Robotics in Arthroplasty: A Comprehensive Review

doi:10.1016/j.arth.2016.05.026

The Journal of Arthroplasty

Volume 31, Issue 10, October 2016, Pages 2353-2363

https://doi.org/10.1016/j.arth.2016.05.026 Get rights and content

Abstract

Robotic-assisted orthopedic surgery has been available clinically in some form for over 2 decades, claiming to improve total joint arthroplasty by enhancing the surgeon's ability to reproduce alignment and therefore better restore normal kinematics. Various current systems include a robotic arm, robotic-guided cutting jigs, and robotic milling systems with a diversity of different navigation strategies using active, semiactive, or passive control systems. Semiactive systems have become dominant, providing a haptic window through which the surgeon is able to consistently prepare an arthroplasty based on preoperative planning. A review of previous designs and clinical studies demonstrate that these robotic systems decrease variability and increase precision, primarily focusing on component positioning and alignment. Some early clinical results indicate decreased revision rates and improved patient satisfaction with robotic-assisted arthroplasty. The future design objectives include precise planning and even further improved consistent intraoperative execution. Despite this cautious optimism, many still wonder whether robotics will ultimately increase cost and operative time without objectively improving outcomes. Over the long term, every industry that has seen robotic technology be introduced, ultimately has shown an increase in production capacity, improved accuracy and precision, and lower cost. A new generation of robotic systems is now being introduced into the arthroplasty arena, and early results with unicompartmental knee arthroplasty and total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications. Further studies are needed to confirm the cost effectiveness of these technologies.

Section snippets

History of Robotics

Several definitions of “robot” exist. According to the Robot Institute of America, a robot is defined as a reprogrammable, multifunctional manipulator designed to move material, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks [19]. Webster's Dictionary describes a robot as an automatic device that performs functions normally ascribed to humans or a machine in the form of a human [20]. Mike Brady is perhaps the world's

CASPAR

CASPAR (URS Ortho, Rastatt, Germany) was another early autonomous system. The CASPAR system (Ortho-Maquet/URS, Schwerin, Germany) was an image-guided active robot used for THA and TKA similar to Robodoc [43]. Initial results focused on improving and decreasing the variability in the mechanical axis of the leg. Many studies have demonstrated the importance of the mechanical axis in TKA function, outcomes, and longevity 44, 45. A study performed by Siebert et al, using CASPAR for TKA, noted

Contemporary Systems

Robotic systems coupled with navigation were initially developed in orthopedics to improve clinical outcomes and allow consistent reproducibility of more accurate results. Most robotic systems consist of similar components. The steps to a robotically assisted surgery typically involve (a) creating a patient-specific model and interventional plan, (b) intraoperatively registering the model and plan to the patient's anatomy, and (c) using robotic assistance to make bone cuts and carry out the

Cost and Return on Investment

Introducing robots into the orthopedic operating room may improve precision, lower complication rates, and offer higher patient satisfaction scores, but the ultimate acceptance of robotic surgery into common orthopedic practice will also depend on its cost effectiveness, especially in the short term. The initial start-up cost of devices that requires extensive research and development is high and to be commercially viable; these costs must be offset by the average sale price of the device. In

Discussion

Robotic surgery is beginning to change the landscape of orthopedics. Robots were initially introduced into orthopedic operating rooms to improve precision, accuracy, and patient's overall outcome and satisfaction rates. Robotic-assisted surgery has the potential to achieve these goals by enhancing the surgeon' ability to generate reproducible techniques through an individualized surgical approach. Anatomic restoration with optimized soft tissue balancing, reproducible alignment, and restoration

Conclusion

To date, robotics has improved consistency and decreased variability at the cost of increased operative times at the onset with only some emerging evidence supporting improved clinical outcomes. In the future, robotics is moving toward becoming a valuable adjunct to the surgeon in optimizing patient-specific arthroplasty. Although additional research will be required to fully define the costs and benefits of robotics, one thing is clear: robotics appears to be here to stay. Given the universal

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Cited by (282)

