Objectives: A surgical robot (ROBODOC®) is used for total knee replacement. The same system has been in clinical use for total hip replacement at BGU Frankfurt since 1994 and since March 2000 TKR is another clinical application. The presentation intends to give an overview of the system and of the first experiences in clinical use. Background: The outcome of conventional total knee replacement has always been very dependent on the surgeon’s individual skills and routine. The most common mistakes have been malpositionings and malrotations of the prosthesis, which postoperatively caused varus and valgus malalignments of the lower limb resulting in an incorrect mechanical axis. The system permits a three-dimensional pre-operative planning of the correct axis and rotation as well as the correct implant size. The introperative cutting is entirely executed by the surgical robot according to the preoperative planning. Design / Methods: The ROBODOC® Surgical Assistant System consists of three major components: The pre-operative planning workstation called ORTHODOC®, the surgical robot and the robot control unit that receives the preoperative planning data and controls ROBODOC®. Presently, four titanium pins have to be implanted at the beginning of the procedure, one in the proximal femur, one in the distal femur, one in the proximal and one in the distal tibia. These pins are the landmarks for the following procedures. A CT scan is made of the femoral head, the distal femur and the proximal tibia including all the pins and the ankle. A rod is laid on the patient’s leg to detect the motion during CT scan. The CT data is being transferred to the ORTHODOC® workstation on an optical disk. The ORTHODOC® displays three orthogonal cross-sections of the bone on a high-resolution screen. A manipulation on one of the cross-sections is shown in nearly real-time on the other two cross-sections. The first step is to find all the four pins on the CT scan and to check their position. The next step is to create a femoral and tibial axis using four markers (i.e. proximal and distal femur and proximal an distal tibia). The bone is then aligned along the axis. Once those steps have been performed and implant can be selected from an implant library. The femoral component is the first part of the planning. Once the correct size, alignment and rotation have been found the tibial component is added and adjusted. The final step is to select the tibial liner. Once the planning is finished a synthetic x-ray can be created which shows the postoperative result and helps to determine if the correct axis was planned. After finishing the planning a transfer tape that can be loaded into the ROBODOC® is created. The patient’s leg is positioned using a special leg holder and thigh support plate. The patient’s knee should be flexed to an angle of approximately 70 to 80 degrees, a gap of 1 to 2 mm should be achieved. The patient is prepared and draped in the normal manner. Surgery proceeds normally and the regular approach for TKA is used. Once the exposure is finished and the four pins are clearly accessible, two Steinmann pins are inserted, one in the femur and one in the tibia. The Hoffmann II Orthopedic Fixation System is used to connect the two Steinmann pins and to distract the knee joint. Now the robot is moved to the OR table. The femur and the tibia must be rigidly fixated to the robot base. Following this two bone motion monitors are attached to the bone, one to the femur and one to the tibia. The registration program is started. Using ROBODOC®’s ball probe the four pins have to be located, including the use of pin extenders so that the robot can find the patient’s position on the OR table by comparing the data to the preoperative CT data of that particular patient. First the femoral pins are found, then the tibial pins. If the registration is correct the cutter can be installed, the irrigation system is connected and the robot starts cutting the surface for the planned implant. First the femur is prepared, then the tibia. The final cut is the cruciform in the tibia for which a special cutter is required. Should bone motion occur during any part of the cutting procedure the robot will stop and the pins have to be re-registered. Once the cutting is finished, the robot is moved away from the OR-table, the pins and fixators are removed an the surgeon inserts the planned implant manually – normally using the cementless tecnique. The surgery is finished the traditional way. Fifty patients who had received total knee replacement using the ROBODOC® System were followed up and examined using a pre-defined protocol: 23 patients were male, 27 were female. All cases showed severe signs of osteoarthrosis. In 35 cases we saw a varus deviation, in 13 cases a valgus deviation, in two cases there was no deviation from the axis. four patients were post-traumatic cases, in one case a complex osteotomy had been performed. In 38 patients the cementless technique was used, in eight cases the tibial component was cemented and in four cases both components were cemented due to poor bone quality. We had an obvious learning curve, OR time went down from 130 minutes for the first procedure to 90 minutes average OR time. Due to the three-dimensional pre-operative planning of the correct axis and rotation we saw a good alignment of the femoral and tibial component in all cases. Besides the optimal size of the components could be selected for the patients in this group. Results/Conclusions: The system permits a three-dimensional pre-operative planning of the correct axis and rotation as well as the correct implant size. Due to the exact cut surfaces the cementless technique can be used in the makority of cases. The patients are permitted full weight bearing immediately postoperatively. None of the templates or tools that are needed for manual TKR are necessary when the ROBODOC® system is used which means an immense reduction of surgical tools for that procedure. The OR-time is not significantly longer compared to traditional TKR. The surgeon has total control of the procedure at all times and the procedure can be finished manually if necessary. Correct aligment and rotation are the known preconditions for durability in TKR. The present disadvantages of the system are soft tissue management including ligament balancing, the rigid fixation and the use of pins (markers). By June 2001 about 280 surgeries have been performed using the system. The development of a pinless system is already on its way and clinical testings are abour to start at BGU Frankfurt

