Article

Patient Satisfaction Outcomes after Robotic Arm-Assisted Total Knee Arthroplasty: A Short-Term Evaluation

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Abstract

Robotic arm-assisted total knee arthroplasty (RATKA) presents a potential, new added value for orthopedic surgeons. In today's health care system, a major determinant of value can be assessed by patient satisfaction scores. Therefore, the purpose of the study was to analyze patient satisfaction outcomes between RATKA and manual total knee arthroplasty (TKA). Specifically, we used the Western Ontario and McMaster Universities Arthritis Index (WOMAC) to compare (1) pain scores, (2) physical function scores, and (3) total patient satisfaction outcomes in manual and RATKA patients at 6 months postoperatively. In this study, 28 cemented RATKAs performed by a single orthopedic surgeon at a high-volume institution were analyzed. The first 7 days were considered as an adjustment period along the learning curve. Twenty consecutive cemented RATKAs were matched and compared with 20 consecutive cemented manual TKAs performed immediately. Patients were administered a WOMAC satisfaction survey at 6 months postoperatively. Satisfaction scores between the two cohorts were compared and the data were analyzed using Student's t-tests. A p-value < 0.05 was used to determine statistical significance. The mean pain score, standard deviation (SD), and range for the manual and robotic cohorts were 5 ± 3 (range: 0–10) and 3 ± 3 (range: 0–8, p < 0.05), respectively. The mean physical function score, SD, and range for the manual and robotic cohorts were 9 ± 5 (range: 0–17) and 4 ± 5 (range, 0–14, p = 0.055), respectively. The mean total patient satisfaction score, SD, and range for the manual and robotic cohorts were 14 points (range: 0–27 points, SD: ± 8) and 7 ± 8 points (range: 0–22 points, p < 0.05), respectively. The results from this study further highlight the potential of this new surgical tool to improve short-term pain, physical function, and total satisfaction scores. Therefore, it appears that patients who undergo RATKA can expect better short-term outcomes when compared with patients who undergo manual TKA.

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... Robotic-assisted techniques that adopt enhanced preoperative planning using a computed tomography (CT)-based platform, quantitative intraoperative deformity assessment, and haptically guided robotic bone preparation have been introduced. This approach has demonstrated improved durability when comparing robotic-assisted unicompartmental knee arthroplasty (raUKA) with manual UKA techniques [14], reduced rates of complication and improved functional outcome when comparing robotic-assisted with manual total hip arthroplasty at minimum 2-year interval [8], and improved rate of recovery and functional outcomes when comparing robotic-assisted TKA (raTKA) with mTKA techniques at short-term follow-up interval [11,16]. These promising early results with raTKA suggested analysis at long-term intervals is warranted. ...
... Roboticassisted technique was introduced to improve accuracy, reproducibility, and patient outcomes following joint replacement. Previous studies have demonstrated that such robotic techniques have benefit compared with traditional manual technique regarding reduced rates of revision with raUKA at 5 years [14], reduced rates of dislocation and improved PROM at 2 years with raTHA [8], and improved short-term outcomes (3-6 months) comparing raTKA with mTKA [11,16]. Kayani et al found superior early clinical results with raTKA compared with mTKA during the initial hospitalization [11]. ...
... Although this study included only 40 patients in each cohort, findings included reduced levels of postoperative analgesic requirements, decreased blood loss, shorter time to straight leg raise, and improved knee flexion with raTKA. Marchand et al compared results of raTKA with mTKA at 6-month follow-up interval, demonstrating improvements in pain, function, and overall satisfaction [16]. Our study similarly demonstrated statistically significant and clinically relevant early benefits with raTKA compared with mTKA technique, but no differences in complication rates or PROMs (UCLA and KOOS-JR) at 1-year follow-up. ...
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Background: Total knee arthroplasty (TKA) demonstrates excellent durability using jig-based manual techniques (manual TKA [mTKA]), but significant rates of dissatisfaction remain. Modifications of mTKA techniques and TKA implant designs to improve outcomes have had minimal success. Studies comparing relative outcomes of mTKA and robotic-assisted TKA (raTKA) are limited. Purpose: This study sought to compare outcomes of mTKA and raTKA in patients at a single institution. Methods: We retrospectively reviewed all primary TKAs performed by 1 surgeon from 2015 to 2017. In all, 139 consecutive mTKAs (2015–2016) and 148 consecutive raTKAs (2016–2017) were included. No cases were excluded. Patient demographics, complications, readmission rates, and clinical and patient-reported outcomes were compared at a minimum of 1-year follow-up. A post hoc student t test and Pearson χ ² test were used for continuous and categorical data. Results: We found that mTKA patients compared with raTKA patients required significantly longer length of stay (LOS) (1.73 vs 1.18 days, respectively), greater morphine milligram equivalents consumption (89.6 vs 65.2, respectively), and increased physical therapy (PT) visits (13.0 vs 11.0, respectively) with increased 30-day readmission rates (4.3 vs 0.7%, respectively) that approached significance. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and the University of California at Los Angeles activity score did not differ significantly comparing raTKA with mTKA patients at 1 year. There were no differences in complication rates. Conclusion: Significant early clinical benefits were noted with raTKA, including lower opioid requirements, shorter LOS, and fewer PT visits when compared with mTKA. A reduction in 30-day readmission rates was noted with raTKA that was not significant. Excellent clinical results with similar patient-reported outcomes were noted in both groups at 1-year follow-up. Further prospective investigations at longer follow-up intervals comparing these techniques are warranted.
... 6,7 early outcomes after RA-tKA have shown decreased pain, improved patient satisfaction, and improved early functional recovery compared to manual or conventional tKA. 6,[8][9][10][11] However, mid-and long-term clinical and patient-reported outcome measures (PROms) data remain sparse with relatively small sample sizes, particularly across institutions. 12 the purpose of this multicentre study was to report the clinical and PROms results preoperatively, at one to two years, and greater than two years following primary RA-tKA in a large patient cohort and determine if the results were consistent across various sites. ...
... data, and achieves the target implant position and limb alignment that may improve overall patient satisfaction . [4][5][6][8][9][10][11][18][19][20] those questioning the use of RA-tKA argue that there are no long-term data, and that the cost of RA-tKA implementation is a limiting factor for many hospital systems. 5 With any new advances in medical technology, validation in the form of short-, mid-, and long-term studies must be carried out to ensure continued safety and efficacy of a novel product. ...
... Prior studies comparing patients who have undergone RA-tKA versus conventional jig-based tKA have demonstrated statistical improvements in RA-tKA PROms from the preoperative to postoperative state. 8,11 Our study demonstrated significant improvements in PROms from preoperative to one and two years postoperatively for FJs, KOOs JR, and pain scores. mCid for FJs, KOOs JR, and pain scores were met for 91%, 96%, and 90% of patients, respectively, with low rates of revision. ...
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Aims: The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. Methods: This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants. Results: There were significant improvements in PROMs over time between preoperative, one- to two-year, and > two-year follow-up, with a mean FJS of 17.5 (SD 18.2), 70.2 (SD 27.8), and 76.7 (SD 25.8; p < 0.001); mean KOOS JR of 51.6 (SD 11.5), 85.1 (SD 13.8), and 87.9 (SD 13.0; p < 0.001); and mean pain scores of 65.7 (SD 20.4), 13.0 (SD 19.1), and 11.3 (SD 19.9; p < 0.001), respectively. There were eight superficial infections (0.9%) and four revisions (0.5%). Conclusion: RA-TKA demonstrated consistent clinical results across multiple institutions with excellent PROMs that continued to improve over time. With the ability to achieve target alignment in the coronal, axial, and sagittal planes and provide intraoperative real-time data to obtain balanced gaps, RA-TKA demonstrated excellent clinical outcomes and PROMs in this patient population.Cite this article: Bone Jt Open 2022;3(7):589-595.
... Seven (44%) of the 16 clinical studies reported the balancing and/or the alignment techniques utilised for the TKAs groups ( Table 4). Out of the seven studies, two stated that the mTKAs were performed using a standard measured resection technique followed by soft tissue releases to achieve a balanced and mechanically aligned knee, but did not define how the RATKA groups were balanced or how the alignment was achieved and whether it was using mechanical, kinematic or restricted kinematic alignment methods [30,51]. Two studies used same methods in both groups, Bhimani et al. using gap balancing techniques and Mahoney et al. using measured resection techniques [4,28]. ...
... There were seven clinical studies reporting the functional outcomes following RATKA compared to mTKA (Table 5) [19,23,28,30,31,35,49]. Different outcome scores were utilised across the included studies, with the Knee Society [23,28]. ...
... There is a need for improved reporting criteria for alignment and balancing techniques used in studies comparing RATKA with mTKA. Of the seven clinical studies that reported balancing and alignment techniques, only two studies used same balancing and alignment methods and two studies did not even state how their RATKAs groups were balanced or aligned [4,28,30,51]. RATKA appear to be highly effective in improving the precision of restricted kinematic alignment techniques. Kayani et al. utilised measured resection for mTKA and restricted kinematic alignment for RATKA and recorded a significantly better component position accuracy in all three variables, namely coronal femur and tibia position and tibia posterior slope [20]. ...
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This systematic review and meta-analysis were conducted to compare the accuracy of component positioning, alignment and balancing techniques employed, patient-reported outcomes, and complications of robotic-arm assisted total knee arthroplasty (RATKA) with manual TKA (mTKA) and the associated learning curve. Searches of PubMed, Medline and Google Scholar were performed in October 2020 using PRISMA guidelines. Search terms included “robotic”, “knee” and “arthroplasty”. The criteria for inclusion were published clinical research articles reporting the learning curve for RATKA and those comparing the component position accuracy, alignment and balancing techniques, functional outcomes, or complications with mTKA. There were 198 articles identified, following full text screening, 16 studies satisfied the inclusion criteria and reported the learning curve of rTKA (n=5), component positioning accuracy (n=6), alignment and balancing techniques (n=7), functional outcomes (n=7), or complications (n=5). Two studies reported the learning curve using CUSUM analysis to establish an inflexion point for proficiency which ranged from 7 to 11 cases and there was no learning curve for component positioning accuracy. The meta-analysis showed a significantly lower difference between planned component position and implanted component position, and the spread was narrower for RATKA compared with the mTKA group (Femur coronal: mean 1.31, 95% confidence interval (CI) 1.08–1.55, p<0.00001; Tibia coronal: mean 1.56, 95% CI 1.32–1.81, p<0.00001). Three stud- ies reported using different alignment and balancing techniques between mTKA and RATKA, two studies used the same for both group and two studies did not state the methods used in their RATKA groups. RATKA resulted in better Knee Society Score Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation compared to mTKA in the short-to-mid-term follow up (95%CI [− 1.23, − 0.51], p=0.004). There was no difference in arthrofibrosis, superficial and deep infection, wound dehiscence, or overall complication rates. RATKA demonstrated improved accuracy of component positioning and patient-reported outcomes. The learning curve of RATKA for operating time was between 7 and 11 cases. Future well-powered studies on RATKAs should report on the knee alignment and balancing techniques utilised to enable better comparisons on which techniques maximise patient outcomes.
... Robotic-assisted TKA (raTKA) is a newly developed technology aiming to increase surgical precision, repeatability, and patient satisfaction following TKA [4]. Various active [5,6] or haptic [7][8][9] robotic-assisted systems have been designed based on robot autonomy, the requirement or not of 3-D preoperative images, the use of a cutting guide, haptic or assistive technologies, and a burr or a saw [10,11]. Although their precision and safety have been lately established, they do have certain limits in terms of application. ...
... Previous comparative studies concerning other robotic TKA systems demonstrated contradictory outcomes. A recent study showed that pain, functional scores, and patient satisfaction improved in the MAKO robotic group than in the manual control group 6 months after surgery [8]. On the other hand, no significant different clinical outcomes and PROMs at 5 years of follow-up between manual and robotic arm-assisted unicompartmental knee arthroplasty groups using the MAKO robotic system were recorded; however, the robotic group showed a lower reintervention rate [15]. ...
Article
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Purpose Studies comparing clinical outcomes between manual (mTKA) and robotic-assisted TKA (raTKA) are limited. This prospective comparative cohort study aimed to compare early postoperative outcomes, satisfaction, and patient-reported outcome measures (PROMS) between patients undergoing mTKA and ROSA raTKA (Zimmer Biomet, Warsaw, IN) performed by one surgeon. Methods Thirty ROSA raTKAs and 30 mTKAs performed by one surgeon during 2020-2021 were prospectively evaluated. Groups were matched for age, sex, and body mass index. All procedures were primary unilateral TKAs using the same posterior-stabilized prosthesis (Nexgen Legacy, Zimmer Biomet, Warsaw, IN). Length of hospital stay (LOS) and blood transfusion rate were recorded. Complications, visual analogue scale score (VAS), and Oxford Knee Score (OKS) were assessed preoperatively and for six postoperative months. The Forgotten Joint Score (FJS) and patient satisfaction were evaluated 6 months postoperatively. Results No complications and similar blood transfusion rate were recorded between groups (p = 0.228). The LOS was non-significantly shorter in raTKA than in the mTKA group (p = 0.120). Mean preoperative and third-month OKS and VAS scores were comparable between groups. However, the mean 6-month OKS (p = 0.006) and VAS score (p = 0.025) were significantly better for the raTKA group. The 6-month FJS was significantly greater for raTKA than the mTKA group (p < 0.001). One patient was unhappy in raTKA, and three in the mTKA group (p = 0.301). Significantly more raTKA patients answered that they would undergo surgery again (p = 0.038). Conclusion raTKA was associated with the same complication risk, less pain level, better patient satisfaction, and PROMs on 6-month follow-up than the mTKA group.
... [52, 54,56,57,73] reporting PROMs after 6 months on the MAKO TKR were identified. Most reported a small trend to improved outcome with the MAKO. ...
... Most reported a small trend to improved outcome with the MAKO. Marchand et al. reported improved pain scores at 6 [57] and 12 months [56] compared to conventional TKA, with the difference at 1 year being less pronounced and not statistically significant. Smith et al. [73] reported improved satisfaction at 12-month follow-up compared to conventional TKA, however Mahoney et al. [52] reported no difference in 12-month PROMS including satisfaction at 12-month follow-up. ...
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IntroductionA review of the data supporting robotic systems currently available is presented focussing on precision and reproducibility, radiological outcomes, clinical outcomes, and survivorship.Materials and methodsScientific literature published on robotic systems for knee arthroplasty was reviewed using the reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were any study involving robotic-assisted UKA or TKA that reported precision of implant positioning or functional outcomes or range of motion or survivorship, including cadaveric or dry bone studies with a minimum of 6-month follow-up.ResultsThirty-nine studies were identified for robotic-assisted unicompartmental knee arthroplasty, and 24 studies for robotic-assisted total knee arthroplasty. Those that reported on radiological outcomes or cadaver studies consistently demonstrated improved precision with the use of robotic systems irrespective of the system. PROMS and survival data demonstrated equivalent short-term results. However, many studies reported outcomes inconsistently and few had long-term clinical follow-up or survivorship data.Conclusions This review adds to the body of evidence supporting improved precision and reproducibility with robotic assistance in knee arthroplasty. Despite intensive funding of research into robotic knee systems, there remains considerable heterogeneity in exposure and outcome analysis and few quality long-term studies demonstrating translation to better clinical outcomes and implant survivorship.
