The learning curve of robotic-arm assisted acetabular cup positioning during total hip arthroplasty

Robotic surgery and work-related stress: A systematic review

Despite robot-assisted surgery (RAS) becoming increasingly common, little is known about the impact of the underlying work organization on the stress levels of members of the operating room (OR) team. To this end, assessing whether RAS may impact work-related stress, identifying associated stress factors and surveying relevant measurement methods seems critical. Using three databases (Scopus, Medline, Google Scholar), a systematic review was conducted leading to the analysis of 20 articles. Results regarding OR team stress levels and measurement methods were heterogeneous, which could be explained by differing research conditions (i.e., lab. vs. real-life). Relevant stressors such as (in)experience with RAS and quality of team communication were identified. Development of a common, more reliable methodology of stress assessment is required. Research should focus on real-life conditions in order to develop valid and actionable knowledge. Surgical teams would greatly benefit from discussing RAS-related stressors and developing team-specific strategies to handle them.

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.

Understanding economic analysis and cost-effectiveness of CT scan-guided, 3-dimensional, robotic-arm assisted lower extremity arthroplasty: a systematic review

Aim: The overall goal of this review was to examine the cost-utility of robotic-arm assisted surgery versus manual surgery. Methods: We performed a systematic review of all health economic studies that compared CT-based robotic-arm assisted unicompartmental knee arthroplasty, total knee arthroplasty and total hip arthroplasty with manual techniques. The papers selected focused on various cost-utility measures. In addition, where appropriate, secondary aims encompassed various clinical outcomes (e.g., readmissions, discharges to subacute care, etc.). Only articles directly comparing CT-based robotic-arm assisted joint arthroplasty with manual joint arthroplasty were included, for a resulting total of 21 reports. Results: Almost all twenty-one studies demonstrated a positive effect of CT scan-guided robotic-assisted joint arthroplasty on health economic outcomes. For studies reporting on 90-day episodes of costs, 10 out of 12 found lower costs in the robotic-arm assisted groups. Conclusion: Robotic-arm assisted joint arthroplasty patients had shorter lengths of stay and cost savings based on their 90-day episodes of care, among other metrics. Payors would likely benefit from encouraging the use of this CT-based robotic technology.

A prospective randomized controlled trial comparing CT-based planning with conventional total hip arthroplasty versus robotic arm-assisted total hip arthroplasty

Aims

Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA.

Methods

This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery.

Results

There were no significant differences for any of the baseline characteristics including spinopelvic mobility. The absolute error for achieving the planned horizontal COR was median 1.4 mm (interquartile range (IQR) 0.87 to 3.42) in RO THA versus 4.3 mm (IQR 3 to 6.8; p < 0.001); vertical COR mean 0.91 mm (SD 0.73) in RO THA versus 2.3 mm (SD 1.3; p < 0.001); and combined offset median 2 mm (IQR 0.97 to 5.45) in RO THA versus 3.9 mm (IQR 2 to 7.9; p = 0.019). Improved accuracy was observed with RO THA in achieving the desired acetabular component positioning (root mean square error for anteversion and inclination was 2.6 and 1.3 vs 8.9 and 5.3, repectively) and leg length (mean 0.6 mm vs 1.4 mm; p < 0.001). Patient-reported outcome measures were comparable between the two groups at baseline and one year. Participants in the RO THA group needed fewer physiotherapy sessions postoperatively (median six (IQR 4.5 to 8) vs eight (IQR 6 to 11; p = 0.005).

Conclusion

This RCT suggested that robotic-arm assistance in THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset, leg length correction, and superior accuracy in achieving the desired acetabular component positioning. Further evaluation through long-term and registry data is necessary to assess whether these findings translate into improved implant survival and functional outcomes.

Navigating the learning curve: assessing caseload and comparing outcomes before and after the learning curve of computer-navigated total hip arthroplasty

PURPOSE

Computer-navigated (CN) 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 a novel platform challenging. Therefore, we conducted a systematic review to assess the learning curve associated with CN-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA).

METHODS

A search was conducted using PubMed, MEDLINE, EBSCOhost, and Google Scholar on June 16, 2023 to find research articles published after January 1, 2000 (PROSPERO registration: CRD4202339403) that investigated the learning curve associated with CN-THA. 655 distinct articles were retrieved and subsequently screened for eligibility. In the final analysis, nine publications totaling 847 THAs were evaluated. The Methodological Index for Nonrandomized Studies (MINORS) tool was utilized to evaluate the potential for bias, with the mean MINORS score of 21.3 ± 1.2.

RESULTS

CN-THA showed early advantages to M-THA for component placement accuracy and radiographic outcomes but longer operative times (+ 3- 20 min). There was a learning curve required to achieve peak proficiency in these metrics, though mixed methodologies made the required caseload unclear.

CONCLUSIONS

CN-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes, though CN-THA's advantages become more pronounced with experience. Surgeons should anticipate longer operative times during the learning curve for CN-THA, which lessen following a modest caseload. A more thorough evaluation of novel computer-navigated technologies would be enhanced by adopting a more uniform method of defining learning curves for outcomes of interest. Registration PROSPERO registration of the study protocol: CRD42023394031, 27 June 2023.

The LANCET robotic system can improve surgical efficiency in total hip arthroplasty: A prospective randomized, multicenter, parallel-controlled clinical trial

Objective

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.

Methods

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.

Results

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.

Conclusion

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.

The translational potential of this article

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.

Robotic trials in arthroplasty surgery

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.

Digitalization in orthopaedics: a narrative review

Advances in technology and digital tools like the Internet of Things (IoT), artificial intelligence (AI), and sensors are shaping the field of orthopaedic surgery on all levels, from patient care to research and facilitation of logistic processes. Especially the COVID-19 pandemic, with the associated contact restrictions was an accelerator for the development and introduction of telemedical applications and digital alternatives to classical in-person patient care. Digital applications already used in orthopaedic surgery include telemedical support, online video consultations, monitoring of patients using wearables, smart devices, surgical navigation, robotic-assisted surgery, and applications of artificial intelligence in forms of medical image processing, three-dimensional (3D)-modelling, and simulations. In addition to that immersive technologies like virtual, augmented, and mixed reality are increasingly used in training but also rehabilitative and surgical settings. Digital advances can therefore increase the accessibility, efficiency and capabilities of orthopaedic services and facilitate more data-driven, personalized patient care, strengthening the self-responsibility of patients and supporting interdisciplinary healthcare providers to offer for the optimal care for their patients.

Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance

BACKGROUND

While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated.

METHODS

This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores.

RESULTS

No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468).

CONCLUSION

Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.