From 01/1988 to 04/2001 224 THR were performed assisted by a surgical robot (ROBODOC). The short term run of 5 years should reveal, if any benefit ore disadvantage could be detected comparing Robodo chips with hand -broached hips. In all 224 cases a straight stem prosthesis with a proximal sleeve was used (S-Rom-Prosthesis). The cup was implanted manually (RM-Cup). The average follow up has been 5 years (4,0–6,2 years). At the last investigation 3 patients had died, 6 patients could not be reached. 215 patients (96%) were examined. According to Merle d’Aubigné pain and walking ability were mesured with a maximal score of 12 points. Robot assisted hip surgery surely offers an improved primary stability of the stem because of the outstanding precision. Missing stem loosening after 5 years seem to promiss a longer survival rate. To avoid a high learning curve certificated qualifying courses are compulsory

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.

Accurate cup placement in total hip arthroplasty (THA) for the patients with developmental dysplasia of the hip (DDH) is one of the challenges due to distinctive bone deformity. Robotic-arm assisted system have been developed to improve the accuracy of implant placement. This study aimed to compare the accuracy of robotic-arm assisted (Robo-THA), CT-based navigated (Navi-THA), and manual (M-THA) cup position and orientation in THA for DDH.

A total of 285 patients (335 hips) including 202 M-THAs, 45 Navi-THAs, and 88 Robo-THA were analyzed. The choice of procedure followed the patient's preferences. Horizontal and vertical center of rotation (HCOR and VCOR) were measured for cup position, and radiographic inclination (RI) and anteversion (RA) were measured for cup orientation. The propensity score-matching was performed among three groups to compare the absolute error from the preoperative target position and angle.

Navi-THA showed significantly smaller absolute errors than M-THA in RI (3.6° and 5.4°) and RA (3.8° and 6.0°), however, there were no significant differences between them in HCOR (2.5 mm and 3.0 mm) or VCOR (2.2 mm and 2.6 mm). In contrast, Robo-THA showed significantly smaller absolute errors of cup position than both M-THA and Navi-THA (HCOR: 1.7 mm and 2.9 mm, vs. M-THA, 1.6 mm and 2.5 mm vs. Navi-THA, VCOR:1.7 mm and 2.4 mm, vs. M-THA, 1.4 mm and 2.2 mm vs. Navi-THA). Robo-THA also showed significantly smaller absolute errors of cup orientation than both M-THA and Navi-THA (RI: 1.4° and 5.7°, vs. M-THA, 1.5° and 3.6°, vs. Navi-THA, RA: 1.9° and 5.8° vs. M-THA, 2.1° and 3.8° vs. Navi-THA).

Robotic-arm assisted system showed more accurate cup position and orientation compared to manual and CT-based navigation in THA for DDH. CT-based navigation increased the accuracy of cup orientation compared to manual procedures, but not cup position.

