviews and meta-analyses comparing rTKA with conventional TKA were included. Methodological quality was assessed using AMSTAR 2 and ROBIS tools. Primary outcomes included hospital stay, radiographic alignment, postoperative pain, functional outcomes, and patient satisfaction. Results: Ten systematic reviews were included. rTKA demonstrated superior alignment accuracy and a reduction in alignment outliers. Some studies reported shorter hospital stays and lower early postoperative pain scores for rTKA. However, these benefits did not consistently translate into improved long-term functional outcomes, patient satisfaction, or reduced revision rates. Cost-effectiveness analyses indicated that rTKA remains an expensive option, with benefits largely dependent on surgical volume and healthcare system resources. Conclusions: While rTKA improves surgical precision and may offer short-term advantages, its long-term superiority over conventional TKA remains unproven. Higher costs and longer operative times limit its widespread adoption. Further high-quality, long-term studies are needed to determine its clinical and economic value.

Orthopedic surgical robotic systems in knee arthroplasty: a comprehensive review

In conjunction with the accelerated evolution of robotics, the advancement of robot-assisted minimally invasive surgical systems is occurring at a similarly accelerated pace, and is becoming increasingly accepted. It is employed in numerous surgical specialties, including orthopedics, and has significantly transformed traditional surgical techniques. Among these applications, knee arthroplasty represents one of the most prevalent and efficacious procedures within the domain of robot-assisted orthopedic surgery. The implementation of surgical robotic systems has the potential to enhance the precision and accuracy of surgical outcomes, facilitate reproducibility, reduce technical variability, mitigate patient discomfort, and accelerate recovery. In this paper, a literature review of the Web of Science and PubMed databases was conducted to search for all articles on orthopedic surgical robotics through November 2024. It mainly summarizes the most commonly used and widely accepted robotic systems in the field of orthopedic surgery, with a particular focus on their application in knee arthroplasty procedures. Orthopedic robotic systems can be classified into three principal categories: autonomous robotic systems, semi-autonomous robotic systems, and teleoperated robotic systems. In the context of knee arthroplasty, the characteristics of different robotic systems are examined in relation to three types of Total Knee Arthroplasty (TKA), Unicompartmental Knee Arthroplasty (UKA) and Patellofemoral Arthroplasty (PFA). In conclusion, the current state of orthopedic surgical robotics is reviewed, and future development prospects and challenges are proposed.

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.

Current developments in robotic assistance technology for total knee arthroplasty: a comprehensive overview

Knee arthritis is a common degenerative joint disease, usually with joint swelling, chronic pain, and dysfunction as the main clinical manifestations. At present, the conservative treatment for knee arthritis is mostly using anti-inflammatory and analgesic drugs, but the effect is mostly temporary, and can not prevent its progress and surgery is usually the last treatment method. Total knee arthroplasty, also known as TKA, is one of the most effective treatments for osteoarthritis of the knee that has progressed to the end stage. The inevitable human factor in conventional total knee arthroplasty (TKA) frequently results in poor positioning of the prosthesis during the reconstruction of the lower limb's biomechanical axis. This can lead to severe postoperative pain, accelerated wear of the prosthesis, early loosening, and other problems in the affected knee, which has always been a primary concern for orthopaedic surgeons. Over the course of the past few years, China has gradually begun to develop joint robots. The idea is to plan the surgical plan based on the anatomical structure of the affected limb before the operation, and then to use a mechanical arm and a visual system to assist in the implantation of the prosthesis while the operation is being performed. The treatment costs of robot-assisted technology, on the other hand, vary greatly, and there is still a relatively small amount of high-quality evidence on clinical efficacy. This is because the field of robotic-assisted technology is a relatively new one that has gradually developed over the past few years. In order to provide a fundamental reference for the application value of new treatment methods for advanced knee osteoarthritis, it is necessary to conduct an analysis of the current status of the application of joint robots, as well as the technical advantages and disadvantages that they bring.This narrative study delineates the historical context and current clinical application of robots in knee replacement surgery. An examination of the advantages and disadvantages of RATKA in comparison to TKA offers insights on the prospective application value of the technology.Clinical trial number: Not applicable.

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.

Angiopoietin 1 Relieves Osteolysis by Promoting Macrophage Mitophagy Through the TBK1-SQSTM1 Pathway to Inhibit AIM2 Inflammasome-Mediated Pyroptosis

Osteolysis resulting from wear particles and subsequent aseptic loosening is a leading cause of revision surgery of artificial joints. The underlying pathogenesis of particle-induced osteolysis (PPO) has remained largely uncertain. Addressing how to mitigate osteolysis caused by wear particles presents a significant challenge for orthopedic surgeons. This study aimed to explore the molecular mechanism by which Angiopoietin (Ang-1) inhibits osteoclast activation to alleviate osteolysis. RAW264.7 mouse macrophages were stimulated with LPS or RANKL to induce osteoclast formation. Additionally, titanium (Ti) particles (50 mg) were subperiosteally implanted around the cranial suture of mice to establish a calvarial osteolysis model. Ang-1, a member of the pro-angiogenic factor protein family and an important inflammatory regulator molecule, was utilized in this model. TRAP staining was utilized to detect osteoclast activation, while a western blot was conducted to identify key proteins associated with mitophagy and pyroptosis. Scanning electron microscopy was employed to observe the morphology and dimensions of Ti particles. Additionally, a combination of micro-CT, H&E, Masson's trichrome, and immunohistochemical staining techniques were applied to analyze the calvarial samples. Results indicated that Ang-1 could inhibit LPS- or RANKL-induced osteoclastogenesis and alleviate Ti particle-induced calvarial osteolysis in mice. TBK-1, a key signaling molecule involved in initiating mitophagy, was found to be mechanistically enhanced by Ang-1 through promoting TBK-1 phosphorylation in macrophages. This process inhibited AIM2 inflammasome-mediated pyroptosis and impeded osteoclastogenesis. Overall, this research uncovers a novel mechanism by which Ang-1 can attenuate inflammatory osteolysis, potentially offering a new therapeutic approach for PPO.