... The bone cuts, according to the pre-operative plan, are then made using the robotic-arm-assisted saw which also protects the soft tissue structures around the knee (haptic boundary). Non-randomised comparative cohort studies have shown a significant shorter hospital stay, improved early range of movement and function, and a greater rate of satisfaction with the robotic-arm-assisted TKR when compared to manual TKR [10,11]. Despite the accuracy of the bone cuts to align the knee prosthesis correctly, the soft tissues, which can be scared and tight from the deformity, often need to be released to balance the knee as part of a measured resection technique [12,13]. ...
... Potential risks and steps taken to minimise these risks are outline in the PIL. In addition it is anticipated that those patients with patients who are randomised to use of the robotic instrumentation may require a longer procedure of up to 5 min [10], and there is a theoretical increased risk of infection. There is also a small (1%) risk of sustaining a fracture through a tracker pin (a threaded pin inserted into the bone so the robot can establish the position of the bone in time and place) [30,31]. ...
Article
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Background Robotic-arm-assisted knee arthroplasty allows for more accurate component positioning and alignment and is associated with better patient-reported outcomes compared to manually performed jig-based knee arthroplasty. However, what is not known is whether the addition of an intra-articular sensor (VerasenseTM) to aid intraoperative balancing of the total knee replacement (TKR) offers improved functional outcomes for the patient. The purpose of this research is to compare the outcomes of patients undergoing a conventional manual knee replacement to those undergoing TKR using robotic-assisted surgery and the VerasenseTM to optimise alignment and balance the knee joint, respectively, and assess the associated cost economics of such technology. Methods and analysis This randomised controlled trial will include 90 patients with end-stage osteoarthritis of the knee undergoing primary TKR. Patients meeting the inclusion/exclusion criteria that consent to be in the study will be randomised at a ratio of 1:1 to either manual TKR (standard of care) or robotic-arm-assisted TKR with VerasenseTM to aid balancing of the knee. The primary objective will be functional improvement at 6 months following surgery between the two groups. The secondary objectives are to compare changes in knee-specific function, joint awareness, patient expectation and fulfilment, satisfaction, pain, stiffness and functional ability, health-related quality of life, cost-effectiveness, and gait patterns between the two groups. Ethical approval was obtained by the Tyne & Wear South Research Ethics Committee, UK. The study is sponsored by the Newcastle Hospitals NHS Foundation Trust. Discussion This study will assess whether the improved accuracy of component positioning using the robotic-arm-assisted surgery and the VerasenseTM to aid balancing of the TKR offers improved outcome relative to standard manual jig-based systems that are currently the standard of care. This will be assessed primarily according to knee-specific function, but several other measures will also be assessed including whether these are cost-effective interventions. Trial registration International Standard Randomised Controlled Trial Number ISRCTN47889316 https://doi.org/10.1186/ISRCTN47889316. Registered on 25 November 2019 Date and version for protocol ROAM Protocol V1.0 (13-12-2018)
... The MAKO robot system was the most intensively researched out of all robotic systems for total knee surgery. There were some studies advocating improved clinical outcomes up to 1 year postoperatively compared to the conventional technique [22,[39][40][41]52]. However, long-term clinical outcomes are still lacking. ...
... Unfortunately, patient-reported outcomes and functional outcomes were deemed to heterogeneously due to different time intervals per individual robot to perform a meaningful metaanalysis. There are some studies advocating early improved [15,22,32,[39][40][41]52]. Of note, especially for ROBODOC, is that the clinical studies were mainly based on a principle of mechanical alignment. ...
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Introduction Robotic systems have been introduced to improve the precision of total knee arthroplasty. However, different robotic systems are available, each with unique features used to plan and execute the surgery. As such, due to this diversity, the clinical evaluation of each robotic platform should be separated. Methods An extensive literature search of PubMed, Medline, Embase and Web of Science was conducted with subsequent meta-analysis. Randomised controlled trials, comparative studies, and cohort studies were included regarding robot-assisted total knee arthroplasty. Evaluated outcomes included clinical results, surgical precision, ligament balance, surgical time, learning curve, complications and revision rates. These were split up based on the robot-specific brand: ROBODOC (T-SOLUTION ONE), OMNIBOT, MAKO, NAVIO (CORI) and ROSA. Results With a follow-up of more than 10 years, no improved clinical outcomes have been noted with the ROBODOC system compared to the conventional technique. If available, other platforms only present short-term clinical outcomes. Radiological outcomes are published for most robotic setups, demonstrating improved surgical precision compared to the conventional technique. Gap balance assessment is performed differently between all systems, leading to heterogeneous outcomes regarding its relationship on clinical outcomes. There is a similar learning curve based on operative time for all robotic platforms. In most studies, robot assistance requires longer operative time compared to the conventional technique. Complications and revision rates are published for ROBODOC and MAKO, without clear differences to conventional total knee arthroplasty. Conclusion The main finding of this systematic review is that the current evidence regarding each robotic system is diverse in quantity and quality. Each system has its own specificities and must be assessed for its own value. Regarding scientific literature, the generic term of robotic should be banned from the general conclusion. Level of evidence Systematic review level IV.
... Robotic surgeries have proven successful in increasing early functional outcomes and reducing radiographic outliers compared with conventional technique, however, mid-to-long term studies have yet to prove meaningful enhancement in terms of implant survivorship, patient satisfaction, and functional outcomes [10]. However, most of the available literature refers to CT-guided robotic TKA [11][12][13], while few studies report on imageless robotic systems [14,15]. In fact, avoiding the need of a preoperative CT-scan, imageless robotic systems have the advantages of reducing the radiation exposition of the patients while ensuring smoother preoperative and intraoperative procedures. ...
... During this time, a total of 173 primary TKAs were performed in the orthopaedic department, including 87 consecutive navigated TKAs ( Eleven patients in the RTKA group were excluded from this cohort for different reasons such as: patients with ligament insufficiency that required higher level of constraint, patients with a diagnosis other than primary osteoarthritis, patients with a deformity requiring augmentation, neurological movement disorders, patients with severe varus deformity (> 15°), patients with valgus deformity, and patients that did not complete their 1-year clinical and radiographic follow-up. Fifty RTKA patients with mild-to-moderate varus deformity (≤ 15°) undergoing primary unilateral TKA were, finally, included for final analysis with a mean follow-up of 13.4 months (± 1.3, range [12][13][14][15]. Varus deformity was defined as a hip-knee-ankle (HKA) angle greater than or equal to 1° with the mechanical axis (MA) passing medial to the knee joint. ...
Article
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Background Robotic assisted total knee arthroplasty (RTKA) has shown improved knee alignment and reduced radiographic outliers. However, there remains debate on functional outcomes and patient-reported outcomes (PROMs). This study compares the 1-year clinical outcomes of a new imageless robotically assisted technique (ROSA Knee System, Zimmer Biomet, Warsaw, IN) with an imageless navigated procedure (NTKA, iAssist Knee, Zimmer, Warsaw, IN). Methods The study is a retrospective analysis of prospectively collected data that compared the functional outcomes and PROMs of 50 imageless RTKA with 47 imageless NTKA at 1-year follow-up. Baseline characteristics, intraoperative and postoperative information were collected including complications, revisions, Knee Society Score (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS) score, and Forgotten Joint Score (FJS-12). Radiographic analysis of preoperative and postoperative images evaluating hip–knee–ankle (HKA) angle was performed. Results There was no difference regarding baseline characteristics between the groups. Mean operative time was significantly longer in the RTKA group (122 min vs. 97 min; p < 0.0001). Significant differences were reported for the “Pain” (85 [RTKA] vs 79.1 [NTKA]; p = 0.0283) subsection of the KOOS score. In addition, RTKA was associated with higher maximum range of motion (119.4° vs. 107.1°; p < 0.0001) and better mean improvement of the arc of motion by 11.67° (23.02° vs. 11.36°; p < 0.0001). No significant differences were noted for other subsections of KOOS, KSS, FJS-12, complications, or limb alignment at 1-year follow-up. Conclusions Imageless RTKA was associated with longer surgical time, better pain perception and improved ROM at 12-month follow-up compared with NTKA. No significant differences were reported on other PROMs, complication rates and radiographic outcomes. Level of evidence III.
... Postoperatively, patients who underwent rKA have demonstrated lower pain scores and improved physical function and have reported improved satisfaction and activity when compared with mKA patients. 11,16,17 Patients with rKA surgery may require less inpatient therapy, experience faster hospital discharge times, and utilize less postoperative therapy, all of which are major contributors to healthcare costs. 8,9,18 Despite the many advantages of rKA, early adoption of this technology has been slow with varied rates of utilization influenced by practice type, surgical volume, clinical concerns, and financial considerations. ...
... We also do not have a way to quantify or account for better patient-reported outcomes and higher patient satisfaction experienced by rKA patients, which several studies have demonstrated. [8][9][10][11][12][13][14][15][16][17][18] This study only includes cost data through the 90-day postoperative period. Finally, we did not include the capital expenditure of institutional investment in the robotic technology. ...
Article
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Background: The number of total knee arthroplasties (TKA) carried out globally is expected to substantially rise in the coming decades. Consequently, focus has been increasing on improving surgical techniques and minimizing expenses. Robotic arm–assisted knee arthroplasty has garnered interest to reduce surgical errors and improve precision. Objectives: Our primary aim was to compare the episode-of-care cost up to 90 days for unicompartmental knee arthroplasty (UKA) and TKA performed before and after the introduction of robotic arm–assisted technology. The secondary aim was to compare the volume of UKA vs TKA. Methods: This was a retrospective study design at a single healthcare system. For the cost analysis, we excluded patients with bilateral knee arthroplasty, body mass index >40, postoperative infection, or noninstitutional health plan insurance. Costs were obtained through an integrated billing system and affiliated institutional insurance company. Results: Knee arthroplasty volume increased 28% after the introduction of robotic-assisted technology. The TKA volume increased by 17%, while the UKA volume increased 190%. Post introduction, 97% of UKA cases used robotic arm–assisted technology. The cost analysis included 178 patients (manual UKA, n = 6; robotic UKA, n = 19; manual TKA, n = 58, robotic TKA, n = 85). Robotic arm–assisted TKA and UKA were less costly in terms of patient room and operating room costs but had higher imaging, recovery room, anesthesia, and supply costs. Overall, the perioperative costs were higher for robotic UKA and TKA. Postoperative costs were lower for robotic arm–assisted surgeries, and patients used less home health and home rehabilitation. Discussion: Surgeons performed higher volumes of UKA, and UKA comprised a greater percentage of total surgical volume after the introduction of this technology. The selective cost analysis indicated robotic arm–assisted technology is less expensive in several cost categories but overall more expensive by up to $550 due to higher cost categories including supplies and recovery room. Conclusions: Our findings show a change in surgeons’ practice to include increased incidence and volume of UKA procedures and highlights several cost-saving categories through the use of robotic arm–assisted technology. Overall, robotic arm–assisted knee arthroplasty cost more than manual techniques at our institution. This analysis will help optimize costs in the future.
... Postoperatively, patients who underwent rKA have demonstrated lower pain scores and improved physical function and have reported improved satisfaction and activity when compared with mKA patients. 11,16,17 Patients with rKA surgery may require less inpatient therapy, experience faster hospital discharge times, and utilize less postoperative therapy, all of which are major contributors to healthcare costs. 8,9,18 Despite the many advantages of rKA, early adoption of this technology has been slow with varied rates of utilization influenced by practice type, surgical volume, clinical concerns, and financial considerations. ...
... We also do not have a way to quantify or account for better patient-reported outcomes and higher patient satisfaction experienced by rKA patients, which several studies have demonstrated. [8][9][10][11][12][13][14][15][16][17][18] This study only includes cost data through the 90-day postoperative period. Finally, we did not include the capital expenditure of institutional investment in the robotic technology. ...
Article
Full-text available
Background: The number of total knee arthroplasties (TKA) carried out globally is expected to substantially rise in the coming decades. Consequently, focus has been increasing on improving surgical techniques and minimizing expenses. Robotic arm–assisted knee arthroplasty has garnered interest to reduce surgical errors and improve precision. Objectives: Our primary aim was to compare the episode-of-care cost up to 90 days for unicompartmental knee arthroplasty (UKA) and TKA performed before and after the introduction of robotic arm–assisted technology. The secondary aim was to compare the volume of UKA vs TKA. Methods: This was a retrospective study design at a single healthcare system. For the cost analysis, we excluded patients with bilateral knee arthroplasty, body mass index >40, postoperative infection, or noninstitutional health plan insurance. Costs were obtained through an integrated billing system and affiliated institutional insurance company. Results: Knee arthroplasty volume increased 28% after the introduction of robotic-assisted technology. The TKA volume increased by 17%, while the UKA volume increased 190%. Post introduction, 97% of UKA cases used robotic arm–assisted technology. The cost analysis included 178 patients (manual UKA, n = 6; robotic UKA, n = 19; manual TKA, n = 58, robotic TKA, n = 85). Robotic arm–assisted TKA and UKA were less costly in terms of patient room and operating room costs but had higher imaging, recovery room, anesthesia, and supply costs. Overall, the perioperative costs were higher for robotic UKA and TKA. Postoperative costs were lower for robotic arm–assisted surgeries, and patients used less home health and home rehabilitation. Discussion: Surgeons performed higher volumes of UKA, and UKA comprised a greater percentage of total surgical volume after the introduction of this technology. The selective cost analysis indicated robotic arm–assisted technology is less expensive in several cost categories but overall more expensive by up to $550 due to higher cost categories including supplies and recovery room. Conclusions: Our findings show a change in surgeons’ practice to include increased incidence and volume of UKA procedures and highlights several cost-saving categories through the use of robotic arm–assisted technology. Overall, robotic arm–assisted knee arthroplasty cost more than manual techniques at our institution. This analysis will help optimize costs in the future.
... by contrast, several studies have suggested greater functional improvements as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society Score (KSS) in the short term. [61][62][63][64] There are limited data on use of the navio system in TKA. A prospective cohort study comparing the clinical, radiographic and PROMs data between navio-assisted and conventional TKA is currently underway. ...
