Is it prime time for robotic-assisted TKAs? A systematic review of current studies

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.

Accuracy of a New Augmented Reality Assisted Technique for Total Knee Arthroplasty: An In Vivo Study

Background

Total knee arthroplasty (TKA) remains the standard of care for treating end-stage osteoarthritis of the knee. Approximately 15%-20% of the patients are dissatisfied following surgery. To improve accuracy and outcomes of TKA, various assistive technologies have been introduced. For this study, an augmented reality (AR) system was explored and tested.

Methods

The Knee + system (Pixee Medical, Besancon, France) was used to guide TKA. It uses a combination of quick response-code labeled instruments and AR glasses to guide tibial and femoral cuts. The primary research goal was to evaluate its accuracy by direct comparing the planned angular values for lateral distal femoral angle, medial proximal tibial angle, hip-knee-ankle axis, and tibial slope to the intraoperative obtained values and the measured angles on postoperative full leg radiographs. The secondary research goal was to assess its feasibility.

Results

This retrospective study evaluated 124 patients, with a follow-up of at least 1 year. The average absolute difference between planned and measured postop values were 1.39° for lateral distal femoral angle, 1.03° for medial proximal tibial angle, 2.16° for tibial slope, and 1.51° for hip-knee-ankle axis. Within the follow-up period, 8 complications were observed. The average surgical time was 83 minutes.

Conclusions

This study has demonstrated a high accuracy, comparable to robotic-assisted total knee arthroplasty, of the Knee + AR system. It has shown to be a safe, cheap and time-efficient assistive technology for patients undergoing medial pivot TKA.

Patient-Reported Outcomes in Robotic-Assisted vs Manual Cementless Total Knee Arthroplasty

Background

Robotic-assisted total knee arthroplasty (RA-TKA) was introduced to provide surgeons with virtual preoperative planning and intraoperative information to achieve the desired surgical goals in an effort to improve patient outcomes. The purpose of this study was to compare clinical outcomes and patient-reported outcome measures following primary TKA using RA-TKA vs manual instrumentation.

Methods

This was a retrospective cohort review study comparing 393 primary RA-TKAs vs 312 manual TKAs at a minimum 2-year follow-up. The same cementless implant design was utilized in all cases at a single institution. There were no significant differences in age or gender between groups. Outcome measures included range-of-motion, Knee Society (KSS), Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score-12, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and overall patient satisfaction scores along with complications and survivorship.

Results

Compared to manual TKA, the RA-TKA group had significant higher postoperative KSS Function and Knee scores, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores (P < .001). A total percentage of 95.0% of RA-TKA vs 87.4% of manual TKAs were very satisfied or satisfied (P = .001). Survivorship with all-cause failure as the endpoint at 3 years was 96.9% in the RA-TKA group compared to 95.8% in the manual group (P = .54).

Conclusions

RA-TKA demonstrated significant improvement over manual jig-based instruments in KSS Function, KSS Knee, Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and patient satisfaction scores following primary TKA with no differences in complications and revision incidence. RA-TKA provided a virtual 3-dimensional preoperative plan along with intraoperative information for adjustments to approximate the patients' native joint line and achieve a well-balanced soft-tissue sleeve about the knee for primary TKA.

Does Robotic Assisted Technique Improve Patient Utility in Total Knee Arthroplasty? A Comparative Retrospective Cohort Study

BACKGROUND

Even if robotic assisted total knee arthroplasty (RATKA) is a widely used technique, there is still a gap of knowledge about whether this technology is effective in improving the patient utility. This measure is of paramount importance for conducting cost effectiveness analysis. The aim of this study was to compare the utility measure derived from self-reported outcomes questionnaires in patients who underwent RATKA compared to patients who underwent the manual surgery.

METHODS

We compared 72 patients operated with a robotic technique with 70 operated with traditional technique. The utility data were collected with the WOMAC (Western Ontario and McMaster University Osteoarthritis index) self-administrated questionnaire that investigates pain, stiffness and functionality of the patients, an then mapped to a utility value through a validated transforming function. We performed three surveys: the first one before the intervention (t0), the second one 1 year after the surgery (t1) and the third one at the 2 year follow up (t2).