Introduction

Robotically-assisted unicondylar knee arthroplasty (UKA) is intended to improve the precision with which the components are implanted, but the impact of alignment using this technique on subsequent polyethylene surface damage has not been determined. Therefore, we examined retrieved ultra-high-molecular-weight polyethylene UKA tibial inserts from patients who had either robotic-assisted UKA or UKA performed using conventional manual techniques and compared differences in polyethylene damage with differences in implant component alignment between the two groups. We aimed to answer the following questions: (1) Does robotic guidance improve UKA component position compared to manually implanted UKA? (2) Is polyethylene damage or edge loading less severe in patients who had robotically aligned UKA components? (3) Is polyethylene damage or edge loading less severe in patients with properly aligned UKA components?

The subject of noise in the operating theatre was recognized as early as 1972 and has been compared to noise levels on a busy highway. While noise-induced hearing loss in orthopaedic surgery specifically has been recognized as early as the 1990s, it remains poorly studied. As a result, there has been renewed focus in this occupational hazard. Noise level is typically measured in decibels (dB), whereas noise adjusted for human perception uses A-weighted sound levels and is expressed in dBA. Mean operating theatre noise levels range between 51 and 75 dBA, with peak levels between 80 and 119 dBA. The greatest sources of noise emanate from powered surgical instruments, which can exceed levels as high as 140 dBA. Newer technology, such as robotic-assisted systems, contribute a potential new source of noise. This article is a narrative review of the deleterious effects of prolonged noise exposure, including noise-induced hearing loss in the operating theatre team and the patient, intraoperative miscommunication, and increased cognitive load and stress, all of which impact the surgical team’s overall performance. Interventions to mitigate the effects of noise exposure include the use of quieter surgical equipment, the implementation of sound-absorbing personal protective equipment, or changes in communication protocols. Future research endeavours should use advanced research methods and embrace technological innovations to proactively mitigate the effects of operating theatre noise.

Cite this article: Bone Joint J 2024;106-B(10):1039–1043.

Aims

Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods.

Aims

Total knee arthroplasty (TKA) using functional alignment aims to implant the components with minimal compromise of the soft-tissue envelope by restoring the plane and obliquity of the non-arthritic joint. The objective of this study was to determine the effect of TKA with functional alignment on mediolateral soft-tissue balance as assessed using intraoperative sensor-guided technology.

Dissatisfaction following total knee arthroplasty is a well-documented phenomenon. Although many factors have been implicated, including modifiable and nonmodifiable patient factors, emphasis over the past decade has been on implant alignment and stability as both a cause of, and a solution to, this problem. Several alignment targets have evolved with a proliferation of techniques following the introduction of computer and robotic-assisted surgery. Mechanical alignment targets may achieve mechanically-sound alignment while ignoring the soft tissue envelope; kinematic alignment respects the soft tissue envelope while ignoring the mechanical environment. Functional alignment is proposed as a hybrid technique to allow mechanically-sound, soft tissue-friendly alignment targets to be identified and achieved.

Cite this article: Bone Joint J 2020;102-B(3):276–279.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568–572

Abstract. Introduction. Total knee replacement (TKR) in patients with skeletal dysplasia is technically challenging surgery due to deformity, joint contracture, and associated co-morbidities. The aim of this study is to follow up patients with skeletal dysplasia following a TKR. Methodology. We retrospectively reviewed 22 patients with skeletal dysplasia who underwent 31 TKRs at our institution between 2006 and 2022. Clinical notes, operative records and radiographic data were reviewed. Results. Achondroplasia was the most common skeletal dysplasia (8), followed by Chondrodysplasia punctata (7) and Spondyloepiphyseal dysplasia (5). There were fourteen men and eight women with mean age of 51 years (28 to 73). The average height of patients was 1.4 metres (1.16–1.75) and the mean weight was 64.8 Kg (34.3–100). The mean follow up duration was 68.32 months (1–161). Three patients died during follow up. Custom implants were required in twelve patients (38.71%). Custom jigs were utilised in six patients and two patients underwent robotic assisted surgery. Hinged TKR was used in seventeen patients (54.84%), posterior stabilised TKR in nine patients (29.03%), and cruciate retaining TKR in five patients (16.13%). One patient underwent a patella resurfacing for persistent anterior knee pain and another had an intra-operative medial tibial plateau fracture which was managed with fixation. No revisions occurred during the follow up period. Conclusion. Despite the technical challenges and complexity of TKR within this unique patient group, we demonstrate good implant survivorship during the study period. Cross sectional imaging is recommended preoperatively for precise planning and templating