Acetabular cup positioning in primary routine total hip arthroplasty-a review of current concepts and technologies

INTRODUCTION

Total hip arthroplasty (THA) has revolutionized the treatment of hip joint arthritis. With the increased popularity and success of the procedure, research has focused on improving implant survival and reducing surgical complications. Optimal component orientation has been a constant focus with various philosophies proposed. Regardless of the philosophy, achieving an accurate acetabular position for each clinical scenario is crucial. In this paper, we review the recent developments in improving the accuracy and ideal positioning of the acetabular cup in routine primary THA.

METHODOLOGY

A review of the recent scientific literature for acetabular cup placement in primary THA was performed, with available evidence for safe zones, spinopelvic relationship, preoperative planning, patient-specific instrumentation, navigation THA and robotic THA.

CONCLUSION

Though the applicability of Lewinnek safe zones has been questioned with an improved understanding of spinopelvic relationships, its role remains in positioning the acetabular cup in a patient with normal spinopelvic alignment and mobility. Evaluation of spinopelvic relationships and accordingly adjusting acetabular anteversion and inclination can significantly reduce the incidence of dislocation in patients with a rigid spine. In using preoperative radiography, the acetabular inclination, anteversion and intraoperative pelvic position should be evaluated. With improving technology and the advent of artificial intelligence, superior and more accurate preoperative planning is possible. Patient-specific instrumentation, navigated and robotic THA have been reported to improve accuracy in acetabular cup positioning as decided preoperatively but any significant clinical advantage over conventional THA is yet to be elucidated.

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform

Robotic-assisted total hip arthroplasty (THA) using a computerized-tomography (CT) based workflow increases surgical time relative to traditional manual technique. The purpose of this investigation was to compare the intra-operative efficiencies of two robotic THA systems: a fluoroscopy-based platform (FL-RTHA) and a contemporary, CT-based (CT-RTHA) platform. A review of 107 consecutive FL-RTHA and 159 CT-RTHA primary, direct anterior approach (DAA) THA procedures was conducted. All cases were performed by one of two surgeons operating at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included averages and consistencies (variances) for surgical times and operating room (OR) times. A secondary outcome was to quantify the duration of robot-active phases in the FL-RTHA workflow. The FL-RTHA cohort experienced shorter surgical times (38.71 min ± 7.00 vs. 75.33 min ± 11.38; p < 0.001) and OR times (101.35 min ± 12.22 vs. 156.74 min ± 17.79; p < 0.001) compared to the CT-RTHA cohort. Surgical times and OR times were both more consistent in the FL-RTHA cohort compared to the CT-RTHA cohort (p < 0.001). Patients who underwent DAA THA with the assistance of a fluoroscopy-based robotic system experienced shorter and more consistent surgical times and OR times compared to patients who underwent similar DAA THA procedures with a contemporary, CT-based robotic platform.

A review of robotic-assisted total hip arthroplasty

Total hip arthroplasty (THA) is a successful surgical method for hip replacement but still poses challenges and risks. Robotic-assisted THA (rTHA) using new generation robotic systems has emerged to improve surgical precision and outcomes. The purpose of this paper is to review the literature on rTHA, with a focus on its advantages, such as individualized preoperative planning, intraoperative assistance, and improved accuracy in implantation, especially in complex cases. Additionally, it aims to explore the disadvantages associated with the use of rTHA, including high costs, the learning curve, and prolonged operation time compared to manual THA (mTHA), which are critical drawbacks that require careful consideration and efforts for minimization. Some financial analyses suggest that rTHA may offer cost-effectiveness and reduced postoperative costs compared to mTHA. While technological advancements are expected to reduce technical complications, there are still debates surrounding long-term outcomes. Practical limitations, such as limited availability and accessibility, also warrant attention. Although the development of rTHA shows promise, it is still in its early stages, necessitating critical evaluation and further research to ensure optimal patient benefits.

Preliminary study of short-term outcomes and learning curves of robotic-assisted THA: comparison between closed platform robotic system and open platform robotic system

BACKGROUND

Both closed platform and open platform robotic-assisted total hip arthroplasty (THA) have recently been recommended as a viable treatment option for achieving accurate positioning of components. Yet, limited studies paid attention to the differences between the closed platform robotic system and the open platform robotic system. Hence, this study aimed to investigate clinical outcomes, radiographic outcomes, complication rates and learning curve of two systems.

MATERIALS AND METHODS

We retrospectively included 62 patients (31 closed robotic system and 31 open robotic system) who underwent THA between February 2021 and January 2023. The demographics, operating time, cup positioning, complications and hip Harris score were evaluated. Learning curves of operation time was conducted using cumulative sum (CUSUM) analysis.

RESULTS

There were no differences in surgical time (76.7 ± 12.1 min vs. 72.3 ± 14.8 min), estimated blood loss (223.2 ± 13.2 ml vs. 216.9 ± 17 ml) and Harris Hip score (HHS) between closed platform robotic system and the open platform robotic system. The closed robotic system and the open robotic system were associated with a learning curve of 9 cases and 7 cases for surgical time respectively, based on the satisfying rate of Lewinnek's safe zone outliers (1/31, 96.8%) and no occurrence of complication. Both robotic systems had significant reduction in overall surgical time, the duration of acetabulum registration, and estimated blood loss between learning phase and proficiency phase.

CONCLUSION

The authors suggest that the surgical outcomes and safe zone outlier rate of the open robotic-assisted THA were similar to those of the closed robotic-assisted THA. These two robotic-assisted are associated with comparable learning curves and both have the precise positioning of acetabular component. From learning phase to proficiency phase, the rate of positions within the safe zone differed only marginally (88.9-100% vs. 85.7-100%) based on a rather low number of patients. This is not a statistically significant difference. Therefore, we suggest that THA undergoing with the robotic-assisted system is the relatively useful way to achieve planned acetabular cup position so far.

Artificial intelligence in orthopaedic surgery

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as 'big data', AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI's limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

Patient-Reported Outcome Measures in Conventional Total Hip Arthroplasty Versus Robotic-Arm Assisted Arthroplasty: A Prospective Cohort Study With Minimum 3 Years' Follow-Up

BACKGROUND

Robotic-arm assisted total hip arthroplasty (RO THA) has been shown to improve the accuracy of component positioning compared with conventional total hip arthroplasty (CO THA). This study reports Patient-Reported Outcome Measures (PROMs) of a previous trial that showed that RO THA was associated with improved accuracy and reduced outliers in acetabular component positioning compared with CO THA.

METHODS

This prospective cohort study included 50 patients undergoing CO THA versus 50 patients receiving RO THA. The Oxford hip score, Forgotten Joint Score (FJS), University of California at Los Angeles hip score were recorded at a minimum of 3 years following surgery.

RESULTS

At minimum 3 years follow-up, there was no statistically significant difference in CO THA versus RO THA with respect to the Oxford hip score [median 42(6.25) versus 41(5.5), P = .914]; FJS [89 (9.25) versus 86 (9), P = .065], and University of California at Los Angeles score [median 7.5 (3) versus 7 (2), P = .381]. None of the study patients had dislocations or underwent revision surgery within 3 years follow-up.

