Robotics-Assisted Knee Arthroplasty: JBJS Summary

JBJS SUMMARY

Knee

Robotics-Assisted Knee Arthroplasty

By: T. Jacob Selph Jr., BS, and Linda I. Suleiman, MD

Published: April 26, 2024

The number of robotics-assisted knee arthroplasties (RA KA) performed annually in the U.S. has risen since the technology’s initial implementation and is projected to continue rising; this is especially the case for RA unicompartmental knee arthroplasty (RA UKA).‍^[1] The capital investment required before implementation of RA KA is formidable, but financial modeling has demonstrated its economic feasibility with a sufficiently high case volume.‍^[2],‍^[3]

RA KA has demonstrated superiority to manual surgery especially in UKA studies, in which it has provided more accurate component positioning resulting in improved recovery and short-term patient-reported outcomes (PROs).‍^[4],‍^[5],5 Precise component alignment is understood to be a key factor influencing implant survivorship in non-RA UKA.‍^[6],‍^[7] However, more long-term research is needed to establish evidence—beyond assumptions based on patterns observed in non-RA UKA—that improved component alignment in RA UKA directly translates to superior long-term PROs and implant survivorship.‍^[8],‍^[9] RA UKA is associated with a short learning curve to steady-state procedure time and accurate component positioning.‍^[10]

RA TKA is also associated with higher component positioning accuracy relative to manual surgery.‍^[11] However, unlike UKA, TKA precision does not serve as a reliable proxy for improved PROs.‍^[12] Of note, the role of strict coronal alignment target precision in TKA is a subject of debate, with data from new implant designs showing success in a broader range of limb and implant alignments than previously recommended.‍^[13]

Direct comparison of postoperative pain and function PROs between manual and RA TKAs has demonstrated mixed results, with RA TKA associated with significantly higher Hospital for Special Surgery (HSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores but no significant differences in Knee Society Scores (KSS) or range of motion.‍^[14] RA TKA is associated with decreased short-term postoperative inflammation as measured by interleukin (IL)-6 and IL-8 levels but no significant difference in tumor necrosis factor (TNF)-α levels.‍^[15] RA TKA was significantly associated with lower visual analog scale scores on postoperative days 1, 2, and 7.‍^[16] However, there was no significant difference in PROs between the cohorts at 2-year follow-up.‍^[17]

Further research, particularly prospective randomized controlled trials and long-term cohort studies with 10 to 20-year follow-up, will help clarify the role of robotics in TKA.

GIVE FEEDBACK

References

[1, 4, 6, 8, 10]

Lonner JH, Fillingham YA. Pros and Cons: A Balanced View of Robotics in Knee Arthroplasty. The Journal of arthroplasty. 2018;33(7):2007-13.

https://pubmed.ncbi.nlm.nih.gov/29680583/

[2, 7]

Swank ML, Alkire M, Conditt M, Lonner JH. Technology and cost-effectiveness in knee arthroplasty: computer navigation and robotics. The American journal of orthopedics (Belle Mead, NJ). 2009;38(2 Suppl):32.

https://pubmed.ncbi.nlm.nih.gov/19340382/

[3]

Hua Y, Salcedo J. Cost-effectiveness analysis of robotic-arm assisted total knee arthroplasty. PLOS ONE. 2022;17(11):e0277980.

https://pubmed.ncbi.nlm.nih.gov/36441807/

[5]

Bell SW, Anthony I, Jones B, MacLean A, Rowe P, Blyth M. Improved Accuracy of Component Positioning with Robotic-Assisted Unicompartmental Knee Arthroplasty. Journal of bone and joint surgery American volume. 2016;98(8):627-35.

https://pubmed.ncbi.nlm.nih.gov/27098321/

[9]

Chen AF, Kazarian GS, Jessop GW, Makhdom A. Robotic Technology in Orthopaedic Surgery. Journal of bone and joint surgery American volume. 2018;100(22):1984-92.

https://pubmed.ncbi.nlm.nih.gov/30480604/

[11, 14]

Agarwal N, To K, McDonnell S, Khan W. Clinical and Radiological Outcomes in Robotic-Assisted Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty. 2020 2020/11/01/;35(11):3393-409.e2.

https://pubmed.ncbi.nlm.nih.gov/32234326/

[12-13]

Vigdorchik JM, Wakelin EA, Koenig JA, Ponder CE, Plaskos C, DeClaire JH, et al. Impact of Component Alignment and Soft Tissue Release on 2-Year Outcomes in Total Knee Arthroplasty. The Journal of arthroplasty. 2022;37(10):2035-40.e5.

https://pubmed.ncbi.nlm.nih.gov/35533822/

[-1, 15-16]

Fontalis A, Kayani B, Asokan A, Haddad IC, Tahmassebi J, Konan S, et al. Inflammatory Response in Robotic-Arm-Assisted Versus Conventional Jig-Based TKA and the Correlation with Early Functional Outcomes: Results of a Prospective Randomized Controlled Trial. Journal of bone and joint surgery American volume. 2022;104(21):1905-14.

https://pubmed.ncbi.nlm.nih.gov/36074816/

Related Images from JBJS

Fig. 2-A Photograph showing a sensor-based device that is used to measure the load within the medial and lateral compartments of the knee. Fig. 2-B Computer feedback demonstrating an imbalance between compartments. Fig. 2-C Computer feedback obtained after surgical correction, showing that the measured loads in the medial and lateral compartments are equal.