Article
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Robotic total knee arthroplasty (TKA) has demonstrated improved component positioning and a reduction of alignment outliers with regard to pre-operative planning. Early robotic TKA technologies were mainly active systems associated with significant technical and surgical complications. Current robotic TKA systems are predominantly semi-active with additional haptic feedback which minimizes iatrogenic soft tissue injury compared to conventional arthroplasty and older systems. Semi-active systems demonstrate advantages in terms of early functional recovery and hospital discharge compared to conventional arthroplasty. Limitations with current robotic technology include high upfront costs, learning curves and lack of long-term outcomes. The short-term gains and greater technical reliability associated with current systems may justify the ongoing investment in robotic technology. Further long-term data are required to fully ascertain the cost-effectiveness of newer robotic systems.
... Computer navigated and robotic-assisted techniques for total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) require placement of temporary tracking pins for bone registration. While there is substantial literature supporting the benefits of these advanced techniques compared to conventional UKA and TKA, there is also the intrinsic associated risk of pin site complications [1][2][3]. ...
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Background Optical array placement for robotic-assisted knee replacement introduces the rare, but real risk of periprosthetic fracture. The purpose of this retrospective study was to review the incidence of fracture with the conventional technique of bicortical diaphyseal pin placement. We also evaluated a modified method of unicortical periarticular pin placement to mitigate this risk. Methods We reviewed 2603 knee arthroplasties that were performed between June 2017 and December 2019. The conventional bicortical diaphyseal technique was used in 1571 knees (bicortical diaphyseal group) and the unicortical periarticular technique was used in 1032 knees (unicortical periarticular group). Results A more than 1-year follow-up revealed that 3 femoral shaft fractures (0.19%) occurred in the bicortical diaphyseal group and no fracture took place in the unicortical periarticular group. There was no array loosening in either group. Conclusions The modified unicortical periarticular pin placement is a reliable technique for computer-navigated and robotic-assisted knee arthroplasties. It may be associated with a lower incidence of postoperative femoral shaft fractures, compared to conventional bicortical diaphyseal pinning.
... A new robotically assisted system for TKA (ROSA knee System; Zimmer Biomet; Warsaw, IN) has been recently introduced. The previous systems available in the market were either active: the surgeon sets the robotic arm close to the patient and then the robot autonomously performs the surgery [5][6][7][8], or haptic: the surgeon pushes the "Go Button" but the robot keeps the instrument within pre-determined boundaries [9][10][11][12][13][14]. During the last decade, these systems have shown their accuracy and safety, but they also have some limits in terms of usability, as the movements of the surgeon are constrained on a predefined surface. ...
Article
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Introduction The ROSA (Robotic Surgical Assistant) Knee system (Zimmer Biomet, Warsaw, IN) for total knee arthroplasty (TKA) can be considered as collaborative robotics, where the surgeon remains in charge of the procedure and collaborates with a smart robotic tool, to perform the surgery with a high accuracy and reproducibility. The aim was to describe: (1) its concept and surgical technique; (2) its advantages and potential limits; (3) the early experience with this system. Materials and methods The goal during its development phase was to keep the surgeon active and at the center of the operation: the surgeon handles the saw and performs the cuts while the robotic arm places and holds the guide at the right place. The ROSA knee platform assists the surgeon for the distal femoral cut, the femoral component sizing and positioning, the tibial cut and the ligament balance. This robotic system has two options: image-based with 3D virtual model; or image-less, based on intraoperative landmarks acquisition. All the classic surgical techniques can be used: measured resection, gap balancing, functional alignment, kinematic alignment. Some techniques recently developed are more ROSA-specific: Robotic personalized TKA, ROSA-FuZion technique. Results Its advantages as compared to other available systems include: radiographs in standing position, collaborative robotic system where the robot completes the surgeon skills, “off-the-shelf” implants, predictive robotic with concept of machine learning incorporated into the system. Two cadaveric studies have reported the high accuracy and reproducibility of this device. This robotic system is recent and currently no clinical series has enough follow-up to report clinical outcomes. Conclusion The ROSA knee system is a robotically assisted semi-autonomous surgical system with some specific characteristics. The aim of this collaborative robotic system is to improve the accuracy and reliability of the bone resections and the ligament balancing, without replacing the steps well performed by the surgeon.
... Patient satisfaction Marchand et al. 59 used the Western Ontario and McMaster Universities Osteoarthritis Index to investigate the patients' satisfaction at 6 months after surgery. Among them, 20 cases received traditional surgery and 20 cases robotic surgery. ...
Article
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Joint arthroplasty is an effective method for treating end-stage joint lesions and damages. Robotic arm-assisted arthroplasty, a rapidly developing technology that combines navigation technology, minimally invasive technology, and precise control technology of the robotic arm, can achieve accurate preoperative planning, optimal selection of implants, minimally invasive surgery, precise osteotomy, and accurate placement of artificial joints. It has the characteristics of high accuracy and high stability, and it is more and more widely used in the field of joint surgery. In this paper, we systematically reviewed the application and clinical efficacy of robotic arm-assisted technology in hip and knee arthroplasty to provide a reference for its future promotion.
... Several studies have also reported on decreased soft tissue complication rates associated with robotic-assisted TKA [11,12] including one cadaver study that showed decreased damage to the PCL when comparing robotic-assisted and manual cruciate-retaining TKA [13]. In addition to accuracy and safety, a number of studies have recently been published addressing patient satisfaction after robotic TKA, many of which suggest that robotics may help improve patient satisfaction and clinical outcomes [14,15]. Revision knee arthroplasty is an increasing challenge for the orthopedic surgeon, with rising case numbers secondary to infection, aseptic loosening and instability, peri-prosthetic fracture, and progression of arthritic disease [6]. ...
Article
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Introduction: With increasing numbers of knee arthroplasty procedures being performed, revision total knee arthroplasty (TKA) remains a challenge to orthopedic surgeons. The use of robotics in primary joint arthroplasty is also increasing due to better technology and surgeon familiarity. Robotic arms have the ability to execute bone cuts within 1 mm of a preoperative plan, can measure soft tissue gap tension, and can plan femoral and tibial augments and rotation. The use of robotic arm assistance for revision TKA, however, has not been documented in the literature. Case report: We present a case describing a novel technique in which the Mako robot (Stryker, Ft. Lauderdale, FL) was utilized for revision of a failed primary TKA secondary to aseptic loosening. The patient is a 68-year-old Caucasian male who underwent right revision TKA with robotic assistance. Stryker Triathlon TS implants were utilized with the use of both femoral and tibial cones and medial and lateral posterior femoral augments. He had satisfactory component alignment based on postoperative radiographs, and excellent clinical outcomes 6 months postoperatively. Conclusion: The use of robotic arm assistance in revision TKA for failed primary TKA is a novel technique and resulted in excellent operative outcomes in this case. Further study should be done to confirm its use in revision TKA.
... They found that RA-TKA reduced pain andimproved early functional recovery within the primary3 days compared to conventional TKA. Several studies have suggested greater functionalimprovements using the Mako system as measured by the Knee Society Score andtherefore the Western Ontario andMcMaster Universities Osteoarthritis Indexin the short term [13,14]. However, there arelimited data about the early postoperative period, like 14 days after surgery, on the employment of NavioRA-TKA. ...
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This study aimed to examine whether it is advantageous in robotic-assisted TKA (RA-TKA) compared with conventional TKA throughout a 14 postoperative days (PODs). A total of 113 knees (100 patients) were reviewed and divided into the control group (55 knees) and the RA-TKA group (58 knees). We assessed postoperative pain intensity using a visual analogue scale at rest (rVAS) and during movement (mVAS), evaluated lower extremity functional recovery through quadriceps muscle strength and knee range of motion (ROM), preoperatively and on PODs 3, 7, 10, and 14. We also assessed the rescue analgesia intake and postoperative implant coronal alignment. The mean rVAS and mVAS scores did not differ significantly between the two groups. Muscle strength recovery was significantly faster in the RA-TKA group than in the control group on every PODs. ROM recovery was better in the RA-TKA group than in the control group on POD 10. The amount of postoperative analgesia was significantly lower in the RA-TKA group than in the control group. Attainment of a β angle <2° significantly better in RA-TKA. This study demonstrated better functional recovery in RA-TKA, particularly for muscle strength and ROM. RA-TKA reduced rescue drug intake and provided better implant positioning.
... Robotic-assisted knee replacement technology helps reduce postoperative pain [24,[30][31][32][33], restore knee function, and thus improve the quality of life in patients with severe osteoarthritis [34]. Khlopas et al [35] and Kayani et al [25] have suggested, in their studies, that these systems also reduce excessive soft tissue trauma during surgery compared to the conventional systems and thus reduce the postoperative pain. ...
Article
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Background Our study aims to determine the effectiveness of robotic technology for total knee arthroplasty in the successful restoration of the joint line of the knee with respect to that of a normal human anatomical knee. The restoration of the joint line is an important technical goal on which the postoperative outcomes and the success of the surgery depend. Methods Sixty-four postoperative plain anteroposterior radiographs of 60 patients, who received total knee arthroplasty by using the robotic technology were analyzed and compared with 66 similar radiographs of 60 patients who received the conventional method. The distances of the lateral epicondyle to the joint line (LEJL) and proximal tibiofibular joint to the joint line (PTFJJL) were calculated and analyzed. Results We found that the mean value of LEJL minus PTFJJL in the robotic group was 0.334 ± 0.115 (mean ± SD), while in the conventional group, it was 2.304 ± 0.308. The difference between the two groups was statistically significant. The mean ratio (LEJL:PTFJJL) in the robotic group was also equal to 1.017 ± 0.042. Conclusion From these findings it could be concluded that the robotic technology significantly increases the accuracy of the total knee arthroplasty and, compared to the conventional method, achieves an almost anatomical position of the joint line.
... To our knowledge, there have been only two short-term follow-up studies comparing manual TKA and RA-TKA outcome differences at 6 months and 1 year. Both studies demonstrate better functional scores and pain scores in the robotic-assisted cohort [35,36]. Kayani et al. demonstrated decreased intraoperative tissue damages and more precise bone cuts with RA-TKA and another, earlier study demonstrated decreased postoperative swelling with RA-TKA [37,38]. ...
Article
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The purpose of this study was to determine if significant clinical differences exist in patient-reported outcome measures (PROMs) between PS and CR TKAs implanted using robotic-assisted technology. This was an IRB-approved retrospective study from an institutional database evaluating 214 knees in 190 patients. Inclusion criteria included: primary RA-TKA, age 22–89 at the time of surgery, preoperative coronal limb deformity within 15º of neutral alignment, and minimum 1-year follow-up. The PS cohort consisted of 103 patients with 107 RA-TKAs, whereas the CR cohort consisted of 87 patients with 107 RA-TKAs. Cohorts were compared on the basis of demographics and PROMs (KSS knee, KSS function, FJS-12, KOOS-JR, WOMAC, and 5-point satisfaction Likert scale) collected preoperatively and at 1-year follow-up. Statistical analyses comparing measures were conducted via Student’s t tests for continuous data and Chi-squared analyses for categorical data. There were no significant differences identified in short-term PROMs at 1-year follow-up between cohorts (all p values > 0.05). 93.1% of patients with CR knees and 94.7% of patients with PS knees reported a satisfaction level of “very satisfied” or “satisfied”. Revision arthroplasty occurred in six knees (2.8%, 3 knees in CR cohort, 3 knees in PS cohort) with no differences in overall complications between groups. The use of RA-TKA technology promoted high patient satisfaction scores within this study, independent of CR or PS implant type with no significant differences in PROMs, satisfaction, revisions, or complications between the two groups.
... RA-TKA has been shown to decrease analgesia requirements, length of stay (LOS), and physical therapy requirements immediately after surgery when compared with the use of conventional instrumentation [25]. Decreased pain has been documented up to 6 months after surgery [26]. It is unclear how much of this benefit would be maintained compared with CN-TKA. ...
Article
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Background The purpose of this study was to compare early clinical and patient-reported outcomes between robotic assisted (RA) and computer navigation (CN) total knee arthroplasty (TKA). Methods One hundred and fifty patients were enrolled in this prospective, single-surgeon, cohort study, with 75 patients each receiving CN-TKA or RA-TKA in a consecutive series. There were no differences in patient age (P = .34) or body mass index (P = .09), but a higher proportion of males underwent RA-TKA (P = .03). We recorded hospital knee pain, analgesic usage, length of hospital stay, range of motion, and patient-reported outcome measures postoperatively for both patient cohorts. Results Hospital length of stay was shorter for the RA-TKA patients (P < .001). RA-TKA patients showed improved range of motion (P < .001) and decreased pain scores (P = .006) on day 1. Subsequent days showed no significant differences. Narcotic usage was lower for the RA-TKA group on day 2 postoperatively (P = .03) and onwards. Total morphine equivalent dose was also significantly lower for the RA-TKA than for the CN-TKA group (P < .001). There was no difference in Forgotten Joint Score (P = .24) or Oxford Knee Score (P = .51) between groups at 2 years postoperatively. Conclusion The use of RA-TKA demonstrated reduced postoperative analgesia usage and length of stay. There were no differences seen between CN-TKA and RA-TKA with respect to clinical outcomes at 2 years after surgery.
... Ağrı daha azdır ve fonksiyonel skorlar daha iyidir. [7] Daha az kan kaybı, daha iyi kuadriseps gücü ve diz hareket açıklığı elde edilebilir; rehabilitasyon daha kolaydır. [8] Aynı avantajlar, unikondiler artroplasti için de geçerlidir. ...
... 37,64 This in part has allowed roboticassisted arthroplasty to evolve and aim to equalize the gap between high-and low-volume surgeons. Studies have shown benefits in the short-to medium-term, of the efficacy of robotic-assisted TKA in improving both functional outcomes and survivorship, 75 in addition to causing less periarticular soft tissue trauma, 76 reduced postoperative pain, decreased analgesia requirements, and increased knee flexion at discharge. 77 The reduced soft tissue trauma may lead to faster recovery thus improving surgical efficiency. ...
Article
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Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes. Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty. This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice. Cite this article: Bone Jt Open 2021;2(1):48–57.
... [1][2][3] Robotic-arm assisted total knee arthroplasty (RATKA) has the potential to enhance clinical, radiographic, and patientreported outcomes. [4][5][6] Many reports suggest that CT-based TKAs have improved accuracy of bone resections, decreased iatrogenic soft tissue and bone injuries, and increased achievement of desired alignments in all axes. [7][8][9][10][11][12][13][14] Although this improved precision is important for implant positioning and survivorship, there has been continuing interest in the relationship of this technology to costs. ...
