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Bollars P, Janssen D, De Weerdt W, Albelooshi A, Meshram P, Nguyen TD, Lacour MT, Schotanus MGM. Improved accuracy of implant placement with an imageless handheld robotic system compared to conventional instrumentation in patients undergoing total knee arthroplasty: a prospective randomized controlled trial using CT-based assessment of radiological outcomes. Knee Surg Sports Traumatol Arthrosc 2023; 31:5446-5452. [PMID: 37796307 DOI: 10.1007/s00167-023-07590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Image-free handheld robotic-assisted total knee arthroplasty (RATKA) has shown to achieve desired limb alignment compared to conventional jig-based instrumented total knee arthroplasty (CTKA). The aim of this prospective randomized controlled trial (RCT) was to evaluate the accuracy of a semi-autonomous imageless handheld RATKA compared to CTKA in order to achieve the perioperative planned target alignment of the knee postoperatively. METHODS Fifty-two patients with knee osteoarthritis were randomized in 1:1 ratio to undergo unilateral CTKA or an imageless handheld RATKA. A full-length lower limb CT-scan was obtained pre- and 6-week postoperative. The primary outcomes were radiologic measurements of achieved target hip-knee-ankle axis (HKA-axis) and implant component position including varus and external rotation and flexion of the femur component, and posterior tibial slope. The proportion of outliers in above radiographic outcomes, defined as > 3° deviation in postoperative CT measurements as compared to perioperative planned target, were also noted. Knee phenotypes were compared with use of the Coronal Plane Alignment of the Knee (CPAK) classification. RESULTS Baseline conditions were comparable between both groups. The overall proportion and percentage of outliers (n = 38, 24.4% vs n = 9, 5.8%) was statistically significant (p < 0.001) in favor of RATKA. The achieved varus-valgus of the femoral component (varus 1.3° ± 1.7° vs valgus - 0.1° ± 1.9°, p < 0.05) with statistically significant less outliers (0% vs 88.5%, p < 0.01), the achieved HKA-axis (varus 0.4° ± 2.1° vs valgus - 1.2° ± 2.1°, p < 0.05) and the posterior tibial slope (1.4° ± 1.1° vs 3.2° ± 1.8°, p < 0.05) were more accurate with RATKA. The most common postoperative CPAK categories were type II (50% CTKA vs 61.5% RATKA), type I (3.8% CTKA vs 23.1% RATKA) and type V (26.9% CTKA vs 15.4% RATKA). CPAK classification III was only found in CTKA (19.2%). Type VI, VII, VIII, and IX were rare in both populations. CONCLUSIONS The present trial demonstrates that an imageless handheld RATKA system can be used to accurately perioperatively plan the desired individual component implant positions with less alignment outliers whilst aiming for a constitutional alignment. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Peter Bollars
- Department of Orthopedic Surgery, St. Trudo Hospital, Sint-Truiden, Belgium.
| | - Daniel Janssen
- Department of Orthopedic Surgery, St. Trudo Hospital, Sint-Truiden, Belgium
| | - Wim De Weerdt
- Department of Orthopedic Surgery, St. Trudo Hospital, Sint-Truiden, Belgium
| | - Ali Albelooshi
- Department of Orthopedic Surgery, Mediclinic City Hospital, Dubai Healthcare City, Dubai, United Arab Emirates
- Orthocure Medical Center, Dubai, United Arab Emirates
| | - Prashant Meshram
- Department of Orthopedic Surgery, Mediclinic City Hospital, Dubai Healthcare City, Dubai, United Arab Emirates
- Orthocure Medical Center, Dubai, United Arab Emirates
| | - Thang D Nguyen
- Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
| | - Michael T Lacour
- Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
| | - Martijn G M Schotanus
- Department of Orthopedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
- School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Herregodts S, Vermue H, Herregodts J, De Coninck B, Chevalier A, Verstraete M, De Baets P, Victor J. Accuracy of intraoperative bone registration and stereotactic boundary reconstruction during total knee arthroplasty surgery. Int J Med Robot 2023; 19:e2460. [PMID: 36088533 DOI: 10.1002/rcs.2460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/30/2022] [Accepted: 09/09/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The intraoperative registration of the bones play a crucial role in image-based computer-assisted knee arthroplasty to achieve accurate implant placement and to create reliable stereotactic bone boundaries for robot-assisted surgical systems. METHOD This study assessed the intraoperative registration accuracy on six intact fresh frozen cadavers. RESULTS Rotational errors around the mechanical axis were the largest, with a standard deviation of 1.2° and outliers up to 3.7°. The mean translational errors were lower than 1 mm, with outliers up to 1.5 mm. These errors were amplified to 2 mm for the registration-based reconstruction of the posterior bone surface at the resection levels. CONCLUSION Given the cumulative behaviour of surgical errors, registration errors can affect the final implant positioning. Furthermore, inaccuracies in the reconstructed bone boundary directly affect the virtual stereotactic boundaries used in robotic-assisted surgery and can result in an incomplete resection or inadvertent soft tissue damage.