Conventionally instrumented inverse kinematic alignment for total knee arthroplasty: How is it done?

Purpose

For primary total knee arthroplasty (TKA), there is an increasing trend towards patient-specific alignment strategies such as kinematic alignment (KA) and inverse kinematic alignment (iKA), which by restoring native joint mechanics may yield higher patient satisfaction rates. Second, the most recent Australian joint registry report describes favourable revision rates for conventionally instrumented TKA compared to technology-assisted techniques such as those using navigation, robotics or custom-cutting blocks. The aim of this technique article is to describe in detail a surgical technique for TKA that: (1) utilises the principles of iKA and (2) uses conventionally instrumented guided resections thereby avoiding the use of navigation, robotics or custom blocks.

Methods

A TKA technique is described, whereby inverse kinematic principles are utilised and patient-specific alignment is achieved. Additionally, the patellofemoral compartment of the knee is restored to the native patellofemoral joint line. The sequenced technical note provided may be utilised for cemented or cementless components; cruciate retaining or sacrificing designs and for fixed or rotating platforms.

Results

An uncomplicated, robust and reproducible technique for TKA is described.

Discussion

Knee arthroplasty surgeons may wish to harness the emerging benefits of both a conventionally instrumented technique and a patient-specific alignment strategy.

Level of Evidence

Level V.

Can Robotic Arm-assisted Total Knee Arthroplasty Remain Cost-effective in Volume-based Procurement System in China? A Markov Model-based Study

OBJECTIVE

The volume based procurement (VBP) program in China was initiated in 2022. The cost-effectiveness of robotic arm assisted total knee arthroplasty is yet uncertain after the initiation of the program. The objective of the study was to investigate the cost-effectiveness of robotic arm-assisted total knee arthroplasty and the influence of the VBP program to its cost-effectiveness in China.

METHODS

The study was a Markov model-based cost-effectiveness study. Cases of primary total knee arthroplasty from January 2019 to December 2021 were included retrospectively. A Markov model was developed to simulate patients with advanced knee osteoarthritis. Manual and robotic arm-assisted total knee arthroplasties were compared for cost-effectiveness before and after the engagement of the VBP program in China. Probability and sensitivity analysis were conducted.

RESULTS

Robotic arm-assisted total knee arthroplasty showed better recovery and lower revision rates before and after initiation of the VBP program. Robotic arm-based TKA was superior to manual total knee arthroplasty, with an increased effectiveness of 0.26 (16.87 vs 16.61) before and 0.52 (16.96 vs 16.43) after the application of Volume-based procurement, respectively. The procedure is more cost-effective in the new procurement system (17.13 vs 16.89). Costs of manual or robotic arm-assisted TKA were the most sensitive parameters in our model.

CONCLUSION

Based on previous and current medical charging systems in China, robotic arm-assisted total knee arthroplasty is a more cost-effective procedure compared to traditional manual total knee arthroplasty. As the volume-based procurement VBP program shows, the procedure can be more cost-effective.

Tracing the evolution of robotic-assisted total knee arthroplasty: a bibliometric analysis of the top 100 highly cited articles

Robotic-assisted surgical systems hold promise in enhancing total knee arthroplasty (TKA) outcomes and patients' quality of life. This study aims to comprehensively analyze the literature on robot-assisted total knee arthroplasty (r-TKA), providing insights into its current development, clinical application, and research trends. A systematic search was conducted in the Web of Science Core Collection (WOSCC) to identify relevant articles. Data were collected from the top 100 highly cited articles. Article evidence levels were assessed following established guidelines. Statistical analyses and visualizations were performed to reveal publication trends, citations, research hotspots, and collaborative networks. The analysis covered 100 highly cited articles meeting the research criteria, with a focus on the last five years. The United States emerged as a major contributor, with most publications and citations in the Journal of Knee Surgery and Knee Surgery Sports Traumatology Arthroscopy. Research priorities revolved around clinical outcomes, accuracy, and alignment of r-TKA. Notably, higher evidence levels correlated with more citations, indicating greater attention. Interest in and research on r-TKA is steadily increasing, with a few countries at the forefront of these endeavors. While numerous studies have already reported short- to medium-term follow-up results, it is crucial to conduct longer-term investigations to gain a more comprehensive understanding of the clinical benefits that r-TKA offers compared to conventional techniques. Through ongoing research and a greater embrace of robotic technology, we can continue to improve the quality of life for patients undergoing knee arthroplasty.