Article
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Purpose: Robotic-arm assisted total knee arthroplasty (RATKA) has the potential to enhance radiographic, clinical, and patient-reported outcomes. The purpose of this study was to compare resource utilization, episode-of-care (EOC) costs, readmissions, and complications of robotic-arm assisted total knee arthroplasty (RATKA) and manual TKA (MTKA). Methods: TKA procedures were identified from a private payer claims database. RATKA procedures required both a robotic arm-assisted procedure code and a 60-day pre-operative computed tomography scan. Propensity score matching (1:5 RATKA to MTKA) was performed, based on various patient characteristics and comorbidities. After matching, 4452 patients (742 RATKA and 3710 MTKA) were analyzed for 90-day and one-year EOC costs, index TKA costs, lengths of stay (LOS), discharge statuses, rehabilitation utilizations, as well as 90-day and one-year readmissions- and knee-related complications. Results: RATKA patients had shorter LOS (mean 1.56 versus 1.91 days; p < 0.001), lower index costs by $1762 ($32,747 versus $34,509; p = 0.003), and higher discharges to home rates (51.8 versus 47.8%; p = 0.049) than MTKA patients. RATKA patients had less 90-day (68.5 versus 72.0%; p = 0.048) and one-year (70.8 versus 75.0%; p = 0.016) home health utilizations. The RATKA cohort had lower 90-day ($39,260 versus $41,458; p = 0.001) and one-year ($51,462 versus $54,171; p = 0.011) EOC costs. No significant differences in readmission and overall complication rates were observed (p > 0.05). Conclusion: RATKA was associated with lower index costs and EOC costs at both 90 days and one year. These patients had shorter LOS, were discharged home more frequently, and used less home health services. Cost savings were demonstrated for RATKA beyond the 90-day period with an increase in savings between 90-day and one-year time points. These data may be of importance to payers and providers interested in the longer-term value of RATKA.
... Continued follow-up is needed as raTKA has yet to demonstrate, in the current literature, any improvement of the functional outcomes in the mid or long term [55][56][57][58]. Nevertheless, some studies reported better early functional recovery, improved satisfaction, and lower postoperative pain with a robotic-assisted system compared to conventional technique after unilateral TKA [9,59,60]. Two explanations are suggested in the literature for the faster recovery for the raTKA: less damage on the soft tissues [61], and better restoration of knee kinematics associated with better implant positioning [62]. This advantage on the early recovery is particularly interesting in sequential bilateral TKA, where the postoperative pain could be higher. ...
Article
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Introduction To our knowledge, no papers have reported the results of robotic-assisted surgery for sequential bilateral Total Knee Arthroplasty (TKA). Indeed, sequential bilateral TKA present several benefits, as one single anesthesia, surgical episode, hospitalization, and rehabilitation. The purpose of our study was to evaluate peri-operative outcomes and compare the complication rates, clinical outcomes, and implant positioning of sequential bilateral TKA performed with a robotic-assisted system versus a conventional technique. Materials and methods All patients who underwent a sequential bilateral robotic-assisted primary TKA (raTKA) in our institution between November 2019 and February 2021 were included. Twenty patients met the inclusion criteria and were matched with 20 sequential bilateral TKA performed with a conventional technique. The two groups were comparable for the demographic data and the preoperative parameters, including preoperative anticoagulation and ASA score. The minimum follow-up was 6 months. Results The operative time was significantly longer in the robotic group (< 0.0001), with a mean additional time of 29 min. There was no significant difference between both groups for postoperative blood loss, rate of blood transfusion, or postoperative pain. The average length of stay was 5 days. There was one early complication in the robotic group due to the tibial trackers. The functional outcomes were similar between both groups, except for the functional KSS score, which was better at 6 months in the robotic group (p < 0.0001). The restoration of the knee alignment and the distal femoral anatomy were significantly better in the robotic group than in the conventional group. Conclusions Despite a longer operative time, the peri-operative parameters of sequential bilateral TKA were similar between robotic and conventional techniques. Further, sequential bilateral raTKA was at least as safe as a conventional technique, without additional risk of medical complications.
... This was not achieved by the aMA group. Some studies reported better early functional recovery with a personalized alignment [53] or a more accurate surgical technique such as robotic-assisted systems [25,32,49]. This faster recovery for functional outcomes can be explained by a better restoration of knee kinematics associated with better implant positioning [23] or by less damage on the soft tissues [24]. ...
Article
Purpose: An anatomo-functional implant positioning (AFIP) technique in total knee arthroplasty (TKA) could restore physiological ligament balance (symmetric gap in extension, asymmetric gap in flexion). The purposes were to compare (1) ligament balancing in extension and flexion after TKA in the AFIP group, (2) TKA alignment, implant positioning and patellar tracking between AFIP and adjusted mechanical alignment (aMA) techniques, (3) clinical outcomes between both groups at 12 months. Methods: All robotic-assisted TKA with an AFIP technique were included (n = 40). Exclusion criteria were genu valgum (HKA angle > 183°), extra-articular deformity more than 10°, and patellar maltracking (high-grade J-sign). One control patient with a TKA implanted by an aMA technique was matched for each case, based on age, body mass index, sex, and knee alignment. Ligament balancing (medial and lateral gaps in millimeters) in full extension and at 90° of flexion after TKA in the AFIP group was assessed with the robotic system. TKA alignment (HKA angle), implants positioning (femoral and tibial coronal axis, tibial slope, joint-line orientation), patellar tracking (patellar tilt and translation) and the Knee Society Score (KSS) at 6 and 12 months were compared between both groups. The ligament balancing was compared using a t test for paired samples in the AFIP group. The radiographic measurements and KSS scores were compared between groups using a t test for independent samples. Results: In the AFIP group, there was no significant difference between the medial and lateral gap laxity in extension (NS). A significant opening of the lateral gap was observed in flexion compared to extension (mean: + 2.9 mm; p < 0.0001). The mean postoperative HKA angle was comparable between both groups (177.3° ± 2.1 in the AFIP group vs 176.8° ± 3.2; NS). In the AFIP group, the femoral anatomy was restored (90.9° ± 1.6) and the tibial varus was partially corrected (87.4° ± 1.8). The improvement of Knee and Function KSS at 6 months was better in the AFIP group (59.3 ± 11.9 and 51.7 ± 20, respectively, versus 49.3 ± 9.7 and 20.8 ± 13; p < 0.001). Conclusion: The AFIP concept allowed the restoration of the native knee alignment and a natural functional ligament pattern. With a more physiological target for ligament balancing, the AFIP technique had equivalent clinical outcomes at 12 months compared to aMA, with a faster recovery. Level of evidence: III retrospective therapeutic case control series.
Article
Background Nearly 20% of Total knee Arthroplasty patients remain dissatisfied. This is a major concern in twenty-first century arthroplasty practice. Accurate implant sizing is shown to improve the implant survival, knee balance and patient reported outcome. Aim of the current study is to assess the efficacy of pre-operative three-dimensional (3D) CT scan templating in a robot-assisted TKA in predicting the correct implant sizes and alignment.Materials and methodsProspectively collected data in a single center from 30 RA-TKAs was assessed. Inclusion criterion was patients with end stage arthritis (both osteoarthritis and rheumatoid arthritis) undergoing primary TKA. Patients undergoing revision TKA and patients not willing to participate in the study were excluded. Preliminary study of ten patients had indicated almost 100% accuracy in determining the implant size and position. Sample size was estimated to be 28 for 90% reduction in implant size and position error with α error of 0.05 and beta error of 0.20 with power of study being 80. Post-operative radiographs were assessed by an independent observer with respect to implant size and position. The accuracy of femoral and tibial component sizing in the study was compared with the historic control with Chi-squared test. The p value < 0.05 was considered significant.ResultsThe pre-operative CT scan 3D templating accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component. The implant position and limb alignment was accurate in 100% of patients. The accuracy of femoral component and tibial component sizing is statistically significant (Chi-squared test, p value 0.0105 and 0.0461, respectively).Conclusion The study results show the effectiveness of pre-operative 3 D CT scan planning in predicting the implant sizes and implant positioning. This may have a potential to improve the implant longevity, clinical outcomes and patient satisfaction.
Article
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Background Robotic arm–assisted total knee arthroplasty (RATKA) has demonstrated improved patient-reported outcome measures. Less evidence has been reported on how frequently patients return to complex activities of daily living. Our purposes were to investigate (1) hospital lengths of stay (LOSs) (2) discharge dispositions and (3) the rates and postoperative time intervals at which patients returned to driving and working. Methods A total of 50 RATKA patients who were employed prior to surgery were included. Outcomes included hospital LOS, discharge dispositions, return to driving, and return to work. Results A total of 48 patients (96%) were discharged home with self-care or health aid discharge after a mean LOS of 1.2 ± 0.6 days. Twelve patients (24%) returned to driving within 3 weeks of surgery. In our study, 100% of patients who underwent RATKA returned to driving after a mean of 29 days (range, 4 to 62 days). Forty-five patients (90%) returned to their preoperative level of work after a mean of 46 days (range, 2 to 96 days). Nineteen patients (38%) returned to work within 3 weeks. Conclusions This study showed fast recovery after RATKA, with >90% returning to driving and working at full capacity within 2 months. Many (38%) returned to work within 3 weeks. Further studies to demonstrate the value of RATKA with respect to recovery of complex activities are needed. Compared to controls from previously published literature on manual total knee arthroplasties, it appears that patients who undergo RATKA have similar or better outcomes in reference to return to driving.
Article
Background: Technology-assisted knee arthroplasty (KA), including robotic-arm-assisted knee arthroplasty (RA-KA) and computer-assisted (CA-KA) knee arthroplasty, was developed to improve surgical accuracy of implant positioning and alignment, which may influence implant stability, longevity, and functional outcomes. However, despite increased adoption over the past decade; its value is still to be determined. Questions/purpose: This study aimed to compare robotic-arm (RA)-KA, CA-KA, and manual (M)-KA regarding (1) in-hospital metrics (length of stay [LOS], discharge disposition, in-hospital complications, and hospitalization-episode costs), (2) characterize annual utilization trends, and (3) future RA-KA and CA-KA utilization projections. Methods: National Inpatient Sample was queried for primary KAs (unicompartmental/total; 2008 to 2018). KAs were classified by modality (M-KA/CA-KA/RA-KA) using International Classification of Disease-9/10 codes. A propensity score-matched comparison of LOS, discharge disposition, in-hospital complications (implant-related mechanical or procedure-related nonmechanical complications), and costs was conducted. Trends and projected utilization rates were estimated. Results: After propensity score matched to their respective M-KA cohorts, RA-KA and CA-KA exhibited shorter LOS (RA-KA versus M-KA: 2.0 ± 1.4 days versus 2.5 ± 1.8 days; P < 0.001; CA-KA versus M-KA: 2.7 ± 1.4 days versus 2.9 ± 1.6 days; P < 0.001) and in-hospital implant-related mechanical complications (P < 0.05, each). RA-KA demonstrated lower nonhome discharge (P < 0.001) and in-hospital procedure-related nonmechanical complications (P = 0.005). RA-KA had lower in-hospital costs ($16,881 ± 7,085 versus $17,320 ± 12,820; P < 0.001), whereas CA-KA exhibited higher costs ($18,411 ± 7,783 versus $17,716 ± 8,451; P < 0.001). RA-KA utilization increased from <0.1% in 2008 to 4.3% in 2018. CA-KA utilization rose temporarily to 6.2% in 2014, then declined to pre-2010 levels in 2018 (4.5%). Projections indicate that RA-KA and CA-KA will represent 49.9% (95% confidence interval, 41.1 to 59.9) and 6.2% (95% confidence interval, 5.3% to 7.2%) of KAs by 2030. Discussion: RA-KA may provide value through improving in-hospital metrics and mitigating net costs. Similar advantages may not be reliably attainable with CA-RA. Because RA-KA is projected to reach half of all knee arthroplasties done in the United States by 2030, further cost analyses and long-term studies are warranted.
Article
Background Currently, robot-assisted surgical systems are used to reduce the error range of TKA osteotomy and component positioning. Methods We used 20 sawbone models of the femur and 20 sawbone models of the tibia and fibula to evaluate the osteotomy effect of “Skywalker” robot-assisted TKA. Results The maximal movement of the cutting jig was less than 0.25 mm at each osteotomy plane. The mean and standard deviation values of the angle deviation between the planned osteotomy plane and the actual osteotomy plane at each osteotomy plane were not more than 1.03° and 0.55°, respectively. The mean and standard deviation values of absolute error of resection thickness at each osteotomy position were less than 0.78 mm and 0.71 mm, respectively. Conclusions The “Skywalker” system has good osteotomy accuracy, can achieve the planned osteotomy well, and is expected to assist surgeons in performing accurate TKA in clinical applications in future. This article is protected by copyright. All rights reserved.
Article
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Background Robotic (RTKA) and computer-navigated total knee arthroplasty (CNTKA) are increasingly replacing manual techniques in orthopaedic surgery. This systematic review compared clinical outcomes associated with RTKA and CNTKA and investigated the utility of natural language processing (NLP) for the literature synthesis.MethodsA comprehensive search strategy was implemented. Results of included studies were combined and analysed. A transfer learning approach was applied to train deep NLP classifiers (BERT, RoBERTa and XLNet), with cross-validation, to partially automate the systematic review process.Results52 studies were included, comprising 5,067 RTKA and 2,108 CNTKA. Complication rates were 0–22% and 0–16% and surgical time was 70–116 and 77–102 min for RTKA and CNTKA, respectively. Technical failures were more commonly associated with RTKA (8%) than CNTKA (2–4%). Patient satisfaction was equivalent (94%). RTKA was associated with a higher likelihood of achieving target alignment, less femoral notching, shorter operative time and shorter length of stay. NLP models demonstrated moderate performance (AUC = 0.65–0.68).ConclusionsRTKA and CNTKA appear to be associated with similarly positive clinical outcomes. Further work is required to determine whether the two techniques differ significantly with regard to specific outcome measures. NLP shows promise for facilitating the systematic review process.