CONCLUSION

The previously reported improvement in accuracy of acetabular component in this study population did not translate to statistically significant improvements in PROMs. Patients in both groups achieved excellent PROMs and there was a trend towards higher FJS scores postoperatively in the RO THA group that did not reach statistical significance. Further studies are needed to assess the significance of these findings on longer-term clinical outcomes and implant survivorships, and also to explore the impact of the enhanced RO THA workflow and functional implant positioning on these outcomes.

Does robotic-assisted surgery improve outcomes of total hip arthroplasty compared to manual technique? A systematic review and meta-analysis

BACKGROUND

Robot-assisted total hip arthroplasty (THA) is an emerging technology that claims to position implants with very high accuracy. However, there is currently limited data in literature on whether this improved accuracy leads to better long-term clinical outcomes. This systematic review compares the outcomes of THA done with the help of robotic assistance (RA) to those done with conventional manual techniques (MTs).

METHODS

Four electronic databases were searched for eligible articles that directly compared robot-assisted THA to manual THA and had data on the radiological or clinical outcomes of both. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% CIs.

RESULTS

A total of 17 articles were found eligible for inclusion, and 3600 cases were analysed. Mean operating time in the RA group was significantly longer than in the MT group. RA resulted in significantly more acetabular cups being placed inside Lewinnek's and Callanan's safe zones (p<0.001) and had significantly reduced limb length discrepancy compared with MT. There were no statistically significant differences in the two groups in terms of incidence of perioperative complications, need for revision surgery and long-term functional outcome.

CONCLUSION

RA leads to highly accurate implant placement and leads to significantly reduced limb length discrepancies. However, the authors do not recommend robot-assisted techniques for routine THAs due to lack of adequate long-term follow-up data, prolonged surgical times and no significant differences in the rate of complications and implant survivorship compared with conventional MTs.

The learning curve for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system

BACKGROUND

Adoption of robotic-assisted total hip arthroplasty (RA-THA) systems can improve the accuracy of acetabular cup placement, but no group has reported the learning curve of novel, fluoroscopy-based RA-THA systems.

METHODS

A learning-curve cumulative summation (LC-CUSUM) analysis was performed on a consecutive series of the first 100 patients who received fluoroscopy-based RA-THA by the study surgeon. Operative times and specific robotic timepoints were compared between learning and proficiency phases.

RESULTS

Implementation of fluoroscopy-based RA-THA was associated with a learning curve of 12 cases. A 6-min increase in operative time was seen during the learning phase compared to the proficiency phase (44.3 ± 4.4 vs. 38.0 ± 7.1 min; p < 0.001), with a 3-min longer robotic cup impaction sequence during the learning phase (7.8 ± 1.9 vs. 4.8 ± 1.3 min; p < 0.001).

CONCLUSION

Adoption of fluoroscopy-based RA-THA is associated with a brief learning curve of 12 cases, with the most significant improvements in surgical efficiency realised during acetabular cup placement.

Functional Component Positioning in Total Hip Arthroplasty and the Role of Robotic-Arm Assistance in Addressing Spinopelvic Pathology

Hip, spine, and pelvis function as a unified kinetic chain. Any spinal pathology, results in compensatory changes in the other components to accommodate for the reduced spinopelvic motion. The complex relationship between spinopelvic mobility and component positioning in total hip arthroplasty presents a challenge in achieving functional implant positioning. Patients with spinal pathology, especially those with stiff spines and little change in sacral slope, are at high instability risk. In this challenging subgroup, robotic-arm assistance enables the execution of a patient specific plan, avoiding impingement and maximizing range of motion; especially utilizing virtual range of motion to dynamically assess impingement.

Precise acetabular positioning, discrepancy in leg length, and hip offset using a new seven-axis robot-assisted total hip arthroplasty system requires no learning curve: a retrospective study

Objective

The purpose of the present study was to determine the learning curve for a novel seven-axis robot-assisted total hip arthroplasty (RA-THA) system, and to explore whether it was able to provide greater accuracy in acetabular cup positioning, superior leg length discrepancy (LLD), and hip offset than conventional methods.

Methods

A total of 160 patients in which unilateral THA was performed in the second affiliated Hospital of Xi'an Jiaotong University from July 2021 to September 2022 were studied. The first 80 patients underwent robot-assisted THA, while conventional THA was performed on the subsequent 80 by the same team of experienced surgeons. The learning curve for the RA-THA system was evaluated using cumulative sum (CUSUM) analysis. The demographic data, preoperative clinical data, duration of surgery, postoperative Harris hip score (HHS) and postoperative radiographic data from patients that had conventional THA were compared.

Results

The 80 patients who underwent primary unilateral RA-THA comprised 42 males and 38 females and were followed up for 12 weeks. Using analysis by CUSUM, the learning curve of the RA-THA system could be divided into learning and proficiency phases, the former of which consisted of the first 17 cases. There was no significant difference between the learning and proficiency phases in terms of LLD, hip offset, or accuracy of acetabular prosthesis position in the RA-THA groups. The proportion of acetabular prostheses located in the Lewinnek safe zone was 90.5% in the proficiency group and 77.5% in the conventional group, respectively, a difference that was statistically significant (P < 0.05). The absolute error between target angle and postoperative measured angle of anteversion was statistically significant in the proficiency group and the conventional group((P < 0.05). Postoperative acetabular anteversion and LLD were 19.96 ± 5.68° and 6.00 (5.00) mm in the proficiency group, respectively, and 17.84 ± 6.81° and 8.09 (4.33) mm using conventional surgery, respectively (anteversion: P = 0.049; LLD: P < 0.001).

Conclusions

The surgical team required a learning curve of 17 cases using the RA-THA system to become proficient. There was no learning curve for other parameters, namely LLD, hip offset, or accuracy of acetabular prosthesis positioning. During the proficiency phase, the RA system was superior to conventional THA for control of leg length and accuracy of acetabular cup placement.

Equivalent radiation exposure with robotic total hip replacement using a novel, fluoroscopic-guided (CT-free) system: case-control study versus manual technique

Accurate and precise positioning of the acetabular cup remains a prevalent challenge in total hip arthroplasty (THA). Robotic assistance for THA has increased over the past decade due to the potential to improve the accuracy of implant placement. However, a common criticism of existing robotic systems is the requirement for preoperative computerized tomography (CT) scans. This additional imaging increases patient radiation exposure, as well as cost, and requires pin placement during surgery. The goal of this study was to analyze the radiation burden associated with a novel, CT-free robotic THA system compared to an unassisted manual THA approach (n = 100/arm). On average, the study cohort had a higher number of fluoroscopic images captured (7.5 vs. 4.3 images; p < 0.001), radiation dose (3.0 vs. 1.0 mGy; p < 0.001), and a longer duration of radiation exposure (18.8 vs. 6.3 s; p < 0.001), per procedure, than the control group. Additionally, no learning curve was detected by CUSUM analysis with respect to the number of fluoroscopic images taken during the adoption of the robotic THA system. While statistically significant, in comparison to published literature, the radiation exposure of the CT-free robotic THA system was comparable to that of unassisted manual THA approach and less than that of CT-based robotic approaches. Thus, the novel CT-free robotic system likely poses no clinically significant increase in radiation exposure to the patient compared to manual approaches.