RESULTS

we observed higher utility values in both groups. In detail, the mean utility score in the RATKA group increased from 0.37 to 0.71 (t1) and 0.78 (t2), while in the conventional group it increased from 0.41 to 0.78 (t1) and 0.78 (t2). The fixed effect coefficients of t1 and t2 were found to be 0.37 and 0.363 (p < 0.001 for both). The coefficient of the robotic technique, along with its interaction with the t1 and t2 time effect was non-significant.

CONCLUSIONS

Even if at t1 the utility of patient who underwent RATKA were lower, at longer follow up (t2) we found no significant difference compared to traditional technique, leaving the superiority of robotic assisted technique yet to be proved. Our results may be useful for calculating the gained or lost Quality Adjusted Life Years (QALYs), so that the health care system (or an insurance company) could make an appropriate decision whether to fund the robotic approach or not, after a careful assessment of the incremental costs incurred.

Patient satisfaction following robotic unicompartmental knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is a viable alternative to total knee arthroplasty (TKA) for osteoarthritis patients with single-compartment involvement, with advantages including accelerated recovery, reduced pain, and improved function. Robotic-assisted UKA (rUKA) is a promising development that ensures precise implant positioning and limb alignment. However, concerns about complications remain.

OBJECTIVE

This study looks at patient satisfaction as a key metric for determining the efficacy of rUKA versus manual UKA (mUKA).

METHODS

The search strategy for this study followed PRISMA. Using precise keywords, PubMed, Scopus, Web of Science, and the Cochrane library were searched. English articles were searched until August 2, 2023. Selection criteria included mUKA and rUKA patient satisfaction studies. The NOS scale evaluated study quality. Meta-analysis was done with R and heterogeneity analysis.

RESULTS

This systematic review examined 5 studies with 1060 UKAs (532 robotic-assisted and 528 manual). Variable satisfaction assessment methods were used. Three studies found no difference in patient satisfaction after robotic-assisted UKA, but two found a higher satisfaction. Meta-analysis showed robotic-assisted UKA improved patient satisfaction (OR = 1.72 [1.25-2.37]). Overall, most studies showed low risk of bias, except one with higher bias.

CONCLUSION

This review suggests that robotic assistance may enhance patient satisfaction in UKA procedures.

Robotic-assisted total knee arthroplasty is not associated with increased risk of postoperative deep vein thrombosis

PURPOSE

Prolongation of operation time due to registration and pin insertion has been reported with robotic-assisted total knee arthroplasty (RATKA), and there has been concern about an increase in the postoperative incidence of deep vein thrombosis (DVT). In this study, we compared the incidence of DVT after RATKA with that after conventional manual TKA (mTKA).

METHODS

This consecutive retrospective series included 141 knees that underwent primary TKA using the Journey II system. The CORI robot was used. There were 60 RATKAs and 81 mTKAs. Doppler ultrasound was performed in all patients on postoperative day 7 to determine whether DVT was present.

RESULTS

The operation time was longer in the RATKA cohort (99.5 min vs 78.0 min, p < 0.001). The overall incidence of DTV was 43.9% (62/141 knees), all of which were asymptomatic. There was no significant difference in incidence of DVT between RATKA and mTKA (50.0% vs 39.5%, p = 0.23). Use of the robot did not affect the incidence of DVT following TKA (odds ratio 1.02, 95% confidence interval 0.40-2.60; p = 0.96).

CONCLUSION

The incidence of DVT was not significantly different between RA-TKA and mTKA. Multiple logistic regression indicated that RATKA is not associated with increased risk of postoperative DVT.

LEVEL OF EVIDENCE

IV.

Radiographic Outcomes of Robot-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Total knee arthroplasty (TKA) has long been considered the definitive treatment for knee osteoarthritis. Although tremendous improvements have been made in surgical techniques for conventional TKA, a substantial dissatisfaction rate among patients has persisted because of moderate-to-severe pain and stiffness following TKA. Robot-assisted TKA was developed as an alternative to conventional TKA with the goal of improving operative precision and producing better clinical outcomes with minimal postoperative complications. The aim of this study was to compare the radiographic outcomes, duration of surgery, and complication rate between robot-assisted TKA and conventional TKA.