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Background Robotic-arm assisted knee arthroplasty allows for more accurate component positioning and alignment and is associated with better patient reported outcomes comparted to manually performed jig-based knee arthroplasty. However, what is not known is whether the addition of an intra-articular sensor (VerasenseTM) to aid intraoperative balancing of the total knee replacement (TKR) offers improved functional outcomes for the patient. The purpose of this research is to compare the outcomes of patients undergoing a conventional manual knee replacement to those undergoing TKR using robotic assisted surgery and the VerasenseTM to optimise alignment and balance the knee joint, respectively, and assess the associated cost economics of such technology. Methods and Analysis This randomised controlled trial will include 90 patients with end stage osteoarthritis of the knee undergoing primary TKR. Patients meeting the inclusion/exclusion criteria that consent to be in the study will be randomised at a ratio of 1:1 to either manual TKA (standard of care) or robotic-arm assisted TKA with VerasenseTM to aid balancing of the knee. The primary objective will be functional improvement at 6-months following surgery between the two groups. The secondary objectives are to compare changes in knee specific function, joint awareness, patient expectation and fulfilment, satisfaction, pain, stiffness and functional ability, health related quality of life, cost effectiveness, and gait patterns between the two groups. Ethical approval was obtained by the Tyne & Wear South Research Ethics Committee, UK. The study is sponsored by the Newcastle Hospitals NHS Foundation Trust. Discussion This study will assess whether the improved accuracy of component positioning using the robotic-arm assisted surgery and the VerasenseTM to aid balancing of the TKA offers improved outcome relative to standard manual jug-based systems that are currently the standard of care. This will be assessed primarily according to knee specific function, but several other measure will also be assessed including whether this is a cost effective intervention. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN47889316 https://doi.org/10.1186/ISRCTN47889316 (registered on 25/11/2019) Date and version for protocol ROAM Protocol V1.0 (13-12-2018)
Article
Robotic-assisted technology has been developed to optimize the consistency and accuracy of bony cuts, implant placements, and knee alignments for total knee arthroplasty (TKA). With recently developed designs, there is a need for the reporting longer than initial patient outcomes. Therefore, the purpose of this study was to compare manual and robotic-assisted TKA at 2-year minimum for: (1) aseptic survivorship; (2) reduced Western Ontario and McMaster Universities Osteoarthritis Index (r-WOMAC) pain, physical function, and total scores; (3) surgical and medical complications; and (4) radiographic assessments for progressive radiolucencies. We compared 80 consecutive cementless robotic-assisted to 80 consecutive cementless manual TKAs. Patient preoperative r-WOMAC and demographics (e.g., age, sex, and body mass index) were not found to be statistically different. Surgical data and medical records were reviewed for aseptic survivorship, medical, and surgical complications. Patients were administered an r-WOMAC survey preoperatively and at 2-year postoperatively. Mean r-WOMAC pain, physical function, and total scores were tabulated and compared using Student's t-tests. Radiographs were reviewed serially throughout patient's postoperative follow-up. A p < 0.05 was considered significant. The aseptic failure rates were 1.25 and 5.0% for the robotic-assisted and manual cohorts, respectively. Patients in the robotic-assisted cohort had significantly improved 2-year postoperative r-WOMAC mean pain (1 ± 2 vs. 2 ± 3 points, p = 0.02), mean physical function (2 ± 3 vs. 4 ± 5 points, p = 0.009), and mean total scores (4 ± 5 vs, 6 ± 7 points, p = 0.009) compared with the manual TKA. Surgical and medical complications were similar in the two cohorts. Only one patient in the manual cohort had progressive radiolucencies on radiographic assessment. Robotic-assisted TKA patients demonstrated improved 2-year postoperative outcomes when compared with manual patients. Further studies could include multiple surgeons and centers to increase the generalizability of these results. The results of this study indicate that patients who undergo robotic-assisted TKA may have improved 2-year postoperative outcomes.
Article
The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal–Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0–13.0] vs. 11.5 [9.5–15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.
Article
In this observational, retrospective study, we performed economic analyses between robotic arm-assisted total knee arthroplasty (RATKA) and manual total knee arthroplasty (MTKA). Specifically, we compared: (1) index costs including computed tomography (CT) scans; (2) 90-day postoperative health care utilization, (3) 90-day episode-of-care (EOC) costs, and (4) lengths of stay between CT scan-based robotically-assisted versus MTKAs. A large national database, Blue Health Intelligence (BHI), was used for RATKAs and MTKAs performed between April 1, 2017 and September 30, 2019. Based on strict inclusion–exclusion criteria, with propensity score matching, 4,135 RATKAs and 4,135 MTKAs were identified and analyzed. Index costs to the payer for RATKA patients were found to be less than those for MTKA patients ($29,984 vs. $31,280, p <0.0001). Overall, 90-day EOC costs for RATKA patients were found to be less than that for MTKA patients in the inpatient and outpatient settings. This also holds true for the use of skilled nursing facilities, pharmacies, or other services. In conclusion, the results from our study show that RATKA were associated with lower costs than MTKAs, even when including the cost of CT scans. These results are of marked importance given the emphasis to contain and reduce health care costs.
Chapter
We review the role of total knee arthroplasty in obese patients with special consideration given to complication rates, overall survivorship, technical surgical challenges and specific implant types suitable for use in this cohort.
Article
Aims Recent studies have attempted to quantify the learning curve associated with integration of robotic technology into surgical practice, but to our knowledge, no study has demonstrated the number of cases needed to reach a steady state of maximum efficiency in operating times using robotic assisted technology. Patients and methods This was a retrospective analysis of 682 consecutive knees that underwent a robotic-assisted TKA for osteoarthritis by a single surgeon between 2017-2020. Procedure times (minutes), length of stay (LOS), and short-term postoperative complications and reoperations were analyzed to define trends. Time series analyses were used to identify the approximate time-point at which a maximum level of surgical operating speed was achieved. Analysis of Variance (ANOVA) and chi-square analyses then followed to compare average procedure duration, LOS, and complications across distinct moving groups of 50 procedures. Results Time series analyses suggest substantially improved times by the 50th procedure and reached a stable plateau between the 150th and 200th procedure. Average duration for the first 50 procedures was approximately 85 minutes, dropping to 69 minutes for procedures 51–100, 66 minutes for procedures 101–150, and then plateauing at approximately 61 minutes for procedures 151–682, demonstrating significant improvements in surgical efficiency at each 50-procedure interval (p < 0.05). There was no significant difference in LOS, readmissions, and reoperations with increasing groups of 50 procedures performed. Conclusion Results from this study will allow surgeons to better understand the implications of integrating robotic arm-assisted technology into their practice. Surgeons can expect significant improvement of their operative time following completion of at least 50 procedures, while likely reaching a maximum level of surgical efficiency between 151 and 200 procedures.
Article
Background: Robotic-assisted total knee arthroplasty (rTKA) has emerged as a patient-specific customizable tool that enables 3-dimensional preoperative planning, intraoperative adjustment, robotic-assisted bone preparation, and soft-tissue protection. Haptic rTKA may enhance component positioning, but only a few small studies have examined patient satisfaction and clinical outcomes after haptic rTKA. Purpose: In patients who underwent haptic rTKA, we sought to evaluate (1) the discrepancy in alignment between the executed surgical plan and implanted alignment in the coronal and sagittal planes 1 year postoperatively and (2) patient-reported outcomes 2 years postoperatively. Methods: From a prospectively collected database, we reviewed 105 patients who underwent haptic rTKA from August 2016 to May 2017. Two fellowship-trained arthroplasty surgeons independently reviewed hip-to-ankle standing biplanar radiographs to measure overall limb alignment and individual tibial and femoral component alignment relative to the mechanical axis and compared this to the executed surgical plan. Patient-reported outcomes were collected preoperatively and at 2 years postoperatively using the Lower Activity Extremity Score (LEAS), Knee Injury and Osteoarthritis Outcome Score Junior (KOOS Jr.), and Numeric Pain Rating Scale (NPRS). Results: Mean patient age was 62.4 years, and mean body mass index was 30.6 kg/m ² . Interobserver reliability was significant with a κ of 0.89. Absolute mean deviations in postoperative coronal alignment compared to intraoperative alignment were 0.625° ± 0.70° and 0.45° ± 0.50° for the tibia and femur, respectively. Absolute mean deviations in postoperative tibial sagittal alignment were 0.47° ± 0.76°. Overall mechanical alignment was 0.97° ± 1.79°. Outcomes in LEAS, KOOS Jr., and NPRS changed from 8 to 10, 78 to 88.3, and 8 to 1, respectively. Conclusions: Haptic rTKA demonstrated high reliability and accuracy (less than 1°) of tibial coronal, femoral coronal, and tibial sagittal component alignment postoperatively compared to the surgical plan. Patient-reported outcomes improved, as well. A more rigorous study on long-term outcomes is warranted.
Article
Case: A 26-year-old woman with a complex sequelae of open distal femoral fracture at 4 years of age presented to the office with severe knee pain from posttraumatic osteoarthritis. Robotic arm-assisted total knee arthroplasty (RA-TKA) with the elevation of previous free-flap was performed because of the following: (1) anatomic deformity, (2) small femoral size, and (3) compromised soft-tissue envelope. Conclusion: This case highlights the complexity of planning and performing TKA in a young patient with these unique considerations. The successful outcome demonstrates the viability of RA-TKA techniques.
Article
Zusammenfassung Der Einsatz robotischer Unterstützungssysteme findet seit den 1990er-Jahren zunehmend Anwendung in der Endoprothetik. Durch höhere Präzision und Reproduzierbarkeit sollen Komplikationen reduziert und funktionelle Ergebnisse sowie Standzeiten verbessert werden. Die meisten aktuell verfügbaren Systeme sind bildgeführt und erfordern eine entsprechende präoperative Planung. Bei anderen Systemen erfolgt die Erfassung der Anatomie und die Planung der Prothese erst intraoperativ. In der Knieendoprothetik konnte durch robotische Technik eine verbesserte Gelenkausrichtung erzielt werden. Bei Hüftendoprothesen zeigte sich eine Verringerung von Abweichungen bei der Pfannenpositionierung. Diese Resultate zeigten sich unabhängig von der Erfahrung des Operateurs, sodass besonders Operateure mit geringerer Fallzahl von dem Einsatz robotischer Unterstützungssysteme profitieren könnten. Jedoch steht dem allerdings eine verlängerte Operationszeit gegenüber. Zudem wirft die Technik u.a. Fragen bez. der Kosteneffizienz und des Managements intraoperativer Komplikationen auf. Ob es durch künstliche Intelligenz langfristig tatsächlich möglich sein wird, die Ergebnisse ohnehin bereits sehr erfolgreicher Operationen noch weiter zu verbessern, bleibt abzuwarten. In jedem Fall liegt die Verantwortung für das Gelingen der Operation doch stets beim Operateur.
Article
Robotic-assisted total knee arthroplasty is increasing in prevalence and has been shown to enable improved accuracy in implant positioning in total knee arthroplasty (TKA). Robotic assisted TKA can be categorized into image-guided and imageless techniques. In image-guided robotic TKA systems, pre-operative imaging, most frequently computed tomography (CT), is used to map bony anatomical landmarks to pre-operatively obtained image to plan bone resections and implant sizing and positioning. Imageless robotic-assisted TKA does not require pre-operative advanced imaging and intra-operatively maps bony anatomy to guide bone resection and implant sizing and placement. The purpose of this article is to describe the surgical technique for imageless robotic-assisted TKA and to provide a concise review of literature regarding surgical outcomes.
Article
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IntroductionThe Mako robotic arm knee arthroplasty system was initially indicated in unicompartmental knee arthroplasty followed by bicompartmental and total knee arthroplasty techniques. The system utilizes three elements: (1) Pre-op 3D CT based planning and image based intra-op navigation. (2) Pre-resection implant modifications with integrated alignment, implant position and gap data, and (3) A semi-constrained robotic arm assisted execution of bone resection with “haptic” boundaries, and cemented implants.Materials and methodsThis paper evaluates variable pre-op implant placement, and anatomic reference positioning; data entry with incorporation of alignment, implant congruency through range of motion, and gaps; bone resection with “haptic” boundaries, and final implant evaluation with kinetic sensors.ResultsThe Mako system allowed for improved implant placement utilizing CT guidance, bone resection accuracy, flexibility for functional implant placement with gap balancing. When combined with kinetic sensors, there was improved rotation and soft tissue balance.Conclusion The MAKO robotic system can assist the surgeon with anatomic landmarks, provides the flexibility for independent gap balance through implant and alignment refinement, and three-dimensional soft tissue balancing data to achieve functional stability. Registry data has shown improved outcome survivorship irrespective of the surgeons’ volumes and learning curves.
Preprint
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Background Total knee arthroplasty (TKA) is an effective and also mature surgical interventions that improves life quality and provides pain relief. Accurate bone cuts are important to prevent TKA malalignment and it requires cautious preoperative plan and precise bone resection. Recently, robotic-assisted TKA techniques have been used to improve the accuracy of bone resection and implantation. However, the system described above suits for only one prosthesis type. Methods Five types (MicroPort_CS, Smith& Nephew_GII, Johnson&Johnson_PFC_PS, kingnow _VLQX_PS and Akmedical_A3GT_PS) implants were included in our study and three Sawbones models were used for each implant. Procedures were performed by experienced joint replacement surgeons using HURWA robotic-assisted TKA system. Results our study indicated that the bone resection error of HURWA robotic-assisted system was below 0.5 mm (with SDs below 0.3 mm), and all of the bone resection angles were below 0.5° (with SDs below 0.3°). The bone resection angles and levels deviation of different brand prosthesis types were below 0.5 mm (with SDs below 0.3 mm) and below 0.5° (with SDs below 0.3°) respectively. Conclusion It suggested that our system may be suitable for different prosthesis types.
Chapter
Robotic-assisted knee arthroplasty has become increasingly commercially available as both technology developers and surgeons attempt to address specific limitations of conventional jig-based alignment techniques in order to improve resection accuracy and precision. Semi-active and passive systems predominate in the North American and European markets and can provide surgeons additional instruments for intraoperative calibration and balance assessment or directly assist in performing personalized resections. Recently published and ongoing clinical investigations seek to determine if robotic assistance may result in improved radiographic or clinical outcomes for patients undergoing either unicompartmental or total knee arthroplasty. A number of studies evaluating conventional and robotic-assisted knee arthroplasty did not identify significant radiographic or clinical outcome differences, though heterogeneity in robotic system design and application may limit the generalization of focused studies. Conversely, some studies that identified significant differences noted that robotic-assisted knee arthroplasty may be associated with fewer alignment outliers as well as increased surgical time—at least initially for unfamiliar surgeons. Further limitations include limited follow-up for newer systems on the market as well as the associated variety of arthroplasty implants and authors’ surgical techniques. Future studies will help surgeons and patients determine if intraoperative robotic assistance may be beneficial in total knee arthroplasty.