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Affiliation(s)
- Stijn Herregodts
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium
| | - Hannes Vermue
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Jan Herregodts
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bert De Coninck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Amélie Chevalier
- Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium
| | | | - Patrick De Baets
- Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium
| | - Jan Victor
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
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Doan GW, Courtis RP, Wyss JG, Green EW, Clary CW. Image-Free Robotic-Assisted Total Knee Arthroplasty Improves Implant Alignment Accuracy: A Cadaveric Study. J Arthroplasty 2022; 37:795-801. [PMID: 34979253 DOI: 10.1016/j.arth.2021.12.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Improving resection accuracy and eliminating outliers in total knee arthroplasty (TKA) is important to improving patient outcomes regardless of alignment philosophy. Robotic-assisted surgical systems improve resection accuracy and reproducibility compared to conventional instrumentation. Some systems require preoperative imaging while others rely on intraoperative anatomic landmarks. We hypothesized that the alignment accuracy of a novel image-free robotic-assisted surgical system would be equivalent or better than conventional instrumentation with fewer outliers. METHODS Forty cadaveric specimens were used in this study. Five orthopedic surgeons performed 8 bilateral TKAs each, using the VELYS Robotic-Assisted System (DePuy Synthes) and conventional instrumentation on contralateral knees. Pre-resection and postresection computed tomography scans, along with optical scans of the implant positions were performed to quantify resection accuracies relative to the alignment targets recorded intraoperatively. RESULTS The robotic-assisted cohort demonstrated smaller resection errors compared to conventional instrumentation in femoral coronal alignment (0.63° ± 0.50° vs 1.39° ± 0.95°, P < .001), femoral sagittal alignment (1.21° ± 0.90° vs 3.27° ± 2.51°, P < .001), and tibial coronal alignment (0.93° ± 0.72° vs 1.65° ± 1.29°, P = .001). All other resection angle accuracies were equivalent. Similar improvements were found in the femoral implant coronal alignment (0.89° ± 0.82° vs 1.42° ± 1.15°, P = .011), femoral implant sagittal alignment (1.51° ± 1.08° vs 2.49° ± 2.10°, P = .006), and tibial implant coronal alignment (1.31° ± 0.84° vs 2.03° ± 1.44°, P = .004). The robotic-assisted cohort had fewer outliers (errors >3°) for all angular resection alignments. CONCLUSION This in vitro study demonstrated that image-free robotic-assisted TKA can improve alignment accuracy compared to conventional instrumentation and reduce the incidence of outliers.