Glenoid replacement is a manual bone removal procedure that can be difficult for surgeons to perform. Surgical robotics have been utilized successfully in hip and knee orthopaedic procedures but there are no systems currently available in the shoulder. These robots tend to have low adoption rates by surgeons due to high costs, disruption of surgical workflow and added complexity. As well, these systems typically use optical tracking which needs a constant line-of-sight which is not conducive to a crowded operating room. The purpose of this work was developing and testing a surgical robotic system for glenoid replacement. The new surgical system utilizes flexible components that tether a Stewart Platform robot to the patient through a patient specific 3D printed mount. As the robot moves relative to the bone, reaction loads from the flexible components bending are measured by a load cell allowing the robot to “feel” its way around. As well, a small bone burring tool was attached to the robot to facilitate the necessary bone removal. The surgical system was tested against a fellowship-trained surgeon performing standard surgical techniques. Both the robot and the surgeon performed glenoid replacement on two different scapula analogs: standard anatomy and posterior glenoid edge wear referred to as a Walch B2. Six of each scapula model was tested by the robot and the surgeon. The surgeon created a pre-operative plan for both scapula analogs as a target for both methodologies. CT scans of the post-operative cemented implants were compared to the pre-operative target and implant position and orientation errors were measured. For the standard shoulder analogs the net implant position and orientation errors were 1.47 ± 0.48 mm and 2.57 ± 2.30° for the robot and 1.61 ± 0.29 mm and 5.04 ± 1.92° for the surgeon respectively. For the B2 shoulders, the net implant position and orientation errors were 2.16 ± 0.36 mm and 2.89 ± 0.88° for the robot and 3.01 ± 0.42 mm and 4.54 ± 1.49° for the surgeon respectively. The new tracking system was shown to be able to match or outperform the surgeon in most metrics. The surgeon tended to have difficulty gauging the depth needed as well as the face rotation of the implant. This was not surprising as the reaming tool used by the surgeon obscures the view of the anatomy and the spherical cutter hinders the ability to index the tool. The robot utilized only one surgical tool, the bone burr, precluding the need for multiple instruments used by the surgeon to prepare the glenoid bone bed. The force-space navigation method can be generalized to other joints, however, further work is needed to validate the system using cadaveric specimens

Computer assisted orthopaedic surgery (CAOS) is an emerging and expanding filed. There are some old classification systems that are too comprehensive to cover all new CAOS tools and hybrid devises that are currently present and others that are expected to appear in the near future. Based on our experience and on the literature review, we grouped CAOS devises on the basis of their functionality and clinical use into 6 categories, which are then sub-grouped on technical basis. In future, new devices can be added under new categories or subcategories. This grouping scheme is meant to provide a simple guide on orthopaedic systems rather than a comprehensive classification for all computer assisted systems in surgical practice. For example, the number and diversity of tasks of surgical robots is enormous, up to 159 surgical robots with different mechanisms and functions reported in the literature. These can be classified according to their tasks, mechanism of actions, degree of freedom and level of activity but for the purpose of simplicity we subcategorised the orthopaedic robots to only industrial, hand-held and bone-mounted. Table 1 shows the classification system with the 6 categories and other subcategories