Image-based robotic-assisted total hip arthroplasty through direct anterior approach allows a better orientation of the acetabular cup and a better restitution of the centre of rotation than a conventional procedure

PURPOSE

The aim was to investigate the contribution of robotics assisted total hip arthroplasty (THA) through direct anterior approach (DAA) in improving radiographic precision, functional results and complications.

METHODS

This retrospective study compared 100 primary conventional THA (cTHA) to 50 primary robotic THA (rTHA) through DAA. All cups were placed with the objective of having no anterior overhang while respecting the safe zones (SZ). Radiographic analysis included cup inclination and anteversion, vertical and horizontal changes of the rotation centre (ΔVCOR, ΔHCOR), acetabular and femoral offset. SZ were 30-50° of inclination and 10-30° of anteversion. Outliers were defined as medial displacement of the COR > 5 mm, vertical displacement of the COR > 3 mm superiorly. Harris hip score (HHS) and complications were compared at one year of follow-up.

RESULTS

The robotic cups were better oriented with 98% in the global SZ versus 68% in the cTHA group (p = 0.0002). The COR was on average better restored in the robotic group in both the horizontal and vertical planes (Δ HCOR =  - 5.0 ± 5.0 vs - 3.4 ± 4.9, p = 0.03; Δ VCOR = 1.6 ± 3.3 vs 0.2 ± 2.7, p = 0.04). There were fewer outliers in the rTHA group concerning VCOR (28% versus 10%, p = 0.03). There was no significant difference in HHS and complication rate at one year.

CONCLUSION

The use of robotics for THA by DAA provided an advantage in controlling the orientation of the cup and the restoration of its rotation centre. Thanks to the 3D planning on CT scan, it allowed to respect the thresholds while avoiding the anterior overhangs.

Status of robot-assisted artificial total joint arthroplasty in China: a cross-sectional survey of joint surgeons

PURPOSE

The purpose of this study is to report on the use of Robotic-assisted total joint arthroplasty (RA-TJA) in China as well as the experience and expectations of Chinese doctors regarding this technology.

METHOD

A self-administered questionnaire was used to assess the current status of RA-TJA in China, the practical experience and suggestions for improvement of the technology by joint surgeons who have performed RA-TJA, and the interest and expectations of orthopaedic surgeons who have not used RA-TJA. The questionnaire was administered to all the physicians of the Chinese Association of Orthopedic Surgeons (CAOS).

RESULT

A total of 372 qualified questionnaires were generated, among which 28% (n = 104) of the respondents had performed RA-TJA, among those who had performed RA-TJA. When asked how helpful the joint replacement robot was actually/expected to be, there was no significant difference between the expected and actual experience of nonusers and users (p ≥ 0.05); the biggest disadvantage of the current development of RA-TJA was perceived as additional charges to the patient by those who had used it, while those who had not used it perceived it as a limitation of their hospital, both of which were significant differences. Most respondents in both groups (used: 94.2%; not used: 91.4%) were confident in the clinical development of the joint replacement robot.

CONCLUSION

This survey provides cross-sectional data on the current status of Chinese joint surgeons using or not using robots in their daily clinical practice. Improving surgical precision was the consensus of most respondents, while high surgical costs and limitations of hospital conditions were barriers to its development in China.

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

INTRODUCTION

The purpose of this article is to study whether the newly designed whole-process total hip arthroplasty (THA) robotic arm can improve the accuracy of prosthesis placement in THA.

METHOD

In this study, 72 patients undergoing THA were prospectively included and randomly divided into two groups. The experimental group was treated with THA assisted by a newly designed robotic arm. The control group received THA with conventional surgical methods. The imaging data were compared after operation.

RESULT

Compared with the conventional operation, the whole-process robotic arm can more accurately place the acetabular prosthesis in the anteversion safe zone of 5 ~ 25°, but in terms of the inclination angle, whether the reference is the safe zone of 30 ~ 50° or 30 ~ 45°, there is no statistical difference between the two groups. The average lower limb length discrepancy (LLLD) in the experimental group was 3.77 ± 8.31 mm longer than contralateral side, while the counterpart in the control group was 8.39 ± 9.11 mm, with significant difference (P = 0.029). The femoral prosthesis was fixed in neutral position in 35 (100%) cases in the experimental group and only 30 (83.3%) in the control group (P = 0.036). There was no significant difference in the recovery of hip offset, femoral anteversion, and canal fill ratio (CFR) between the two groups.

CONCLUSION

Robotic arm can improve the accuracy of anteversion of acetabular cup, restore the consistency of the length of lower limbs, and more accurately implant the femoral prosthesis to the neutral position in the coronal position.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2100044124 (date of registration: 2021-3-11).

The learning curve in robotic assisted knee arthroplasty is flattened by the presence of a surgeon experienced with robotic assisted surgery

PURPOSE

The purpose of this study was to investigate the learning curve associated with robotic assisted knee arthroplasty (RAS KA). Therefore, the evaluation of the influence of an experienced surgeon on the overall team performance of three surgeons regarding the learning curve in RAS KA was investigated. It was hypothesized that the presence of an experienced surgeon flattens the learning curve and that there was no inflection point for the learning curve of the surgical team.

METHODS

Fifty-five cases consisting of 31 total knee arthroplasties (TKA) and 24 unicompartmental arthroplasties (UKA) performed by three surgeons during 2021 were prospectively investigated. Single surgeon and team performance for operation time learning curve and inflection points were investigated using cumulative sum analysis (CUSUM).

RESULTS

A downward trend line for individual surgeons and the team performance regarding the operation time learning curve was observed. No inflexion point was observed for the overall team performance regarding TKA and UKA. The surgeon that performed all cases with the assistance of the experienced surgeon had significantly shorter surgical times than the surgeon that only occasionally received assistance from the experienced surgeon (p = 0.004 TKA; p = 0.002 UKA).

CONCLUSION

The presence of an experienced surgeon in robotically assisted knee arthroplasty can flatten the learning curve of the surgical team formerly unexperienced in robotic assisted systems. Manufacturers should provide expanded support during initial cases in centres without previous experience to robotic assisted knee arthroplasty.

LEVEL OF EVIDENCE

III.