Article
Objective: To explore the short-term effectiveness of domestic robot-assisted total knee arthroplasty (RATKA) conducted by a prospective randomized controlled trial. Methods: Patients who were scheduled for primary unilateral TKA between October 2020 and December 2020 were eligible in this randomized controlled trial. According to the random number table method, they were allocated to the traditional TKA group and the RATKA group [application of the Yuanhua robotic-assisted TKA (YUANHUA-TKA) system during operation]. A total of 63 patients met the selection criteria were enrolled in the study, of which 3 cases voluntarily withdrew from the trial. And finally 60 cases were enrolled for analysis; of which 28 cases were in the RATKA group and 32 cases were in the traditional TKA group. There was no significant difference in gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, duration of osteoarthritis, surgical side, and preoperative knee visual analogue scale (VAS) resting and motion scores, joint range of motion (ROM), Knee Society Score (KSS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain, stiffness, and function scores, hip-knee-ankle angle (HKA) deviation ( P>0.05). The operation time and intraoperative blood loss of the two groups were recorded. Knee joint VAS resting and motion scores, ROM, KSS scores, and WOMAC pain, stiffness, and function scores were used to evaluate the knee joint function and pain. Gait analysis (flexion and extension angle) was conducted at 3 months after operation. The full length X-ray films of lower limbs and anteroposterior and lateral X-ray films of knee joint were taken. The HKA deviation, lateral tibia component (LTC), frontal femoral component (FFC), frontal tibia component (FTC), and lateral femoral component (LFC) measured on the X-ray films were used to evaluat the lower limb alignment and prosthesis position. Results: The operations of the two groups completed successfully; the incisions healed by first intention after operation, and no complications related to the operation occurred. The operation time of the RATKA group was significantly longer than that of the traditional TKA group ( t=12.253, P=0.001), and there was no significant difference in intraoperative blood loss between the two groups ( t=3.382, P=0.071). All patients were followed up 3 months. At 3 months after operation, the knee joint VAS resting and motion scores, ROM, KSS scores, and WOMAC pain, stiffness, and function scores improved significantly when compared with preoperatively in the two groups ( P<0.05); there was no significant difference of pre- and post-operative indicators between the two groups ( P>0.05). The gait analysis showed that the flexion and extension angle in the RATKA group was significantly bigger than that in the traditional TKA group ( t=9.469, P=0.003). X-ray films reexamination at 3 months after operation showed that the prostheses in the two groups were in good positions, and there was no adverse events such as prosthesis loosening or sinking. There were significant differences in the HKA deviation between pre- and post-operation in the two groups ( P<0.05), but the difference of pre- and post-operative HKA deviation between the two groups was not significant ( t=1.254, P=0.267). There was no significant difference in FFC, FTC, and LFC between the two groups ( P>0.05); the LTC was significantly smaller in the RATKA group than in the traditional TKA group ( t=17.819, P=0.000), which was closer to the ideal value. Conclusion: YUANHUA-TKA system can improve the accuracy of osteotomy and the prosthesis placement as well as the lower limb alignment. Its short-term effectiveness can be promised, but long-term effectiveness needs to be further studied.
Article
Introduction The purpose of robot-assisted TKA is to improve implant positioning and soft tissue management, and thus improve the clinical results and implant survivorship. This study compared short-term outcomes of an imageless robot-assisted TKA versus conventional TKA. Imageless robot-assisted TKA would demonstrate improved short-term outcomes, in comparison with conventional TKA. Methods In this retrospective cohort study, we compared demographic, intraoperative, and postoperative data of 150 imageless robot-assisted TKA patients and 150 conventional TKA patients. Results Imageless robot-assisted TKA patients had reduced pain scores on day one following the surgery and had shorter postoperative length of stay (LOS). In contrast, there was no difference between the groups in the frequency of post-surgical infection or revision TKA. In addition, no difference was found in the duration of surgery. Conclusion It seems that the imageless robot-assisted TKA leads to similar short-term outcomes, compared with conventional TKA, with a few advantages over the latter, such as reduced pain scores on day one following the surgery and shorter LOS, without prolonging the surgery duration. Further investigation is needed to explore whether these findings have long-term clinical significance. Level of evidence III, retrospective cohort study.
Chapter
The acronym for computer-assisted orthopaedic surgery is CAOS, CAS stands for computer-assisted surgery (CAS).
Article
BACKGROUND: Osteoarthritis of the knee joint leads to a decrease in the volume of movements, a violation of the sliding of articular surfaces, and a change in the axis of the limb under load, which affects the biomechanics of walking. AIM: This study aims to compare the results of robot-assisted total knee arthroplasty (TKA) and manual techniques, their influence on the biomechanical and podometric parameters of the patient’s walk. METHODS: A prospective randomized study of 68 patients was carried out in the period from 2020 to 2021. Our follow-up period was 1 year. All patients were performed arthroplasty of one knee joint. The main Group “A” included 33 patients TKA with the use of an active robotic setting “TSolution-One” (“THINK Surgical, Inc.” [Fremont, California, USA]); the comparison Group “B” consisted of 35 patients with manual technic of TKA. We studied pain syndrome on the visual analog scale, functional state on the Oxford Knee Score (OKS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC), the volume of ROM movements, and the deviation of the mechanical axis by teleroentgenography of the lower limb. Objective analysis of limb function was performed on the «Alter-G» and the «C-mill». RESULTS: Post-operative pain syndrome on the 1st day after surgery in Group A is stronger by 7.9%, but by the 5th day after surgery in Group A, the pain syndrome is lower by 14.3%. ROM in Group A is better by 16% by 3 months after surgery, after 1 year by 10%. The positioning accuracy of the implant in Group A is 30% better. There are no statistically significant differences in the OKS and WOMAC scales between the groups. The results of restoring normal step in Group A are 13.5% better than in Group B. CONCLUSIONS: Robot-assisted TKA gives more accurate alignment of the mechanical axis, which improves the biomechanics of walking.
Article
Objective: To summarize the application and research progress of robotic-arm in total knee arthroplasty (TKA). Methods: Relevant literature at home and abroad was extensively reviewed to analyze the advantages and disadvantages of robotic-arm assisted TKA (RATKA). Results: Accurate reconstruction of lower extremity alignment and rotation alignment, accurate osteotomy and implant prosthesis in TKA are very important to improve the effectiveness and prolong the life of the prosthesis. Traditional TKA deviations occur in key links such as osteotomy due to operator's operation. RATKA solves the above problems to a certain extent and can assist accurate osteotomy and implant prosthesis, and protect the soft tissues around the knee joint. Patients' satisfaction after RATKA is high, and the operator's learning curve is shorter, which improves the efficiency of the operation. But it also has disadvantages such as prolonged operation time, increased complications and medical costs. Conclusion: Preliminary clinical application studies have shown that RATKA has satisfactory effectiveness, but its definite advantages compared with traditional TKA need to be confirmed by a large number of randomized controlled trials and long-term follow-up.
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Objective: Analysis of various parameters related to the patient, the disease, and the needed surgical maneuvers to develop guidance for preoperative selection of the appropriate and the best approach for a given patient. Rapid advances in minimally invasive surgical technology are fascinating and challenging alike. It can be difficult for surgeons to keep up with new modalities that come on to the market place and to assess their true value, i.e., distinguish between fashionable trends versus scientific evidence. Laparoscopy established minimally invasive surgery and has revolutionized surgical concepts and approaches to diseases since its advent in the early 1990s. Now, with robotic surgery rapidly gaining traction in this high-tech surgical landscape, it remains to be seen how the long-term surgical landscape will be affected. Methods: Review of the surgical evolution, published data and cost factors to reflect on advantages and disadvantages in order to develop a broader perspective on the role of various technology platforms. Results: Advocates for robotic technology tout its advantages of 3D views, articulating wrists, lack of hand tremor, and surgeon comfort, which may extend the scope of minimally invasive surgery by allowing for operations in places that are more difficult to access for laparoscopic surgery (e.g., the deep pelvis), for complex tasks (e.g., intracorporeal suturing), and by decreasing the learning curve. But conventional laparoscopy has also evolved and offers high-definition 3D vision to all team members. It remains to be seen whether all together the robot features outweigh the downsides of higher cost, operative times, lack of tactile feedback, possibly unusual complications, inability to move the operative table with ease, and the difficulty to work in different quadrants. Conclusions: While technical and design developments will likely address some shortcomings, the value-based impact of the various approaches will have to be examined in general and on a case-by-case basis. Value as the ratio of quality over cost depends on numerous parameters (disease, complications, patient, efficiency, finances).
Article
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Robotics in total knee arthroplasty (TKA) has undergone vast improvements. Although some of the systems have fallen out of favor due to safety concerns, there has been recent increased interest for semi-active haptic robotic systems that provide intraoperative tactile feedback to the surgeon. The potential advantages include improvements in radiographic outcomes, reducing the incidence of mechanical axis malalignment of the lower extremity and better tissue balance. Proponents of robotic technology believe that these improvements may lead to superior functional outcomes and implant survivorship. We aim to discuss robotic technology development, outcomes of unicompartmental and total knee arthroplasty and the future outlook. Short-term follow-up studies on robotic-assisted knee arthroplasty suggest that, although some alignment objectives may have been achieved, more studies regarding functional outcomes are needed. Furthermore, studies evaluating the projected cost-benefit analyses of this new technology are needed before widespread adoption. Nevertheless, the short-term results warrant further evaluation.
Article
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Many questionnaires are used to assess patient-reported outcomes, but there are few studies assessing the time to complete these questionnaires. The purpose of this study was to: (1) evaluate how much time it takes to complete the most commonly used patient-reported outcome questionnaires; (2) calculate the potential variation for time of completion; and (3) assess the potential role of demographics. After literature review, nine different questionnaires were chosen based on the frequency of citation. Each patient was given one questionnaire and time to complete was recorded. Mean times were compared and statistical analysis was performed on patients based on age ≥ 55 years, gender, and education level. The mean time of completion for each questionnaire is listed from shortest to longest: University of California Los Angeles (UCLA) activity score, Lower Extremity Activity Scale (LEAS), Hospital for Special Surgery Score (HSS), Lower Extremity Functional Scale (LEFS), Oxford Knee Score-12 (OKS-12), Knee Society Scores (KSS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-36 (SF-36), and the Knee Injury and Osteoarthritis Outcome Score (KOOS). The coefficients of variation were smallest in SF-36 and WOMAC while it was the largest in the UCLA activity score. Age of ≥ 55 years was associated with a longer time to complete the questionnaires. There was no association found between gender or education level. It is possible that if it takes longer to complete certain questionnaires, then the answers given may not accurately reflect the patient's condition. Future studies should focus on the accuracy of the respondents' answers to each questionnaire as well as the accuracy after filling out multiple questionnaires at a single patient office visit.
Article
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The advent of computer-assisted knee replacement surgery has focused interest on the alignment of the components. However, there is confusion at times between the alignment of the limb as a whole and that of the components. The interaction between them is discussed in this article. Alignment is expressed relative to some reference axis or plane and measurements will vary depending on what is selected as the reference. The validity of different reference axes is discussed. Varying prosthetic alignment has direct implications for surrounding soft-tissue tension. In this context the interaction between alignment and soft-tissue balance is explored and the current knowledge of the relationship between alignment and outcome is summarised.
Article
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We performed a prospective, randomised controlled trial of unicompartmental knee arthroplasty comparing the performance of the Acrobot system with conventional surgery. A total of 27 patients (28 knees) awaiting unicompartmental knee arthroplasty were randomly allocated to have the operation performed conventionally or with the assistance of the Acrobot. The primary outcome measurement was the angle of tibiofemoral alignment in the coronal plane, measured by CT. Other secondary parameters were evaluated and are reported. All of the Acrobot group had tibiofemoral alignment in the coronal plane within 2° of the planned position, while only 40% of the conventional group achieved this level of accuracy. While the operations took longer, no adverse effects were noted, and there was a trend towards improvement in performance with increasing accuracy based on the Western Ontario and McMaster Universities Osteoarthritis Index and American Knee Society scores at six weeks and three months. The Acrobot device allows the surgeon to reproduce a pre-operative plan more reliably than is possible using conventional techniques which may have clinical advantages.
Article
OBJECTIVE The ROSA device is a robotic stereotactic arm that uses a laser system to register the patient’s head or spine with MR or CT images. In this study, the authors analyze their experience with this system in pediatric neurosurgical applications and present selected cases that exemplify the usefulness of this system. METHODS The authors reviewed all cases that utilized the ROSA system at their institution. Patient demographics, pathology, complications, electrode placement, laser ablation, and biopsy accuracy were analyzed. Patient disposition and condition at follow-up were also analyzed. RESULTS Seventeen patients underwent 23 procedures using the ROSA system. A total of 87 electroencephalography electrodes were placed, with 13% deviating more than 3 mm from target. Six patients underwent stereotactic needle biopsy, and 9 underwent laser interstitial thermotherapy (LITT). One patient who underwent LITT required a subsequent craniotomy for tumor resection. Another patient experienced an asymptomatic extraaxial hematoma that spontaneously resolved. No patient suffered neurological complications during follow-up. Follow-up from the last procedure averaged 180 days in epilepsy patients and 309 days in oncology patients. CONCLUSIONS The precision, ease of use, and versatility of the ROSA system make it well suited for pediatric neurosurgical practice. Further work, including long-term analysis of results and cost-effectiveness, will help determine the utility of this system and if its applications can be expanded.
Article
Introduction: While total knee arthroplasty (TKA) procedures have demonstrated clinical success, occasionally intraoperative complications can occur. Collateral or posterior cruciate ligament injury, instability, extensor mechanism disruption, and tibiofemoral or patellofemoral dislocation are among a few of the intraoperatively driven adverse events prevalently ranked by The Knee Society. Robotic-arm assisted TKA (RATKA) provides a surgeon the ability to three-dimensionally plan a TKA and use intraoperative visual, auditory, and tactile feedback to ensure that only the desired bone cuts are made. The potential benefits of soft tissue protection in these surgeries need to be further evaluated. The purpose of this cadaver study was to assess the a) integrity of various knee soft tissue structures (medial collateral ligament [MCL], lateral collateral ligament [LCL], posterior cruciate ligament [PCL], and the patellar ligament), as well as b) the need for tibial subluxation and patellar eversion during RATKA procedures. Materials and methods: Six cadaver knees were prepared using RATKA by a surgeon with no prior clinical robotic experience. These were compared to seven manually performed cases as a control. The mean Kellgren-Lawrence score was 2.8 (range, 0 to 4) in RATKA and 2.6 (range, 1 to 4) in the manual cohort. The presence of soft tissue damage was assessed by having an experienced surgeon perform a visual evaluation and palpation of the PCL, MCL, LCL, and the patellar ligament after the procedures. In addition, leg pose and retraction were documented during all bone resections. The amount of tibial subluxation and patellar eversion was recorded for each case. Results: For all RATKA-assisted cases, there was no visible evidence of disruption of any of the ligaments. All RATKA cases were left with a bone island on the tibial plateau, which protected the PCL. Tibial subluxation and patella eversion were not required for visualization in any RATKA cases. In two of the seven MTKA cases, there was slight disruption noted of the PCL, although this did not lead to any apparent change in the functional integrity of the ligament. All MTKA cases required tibial subluxation and patellar revision to achieve optimal visualization. Discussion: Several aspects of soft tissue protection were noted during the study. During bone resections, the tibia in RATKA procedures did not require subluxation, which may reduce ligament stretching or decrease complication rates. Potential patient benefits for short-term recovery and decreased morbidity to reduce operative complications should be studied in a clinical setting. Since RATKA uses a stereotactic boundary to constrain the sawblade, which is generated based on the implant size, shape, and plan, and does not have the ability to track the patient's soft tissue structures, standard retraction techniques during cutting are recommended. Therefore, the retractor placement and potential for soft tissue protection needs to be further investigated. RATKA has the potential to increase soft tissue protection when compared to manual TKA.
Article
Purpose: Measuring the effect of operative interventions has been a challenge in orthopaedics. The assessment of patient satisfaction, as measured by the Press Ganey (PG) satisfaction surveys, has gained increasing attention. Our purpose was to determine the factors and patient characteristics that influence patient satisfaction after THA. Materials and methods: The PG database was queried identifying 692 THA patients (November 2009 to January 2015). A multiple regression analysis was conducted. Results: Significant influence was found in communication with nurses (p=<0.001), response time of hospital staff (p=0.001), communication with physicians (p=0.002), and hospital environment (p=0.049). Management of pain and communication about medications were not significant for overall hospital rating. There were no differences between PG scores of patients who did and did not have complications. Conclusions: Hospital rating was significantly influenced by patients' communication with nurses, response time of hospital staff, and communication with physicians. Recognizing the importance of these elements, can greatly improve patient satisfaction after THA.