Introduction. Innovations in surgical robotics and navigation have significantly improved implant placement accuracy in total knee arthroplasty (TKA). However, many comparative studies have not been shown to substantially improve revision rates or other clinical outcome scores. We conducted a simulation study based on the reported distribution of patient-specific characteristics and estimated potential effect of coronal plane alignment (CPA) on risk of revision to evaluate the hypothesis that most published study designs in this area have been too underpowered to detect improvements in revision rates. Methods. To model previously reported studies, we generated a series of simulated TKA patient populations, assigning each patient a set of patient-specific factors (age at index surgery, BMI, and sex (Fig.1a)), as well as one surgeon-controlled factor (CPA) (Fig.1b) based on registry data and published literature. We modelled the survival probability for an individual patient at time t as a Gaussian function (exp[-(t/(k∗τ. max. )). 2. ]), where τ. max. (99.5 years) is selected to ensure the mean survival probability of the patient population matched 92% at 15 years. The value of k was adjusted for simulated patients within a range of 0 to 1 as a function of their patient and surgeon-specific factors (Fig.2). To evaluate power associated with a study design, we ran a Monte Carlo simulation generating 10,000 simulated populations of ten different cohort sizes. We divided the patient population into two groups: one group was assigned CPAs governed by the precision of a navigated/robotic approach (σ=1.5°), and the other CPAs governed by the precision of a conventional approach (σ=3°). We then simulated the time to failure for each patient, computed the corresponding Kaplan-Meier survival curves, and applied a Log-Rank test to each study to test for statistical difference. From the 10,000 simulations associated with each cohort size, we determined the percentage of simulated studies that found a statistically significant difference at each time point. Results. Figure 3 shows a contour plot illustrating the probability that a survival analysis with a specific study design would find statistical significance between the conventional and navigated/robotic patient groups. Entries from recently published literature are overlaid for context. No studies achieved statistical significance (p<0.05). Discussion. The effectiveness of navigated/robotic surgery is one of the most controversial debates in orthopedic surgery. The results from this simulation suggest that most revision studies aiming to settle this debate are likely significantly underpowered, falling below the normal 80% threshold. Limitations of this analysis include using only a single surgeon-controlled variable in the survival simulation, and only a single precision for the navigated/robotic approaches. Further studies will include more implant-related risk factors and a wider range of precisions for navigated/robotic procedures. Based on this simulation, it appears the effect size afforded by navigated/robotic surgeries on revision rates in TKA surgery is too small to recommend broad application, especially since adoption could involve added costs and unforeseen risks associated with novelty. Clinically, it may be beneficial to examine the use of robotics/navigation on high-risk patients, where studies are likely to have higher power due to larger effect sizes. For any figures or tables, please contact the authors directly

The first generation of surgical robots which has been used in orthopaedics was characterized by automatic performance of certain tasks like milling of bone cavities or planes. These systems have not been successful as their application and operation suffered from a number of unacceptable drawbacks. Presently computer assisted surgery is dominated by surgical navigation systems where position and orientation of manually guided instruments are visualized on a computer screen as an overlay to the picture of the anatomical structure. However, new concepts of surgical robots make the benefits of using robotic systems more evident. Such robots do not operate automatically but are designed as assistance systems which support the surgeon by interactive operating modes. Compared to manual instrument guidance in pure navigation they offer several additional advantages some of which are particularly valuable to support less or minimal invasive operating techniques. No problems due to tremor or unintentional slipping of the tool. Precise drilling or reaming by stable tool guidance, surgery will be exact and reproducible to achieve pre-operatively planned targets, to overcome the ergonomic problems, such as difficult hand-eye-coordination and frequent changes of viewing direction. The application of interactive assistance robots in orthopaedic and trauma surgery is illustrated by describing exemplary procedures

Only limited data exists concerning outcomes after total knee arthroplasty (TKA) using a surgical robot. We conducted this study to evaluate the clinical and radiographical results in robotic-assisted implantation of TKAs with a minimum follow-up of two years. A total of 50 primary TKAs using ROBODOC were included in this study. The mean duration of follow-up was 28.3 months. The radiographic measurement with regard to the change of mechanical axis, and the inclination of the femoral and tibial components were assessed. The value within ± 3° of optimum was classified to be “acceptable”, and the value exceeding more than ± 3° to be “outlier” results. Also we evaluated clinical results with the range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores. The mechanical axis was changed from 6.57 varus to 0.81 valgus. Mean coronal inclination of the femoral and tibial component were 88.61 and 89.76 at the last follow up. Also, mean sagittal inclination of the femoral and tibial component were 0.82 and 85.49. On the other hand, all prostheses had no radiolucent lines. On the clinical assessment, the range of motion improved from 124.9 to 128.4, and the improvement of HSS score and Womac score were 70.06 to 95.72 and 65.64 to 28.92 in each. No major adverse events related to the use of the robotic system have been observed. However, one case of the formation of seroma around the pin track and two cases of the partial abrasion of patellar tendon occurred in relation to procedures. A surgical robot system in TKAs provides good clinical and radiographical results at least 2 years follow-up, however further study for the long term follow-up may be needed. A clear advantage of robot-assisted TKA seems to be ability to execute a highly precise preoperative planning and intraoperaive procedures. But current disadvantages such as increased operating times and inability of adjusting the preoperative planning during the procedure have to be resolved in the future

