Prospective randomized controlled trial on the accuracy of prosthesis positioning in total hip arthroplasty assisted by a newly designed whole-process robotic arm

Adverse events associated with robotic-assistance in total hip arthroplasty: an analysis based on the FDA MAUDE database

BACKGROUND

The Food and Drug Administration (FDA) maintains the Manufacturer and User Facility Device Experience (MAUDE) database for reporting adverse events associated with medical devices, including emerging technologies, such as robotic-assisted total hip arthroplasty (THA). Aim of this study was to evaluate the variation of adverse events associated with robotics in THA.

METHODS

Medical device reports (MDRs) within the MAUDE database were identified between 2017 and 2021. For MDR identification the product class "orthopaedic stereotaxic equipment" and terms associated with THA were used. Individual adverse events were identified and organised by type and consequences, such as patient injury, surgical delay, or conversion to the manual technique.

RESULTS

521 MDRs constituting 546 discrete events were found. The most common reported complication was intraoperative hardware failure (304/546, 55.7%), among which the most common failure was a broken impaction handle/platform (110, 20.1%). Inaccurate cup placement was the second most common reported complication (63, 11.5%). Abandoning the robot occurred in 13.0% (71/521) of reports. A surgical delay was noted in 28% (146/521) of reports, with an average delay of 17.9 (range 1-60) minutes.

CONCLUSIONS

Identifying complications that may occur with robotics in THA is an important first step in preventing adverse events and surgical delays. Database analysis provide an overview of the range of complications.

Comparison of Implant Placement Accuracy Between Manual, Robot-Assisted, Computer-Navigated, Augmented Reality Navigated, Patient-Specific Instrumentation, and Accelerometer Navigated Total Hip Arthroplasty: A Systematic Review and Network Meta-Analysis

BACKGROUND

Malpositioning of the acetabular cup during total hip arthroplasty (THA) can lead to complications. Robotic surgery and navigation techniques aim to address this issue, but there is limited evidence regarding which method can achieve better clinical outcomes. Therefore, this network meta-analysis (NMA) aimed to compare the efficacy of various navigation methods.

METHODS

This NMA of prospective randomized controlled trials compared robot-assisted systems (RAS), computer-assisted navigation systems (CAS), augmented reality-based portable navigation (AR), patient-specific instrumentation (PSI), portable accelerometer-based navigation (PN), and conventional methods (C) for THA procedures. We searched MEDLINE, EMBASE, Cochrane, Central Register of Controlled Trials, International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. databases. The primary outcomes included revision surgery and postoperative clinical scores, and the secondary outcomes encompassed cup placement accuracy, acetabular cup placement outliers from the Lewinnek safe zone, surgical time, and complications. We used a Bayesian random-effects NMA, and confidence of evidence was assessed using confidence in NMA.

RESULTS

We identified 45 studies including 2,122 patients. We did not find large differences in revision surgery, clinical outcome scores, cup inclination, or anteversion angle accuracy among the modalities. AR, CAS, and PSI exhibited a lower risk of outliers from safe zones than C. In addition, RAS and CAS had a longer surgical time than C.

CONCLUSIONS

Robotic and navigation tools did not reduce the revision risk or enhance clinical outcomes. AR, CAS, PSI, and PN may decrease the risk of cup placement outliers in safe zones. However, the cup placement accuracy was equivalent, and the surgical time may be longer in RAS and CAS than in C.

LEVEL OF EVIDENCE

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

Robotic-assisted total hip arthroplasty outperforms manual technique in obese and overweight patients: a prospective comparative study

BACKGROUND

With the increasing prevalence of obesity, there is growing awareness of the impact of overweight and obesity on total hip arthroplasty (THA). Research exploring the accuracy of acetabular component orientation in THA between robotic-assisted and manual techniques across different BMI categories is insufficient.

METHODS

This prospective study evaluated 221 patients who underwent THA with a Robotic Interactive Orthopaedic Arm system and 252 patients who underwent manual THA between March 2022 and January 2024. The patients were divided into four groups according to their BMI. We analysed whether there were differences in the accuracy of acetabular component positioning between robotic-assisted THA and manual THA across different BMI categories.

RESULTS

In the overweight group, robotic-assisted THA achieved a significantly higher rate of abductions within the target range (73/6) than manual THA (62/28) (p = 0.000). Both abductions and anteversions within the target range were also significantly more frequent in the robotic-assisted THA group (69/10) than in the manual THA group (56/34) (p = 0.000). Among the obese patients, robotic-assisted THA showed a perfect record for anteversions within the target range (29/0), markedly outperforming manual THA (39/6) (p = 0.040).