Article
Background: Recent healthcare reform has spurred important changes to provider reimbursement. With the implementation of the Value Based Purchasing program, significant weight is placed on patient experience of care. The Press Ganey (PG) survey is currently used by over 10,000 hospitals, as it serves to help optimize patient satisfaction. However, confounding factors, such as clinical depression, are not screened against by PG. Thus, arthroplasty surgeons performing lower extremity total joint arthroplasty (TJA) may have difficulty optimizing patient satisfaction while caring for patients with clinical depression. Therefore, we asked: 1) What Press Ganey elements affect the overall hospital rating in patients who suffer from clinical depression? and 2) Are survey responses different between patients who do and do not have clinical depression? Materials and methods: We queried our institutional PG database for patients who underwent a TJA from November 2009 to January 2015. Our search yielded 1,454 patients, of which 204 suffered from depression and 1,250 did not. Multiple regression analysis was performed to determine the influence (b weight) of selected PG survey domains on overall hospital rating. The weighted mean for domain was also calculated. Results: Multiple regression analyses showed that overall hospital ratings were significantly influenced by communication with nurses (b-weight = 0.881, p< 0.001) in post-TJA patients with depression. The remaining domains were not statistically significant. There were no significant differences in individual PG elements for patients who did and did not have depression. Conclusion: Overall patient satisfaction among patients with depression was greatly influenced by communication with nurses. Understanding these challenges may encourage care coordination across disciplines for the management of patients with depression before and after surgery. As a result, this could optimize orthopedic surgery outcomes, but, more importantly, patient health and satisfaction, while reducing costs of care.
Article
Background: Component malposition in total hip arthroplasty (THA) contributes to instability and early failure. Robotic-assisted total hip arthroplasty (rTHA) utilizes CT-based planning with haptically-guided bone preparation and implant insertion to optimize component position accuracy. This study compared acetabular component position and postoperative complications following manual THA (mTHA) with rTHA. Materials and methods: Consecutive primary THAs performed by one surgeon at three intervals were analyzed in this retrospective cohort study: the initial 100 consecutive manual THAs (mTHA) in clinical practice (year 2000), the last consecutive 100 mTHA before rTHA introduction (year 2011), and the first consecutive 100 rTHA (year 2012). Acetabular abduction (AAB) and anteversion (AAV) angles were measured using validated software. The Lewinnek safe zone was used to define accuracy (AAB 40°±10° and AAV 15°±10°). Comparisons included operative time, estimated blood loss (EBL), infection rate, and dislocation rate. Results: The rate of acetabular component placement within Lewinnek safe zone was the highest in the rTHA cohort (77%), followed by late mTHA (45%) and early mTHA (30%) (p<0.001). Robotic-assisted THA resulted in an additional 71% improvement in accuracy in the first year of use (p<0.001). Dislocation rate was 5% with early mTHA, 3% in the late mTHA cohort, and 0% in the rTHA cohort within the first two years postoperatively. There were no statistically significant differences in the rate of infection between groups. Conclusion: Robotic-assisted THA improved acetabular component accuracy and reduced dislocation rates when compared with mTHA. Further study is needed to determine if similar improvements will be noted in larger multicenter studies using alternative surgical approaches.
Article
Background: The reimbursement for medical services by Medicare and Medicaid (CMS) has recently changed from fee-for-service to quality-based payments. This is being implemented through the use of patient administered surveys, most commonly Press Ganey. With a recent strive for fast-track total hip arthroplasty (THA), it is important to ascertain whether length-of-stay (LOS) in post-THA patients influences the Press Ganey scores and overall hospital ratings. Therefore, we looked at: 1) Which Press Ganey survey factors affect overall hospital rating in patients who have a short (=2) or longer (>2) length of stay; and 2) whether hospital satisfaction is different between patients who have varied lengths of stay. Materials and methods: A query of the Press Ganey database at our institution was performed between November 2009 and January 2015. We identified 692 patients who had a mean age of 62 years (range, 15 to 91 years). These patients were stratified into two cohorts based on LOS (=two days, n=403; >two days, n=289). Multiple regression analyses were performed using weighted means of each Press Ganey question category to identify their influence ( b) on hospital ratings. We assessed differences in demographics and survey responses between the two cohorts using x2 tests for categorical data and t-tests for continuous data. Results: There was no statistically significant difference found between our two cohorts in hospital rating after adjusting for gender and ASA score. In patients who had short lengths-of-stay (LOS= two days), the overall hospital rating was most influenced by communication with nurses ( b=0.335, p= 0.004), followed by responsiveness of hospital staff ( b=0.313, p=0.006), and communication with doctors ( b=0.208, p=0.049) after adjusting for gender and ASA score. For patients who stayed longer (LOS>two days), the most important factor in hospital ratings was communication with nurses ( b=0.332, p= 0.007), followed by hospital environment ( b=0.312, p=0.002), communication with doctors ( b=0.233, p=0.013), and staff responsiveness (b=0.223 p=0.042). Conclusion: Short (LOS=2) and long (>two days) lengths of stay did not affect overall hospital rating. However, amongst both cohorts, communication with nurses, staff responsiveness, and communication with doctors were positively correlated with hospital ratings. Hospital environment also played a significant role in overall hospital ratings for patients who had an LOS >two days. More studies should be conducted to assess if the use of minimally invasive THA affects overall hospital ratings.
Article
The Centers for Medicare and Medicaid Services has implemented the Value-Based Purchasing (VBP) score as a pay-for-performance reimbursement model. Patient experience, as measured by the Press Ganey (PG) survey, currently comprises 20% of total VBP score. It is therefore beneficial for the orthopaedist to become familiar with these changes to maximize profits. Currently, a paucity of data exists that elucidates which factors influence PG scores between men and women following total knee arthroplasty (TKA). Therefore, we asked: (1) which PG survey factors most influences hospital ratings among men and women patients post-TKA and (2) is there a significant difference in overall hospital ratings among men and women cohorts post-TKA? We queried the PG database for patients who received a TKA between November 2009 and January 2015, yielding 224 men (mean age 64 years, range: 39–88) and 519 women (mean age 65 years; range, 25–92). A multiple regression analysis was performed for each cohort with overall hospital satisfaction as the dependent variable to assess the influence (β-weight) each PG domain imparted on overall hospital rating. A chi-square analysis and t-test were performed to assess categorical and continuous variables, respectively. For men, communication with nurses (β = 0.408, p = 0.016), followed by communication about medications (β = 0.261, p = 0.032), most influenced overall hospital rating. For women, communication with nurses (β = 0.479, p < 0.001) most influenced overall hospital rating. This was followed by staff responsiveness (β = 0.201, p = 0.046), pain management (β = 0.263, p = 0.015), and communication about medications (β = − 0.152, p = 0.029). It is of great advantage for the orthopaedist to focus on the PG domains most pertinent to each patient gender post-TKA. For both genders, overall hospital rating was significantly influenced by communication with nurses and information about medication. However, staff responsiveness and pain control were of significant importance in determining overall hospital rating for women. Therefore, orthopaedists should consider focusing on these factors depending on the gender of the patient to optimize satisfaction.
Article
Background: The purpose of this study was to assess whether Center for Medicaid and Medicare services-implemented satisfaction (Press Ganey [PG]) survey results correlate with established total knee arthroplasty (TKA) assessment tools. Methods: Data from 736 patients who underwent TKA and received a PG survey between November 2009 and January 2015 were analyzed. The PG survey overall hospital rating scores were correlated with standardized validated outcome assessment tools for TKA (Short form-12 and 36 Health Survey; Knee Society Score; Western Ontario and McMaster Universities Arthritis Index; University of California, Los Angeles; and visual analog scale) at a mean follow-up of 1154 days post-TKA. Results: There was no correlation between PG survey overall hospital rating score and the above-mentioned outcome assessment tools. Conclusion: Our study shows that there is no statistically significant relationship between established arthroplasty assessment tools and the PG overall hospital rating. Therefore, PG surveys may not be an appropriate tool to determine reimbursement for orthopedists performing TKAs.
Article
Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.
Article
Introduction: There are many standardized scales and questionnaires used to evaluate TKA patients; however, individually they do not always assess patients adequately. Consequently, many are used in combinations to provide a thorough evaluation. However, this leads to redundancy, confusion, and an excessive patient time-burden. Therefore, the purpose of this study was to develop a usable combined knee questionnaire that combines questions in a non-redundant manner. Specifically, we aimed to: 1) create a combined knee questionnaire that encompasses questions from multiple systems, while eliminating redundancy; 2) correlate the new system with the existing validated questionnaires; and 3) determine the length of time it takes to administer this new questionnaire. Materials and methods: In a previous study, it was determined that the six most commonly cited validated systems to assess the knee were the: Knee Society Score (KSS), The Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Functional Scale (LEFS), Activity Rating Scale (ARS), and Short-Form-36 (SF-36). Therefore, we ensured that the new questionnaire encompassed all elements of these systems. After development of the combined questionnaire, we co-administered it to 20 subjects alongside the above validated questionnaires. We then transposed the corresponding answers from the combined questionnaire to each selected validated system to perform an intra-class correlation analysis. In addition, we recorded the length of time it took to administer the new questionnaire and compared it to the time it took to administer the individual validated questionnaires. Results: Intra-class correlation analysis demonstrated statistically significant positive correlations between the KSS, WOMAC, KOOS, LEFS, ARS, SF-36, and the corresponding questions in the combined questionnaire. The mean length of time it took to administer the combined questionnaire (mean, 10.1 minutes, range, 6.6 to 12.6 minutes) was significantly shorter than the time it took to administer the selected validated questionnaires (mean, 21.3 minutes, range, 17.3 to 24.1 minutes). Conclusion: We have proposed an all-encompassing combined knee questionnaire that eliminates redundancy and inefficiency during the evaluation of TKA patients. It is a reliable, time-efficient system that can be utilized to fill out the most commonly used questionnaires for assessing TKA. Standardization and uniform use of this questionnaire may simplify future patient assessment following TKA.
Article
Introduction: Functional outcome following total hip arthroplasty (THA) is affected by accurate component positioning and restoration of hip biomechanics. Robotic-assisted THA (rTHA) has been shown to improve accuracy of component positioning, but its impact on functional outcomes has not been demonstrated. The purpose of this study was to compare: 1) operative time; 2) estimated blood loss; 3) postoperative complications; and 4) patient-reported outcome measures (PROMs) between patients who either underwent rTHA or manual THA (mTHA). Materials and methods: In this retrospective cohort study, a single-center database was used to identify all patients who underwent primary THA since introduction of rTHA at a large academic medical center. Surgical factors including operative time and estimated blood loss as well as postoperative complications were recorded. Validated PROMs following rTHA (n = 100) were compared with consecutive mTHA cases (n = 100) performed by the same fellowship-trained surgeon at a minimum one-year follow-up (24 ± 6 months). PROMs included the Short-Form 12 Health Survey (SF-12), UCLA activity score (UCLA), Western Ontario and McMaster (WOMAC) Osteoarthritis Index, and modified Harris Hip Score (mHHS). A categorical analysis was performed to determine differences in proportions of patients with mHHS scores of 90 to 100, 80 to 89, 70 to 79, and < 70 points between the two groups. Chi-square and two-tailed t-tests were used to compare categorical and continuous data between cohorts. Results: Mean operative time was nine minutes longer for the rTHA group compared with the mTHA group (131 ± 23 min vs. 122 ± 29 min, respectively, p = 0.012). Estimated intraoperative blood loss was significantly reduced for the rTHA group when compared to the mTHA group (374 ± 133 mL vs. 423 ± 186 mL, p = 0.035), and there was no difference in overall complication rates between the two groups (p = 0.101). Robotic-assisted THA demonstrated significantly higher mean postoperative mHHS (92.1 ± 10.5 vs. 86.1 ± 16.2, p = 0.002) and mean UCLA scores (6.3 ± 1.8 vs. 5.8 ± 1.7, p = 0.033) compared with mTHA. The difference between pre- and postoperative mHHS scores was statistically significant when comparing rTHA with mTHA (43.0 ± 18.8 vs. 37.4 ± 18.3, p = 0.035). There were no significant differences in SF-12 or WOMAC scores. There was a significantly higher proportion of patients with mHHS scores between 90 to 100 points (75% vs. 61%, p = 0.034) and a lower percentage with scores < 70 points (6% vs. 19%, p = 0.005) in the rTHA cohort compared with the mTHA cohort. Discussion: The rTHA cohort demonstrated significantly higher mean postoperative UCLA scores, higher mean postoperative mHHS scores, and a greater percentage of patients with mHHS of 90 to 100 points compared with mTHA at a minimum one-year follow-up. To our knowledge, this is the first study to demonstrate that robotic-assisted THA leads to improved patient-reported outcomes. The observed improvement in functional outcomes following rTHA is encouraging and warrants additional multi-center studies to determine if these advantages are maintained at longer follow-up intervals.
Article
Recently, there is a growing interest in surgical variables that are intraoperatively controlled by orthopaedic surgeons, including lower leg alignment, component positioning and soft tissues balancing. Since more tight control over these factors is associated with improved outcomes of unicompartmental knee arthroplasty and total knee arthroplasty (TKA), several computer navigation and robotic-assisted systems have been developed. Although mechanical axis accuracy and component positioning have been shown to improve with computer navigation, no superiority in functional outcomes has yet been shown. This could be explained by the fact that many differences exist between the number and type of surgical variables these systems control. Most systems control lower leg alignment and component positioning, while some in addition control soft tissue balancing. Finally, robotic-assisted systems have the additional advantage of improving surgical precision. A systematic search in PubMed, Embase and Cochrane Library resulted in 40 comparative studies and three registries on computer navigation reporting outcomes of 474,197 patients, and 21 basic science and clinical studies on robotic-assisted knee arthroplasty. Twenty-eight of these comparative computer navigation studies reported Knee Society Total scores in 3504 patients. Stratifying by type of surgical variables, no significant differences were noted in outcomes between surgery with computer-navigated TKA controlling for alignment and component positioning versus conventional TKA (p = 0.63). However, significantly better outcomes were noted following computer-navigated TKA that also controlled for soft tissue balancing versus conventional TKA (mean difference 4.84, 95 % Confidence Interval 1.61, 8.07, p = 0.003). A literature review of robotic systems showed that these systems can, similarly to computer navigation, reliably improve lower leg alignment, component positioning and soft tissues balancing. Furthermore, two studies comparing robotic-assisted with computer-navigated surgery reported superiority of robotic-assisted surgery in controlling these factors. Manually controlling all these surgical variables can be difficult for the orthopaedic surgeon. Findings in this study suggest that computer navigation or robotic assistance may help managing these multiple variables and could improve outcomes. Future studies assessing the role of soft tissue balancing in knee arthroplasty and long-term follow-up studies assessing the role of computer-navigated and robotic-assisted knee arthroplasty are needed.