Robotics in Total Hip Arthroplasty: Current Concepts

This current concepts article reviews the literature pertaining to the use of robot-assisted systems in total hip arthroplasty (THA). The bulk of the literature is regarding the MAKO (currently the most used system worldwide) and the historic ROBODOC robotic systems. There is a paucity of literature available on other systems, with several still in pilot-phase development. Whilst the evidence shows improved radiological outcomes with robotic THA, functional outcomes are equivocal between conventional and robotic techniques. Acceptance of robotic THA worldwide is limited by its accessibility including cost, and by already exceptional results with the conventional technique. It is, however, a rapidly developing area of orthopaedic surgery. This article discusses the history of robotics in THA, current surgical techniques, functional and radiological outcomes, and ongoing avenues for development.

Robotic-Arm-Assisted Total Hip Arthroplasty: A Review of the Workflow, Outcomes and Its Role in Addressing the Challenge of Spinopelvic Imbalance

Robotic-arm-assisted total hip arthroplasty (RoTHA) offers the opportunity to improve the implant positioning and restoration of native hip mechanics. The concept of individualised, functional implant positioning and how it relates to spinopelvic imbalance is an important yet rather novel consideration in THA. There is mounting evidence that a significant percentage of dislocations occur within the perceived “safe zones”; hence, in the challenging subset of patients with a stiff spinopelvic construct, it is imperative to employ individualised component positioning based on the patients’ phenotype. Restoring the native centre of rotation, preserving offset, achieving the desired combined anteversion and avoiding leg length inequality are all very important surgeon-controlled variables that have been shown to be associated with postoperative outcomes. The latest version of the software has a feature of virtual range of motion (VROM), which preoperatively identifies potential dynamic causes of impingement that can cause instability. This review presents the workflow of RoTHA, especially focusing on pragmatic solutions to tackle the challenge of spinopelvic imbalance. Furthermore, it presents an overview of the existing evidence concerning RoTHA and touches upon future direction.

Handheld Navigation Improves Accuracy in Direct Anterior Total Hip Replacement

Background

This study sought to determine the accuracy in placing the acetabular component, estimation of leg length, offset, radiation time and dose, and operative time using a handheld navigation device compared to conventional anterior total hip arthroplasty (THA). It also examined the learning curve of the handheld navigation device.

Methods

Data were prospectively collected for a consecutive series of 159 THAs; 99 THAs with handheld navigation and 60 conventional THAs. Thresholds of <5°, ≥5° to <10°, and ≥10° for acetabular inclination and version and thresholds of <5 mm, ≥5 mm to <10 mm, and ≥10 mm for leg-length and combined offset discrepancy were used to assess accuracy. Fluoroscopy time and exposure, operative time, and complications were compared. Learning curve was determined using operative time. Statistical analysis was performed for the different accuracy thresholds with P values set a <0.05 for significance.

Results

The handheld navigation device demonstrated a mean accuracy of 3.2° and 1.8° for version and inclination, respectively. The handheld navigation group had significantly fewer outliers in version (P < .001), inclination (P < .001), leg-length discrepancy (P < .001), and offset discrepancy (P < .001). Fluoroscopic dose and time (P < .001) were lower in the handheld navigation cohort. The learning curve for handheld navigation was 31-35 cases. The mean operative time after the learning curve was similar to that in the conventional fluoroscopy group (P = .113).

Conclusions

Handheld navigation technology provided more accurate results while mitigating radiation exposure to the surgeon and patient. There were fewer outliers in the handheld navigation group. After the learning curve, all metrics improved in accuracy, and operative time was similar to that of the conventional technique.

[Market overview: Robotic-assisted arthroplasty : Current robotic systems, learning curve and cost analysis]

Robotic-assisted arthroplasty has been rapidly entering clinical routine in recent years. The leading endoprosthesis manufacturers have all meanwhile placed robotic systems on the market, which, however, differ significantly from one another technically. Current systems are currently classified according to the degree of autonomy (active vs. semi-active vs. passive) and the data/image source (image-based: CT vs. X‑ray, imageless). Some systems already offer the possibility of robotic-assisted or navigated implantation of hip endoprostheses. In the following review article, the currently leading robotic systems will be presented and compared with regard to their characteristics. Furthermore, the analysis of the learning curves for the different systems, currently available cost analysis models and an outlook on future developments and challenges will be given.

A propensity score-matched comparison between Mako robotic arm-assisted system and conventional technique in total hip arthroplasty for patients with osteoarthritis secondary to developmental dysplasia of the hip

BACKGROUND

The clinical effectiveness of robotic arm-assisted systems remains unclear for total hip arthroplasty (THA) in patients suffering from osteoarthritis secondary to developmental dysplasia of the hip (DDH).

METHODS

Patients with DDH who underwent primary THA were included in this study. We conducted a propensity score-matched comparison between THAs using a robotic arm-assisted system (Mako group) versus those using the manual procedure (manual group) to compare the absolute differences in cup placement angles measured using postoperative computed tomography and those planned preoperatively.

RESULTS

A total of 217 patients with osteoarthritis due to DDH met the inclusion criteria. Eighty-four patients were matched as the Mako group and 84 as the manual group. The differences were smaller in the Mako group than the manual group in terms of both inclination and anteversion angles (1.1 ± 1.0 versus 4.2 ± 3.1, respectively; 95% CI, 2.4 to 3.8; p < 0.0001, and 1.2 ± 1.1 versus 5.8 ± 4.0, respectively; 95% CI, 3.7 to 5.5; p < 0.0001).

CONCLUSIONS

The robotic arm-assisted system may provide more accurate cup placement in THA for DDH.

Total Hip Arthroplasty with Robotic Arm Assistance for Precise Cup Positioning: A Case-Control Study

OBJECTIVE

To determine whether more precise cup positioning can be achieved with robot-assisted total hip arthroplasty (THA) as compared to conventional THA.

METHODS

In this study, between July 2019 and May 2021, 93 patients aged 23-75 years with osteonecrosis of the femoral head (ONFH) and adult developmental dysplasia of hip who underwent first hip surgery were included in the study. They were randomly assigned to either the robotic-assisted THA group (n = 45) or the conventional THA group (n = 48). After the operation, all patients were given routine rapid rehabilitation guidance. The duration of operation was recorded to estimate the learning curve through cumulative summation analysis. We compared the demographics, duration of operation, cup positioning, leg length discrepancy, hip offset, and Harris Hip Score between robot-assisted THA and manual THA. Precision in the positioning of the acetabular prosthesis using the MAKO system was also compared between the two groups.

RESULTS

The mean duration of operation for the robot-assisted THA group was 91.37 ± 17.34 min (range: 63 to 135 min), which was significantly higher than that for the conventional THA group. When the number of procedures was increased to 13, the duration of operation in the robot-assisted group decreased significantly and gradually became stable. In terms of duration of operation, robot-assisted THA was associated with a learning curve of 13 cases. The mean amount of bleeding in the robot-assisted THA group was not significantly different from that in conventional THA group (328 ± 210 ml vs 315 ± 205 ml) (p = 0.741). There was no significant difference in the proportion of prostheses located within Lewinnek's safe zone between robot-assisted THA group and conventional THA group (69.81% vs 64.41%). The leg length discrepancy (LLD) was significantly smaller in the robot-assisted THA group than in the conventional THA group (p < 0.001), but both were within acceptable limits (10 mm). The inclination and anteversion angles of the acetabular prosthesis planned before operations were correlated with the actual measurement (r = 0.857 p < 0.001, r = 0.830, p < 0.001). After surgery, none of the patients experienced hip dislocation, aseptic loosening, or periprosthetic infection during the 3 months of follow-up.