Methods

We conducted relevant literature searches of Medline, Scopus, ClinicalTrials.gov, and the Cochrane Library databases with use of specific keywords. The outcomes for continuous variables were pooled into mean differences, whereas the outcomes for dichotomous variables were pooled into odds ratios with 95% confidence intervals with use of random-effects models.

Results

A total of 12 randomized clinical trials were included. Our pooled analysis revealed that robot-assisted TKA was associated with fewer outliers in the hip-knee-ankle (HKA) angle (p < 0.0001), femoral component (coronal) angle (p = 0.0006), femoral component (sagittal) angle (p = 0.009), tibial component (coronal) angle (p = 0.05), and tibial component (sagittal) angle (p = 0.01) when compared with conventional TKA. The postoperative HKA angle was also significantly more neutral in the robot-assisted TKA group (mean difference, -0.77°; p < 0.0001). However, the complication rate did not differ significantly between the 2 groups.

Conclusions

Robot-assisted TKA may produce more accurate placement of the prosthetic component and better joint alignment accuracy than conventional TKA as shown by fewer outliers in several joint angles.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clinical and radiological outcomes of robotic-assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Robotic-assisted total knee arthroplasty (RATKA) is an alternative surgical treatment method to conventional total knee arthroplasty (COTKA) that may deliver better surgical accuracy. However, its impact on patient outcomes is uncertain. The aim of this systematic review of randomized controlled trials (RCTs) is to evaluate whether RATKA could improve functional and radiological outcomes compared with COTKA in adult patients with primary osteoarthritis of the knee.

METHODS

We searched Ovid MEDLINE, EMBASE, Scopus, and the Cochrane Library to identify published RCTs comparing RATKA with COTKA. 2 reviewers independently screened eligible studies, reviewed the full texts, assessed risk of bias using the Risk of Bias 2.0 tool, and extracted data. Outcomes were patient-reported outcomes, range of motion, and mechanical alignment (MA) deviation and outliers, and complications.

RESULTS

We included 12 RCTs involving 2,200 patients. RATKA probably results in little to no effect on patient-reported outcomes (mean difference (MD) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of -0.35 (95% confidence interval [CI] -0.78 to 0.07) and range of motion (MD -0.73°; CI -7.5° to 6.0°) compared with COTKA. However, RATKA likely results in a lower degree of MA outliers (risk ratio 0.43; CI 0.27 to 0.67) and less deviation from neutral MA (MD -0.94°; CI -1.1° to -0.73°). There were no differences in revision rate or major adverse effects associated with RATKA.

CONCLUSION

Although RATKA likely results in higher radiologic accuracy than COTKA, this may not be clinically meaningful. Also, there is probably no clinically important difference in clinical outcomes between RATKA and COTKA, while it is as yet inconclusive regarding the revision and complication rates due to insufficient evidence.

Technology and orthopaedic surgeons

Modern and innovative technologies are rapidly penetrating the clinical practices of Orthopaedic Surgeons. The ones that have proved successful for clinical use are Additive Manufacturing/3D printing, Artificial Intelligence, Robotics, Smart sensors, and Orthobiologics. Industry 5.0 revolution has helped provide personalised treatment by integrating machines and human beings. In this special issue, we present a collection of excellent articles on these technologies.

Where are We Now and What are We Hoping to Achieve with Robotic Total Knee Arthroplasty? A Critical Analysis of the Current Knowledge and Future Perspectives

Robotic-assisted total knee arthroplasty (rTKA) has been developed to improve knee kinematics and functional outcomes, expedite recovery, and improve implants long-term survivorship. Robotic devices are classified into active, semi-active, and passive, based on their degree of freedom. Their capacity to provide increased accuracy in implants positioning with reduced radiographic outliers has been widely proved. However, these early advantages are yet to be associated with long-term survivorship. Moreover, multiple drawbacks are still encountered including a variable learning curve, increased setup and maintenance costs, and potential complications related to the surgical technique. Despite recent technologies applied to TKA have failed to prove substantial improvements, robotic-assisted surgery seems to be here to stay and revolutionize the field of TKA. To support its consistent usage on a daily basis, long-term results are still awaited, and further improvements are necessary to reduce the expenses related to it.