Robot-assisted Total Knee Arthroplasty is Associated with a Learning Curve for Surgical Time but Not for Component Alignment, Limb Alignment and Gap Balancing

Overview

Journal Knee Surg Sports Traumatol Arthrosc

Publisher Wiley

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2020 Nov 3

PMID 33141246

Citations 50

Authors

Hannes Vermue

Thomas Luyckx

Philip Winnock de Grave

Alexander Ryckaert

Anne-Sophie Cools

Nicolas Himpe

Jan Victor

Affiliations

Soon will be listed here.

Abstract

Purpose: The application of robotics in the operating theatre for total knee arthroplasty (TKA) remains controversial. As with all new technology, the introduction of new systems is associated with a learning curve and potentially associated with extra complications. Therefore, the aim of this study is to identify and predict the learning curve of robot-assisted (RA) TKA.

Methods: A RA TKA system (MAKO) was introduced in April 2018 in our service. A retrospective analysis was performed of all patients receiving a TKA with this system by six surgeons. Operative times, implant and limb alignment, intraoperative joint balance and robot-related complications were evaluated. Cumulative summation (CUSUM) analyses were used to assess learning curves for operative time, implant alignment and joint balance in RA TKA. Linear regression was performed to predict the learning curve of each surgeon.

Results: RA TKA was associated with a learning curve of 11-43 cases for operative time (p < 0.001). This learning curve was significantly affected by the surgical profile (high vs. medium vs. low volume). A complete normalisation of operative times was seen in four out of five surgeons. The precision of implant positioning and gap balancing showed no learning curve. An average deviation of 0.2° (SD 1.4), 0.7° (SD 1.1), 1.2 (SD 2.1), 0.2° (SD 2.9) and 0.3 (SD 2.4) for the mLDFA, MPTA, HKA, PDFA and PPTA from the preoperative plan was observed. Limb alignment showed a mean deviation of 1.2° (SD 2.1) towards valgus postoperatively compared to the intraoperative plan. One tibial stress fracture was seen as a complication due to suboptimal positioning of the registration pins.

Conclusion: RA TKA is associated with a learning curve for surgical time, which might be longer than reported in current literature and dependent on the profile of the surgeon. There is no learning curve for component alignment, limb alignment and gap balancing.

Level Of Evidence: IV.

Citing Articles

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References

Cho K, Seon J, Jang W, Park C, Song E . Robotic versus conventional primary total knee arthroplasty: clinical and radiological long-term results with a minimum follow-up of ten years. Int Orthop. 2018; 43(6):1345-1354. DOI: 10.1007/s00264-018-4231-1. View

Gu Y, Howell S, Hull M . Simulation of total knee arthroplasty in 5° or 7° valgus: A study of gap imbalances and changes in limb and knee alignments from native. J Orthop Res. 2016; 35(9):2031-2039. DOI: 10.1002/jor.23492. View

Hampp E, Chughtai M, Scholl L, Sodhi N, Bhowmik-Stoker M, Jacofsky D . Robotic-Arm Assisted Total Knee Arthroplasty Demonstrated Greater Accuracy and Precision to Plan Compared with Manual Techniques. J Knee Surg. 2018; 32(3):239-250. DOI: 10.1055/s-0038-1641729. View

Jeon S, Kim K, Song S . Robot-Assisted Total Knee Arthroplasty Does Not Improve Long-Term Clinical and Radiologic Outcomes. J Arthroplasty. 2019; 34(8):1656-1661. DOI: 10.1016/j.arth.2019.04.007. View

Kayani B, Konan S, Huq S, Tahmassebi J, Haddad F . Robotic-arm assisted total knee arthroplasty has a learning curve of seven cases for integration into the surgical workflow but no learning curve effect for accuracy of implant positioning. Knee Surg Sports Traumatol Arthrosc. 2018; 27(4):1132-1141. PMC: 6435632. DOI: 10.1007/s00167-018-5138-5. View

Khan M, Osman K, Green G, Haddad F . The epidemiology of failure in total knee arthroplasty: avoiding your next revision. Bone Joint J. 2016; 98-B(1 Suppl A):105-12. DOI: 10.1302/0301-620X.98B1.36293. View

Lau R, Perruccio A, Gandhi R, Mahomed N . The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskelet Disord. 2012; 13:250. PMC: 3534547. DOI: 10.1186/1471-2474-13-250. View

Marchand R, Sodhi N, Khlopas A, Sultan A, Harwin S, Malkani A . Patient Satisfaction Outcomes after Robotic Arm-Assisted Total Knee Arthroplasty: A Short-Term Evaluation. J Knee Surg. 2017; 30(9):849-853. DOI: 10.1055/s-0037-1607450. View

Naziri Q, Cusson B, Chaudhri M, Shah N, Sastry A . Making the transition from traditional to robotic-arm assisted TKA: What to expect? A single-surgeon comparative-analysis of the first-40 consecutive cases. J Orthop. 2019; 16(4):364-368. PMC: 6487301. DOI: 10.1016/j.jor.2019.03.010. View

10.

Paley D, Pfeil J . [Principles of deformity correction around the knee]. Orthopade. 2000; 29(1):18-38. DOI: 10.1007/s001320050004. View

11.

Park S, Lee C . Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty. 2007; 22(7):1054-9. DOI: 10.1016/j.arth.2007.05.036. View

12.

Seon J, Song E . Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial. J Arthroplasty. 2006; 21(6):777-82. DOI: 10.1016/j.arth.2005.08.024. View

13.

Siebert W, Mai S, Kober R, Heeckt P . Technique and first clinical results of robot-assisted total knee replacement. Knee. 2002; 9(3):173-80. DOI: 10.1016/s0968-0160(02)00015-7. View

14.

Sodhi N, Khlopas A, Piuzzi N, Sultan A, Marchand R, Malkani A . The Learning Curve Associated with Robotic Total Knee Arthroplasty. J Knee Surg. 2017; 31(1):17-21. DOI: 10.1055/s-0037-1608809. View

15.

Song E, Seon J, Yim J, Netravali N, Bargar W . Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop Relat Res. 2012; 471(1):118-26. PMC: 3528918. DOI: 10.1007/s11999-012-2407-3. View

16.

Vermue H, Lambrechts J, Tampere T, Arnout N, Auvinet E, Victor J . How should we evaluate robotics in the operating theatre?. Bone Joint J. 2020; 102-B(4):407-413. DOI: 10.1302/0301-620X.102B4.BJJ-2019-1210.R1. View

17.

Victor J, Van Doninck D, Labey L, Innocenti B, Parizel P, Bellemans J . How precise can bony landmarks be determined on a CT scan of the knee?. Knee. 2009; 16(5):358-65. DOI: 10.1016/j.knee.2009.01.001. View

18.

Yang H, Seon J, Shin Y, Lim H, Song E . Robotic Total Knee Arthroplasty with a Cruciate-Retaining Implant: A 10-Year Follow-up Study. Clin Orthop Surg. 2017; 9(2):169-176. PMC: 5435654. DOI: 10.4055/cios.2017.9.2.169. View