CONCLUSION

The proportion of acetabular prostheses in the Lewinnek's safety zone was higher and the extent of LLD was significantly lower in the robot-assisted THA group, as compared to the same metrics in the conventional THA group. The MAKO robot improved the accuracy of implant placement in THA.

[Meta-analysis of leg length discrepancy after robot-assisted and traditional total hip arthroplasty]

OBJECTIVE

To systematically evaluate the difference in leg length discrepancy (LLD) between robot-assisted total hip arthroplasty (THA) and traditional THA.

METHODS

The Cochrane Library, PubMed, Web of Science, EMbase, CNKI, Wanfang, VIP, and CBM databases were searched by computer to collect cohort studies of robot-assisted and traditional THAs from inception to August 11th, 2021. Two researchers independently screened the literature, extracted the data, and evaluated the risk of bias of the included studies. Meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 10 high-quality cohort studies were included. The results of Meta-analysis showed that compared with traditional THA, LLD after robot-assisted THA was smaller [ MD=-1.64, 95% CI (-2.25, -1.04), P<0.001], Harris scores at 3 and 12 months after operation were higher [ MD=1.50, 95% CI (0.44, 2.57), P=0.006; MD=7.60, 95% CI (2.51, 12.68), P=0.003]. However, the operative time was longer [ MD=8.36, 95% CI (4.56, 12.17), P<0.000 1], and the postoperative acetabular anteversion angle was larger [ MD=1.91, 95% CI (1.43, 2.40), P<0.001]. There was no significant difference in Harris score at 6 months, amnesia index (Forgotten joint score, FJS), postoperative acetabular abduction angle, and incidence of complication between the two groups ( P>0.05).

CONCLUSION

Robot-assisted THA is superior to traditional THA in postoperative LLD.

Dislocation risk after robotic arm-assisted total hip arthroplasty: a comparison of anterior, lateral and posterolateral approaches

AIMS

Dislocation is a major cause of early failure after THA and is highly influenced by surgical approach and component positioning. Robotic-arm assisted arthroplasty has been developed in an attempt to improve component positioning and reduce postoperative complications.The purpose of this study was to compare the rate of dislocation after robotic total hip arthroplasty through 3 different surgical approaches.

MATERIALS AND METHODS

All patients who had undergone robotic arm-assisted THA at 3 centres between 2014 and 2019 were reviewed. After applying exclusion criteria, 1059 patients were included in the study. An anterior approach was used in 323 patients, a lateral approach in 394 and a posterior approach in 342 patients.Episodes of dislocation were recorded after 6 months follow-up. Stem anteversion, cup anteversion, cup inclination and combined anteversion were collected using the integrated navigation system.Cumulative incidence (CI), incidence rate (IR) and risk ratio (RR) were calculated with a confidence interval of 95%.

RESULTS

3 cases of dislocation (2 posterior approach, 1 anterior approach) were recorded, with a dislocation rate of 0.28% and an IR of 0.14%.The rate of placement of the cup in the Lewinnek safe zone was 82.2% for the posterior approach, 82.0% for the lateral approach and 95.4% for the anterior approach.The rate of placement in the combined version safe zone was 98.0% for the posterior approach, 73.0% for the lateral approach and 47.1% for the anterior approach.The incidence rate of dislocation was 0.30% for the anterior approach, 0.34% for the posterior approach and 0% for the lateral approach.

CONCLUSIONS

The robotic arm-assisted technique is associated with a low risk of dislocation. The combined version technique appears to be a reliable way to reduce the risk of dislocation through the posterolateral approach but does not appear to be essential when using the lateral and anterior approaches.

[Short-term effectiveness of MAKO robot assisted complex total hip arthroplasty]

OBJECTIVE

To investigate the short-term effectiveness of MAKO robot assisted complex total hip arthroplasty (THA).

METHODS

The clinical data of 15 patients (17 hips) underwent MAKO robot assisted complex THA between May 2020 and June 2021 were analyzed retrospectively. There were 5 males and 10 females with the age ranged from 19 to 70 years (median, 49 years), included 9 cases (9 hips) of developmental dysplasia of the hip (Crowe type Ⅱ in 5 hips, type Ⅲ in 1 hip, and type Ⅳ in 3 hips), 1 case (2 hips) of rheumatoid arthritis, 2 cases (3 hips) of ankylosing spondylitis, 3 cases (3 hips) of secondary arthritis with a history of acetabular fracture and internal fixation. The acetabular cup abduction angle and anteversion angle were measured at 3 months after operation, and compared with those measured by MAKO robot system before and immediately after operation. The femoral offset and leg length discrepancy (LLD) were measured at 3 months after operation, which were compared with those before operation. Harris hip score (HHS) and visual analogue scale (VAS) score were used to evaluate hip function before operation and at 3 months after operation.

RESULTS

All 15 patients (17 hips) completed the operation successfully. The operation time was 75-175 minutes, with an average of 116.3 minutes; the intraoperative blood loss was 100-800 mL, with an average of 381.3 mL. Two patients were not included in the statistics because of intraoperative and postoperative complications, the remaining 13 patients (15 hips) had no serious complication such as vascular and nerve injuries, and 3 patients had intermuscular vein thrombosis. The 13 patients (15 hips) were followed up 3-15 months, with an average of 8 months. At last follow-up, the position of prosthesis did not change and there was no signs of loosening. There was no significant difference in acetabular abduction angle at immediate and 3 months after operation when compared with preoperative one ( P>0.05), and the acetabular anteversion angle was significantly lower than that before operation ( P<0.05). There was no significant difference in acetabular abduction angle and anteversion angle between at immediate and 3 months after operation ( P>0.05). The LLD, offset, HHS score, and VAS score were significantly improved at 3 months after operation when compared with preoperative ones ( P<0.05).

CONCLUSION

MAKO robot assisted complex THA can achieve good short-term effectiveness, improve the hip range of motion, reduce the length difference between bilateral lower limbs, and improve the quality of patients' life.

Comparison of Surgical Time, Short-term Adverse Events, and Implant Placement Accuracy Between Manual, Robotic-assisted, and Computer-navigated Total Hip Arthroplasty: A Network Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Recent years have observed the increasing utilization of robotic-assisted and computer navigation techniques in total hip arthroplasty (THA), given the proposed benefits of enhanced consistency and precision in implant placement. The purpose of this study was to conduct a systematic review of randomized controlled trials (RCTs) to determine whether differences in surgical times, adverse events, and implant positioning existed between manual, robotic-assisted, and computer navigation THA.