The LANCET robotic system can improve surgical efficiency in total hip arthroplasty: A prospective randomized, multicenter, parallel-controlled clinical trial
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To evaluate the accuracy and safety of the LANCET robotic system, a robot arm assisted operation system for total hip arthroplasty via a multicenter clinical randomized controlled trial.
A total of 116 patients were randomized into two groups: LANCET robotic arm assisted THA group (N = 58) and the conventional THA group (N = 58). General information about the patients was collected preoperatively. Operational time and bleeding were recorded during the surgery. The position of the acetabular prosthesis was evaluated by radiographs one week after surgery and compared with preoperative planning. Harris score, hip mobility, prosthesis position and angle and complications were compared between the two groups at three months postoperatively.
None of the 111 patients who ultimately completed the 3-month follow-up experienced adverse events such as hip dislocation and infection during follow-up. In the RAA group, 52 (92.9 %) patients were located in the Lewinnek safe zone and 49 (87.5 %) patients were located in the Callanan safe zone. In the control group were 47 (85.5 %) and 44 (80.0 %) patients, respectively. In the RAA group, 53 (94.6 %) patients had a postoperative acetabular inclination angle and 51 (91.1 %) patients had an acetabular version angle within a deviation of 5° from the preoperative plan. These numbers were significantly higher than those of the control group, which consisted of 42 (76.4 %) and 34 (61.8 %) patients respectively. There were no significant differences between the two groups of subjects in terms of general condition, intraoperative bleeding, hip mobility, and adverse complications.
The results of this prospective randomized, multicenter, parallel-controlled clinical study demonstrated that the LANCET robotic system leads conventional THA surgery in accuracy of acetabular cup placement and does not differ from conventional THA surgery in terms of postoperative hip functional recovery and complications.
In the past, the success rate of total hip arthroplasty (THA) relied heavily on the surgeon's experience. As a result, junior doctors needed extensive training to become proficient in this technique. However, the introduction of surgical robots has significantly improved this situation. By utilizing robotic assistance, both junior and senior doctors can perform THA quickly and efficiently. This advancement is crucial for the widespread adoption of THA, as patients can now receive surgical treatment in local facilities instead of overwhelming larger hospitals and straining medical resources. Moreover, the development of surgical robots with fully independent intellectual property rights holds immense value in overcoming the limitations of high-end medical equipment. This aligns with the objectives outlined in the 14th Five Year Plan for National Science and Technology Strategy.
Trends in unicompartmental knee arthroplasty among 138 international experienced arthroplasty knee surgeons
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Unicompartmental knee arthroplasty (UKA) is an established option for treating isolated unicompartmental knee osteoarthritis (OA), but controversies still exist about patient selection, indications, perioperative management and alignment goals. This survey was designed to understand the current trends of experienced arthroplasty knee surgeons performing UKA.
An online questionnaire was created with SurveyMonkey® to assess global tendencies in the utilization of UKA. A link to the survey was shared with all ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) members. The questionnaire consisted of free and multiple-choice questions and was divided into four sections: demographic information, the surgical activity of the respondents, indications for surgery and postoperative alignment goals.
A total of 138 ESSKA members from 34 different countries completed the survey. A total of 81 % of the responders performed fewer than 50 UKAs per year; 53 % of UKAs represented less than 20 % of their knee replacements; 71 % used mainly or only fixed-bearing implants; 81 % performed UKA in a shorter time compared to TKA; and 61 % and 72 % were interested in custom-made UKA and robotics, respectively. Thirty-six percent considered a minimum postoperative alignment of 0° for medial UKA, and 32 % considered 10° as the maximum valgus deformity for lateral UKA. Fifty-five percent had no minimum age cut-off, 47 % had no BMI cut-off, and 57 % believed TKA was better than UKA in knees with concomitant high-grade patellofemoral OA. Approximately 50 % of the surgeons desired a coronal alignment that was the same as the predegeneration alignment.
A high level of agreement was reached regarding the following: preference for fixed-bearing UKAs, lower surgical time for UKA compared to TKA, interest in custom-made and robotic UKAs, no age and weight cut-off, TKA preferred in the presence of patellofemoral OA, and a final alignment goal of the predegenerative state both for medial and lateral. There was no agreement regarding length of stay, rehabilitation protocol, preoperative varus and valgus cut-off values, and treatment in cases of absence of anterior cruciate ligament or previous osteotomy.
Looking to the Future; Veterinary Robotic Surgery
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Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty
2024, Journal of Arthroplasty
New technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors’ COI and industry funding would be associated with conclusions favorable to a new technology.
Economic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher’s exact test was utilized to determine the relationship between the presence of COI and an article’s conclusions.
Of 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher’s exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author’s COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003).
Financial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.
Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List
2024, Journal of Arthroplasty
Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.
The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).
The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).
Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.
The Relative Importance of Factors That Applicants Weigh When Ranking Adult Reconstruction Fellowships as Well as Their Perspectives on Robotic-Assisted Arthroplasty
2024, Journal of Arthroplasty
Orthopedic Surgery Fellowship programs offer highly specialized training that varies based on the training environment and surgical experience. Additionally, for Adult Reconstruction programs, robotic-assisted surgery exposure has been a widely discussed topic. The purpose of this study was to determine the relative value of various factors to Adult Hip and Knee Fellowship applicants, and their perceptions of robotic-assisted arthroplasty.
We surveyed 780 applicants who applied to our fellowship to matriculate in 2020 to 2024. We received 158 responses (20.3% response rate). We assessed factors concerning people and perceptions, logistics, salary and benefits, program reputation and curriculum, and surgical experience. Additionally, we surveyed fellows’ attitudes toward using robotic surgery and its impact on patient outcomes.
The highest-rated factors were Level of Hands-On Operative Experience (4.83), Revision Hip Volume (4.72), Revision Knee Volume (4.71), Multiple Surgical Exposures to the Hip (4.59), and Clinical Case Variety (4.59). Respondents who were postfellowship matriculation placed significantly more value on Exposure to Multiple Attendings with Surgical Diversity (P = .01), and Anterior Hip Volume (P = .04), and less value on Geographic Location (P = .04) and Patient-Specific Instrumentation (P = .02) than prematriculates. Overall, 65% of applicants plan to or currently use robotics, 7.6% do not, and 27.2% said “Maybe”. Those who plan to or currently use robotics most cited procedure fidelity, patient-preference, and marketability as reasons to use robotics.
Hands-on surgical experience and revision volume were the most important factors for fellowship applicants. Applicants placed lower importance on robotics exposure and their perspectives on robotics in their future practice were highly variable. Our results will inform fellowship programs and future applicants what previous applicants have valued in their training to help guide fellowship program structure, resource management, as well as recruitment.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.05.026.