CONCLUSION

In the overweight (24 kg/m² ≤ BMI < 28 kg/m²) and obese (BMI ≥ 28 kg/m²) groups, robotic-assisted THA demonstrates significantly greater accuracy in acetabular component positioning compared to manual THA. This indicates that robotic-assisted technology may provide a more precise positioning of the acetabular component in overweight and obese patients.

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

This systematic review of randomized controlled trials (RCTs) aims to compare important clinical, functional, and radiological outcomes between robotic-assisted total hip arthroplasty (RATHA) and conventional total hip arthroplasty (COTHA) in patients with hip osteoarthritis. We identified published RCTs comparing RATHA with COTHA in Ovid MEDLINE, EMBASE, Scopus, and Cochrane Library. Two reviewers independently performed study screening, risk of bias assessment and data extraction. Main outcomes were major complications, revision, patient-reported outcome measures (PROMs), and radiological outcomes. We included 8 RCTs involving 1014 patients and 977 hips. There was no difference in major complication rate (Relative Risk (RR) 0.78; 95% Confidence Interval (CI) 0.22 to 2.74), revision rate (RR 1.33; 95%CI 0.08 to 22.74), and PROMs (standardized mean difference 0.01; 95%CI - 0.27 to 0.30) between RATHA and COTHA. RATHA resulted in little to no effects on femoral stem alignment (mean difference (MD) - 0.57 degree; 95%CI - 1.16 to 0.03) but yielded overall lower leg length discrepancy (MD - 4.04 mm; 95%CI - 7.08 to - 1.0) compared to COTHA. Most combined estimates had low certainty of evidence mainly due to risk of bias, inconsistency, and imprecision. Based on the current evidence, there is no important difference in clinical and functional outcomes between RATHA and COTHA. The trivial higher radiological accuracy was also unlikely to be clinically meaningful. Regardless, more robust evidence is needed to improve the quality and strength of the current evidence.PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42023453294). All methods were carried out in accordance with relevant guidelines and regulations.

Techniques and Technologies for the Intraoperative Assessment of Component Positioning, Leg Lengths, and Offset in Total Hip Arthroplasty: A Systematic Review

Background

Many techniques and technologies exist for the intraoperative assessment of component positioning, leg lengths, and offset in total hip arthroplasty, but with limited comparative data. We conducted a systematic review of the available literature to evaluate the range of techniques and technologies for the intraoperative assessment of component position as well as leg lengths and offset in terms of accuracy, precision, surgical time, cost, and relationship to clinical outcomes.

Methods

A comprehensive search of the Embase and Medline databases from 1974 to 2023 was performed. We included controlled or comparative prospective clinical studies. Cochrane's risk-of-bias tool for randomized trials and Risk of Bias in Non-Randomized Studies - of Interventions tools were used by 2 independent reviewers to evaluate each study for risk of bias. We conducted both qualitative and quantitative analyses of the studies included. However, a meta-analysis was deemed not to be feasible due to heterogeneity.

Results

Our review included 25 studies with 52 intraoperative techniques and technologies. Mechanical guides and computerized navigation were most frequently evaluated in the included studies. Computerized navigation systems consistently showed the greatest accuracy and precision across all measures, at the cost of longer mean operative time. In contrast, freehand techniques demonstrated the poorest accuracy and precision. Insufficient data were found to reach any meaningful conclusions in terms of differences in overall surgical cost or clinical outcomes.

Conclusions

Evidence shows that computerized navigation systems are most accurate and precise in positioning components during total hip arthroplasty. Further research is needed to determine their health and economic impact and whether the accuracy and precision of navigated techniques are justified in terms of clinical outcomes.

Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies

Robotic assisted (RA) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting novel platforms challenging. Therefore, we conducted a systematic review to assess the learning curve associated with RA-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA). PubMed, MEDLINE, EBSCOhost, and Google Scholar were searched on June 16, 2023, to identify studies published between January 1, 2000 and June 16, 2023 (PROSPERO registration: CRD42023437339). The query yielded 655 unique articles, which were screened for eligibility. The final analysis included 11 articles, evaluating 1351 THA procedures. Risk of bias was assessed via the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 21.3 ± 0.9. RA-THA provided immediate improvements in acetabular component placement accuracy and radiographic outcomes compared to M-THA, with little to no experience required to achieve peak proficiency. A modest learning curve (12-17 cases) was associated with operative time, which was elevated compared to M-THA (+ 9-13 min). RA-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes. Surgeons should expect to experience increased operative times, which become less pronounced or equivalent to M-THA after a modest caseload.