METHODS

PubMed, OVID/MEDLINE, and Cochrane databases were queried for RCTs comparing robotic-assisted versus manual THA and computer navigation versus manual THA at a minimum 1-year follow-up. Frequentist model network meta-analyses with P-scores were conducted to compare revisions, complications, and surgical times among the three treatment groups. A random-effects meta-analysis between computer navigation and manual THAs was conducted to analyze cup positioning because no robotic-assisted THA studies reported this outcome.

RESULTS

Five RCTs compared robotic-assisted and manual THAs, while seven compared computer navigation and manual THAs. manual THA was associated with significantly reduced surgical time in comparison with computer navigation (mean difference: 23.3 minutes) and robotic-assisted THAs (mean difference: 8.6 minutes; P < 0.001). No difference was observed in the incidence of all-cause complications (computer navigation: 1.7%, manual: 6.6%, and robotic-assisted: 16.2%) or revisions (computer navigation: 1.0%, manual: 1.7%, and robotic-assisted 4.8%) among the three treatment groups based on the network meta-analysis. In three studies that reported acetabular implant positioning, computer navigation had a significantly higher percentage of acetabular cups placed in the Lewinnek "safe zone" compared with manual THA (79% versus 52%; P = 0.02).

CONCLUSIONS

manual THA results in markedly shorter surgical times and a similar incidence of complications and revisions compared with robotic-assisted and computer navigation THAs, given the sample sizes available for study. However, computer navigation THA led to increased precision in the placement of acetabular implants.

[Robot-assisted joint arthroplasty-An emerging technology of the present and the future]

Objective

To review and evaluate the research progress of the robot-assisted joint arthroplasty.

Methods

The domestic and foreign related research literature on robot-assisted joint arthroplasty was extensively consulted. The advantages, disadvantages, effectiveness, and future prospects were mainly reviewed and summarized.

Results

The widely recognized advantages of robot-assisted joint arthroplasty are digital and intelligent preoperative planning, accurate intraoperative prosthesis implantation, and quantitative soft tissue balance, as well as good postoperative imaging prosthesis position and alignment. However, the advantages of effectiveness are still controversial. The main disadvantages of robot-assisted joint arthroplasty are the high price of the robot system, the prolonged operation time, and the increased radioactive damage of the imaging-dependent system.

Conclusion

Compared to traditional arthroplasty, robot-assisted joint arthroplasty can improve the accuracy of the prosthesis position and assist in the quantitative assessment of soft tissue tension, and the repeatability rate is high. In the future, further research is needed to evaluate the clinical function and survival rate of the prosthesis, as well as to optimize the robot system.

Is there increased value in robotic arm-assisted total hip arthroplasty? : a nationwide outcomes, trends, and projections analysis of 4,699,894 cases

AIMS

The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA.

METHODS

The National Inpatient Sample was queried for primary THAs (2008 to 2017) which were categorized into RA-THA, CA-THA, and M-THA. Past and projected use, demographic characteristics distribution, income, type of insurance, location, and healthcare setting were compared among the three cohorts. In-hospital complications, LOS, discharge disposition, and in-hospital costs were compared between propensity score-matched cohorts of M-THA versus RA-THA and M-THA versus CA-THA to adjust for baseline characteristics and comorbidities.

RESULTS

RA-THA and CA-THA did not exhibit any clinically meaningful reduction in mean LOS (RA-THA 2.2 days (SD 1.4) vs 2.3 days (SD 1.8); p < 0.001, and CA-THA 2.5 days (SD 1.9) vs 2.7 days (SD 2.3); p < 0.001, respectively) compared to their respective propensity score-matched M-THA cohorts. RA-THA, but not CA-THA, had similar non-home discharge rates to M-THA (RA-THA 17.4% vs 18.5%; p = 0.205, and 18.7% vs 24.9%; p < 0.001, respectively). Implant-related mechanical complications were lower in RA-THA (RA-THA 0.5% vs M-THA 3.1%; p < 0.001, and CA-THA 1.2% vs M-THA 2.2%; p < 0.001), which was associated with a significantly lower in-hospital dislocation (RA-THA 0.1% vs M-THA 0.8%; p < 0.001). Both RA-THA and CA-THA demonstrated higher mean higher index in-hospital costs (RA-THA $18,416 (SD $8,048) vs M-THA $17,266 (SD $8,396); p < 0.001, and CA-THA $20,295 (SD $8,975) vs M-THA $18,624 (SD $9,226); p < 0.001, respectively). Projections indicate that 23.9% and 3.2% of all THAs conducted in 2025 will be robotic arm- and computer-assisted, respectively. Projections indicated that RA-THA use may overtake M-THA by 2028 (48.3%) and reach 65.8% of all THAs by 2030.

CONCLUSION

Technology-assisted THA, particularly RA-THA, may provide value by lowering in-hospital early dislocation rates and and other in-hospital metrics compared to M-THA. Higher index-procedure and hospital costs warrant further comprehensive cost analyses to determine the true added value of RA-THA in the episode of care, particularly since we project that one in four THAs in 2025 and two in three THA by 2030 will use RA-THA technology. Cite this article: Bone Joint J 2021;103-B(9):1488-1496.

Robotic arm-assisted versus manual total hip arthroplasty : a systematic review and meta-analysis

AIMS

The aims of this systematic review were to assess the learning curve of semi-active robotic arm-assisted total hip arthroplasty (rTHA), and to compare the accuracy, patient-reported functional outcomes, complications, and survivorship between rTHA and manual total hip arthroplasty (mTHA).

METHODS

Searches of PubMed, Medline, and Google Scholar were performed in April 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included "robotic", "hip", and "arthroplasty". The criteria for inclusion were published clinical research articles reporting the learning curve for rTHA (robotic arm-assisted only) and those comparing the implantation accuracy, functional outcomes, survivorship, or complications with mTHA.

RESULTS

There were 501 articles initially identified from databases and references. Following full text screening, 17 articles that satisfied the inclusion criteria were included. Four studies reported the learning curve of rTHA, 13 studies reported on implant positioning, five on functional outcomes, ten on complications, and four on survivorship. The meta-analysis showed a significantly greater number of cases of acetabular component placement in the safe zone compared with the mTHA group (95% confidence interval (CI) 4.10 to 7.94; p < 0.001) and that rTHA resulted in a significantly better Harris Hip Score compared to mTHA in the short- to mid-term follow-up (95% CI 0.46 to 5.64; p = 0.020). However, there was no difference in infection rates, dislocation rates, overall complication rates, and survival rates at short-term follow-up.