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ReviewRobotics in Arthroplasty: A Comprehensive Review

Abstract

Section snippets

History of Robotics

CASPAR

Contemporary Systems

Cost and Return on Investment

Discussion

Conclusion

J Arthroplasty

J Arthroplasty

J Arthroplasty

Knee

Knee

J Arthroplasty

J Arthroplasty

Knee

J Arthroplasty

J Arthroplasty

J Arthroplasty

Robot-assisted total hip arthroplasty

Expert Rev Med Devices

Robot-assisted total knee arthroplasty

Expert Rev Med Devices

From art to science in manufacturing: the evolution of technological knowledge

Foundations and Trends in Technology, Information, Operations Management

The impact of osteoarthritis: implications for research

Clin Orthop Relat Res

Osteoarthritis: new insights. Part 1: the disease and its risk factors

Ann Intern Med

Minimally invasive total knee arthroplasty for osteoarthritis

N Engl J Med

Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991-94

J Rheumatol

Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II

Arthritis Rheum

Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2010-2012

Morb Mortal Wkly Rep

The impact of osteoarthritis in the United States: a population-health perspective: a population-based review of the fourth most common cause of hospitalization in U.S. adults

Orthop Nurs

Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty

J Bone Joint Surg

Risk assessment for chronic pain and patient satisfaction after total knee arthroplasty

Orthopedics

Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain

Bone Joint J

Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales

Bone Joint J

National health spending projections: the estimated impact of reform through 2019

Health Aff

“Computer navigation for total knee arthroplasty reduces revision rate for patients less than sixty-five years of age”

J Bone Joint Surg Am

Biologically inspired collective robots

A review of robotics in surgery

Proc Inst Mech Eng H

Robotic technology in urology

Postgrad Med J

A perspective on robotic assistance for knee arthroplasty

Adv orthopedics

Computer and robotic assisted hip and knee surgery

Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer

Arch Intern Med

History of robotic surgery

Primary and revision total hip replacement using the Robodoc system

Clin Orthop Relat Res

Robots in orthopedic surgery

Clin Orthop Relat Res

The first clinical application of a “hands-on” robotic knee surgery system

Computer Aided Surg

No functional impairment after Robodoc total hip arthroplasty

Acta Orthop Scand

Effectiveness of the Robodoc system in preventing intraoperative pulmonary embolism

Acta Orthop Scand

“Clinical experiences with Robodoc and the Duracon total knee”

Review
Robotics in Arthroplasty: A Comprehensive Review