Background. Use of a robotic tool to perform surgery introduces a risk of unexpected soft tissue damage due to the uncommon tactile feedback for the surgeon. Early experience with robotics in total hip and knee replacement surgery reported having to abort the procedure in 18–34 percent of cases due to inability to complete preoperative planning, hardware and soft tissue issues, registration issues, as well as concerns over actual and potential soft tissue damage. These can result in significant morbidity to the patient, negating all the desired advantages of precision and reproducibility with robotic assisted surgery. The risk of soft tissue damage can be mitigated by haptic software prohibiting the cutting tip from striking vital soft tissues and by the surgeon making sure there is a clear workspace path for the cutting tool. This robotic total knee system with a semi-active haptic guided technique was approved by the FDA on 8/5/2015 and commercialized in August of 2016. Two year clinical results have not been reported to date. Objective. To review an initial and consecutive series of robotic total knee arthroplasties for safety in regard to avoidance of known or delayed soft tissue injuries and the necessity to abort the using the robot to complete the procedure. Report the clinical outcomes with robotic total knee replacement at or beyond two years to demonstrate no delayed effect on expected outcome. Methods. The initial consecutive series of 65 Triathlon. TM. total knee replacements using a semi-active haptic guided system that were performed after commercialization that would be eligible for two year follow-up were reviewed. Pre-operative planning utilizing CT determined the implant placement and boundaries and thus the limit of excursion from any part of the end effector saw tip. Self-retaining retractors were also utilized. Operative reports, 2, 6, and 12 week, and yearly follow-up visit reports were reviewed for any evidence of inadvertent injury to the medial collateral ligament, patellar tendon, or a neurovascular structure from the cutting tool. Operative notes were also reviewed to determine if the robotic procedure was partially or completely aborted due to any issue. Knee Society Knee Scores (KS-KS) and Functional Scores (KS-FS) were recorded from pre-operative and yearly. Any complications were recorded. Results. 40 cases had two year follow-up. The average follow-up for this series was 1.51 years. No cases were unable to be completed robotically. No case had evidence for acute or delayed injury to the medial collateral ligament, patellar tendon, or neurovascular structure. The only complication was a revision total knee for tibial component loosening after a fall induced periprosthetic tibial fracture. Average pre-operative KS-KS and KS-FS improved from 46.9 and 52.1 to 99.2 and 88.6 at one year follow-up, 100.5 and 86.9 at two year follow-up. Conclusions. A semi-active haptic guided robotic system is a safe and reliable method to perform total knee replacement surgery. This series of initial robotic arm assisted surgery had no intraoperative or delayed soft tissue injuries. Preliminary short-term outcomes at up to two years show excellent outcomes