Navigation and Robotics in Knee Arthroplasty

Buza, John A.; Wasterlain, Amy S.; Thakkar, Savyasachi C.; Meere, Patrick; Vigdorchik, Jonathan

JBJS Rev, 5(2):e4 | Review Article | February 28, 2017

Fig. 4-A Preoperative T1-weighted MRI scan used for surgical planning. Fig. 4-B Three-dimensional computer reconstruction of osseous anatomy based on the MRI scan shown in Figure 4-A. Fig. 4-C Three-dimensional computer reconstruction demonstrating virtual component implantation with the use of computer software. Fig. 4-D Computer graphic rendering of the design of patient-specific instrumentation to achieve desired component position and alignment. Fig. 4-E Postoperative radiograph. (Images reprinted with permission from Smith & Nephew.)

Navigation and Robotics in Knee Arthroplasty

Buza, John A.; Wasterlain, Amy S.; Thakkar, Savyasachi C.; Meere, Patrick; Vigdorchik, Jonathan

JBJS Rev, 5(2):e4 | Review Article | February 28, 2017

Photographs showing accelerometer-based technology attached to both tibial (Fig. 1-A) and femoral (Fig. 1-B) cutting guides.

Navigation and Robotics in Knee Arthroplasty

Buza, John A.; Wasterlain, Amy S.; Thakkar, Savyasachi C.; Meere, Patrick; Vigdorchik, Jonathan

JBJS Rev, 5(2):e4 | Review Article | February 28, 2017

Anteroposterior (left) and lateral (right) fluoroscopic images showing the talar array anchor and the provisional fixation wire.

Computer-Assisted Surgery for Subtalar Arthrodesis

A Study in Cadavers

Easley, Mark; Chuckpaiwong, Bavornrit; Cooperman, Nathan; Schuh, Reinhard; Ogut, Tahir; Le, Ian L.D.; Reach, John

J Bone Joint Surg Am, 90(8):1628-1636 | Scientific Articles | August 01, 2008

Figs. 1-A, 1-B, and 1-C Radiographic measurements of the distal femoral angle, the proximal tibial angle, and the posterior slope angle. The distal femoral angle (DFA) was measured on anteroposterior radiographs and was defined as the medial angle (red) between (1) the anatomic axis of the femur (proximal-to-distal line in the medullary canal bisecting the femoral shaft) and (2) a line drawn parallel to the distal aspect of the femoral component (parallel to the medial and lateral condyles of the femoral component)7. Line 1 (blue) was defined by 2 points (green): (1) the proximal-most point of the radiograph at the center of the femoral shaft and (2) 10 cm superior to the knee joint, equidistant from the medial and lateral medullary cortices of the femur42.

The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty

Kazarian, Gregory S.; Lawrie, Charles M.; Barrack, Toby N.; Donaldson, Matthew J.; Miller, Gary M.; Haddad, Fares S.; Barrack, Robert L.

J Bone Joint Surg Am, 101(19):1713-1723 | Scientific Articles | October 02, 2019

Pressure load mismatch identified intraoperatively with VERASENSE tibial sensor insert. (Courtesy of OrthoSensor.)

Soft-Tissue Balancing Technology for Total Knee Arthroplasty

Siddiqi, Ahmed; Smith, Tyler; McPhilemy, John J.; Ranawat, Amar S.; Sculco, Peter K.; Chen, Antonia F.

JBJS Rev, 8(1):e0050 | Review Articles | January 03, 2020

Representative computed tomography scans demonstrating screw position measurements in the lateral (upper left image), coronal (upper right image), and axial planes (lower three images).

Computer-Assisted Surgery for Subtalar Arthrodesis

A Study in Cadavers

Easley, Mark; Chuckpaiwong, Bavornrit; Cooperman, Nathan; Schuh, Reinhard; Ogut, Tahir; Le, Ian L.D.; Reach, John

J Bone Joint Surg Am, 90(8):1628-1636 | Scientific Articles | August 01, 2008

Preoperative images showing implant location before (Figs. 2-A and 2-B) and after (Figs. 2-C and 2-D) bone preparation.

Three-Dimensional Imaging and Templating Improve Glenoid Implant Positioning

Iannotti, Joseph P.; Weiner, Scott; Rodriguez, Eric; Subhas, Naveen; Patterson, Thomas E.; Jun, Bong Jae; Ricchetti, Eric T.

J Bone Joint Surg Am, 97(8):651-658 | Scientific Articles | April 15, 2015

Landmarks to define the plane of the scapula and the plane of the glenoid.

Three-Dimensional Imaging and Templating Improve Glenoid Implant Positioning

Iannotti, Joseph P.; Weiner, Scott; Rodriguez, Eric; Subhas, Naveen; Patterson, Thomas E.; Jun, Bong Jae; Ricchetti, Eric T.

J Bone Joint Surg Am, 97(8):651-658 | Scientific Articles | April 15, 2015

Figs. 1-A, 1-B, and 1-C Radiographs of a patient with bilateral end-stage arthrosis secondary to hemophilia. Bilateral anteroposterior radiographs.

Evidence-Based Management of the Knee in Hemophilia

Liddle, Alexander D.; Rodriguez-Merchan, E. Carlos

JBJS Rev, 5(8):e12 | Review Article | August 22, 2017