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Affiliation(s)
- Gary W Doan
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
| | | | | | | | - Chadd W Clary
- Center for Orthopaedic Biomechanics, University of Denver, Denver, CO
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Pan S, Huang C, Zhang X, Ruan R, Yan Z, Li Z, Pang Y, Guo K, Zheng X. Non-weight-bearing short knee radiographs to evaluate coronal alignment before total knee arthroplasty. Quant Imaging Med Surg 2022; 12:1214-1222. [PMID: 35111617 DOI: 10.21037/qims-21-400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/13/2021] [Indexed: 11/06/2022]
Abstract
Background Whole leg radiograph (WLR) is the gold standard in assessing lower limb alignment before total knee arthroplasty (TKA) although in practice, non-weight-bearing short knee radiographs (NWB SKRs) are used by most medical institutions. The objective of this study was to determine whether the femorotibial angle (FTA) could be used to evaluate lower limb alignment on limited NWB SKRs. We also investigated whether FTA alignment measurements on NWB SKRs and WLRs differed depending on the direction of knee deformity. Methods In all, 105 knees which underwent both NWB SKR and WLR were included. Measurement of hip-knee-ankle angle (HKA) was obtained through WLR, while the FTA was found using NWB SKR (FTASKR) and WLR (FTAWLR). All knees were divided into three groups based on the HKA. The Kappa statistic was used to compare the agreement of categorical alignment variables between the HKA and FTASKR. The agreement of the measurements obtained from the two radiographs was made using Bland-Altman plots and intraclass correlation coefficient (ICC). Pearson correlation coefficient and simple linear regression analysis were also conducted to evaluate the correlation between different angles. Results The agreement for categories of lower limb deformity was rated excellent (kappa =0.804, P<0.001). The Bland-Altman plot showed that the mean difference for the FTASKR and FTAWLR was 4.4°. There was an excellent correlation (r=0.861, P<0.001) and good reliability (ICC, 0.607) between the FTASKR and HKA. For the varus group, there was a good correlation between the FTASKR and HKA (r=0.650, P<0.001); however, there were no significant correlations between the FTAS KR and HKA in the neutral (r=0.106, P=0.543) and valgus groups (r=0.322, P=0.102). Conclusions For outpatient follow-up, we found that the FTA on NWB SKRs is an acceptable means for classifying knee alignment (varus, neutral, or valgus). The measurement on NWB SKR also showed excellent correlation and good agreement with the HKA. For varus knees, NWB SKR measurements showed the best correlation with the HKA. However, for neutral and valgus knees, NWB SKR measurements were insufficient for conducting a reliable calculation and quantification of coronal alignment of the lower limb.
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Affiliation(s)
- Sheng Pan
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chaoran Huang
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xingchen Zhang
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ruxin Ruan
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ziwen Yan
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zheng Li
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Pang
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kaijin Guo
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xin Zheng
- Department of Orthopedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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Stulberg BN, Zadzilka JD. Active robotic technologies for total knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:2069-2075. [PMID: 34259928 DOI: 10.1007/s00402-021-04044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION When active robotic technologies for Total Knee Arthroplasty (TKA) were introduced over 20 years ago, broad usage of robotic technology was not felt to be needed as early data suggested no clear improvement in clinical outcomes compared to conventional techniques of implantation. Only recently has there been renewed enthusiasm for use of robotic technologies for implantation. MATERIALS AND METHODS Active robotic technology specifically refers to the use of a robot for planning and executing the surgical procedure-with surgeon guidance and control. The physical work of bone preparation is performed by a milling tool, following a cut path defined by a CT-based preoperative plan. This manuscript describes the IDE experience of the only active robotic system (ARoS) available in the US, which took place from February 2017 through December 2018. RESULTS 115 patients were enrolled in an IDE study to evaluate the safety and efficacy of an ARoS for TKA. No previously described safety issues for TKA occurred. Three-dimensional accuracy of component placement used the preoperative CT plan compared to the 3-months postoperative CT scan to demonstrate accuracy of all autonomous resections to within 1.5 mm and/or 1.5 degrees. Surgical planning and execution to restore alignment along kinematic principles were used in 40 procedures and to achieve mechanical alignment in 75 procedures. CONCLUSIONS This FDA study of an active robotic approach for TKA represented the first multicenter trial and first US experience with this technology. Results demonstrated an excellent safety profile and high degree of accuracy. Advantages of this approach relate to standardization of the technique, multiple device options in the implant library, an excellent safety and accuracy profile, and consistency of results. Active robotics for TKA represents a viable and safe technique for primary TKA.
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Affiliation(s)
- Bernard N Stulberg
- St. Vincent Charity Medical Center, 33001 Solon Rd., Suite 112, Solon, OH, 44139, USA
| | - Jayson D Zadzilka
- St. Vincent Charity Medical Center, 33001 Solon Rd., Suite 112, Solon, OH, 44139, USA.
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Safe and effective use of active robotics for TKA: Early results of a multicenter study. J Orthop 2021; 26:119-125. [PMID: 34393411 DOI: 10.1016/j.jor.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background A novel active robotic system for total knee arthroplasty (TKA) performs automated milling of bone surfaces. Study objectives were to assess system safety and effectiveness in a US population. Methods A multicenter clinical trial was conducted, following 115 patients for at least 6-months. A pre-defined list of robot-related adverse events was used to evaluate safety. Efficacy was assessed radiographically comparing planned versus achieved coronal limb alignment. Results No pre-defined adverse events occurred and postoperative limb alignment more than ±3° from plan occurred in 11.2 % of cases. Conclusion Active robotics for TKA is safe and effective as demonstrated in this trial.
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