Which way forward? Comparing radiological outcomes using three different surgical approaches in robotic assisted total hip arthroplasty

OBJECTIVES

To assess the accuracy and precision of acetabular component placement in robot-assisted surgery total hip arthroplasty (RAS-THA) using three different approaches.

METHODS

This study is a secondary analysis from a multicenter, randomized controlled trial comparing the Trex RS Hip 1.0 robot navigation system across different surgical approaches. It involved 145 patients treated at three Chinese medical centers from June 2021 to July 2022. Patients with end-stage joint disease were randomly assigned to either the RAS or control group. Acetabular component positioning was evaluated radiographically, and registration accuracy was measured using Root Mean Square Error (RMSE).

RESULTS

The overall RMSE was 0.72 mm (SD = 0.24 mm), indicating consistent accuracy regardless of surgical approach. Significant variations in anteversion were noted across groups (p = 0.001). Lateral RAS-THA showed enhanced precision. The RAS Direct Anterior Approach (DAA) group had the least deviation in the rotation center's horizontal distance (0.89 ± 1.14 mm, p = 0.0014) and minimal leg length discrepancy (2.41 ± 1.17 mm). The RAS DAA approach also produced more consistent results.

CONCLUSION

Robotic assistance in THA, especially via the DAA approach, enhances the accuracy and precision of acetabular component positioning. Consistent registration accuracy across various surgical approaches confirms the reliability of these methods for THA.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is ChiCTR2100044124.

Improved radiographic outcomes and decreased complications rate on the femoral side can be achieved by a novel designed whole-process robotic assisted hip system for total hip arthroplasty: a prospective randomized controlled trial

Postoperative complications due to inaccurate prosthesis positioning are the main causes of early revision. The aim of this study was to (1) determine whether novel designed whole-process robotic assisted hip system allowed better radiographic outcomes and lower complications risk on the femoral side particularly stem subsidence compared to conventional THA, and to (2) identify the comparison of early clinical outcomes. 72 patients were initially enrolled and randomly divided into 2 groups. Finally, only 65 patients (31 RA-THAs, 34 C-THAs) were analyzed who had full 18-month follow-up data. Radiographic follow-up was performed at immediate and 6-month postoperatively, while clinical follow-up at 18-month postoperatively. Stem-related radiographic outcomes, femoral side complications and clinical scores were compared. The robotic arm allowed better radiographic outcomes of the femoral side, including a higher canal fill ratio (CFR) at B1 (P = 0.040), more neutral stem alignment (P = 0.029), lower subsidence (P = 0.023) and lower leg length discrepancy (LLD) (P = 0.010). In addition, low CFR at B1 (P = 0.001) was found the risk factor for subsidence. However, early clinical outcomes were consistent between both groups. The novel designed whole-process robotic assisted hip system covers both femoral and acetabular side operations. It allows accurate and safe manipulation of femoral side, including better stem-related radiographic outcomes and lower risk of subsidence and LLD. However, no advantage of robotic system in early clinical score was identified. Clinical trial registration number: ChiCTR2100044124.

Downsizing and minimising medialisation of the acetabular component: Novel technique to preserve bone in THA

Standard practice for acetabular component placement in total hip arthroplasty (THA) is to medialise the acetabular component. Bone preservation techniques during primary THA are beneficial for possible future revisions. The goal of this study is to examine the effect of downsizing and minimising medialisation of the acetabular component on bone resection volume. The volume of bone resected during acetabular preparation for different sizes of components was calculated and the volume of bone preserved by downsizing the cup was determined. Minimising medialisation of the acetabular component by 1-3 mm from the true floor was calculated. Absolute values and percentage of bone volume preserved when acetabular components are downsized or less medialised is presented. Downsizing the acetabular component by one size (2 mm) preserves between 2.6 cm³ (size 40 vs 42) and 8.4 cm³ (size 72 vs 74) of bone volume and consistently reduces resected bone volume by at least 35% (range 35.2%-37.5%). Similarly, reducing medialisation of a 56 mm acetabular cup (as an example of a commonly implanted component) by 3 mm reduces bone loss by 5.9 cm³- 44% less bone volume resection. Downsizing and minimising medialisation of the cup in THA substantially preserves bone which may benefit future revision surgeries. Surgeons could consider implanting the smallest acceptable acetabular shell to preserve bone without compromising on head size.