Background. Manually instrumented knee arthroplasty is associated with variability in implant and limb alignment and ligament balance. When malalignment, patellar maltracking, soft tissue impingement or ligament instability result, this can lead to decreased patient satisfaction and early failure. Robotic technology was introduced to improve surgical planning and execution. Haptic robotic-arm assisted total knee arthroplasty (TKA) leverages three-dimensional planning, optical navigation, dynamic intraoperative assessment of soft tissue laxity, and guided bone preparation utilizing a power saw constrained within haptic boundaries by the robotic arm. This technology became clinically available for TKA in 2016. We report our early experience with adoption of this technique. Methods. A retrospective chart review compared data from the first 120 robotic-arm assisted TKAs performed December 2016 through July 2018 to the last 120 manually instrumented TKAs performed May 2015 to January 2017, prior to introduction of the robotic technique. Level of articular constraint selected, surgical time, complications, hemoglobin drop, length of stay and discharge disposition were collected from the hospital record. Knee Society Scores (KSS) and range of motion (were derived from office records of visits preoperatively and at 2-weeks, 7-weeks and 3-month post-op. Manipulations under anesthesia and any reoperations were recorded. Results. Less articular constraint was used to achieve balance in the robotic group, with a higher incidence of cruciate retaining retention (92% vs. 55%, p < 0.01) and a trend towards lower use of varus-valgus constrained articulations (5% vs. 11%, p = 0.068). Robotic surgery increased mean operative time by 22 minutes (p < 0.001). Operative time improved by 26 minutes from the first 10 robotic cases to the last 10 robotic cases. The robotic group had a lower hospital length of stay (2.7 vs. 3.4 days, p < 0.001). Discharge home was not significantly different between robotic and manual groups (89% vs. 83%, p = 0.2). Postoperative Knee Society scores were similar between groups at each postoperative time interval. Robotic-arm assisted TKA patients demonstrated lower mean flexion contracture at 2-weeks (1.8 vs. 3.3 degrees, p < 0.01), 7-weeks (1.0 vs. 1.8 degrees, p <0.01), and 3-months (0.6 vs 2.1 degrees, p = 0.02) post-surgery, but these differences were small. Mean flexion did not differ between groups at 3-month follow-up, but motion was achieved with a significantly lower rate of manipulation under anesthesia in the robotic group (4% vs 17%, p = 0.013). Conclusion. Preliminary findings demonstrate robotic-arm assisted TKA is safe and efficacious with outcomes comparable, if not superior, to that of manually instrumented TKA. Keywords. total knee arthroplasty, robotic arm-assisted total knee arthroplasty. For any figures or tables, please contact authors directly

Background. Use of a robotic tool to perform surgery introduces a risk of unexpected soft tissue damage due to the lack of tactile feedback for the surgeon. Early experience with robotics in total hip and knee replacement surgery reported having to abort the procedure in 18–34 percent of cases due to inability to complete preoperative planning, hardware and soft tissue issues, registration issues, as well as concerns over actual and potential soft tissue damage. These damages to the soft tissues resulted in significant morbidity to the patient, negating all the desired advantages of precision and reproducibility with robotic assisted surgery. The risk of soft tissue damage can be mitigated by haptic software prohibiting the cutting tip from striking vital soft tissues and by the surgeon making sure there is a clear workspace path for the cutting tool. This robotic total knee system with a semi-active haptic guided technique was approved by the FDA on 8/5/2015 and commercialized in August of 2016. One year clinical results have not been reported to date. Objective. To review an initial and consecutive series of robotic total knee arthroplasties for safety in regard to avoidance of known or delayed soft tissue injuries and the necessity to abort the robotic assisted procedure and resort to the use of conventional implantation. Report the clinical outcomes with robotic total knee replacement at or beyond one year to demonstrate satisfactory to excellent performance. Methods. The initial consecutive series of 100 robotic total knee replacements using a semi-active haptic guided system including 34 from the initial IDE series in 2014 and those performed after commercial approval beginning in 2016 were reviewed. Pre- operative planning utilizing CT determined the implant placement and boundaries and thus the limit of excursion from any part of the end effector saw tip. Self-retaining retractors were also utilized. Operative reports, 2, 6, and 12 week, and yearly follow-up visit reports were reviewed for any evidence of inadvertent injury to the medial collateral ligament, patellar tendon, or a neurovascular structure from the cutting tool. Operative notes were also reviewed to determine if the robotic procedure was partially or completely aborted due to any issue. Knee Society and Functional scores were recorded from pre-operative and yearly. Results. No cases were unable to be completed robotically. No case had evidence for acute or delayed injury to the medial collateral ligament, patellar tendon, or neurovascular structure. The average follow-up for this series was 1.54 years. Average pre- operative Knee Society and Functional Scores improved from 44.7 and 50 to 98.1 and 87.8 at one year follow-up, 93.8 and 83.1 at two year follow-up, 98.5 and 87.7 at three year follow-up, and 99 and 85 at four year follow-up. Conclusions. A semi-active haptic guided robotic system is a safe and reliable method to perform total knee replacement surgery. Preliminary short-term outcomes data shows excellent clinical and functional results