Article
Although current total knee arthroplasty (TKA) is considered a highly successful surgical procedure, patients undergoing TKA can still experience substantial functional impairment and increased revision rates as compared with those undergoing total hip arthroplasty. Robotic-assisted surgery has been available clinically for almost 15 years and was developed, in part, to address these concerns. Robotic-assisted surgery aims to improve TKA by enhancing the surgeon's ability to optimize soft tissue balancing, reproduce alignment, and restore normal knee kinematics. Current systems include a robotic arm with a variety of different navigation systems with active, semi-active, or passive control. Semi-active systems have become the dominant strategy, providing a haptic window through which the surgeon consistently prepares a TKA based on preoperative planning. A review of previous designs and clinical studies demonstrates that these robotic systems decrease variability and increase precision, primarily with the mechanical axis and restoration of the joint line. Future design objectives include precise planning and consistent intraoperative execution. Preoperative planning, intraoperative sensors, augmenting surgical instrumentation, and biomimetic surfaces will be used to re-create the 4-bar linkage system in the knee. Implants will be placed so that the knee functions with a medial pivot, lateral rollback, screw home mechanism, and patellar femoral tracking. Soft tissue balancing will become more than equalizing the flexion and extension gaps and will match the kinematics to a normal knee. Together, coupled with advanced knee designs, they may be the key to a patient stating, "My knee feels like my natural knee." [Orthopedics. 20xx; xx(x):exxx-exxx.].
Article
In the last 10 years many studies have questioned if the strive to mechanical align any knee may pose some problems related to ligament misbalancing that could explain the high rate of disappointed patients, almost 20% in some reports. Proper indication and difference between patient's and surgeon's expectations are among the most important one's but it must be underlined that, there is indeed a sharp difference between normal knee kinematics, prosthetic knee kinematics and arthritic knee kinematics being the last one extremely variable. A so called kinematic alignment has recently been developed in order to improve patient's knee function and pain control minimizing any surgical gesture focused on ligaments balance. The amount of bone resections may not affect limb alignment but has an important consequence in ligament tension and balance, clinical result and function therefore a measured bone resection technique is essential in order to perform a proper kinematic alignment. Purpose of this paper is to briefly review the different alignment procedures used for TKA and to discuss their definitions, concepts and evidence on outcome.
Article
Introduction: Many standardized scales and questionnaires have been developed to assess outcomes of patients undergoing total hip arthroplasty (THA). However, these surveys can be a burden to both patients and orthopaedists as some are time-inefficient. In addition, there is a paucity of reports assessing the time it takes to complete them. In this study we aimed to: (1) assess how long it takes to complete the most common standardized hip questionnaires; (2) determine the presence of variation in completion time; and (3) evaluate the effects of age, gender, and level of education on completion time. Materials and methods: Based on a previous study, we selected the seven most commonly used hip scoring systems-Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Larson Score, Short-form 36 (SF-36), modified Merle d'Aubigne and Postel Score (MDA), and Lower Extremity Functional Scale (LEFS). The standardized scales and questionnaires were randomly administered to 70 subjects. The subjects were unaware that they were being timed during completion of the questionnaire. We obtained the coefficients of variation of time for each questionnaire. The mean time to complete the questionnaire was then stratified and compared based on age, gender, and level of education. Results: The mean time to complete each of the systems is listed in ascending order: Modified Merle d'Aubigne and Postel Score (MDA), Lower Extremity Functional Scale (LEFS), Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC), Harris Hip Score (HHS), Larson Score, Hip Disability and Osteoarthritis Outcome Score (HOOS), and Short-form 36 (SF-36). The WOMAC and Larson Score coefficients of variation were the largest, and the HOOS and MDA were the smallest. There was a significantly higher mean time to completion in those who were above or equal to the age of 55 years as compared to those who were below the age of 55 (227 vs. 166 seconds). There was no significant association found in time of completion between gender or education level. Conclusion: Standardized scales and questionnaire which assess THA patients can be burdensome and time-inefficient, which may lead to task-induced fatigue. This may result in inaccurate THA patient assessments, which do not reflect the patient's true state. Future studies should aim to create an encompassing questionnaire that is time efficient and can replace all currently used validated systems.
Article
Introduction: There is increasing pressure from Centers for Medicare and Medicaid Services (CMS) to report quality measures for all hospitalizations. These quality measures are determined based on results from satisfaction surveys, such as Press Ganey® (PG) (Press Ganey® Performance Solutions, Wakefield, Massachusetts). Included in this particular survey element are questions regarding staff, including nurses and doctors, as well as items such as pain control. The results of these surveys will dictate the amount doctors are compensated for their services. Therefore, this study was undertaken to evaluate the effect of treating orthopaedists and nurses, as well as pain control, on PG surveys in patients who underwent total knee arthroplasty (TKA). Specifically, we aimed to ascertain the effect of these factors on how post-TKA patients perceive: 1) their orthopaedist, and 2) their overall surgical experience. Materials and methods: We queried the Press Ganey® Database for all patients who underwent a TKA at our institution between November 2009 and January 2015. A weighted mean of question domains was utilized since each had multiple questions. In order to assess if pain management influences orthopaedist perception, a correlation analysis was performed between pain control and perception. In order to assess the influence of pain management on surgical experience, we performed a correlation analysis between pain control and overall hospital rating. A multiple regression analysis was performed using the hospital rating as the dependent variable to determine the most influential factors on surgical experience. Results: Our analysis demonstrated a significantly positive correlation between patient perception of their pain control and their orthopaedist. There was a significant positive correlation between patient's perception of their pain control and their overall surgical experience. Multiple regression analysis using overall surgical experience as the dependent variable demonstrated a significant positive influence of perception of nurses and orthopaedists. Pain management positively influenced surgical experience; however, this was not significant. Conclusions: We found that perception of pain control in post-TKA patients affects perception of the treating orthopaedists, as well as their overall surgical experience. In addition, perception of orthopaedists and nurses both outweigh perception of pain control on overall surgical experience, with nurses being the most important. Orthopaedists should focus on staff education-particularly nurses-and educate them in order to optimize results on PG surveys and, ultimately, improve patient satisfaction. Further studies should correlate current standardized scoring systems and questionnaires for TKA with PG surveys in order to recognize gaps that need to be bridged to improve post-TKA patient satisfaction.
Article
Purpose Despite reduction in radiological outliers in previous randomized trials comparing robotic-assisted versus conventional total knee arthroplasty (TKA), no differences in short-term functional outcomes were observed. The aim of this study was to determine whether there was improvement in functional outcomes and quality-of-life (QoL) measures between robotic-assisted and conventional TKA. Methods All 60 knees (31 robotic-assisted; 29 conventional) from a previous randomized trial were available for analysis. Differences in range of motion, Knee Society (KSS) knee and function scores, Oxford Knee scores (OKS), SF-36 subscale and summative (physical PCS/mental component scores MCS) were analysed. In addition, patient satisfaction, fulfilment of expectations and the proportion attaining a minimum clinically important difference (MCID) in KSS, OKS and SF-36 were studied. Results Both robotic-assisted and conventional TKA displayed significant improvements in majority of the functional outcome scores at 2 years. Despite having a higher rate of complications, the robotic-assisted group displayed a trend towards higher scores in SF-36 QoL measures, with significant differences in SF-36 vitality (p = 0.03), role emotional (p = 0.02) and a larger proportion of patients achieving SF-36 vitality MCID (48.4 vs 13.8 %, p = 0.009). No significant differences in KSS, OKS or satisfaction/expectation rates were noted. Conclusion Subtle improvements in patient QoL measures were observed in robotic-assisted TKA when compared to conventional TKA. This finding suggests that QoL measures may be more sensitive and clinically important than surgeon-driven objective scores in detecting subtle functional improvements in robotic-assisted TKA patients. Level of evidence II.
Article
Introduction: Execution of total knee arthroplasty (TKA) in end-stage haemophilic arthropathy is challenging because of soft tissue fibrosis, flexion contractures, poor quality of the bone, and the altered bony anatomy. Restoring the lower limb alignment and achieving range of motion (ROM) is difficult. Robots have been used in TKA to reduce the chances of malalignment and improve accuracy and precision. However, there has been no report in literature on use of robots for TKA in haemophilic arthropathy. The aim of this study was to evaluate whether robot-assisted TKA can be successfully carried out in haemophilic arthropathy and what precision could be obtained. Methods: Thirty-two robot-assisted TKA were evaluated in 29 haemophilia patients. The mean follow up period was 5 years (range, 3-7 years). Hip-knee-ankle (HKA) axis, component angles, and radiographic loosening were evaluated. Clinically ROM, Knee Society scores (KSS) and SF-36 were assessed. Results: The HKA axis was within a range of 0 ± 3° in 30 knees (93.8%). The alignment of the components also presented satisfying results. KSS were improved from 27.1 to 82.8 postoperatively (P < 0.001). The ROM was improved from 70.7 to 84.7 postoperatively (P = 0.006). Complications included early haematoma in three knees, heterotopic ossification in three knees, periprosthetic infection in two knees. Conclusions: Though robotic TKA gives excellent accuracy of lower limb and component alignment, expensive cost, additional preparation time, longer operation time with similar clinical results in haemophilic arthropathy should be concerned.
Article
Introduction: To assess the success of a total knee arthroplasty (TKA), scoring systems have been developed to provide a straightforward method of evaluating the outcomes of patients following surgery. Fully evaluating these outcomes is a challenging and time consuming task, and these simplistic measures often do not provide a complete picture of a patient's recovery. Therefore, we evaluated different scoring systems to determine the most effective method of assessing the outcomes of patients undergoing total knee arthroplasty. Materials and methods: We evaluated all knee scoring systems currently available in literature, and a total of 46 questionnaires met our inclusion and exclusion criteria. We then identified all the metrics assessed in the questionnaires (n=48) and subdivided them into objective, subjective, rehabilitative, and quality of life outcome measures. We identified the three most commonly referenced questionnaires (the Knee Society Scores, the Knee Osteoarthritis and Outcomes Scores, and the Western Ontario and McMaster Score-WOMAC) and assessed multiple permutations of these with other scoring systems to identify the combinations that would most comprehensively and efficiently evaluate the outcomes of patients undergoing TKA. Results: Of the 48 metrics, we identified four subjective, eight objective, 20 rehabilitation, and 16 quality of life metrics. On permutation of the three most referenced scoring systems, the KSS and the KOOS together yielded the greatest coverage of the above metrics (79%). When the KSS, KOOS, and WOMAC, respectively, were combined with the Lower Extremity Function Scale (LEFS) and Short Form 36 (SF-36), they yielded 77, 73, and 60% coverage of the metrics and 35, 39, and 37% redundancy, respectively. Conclusion: Surgeons and researchers have attempted to fully evaluate the outcomes of patients undergoing TKA. The proposed combinations may provide a more comprehensive way to cost-effectively evaluate outcomes. Further analysis is required before attempting to create newer knee scoring systems.
Article
Complications following total hip arthroplasty (THA), such as dislocation, component loosening and wear, continue to be common indications for revision surgery. Multiple studies have attributed some of these problems to poor acetabular cup alignment and placement outside of the purported radiographic safe zone. In addition, it has been shown that conventional manually performed acetabular cup placement may not lead to optimal alignment, regardless of surgical experience. Additionally, incorrect leg length and offset can lead to dissatisfaction and instability. Therefore, robotic-arm assisted surgery has been introduced to improve accuracy of cup placement and leg length, and to offset with the aim of reducing the risk of hip instability and improving satisfaction after primary THA. Our aim was to prospectively review the use of robotic-arm assisted surgery in 224 patients and to assess whether the pre-operatively determined radiographic targets were achieved post-operatively and the proportion of acetabular cups outside of the safe zone. Pre-determined anteversion and inclination were 15 and 40 degrees, respectively. Our results have shown that the use of robotic-arm assisted surgery resulted in a post-operative mean inclination of 40 degrees (range, 34 to 51 degrees) and a mean anteversion of 16 degrees (range, 9 to 25 degrees). Ninety-nine percent of the patients remained within the pre-designated safe zone. Evidence has shown that robotic-arm assisted surgery may have improved accuracy in cup placement when compared to conventional surgery and possibly to computer-assisted surgery. When compared to the literature on robotic-arm assisted surgery, our results were comparable. We believe that this surgical technique may aid in reducing post-operative THA complications, such as aseptic loosening and dislocations, but further prospective studies are needed to evaluate clinical outcomes and long-term results.
Article
Successful total knee arthroplasty (TKA) has often been based on the restoration of the knee to neutral alignment postoperatively. Numerous reports have linked malaligned TKA components to increased wear, poor functional outcomes, and failure. There have been many different alignment philosophies and surgical techniques that have been established to attain the goal of proper alignment, which includes such techniques as computerized navigation, and custom cutting guides. In addition, these methods could potentially have the added benefit of leading to improved functional outcomes following total knee arthroplasty. In this report, we have reviewed and analyzed recent reports concerning mechanical, anatomic, and kinematic axis/alignment schemes used in total knee arthroplasty.
Article
Background: Several studies have shown mechanical alignment influences the outcome of TKA. Robotic systems have been developed to improve the precision and accuracy of achieving component position and mechanical alignment. Questions/purposes: We determined whether robotic-assisted implantation for TKA (1) improved clinical outcome; (2) improved mechanical axis alignment and implant inclination in the coronal and sagittal planes; (3) improved the balance (flexion and extension gaps); and (4) reduced complications, postoperative drainage, and operative time when compared to conventionally implanted TKA over an intermediate-term (minimum 3-year) followup period. Methods: We prospectively randomized 100 patients who underwent unilateral TKA into one of two groups: 50 using a robotic-assisted procedure and 50 using conventional manual techniques. Outcome variables considered were postoperative ROM, WOMAC scores, Hospital for Special Surgery (HSS) knee scores, mechanical axis alignment, flexion/extension gap balance, complications, postoperative drainage, and operative time. Minimum followup was 41 months (mean, 65 months; range, 41-81 months). Results: There were no differences in postoperative ROM, WOMAC scores, and HSS knee scores. The robotic-assisted group resulted in no mechanical axis outliers (> ± 3° from neutral) compared to 24% in the conventional group. There were fewer robotic-assisted knees where the flexion gap exceeded the extension gap by 2 mm. The robotic-assisted procedures took an average of 25 minutes longer than the conventional procedures but had less postoperative blood drainage. There were no differences in complications between groups. Conclusions: Robotic-assisted TKA appears to reduce the number of mechanical axis alignment outliers and improve the ability to achieve flexion-extension gap balance, without any differences in clinical scores or complications when compared to conventional manual techniques.