CONCLUSION

The learning curve of rTHA was between 12 and 35 cases, which was dependent on the assessment goal, such as operating time, accuracy, and team working. Robotic arm-assisted total hip arthroplasty was associated with improved accuracy of component positioning and functional outcome, however no difference in complication rates or survival were observed at short- to mid-term follow-up. Overall, there remains an absence of high-quality level I evidence and cost analysis comparing rTHA and mTHA. Cite this article: Bone Joint J 2021;103-B(6):1009-1020.

Can robotic technology mitigate the learning curve of total hip arthroplasty?

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.

Methods

Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement.

Results

Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500).

Conclusion

Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty.

Cite this article: Bone Jt Open 2021;2(6):365–370.

Advances and innovations in total hip arthroplasty

Total hip arthroplasty (THA) has been quoted as one of the most successful and cost-effective procedures in Orthopaedics. The last decade has seen an exponential rise in the number of THAs performed globally and a sharp increase in the percentage of young patients hoping to improve their quality of life and return to physically demanding activities. Hence, it is imperative to review the various applications of technology in total hip arthroplasty for improving outcomes. The development of state-of-the-art robotic technology has enabled more reproducible and accurate acetabular positioning, while long-term data are needed to assess its cost-effectiveness. This opinion piece aims to outline and present the advances and innovations in total hip arthroplasty, from virtual reality and three-dimensional printing to patient-specific instrumentation and dual mobility bearings. This illustrates and reflects the debate that will be at the centre of hip surgery for the next decade.

Robotics in total hip arthroplasty: a review of the evolution, application and evidence base

Robotic systems used in orthopaedics have evolved from active systems to semi-active systems.

Early active systems were associated with significant technical and surgical complications, which limited their clinical use.

The new semi-active system Mako has demonstrated promise in overcoming these limitations, with positive early outcomes.

There remains a paucity of data regarding long-term outcomes associated with newer systems such as Mako and TSolution One, which will be important in assessing the applicability of these systems.

Given the already high satisfaction rate of manual THA, further high-quality comparative studies are required utilizing outcome scores that are not limited by high ceiling effects to assess whether robotic systems justify their additional expense.

Cite this article: EFORT Open Rev 2020;5:866-873. DOI: 10.1302/2058-5241.5.200037

Current concepts in robotic total hip arthroplasty

INTRODUCTION

Total hip replacement provides mostly fair functional and clinical results. Many factors play an essential role in hip stability and long-term outcomes. Surgical positioning remains fundamental for obtaining accurate implant fit and prevent hip dislocation or impingement. Different categories of robotic assistance have been established throughout the previous years and all of the technologies target accuracy and reliability to reduce complications, and enhance clinical outcomes.

MATERIALS AND METHODS

An overview is proposed over the principles of robotic assistance in hip arthroplasty surgery. Accuracy, reliability, management of the bone stock, clinical outcomes, constraints and limits of this technology are reported, based on recent literature.

RESULTS

Potential advantages regarding pre-operative planning accuracy, cup positioning, maintenance of the center of rotation, preservation of an adequate bone stock nay clinical short- and mid-term outcomes are balanced with some reported disadvantages and limits like hip anatomical specificity, cost-effectiveness, engineering dependence.

DISCUSSION

The use of robotic-assisted THA presents clear and evident benefits related to accurate implant positioning and maintenance of a minimal bone while allowing. For some authors, an early improvement in functional results and patient's recovery. This technology demonstrated a shorter surgical time and a short learning curve required to optimize its use and this technology presents promising outcomes and results and potential use in routine clinical application but its limitation of use is still present especially the cost of the robot, the need for the presence of an engineer during the surgery, its availability of use in all hospitals as well as the difficulty presented in dysplastic or dysmorphic hip joints.

Computer-Assisted Orthopedic and Trauma Surgery

BACKGROUND

There are many ways in which computer-assisted orthopedic and trauma surgery (CAOS) procedures can help surgeons to plan and execute an intervention.

METHODS

This study is based on data derived from a selective search of the literature in the PubMed database, supported by a Google Scholar search.

RESULTS

For most applications the evidence is weak. In no sector did the use of computer-assisted surgery yield any relevant clinical or functional improvement. In trauma surgery, 3D-navigated sacroiliac screw fixation has become clinically established for the treatment of pelvic fractures. One randomized controlled trial showed a reduction in the rate of screw misplacement: 0% with 3D navigation versus 20.4% with the conventional procedure und 16.6% with 2D navigation. Moreover, navigation-assisted pedicle screw stabilization lowers the misplacement rate. In joint replacements, the long-term results showed no difference in respect of clinical/functional scores, the time for which the implant remained in place, or aseptic loosening.

CONCLUSION

Computer-assisted procedures can improve the precision of certain surgical interventions. Particularly in joint replacement and spinal surgery, the research is moving away from navigation in the direction of robotic procedures. Future studies should place greater emphasis on clinical and functional results.

Robotic-Arm Assistance Simplifies Hip Arthrodesis Conversion to Total Hip Arthroplasty

Hip fusion takedown to total hip replacement is a challenging operation. Neck osteotomy and acetabular component placement are technically demanding and often require fluoroscopic guidance. Robotic arm–assisted total hip arthroplasty enhances accuracy of preoperative planning and provides navigated guidance for neck osteotomy and haptic guidance on acetabular reaming and cup implantation. Fluoroscopic guidance is replaced by real-time navigation and on-screen data. This article describes how robotic arm assistance can simplify this complex operation.

Computerised tomography-based planning with conventional total hip arthroplasty versus robotic-arm assisted total hip arthroplasty: study protocol for a prospective randomised controlled trial

Background

Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning during total hip arthroplasty. The objective of this study is to compare the accuracy of implant positioning, restoration of hip biomechanics, patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications in conventional manual total hip arthroplasty (CO THA) versus robotic-arm assisted total hip arthroplasty (RO THA). Preoperative pelvic computerised tomography (CT) scans will be used to create patient-specific, virtual, three-dimensional reconstructions for surgical planning in both treatment groups.

Methods and analysis

This prospective randomised controlled trial will include 60 patients with symptomatic hip osteoarthritis undergoing primary THA. Following informed consent, patients will be randomised to CO THA (control group) or RO THA (investigation group) at a ratio of 1:1 using an online random number generator. Observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to the accuracy of implant positioning, hip biomechanics, postoperative rehabilitation, clinical progress, functional outcomes, cost-effectiveness, and complications. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. Intention to treat relates to the allocated treatment (CO THA or RO THA), and per-protocol refers to the actual treatment received by the patient. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Bromley Research Ethics Committee, UK. The study is sponsored by University College London, UK.

Discussion

This study compares a comprehensive and robust range of clinical, functional, and radiological outcomes in CT-planned CO THA versus CT-planned RO THA. The findings of this study will enable an improved understanding of the differences in CO THA versus RO THA with respect to patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications.

Trial registration

ClinicalTrials.gov NCT04095845. Registered on 19 September 2019