Advertisement
Review| Volume 31, ISSUE 10, P2353-2363, October 2016

Robotics in Arthroplasty: A Comprehensive Review

      Abstract

      Robotic-assisted orthopedic surgery has been available clinically in some form for over 2 decades, claiming to improve total joint arthroplasty by enhancing the surgeon's ability to reproduce alignment and therefore better restore normal kinematics. Various current systems include a robotic arm, robotic-guided cutting jigs, and robotic milling systems with a diversity of different navigation strategies using active, semiactive, or passive control systems. Semiactive systems have become dominant, providing a haptic window through which the surgeon is able to consistently prepare an arthroplasty based on preoperative planning. A review of previous designs and clinical studies demonstrate that these robotic systems decrease variability and increase precision, primarily focusing on component positioning and alignment. Some early clinical results indicate decreased revision rates and improved patient satisfaction with robotic-assisted arthroplasty. The future design objectives include precise planning and even further improved consistent intraoperative execution. Despite this cautious optimism, many still wonder whether robotics will ultimately increase cost and operative time without objectively improving outcomes. Over the long term, every industry that has seen robotic technology be introduced, ultimately has shown an increase in production capacity, improved accuracy and precision, and lower cost. A new generation of robotic systems is now being introduced into the arthroplasty arena, and early results with unicompartmental knee arthroplasty and total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications. Further studies are needed to confirm the cost effectiveness of these technologies.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Banerjee S.
        • Cherian J.J.
        • Elmallah R.K.
        • et al.
        Robot-assisted total hip arthroplasty.
        Expert Rev Med Devices. 2016; 13: 47
        • Banerjee S.
        • Cherian J.J.
        • Elmallah R.K.
        • et al.
        Robot-assisted total knee arthroplasty.
        Expert Rev Med Devices. 2015; 12: 727
        • Bohn R.E.
        From art to science in manufacturing: the evolution of technological knowledge.
        Foundations and Trends in Technology, Information, Operations Management. 2005; 1: 2
        • Buckwalter J.A.
        • Saltzman C.
        • Brown T.
        The impact of osteoarthritis: implications for research.
        Clin Orthop Relat Res. 2004; : S6
        • Felson D.T.
        • Lawrence R.C.
        • Dieppe P.A.
        • et al.
        Osteoarthritis: new insights. Part 1: the disease and its risk factors.
        Ann Intern Med. 2000; 133: 635
        • Leopold S.S.
        Minimally invasive total knee arthroplasty for osteoarthritis.
        N Engl J Med. 2009; 360: 1749
        • Dillon C.F.
        • Rasch E.K.
        • Gu Q.
        • et al.
        Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991-94.
        J Rheumatol. 2006; 33: 2271
        • Lawrence R.C.
        • Felson D.T.
        • Helmick C.G.
        • et al.
        • National Arthritis Data Workgroup
        Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.
        Arthritis Rheum. 2008; 58: 26
        • Barbour K.E.
        • Helmick C.G.
        • Theis K.A.
        • et al.
        Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2010-2012.
        Morb Mortal Wkly Rep. 2013; 62: 869
        • Murphy L.
        • Helmick C.G.
        The impact of osteoarthritis in the United States: a population-health perspective: a population-based review of the fourth most common cause of hospitalization in U.S. adults.
        Orthop Nurs. 2012; 31: 85
      1. National Institute for Health and Care Excellence (NICE). Osteoarthritis: care and management in adults [CG177], http://www.nice.org.uk/guidance/cg177 [accessed 30.12.15].

        • King J.
        • Stamper D.L.
        • Schaad D.C.
        • et al.
        Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty.
        J Bone Joint Surg. 2007; 89: 1497
      2. Illgren R. Robotically assisted total hip arthroplasty improves clinical outcome compared with manual technique. From 43rd annual course: advances in arthroplasty, October 22-25, 2013, Cambridge, MA.

        • Sakellariou V.I.
        • Poultsides L.A.
        • Ma Y.
        • et al.
        Risk assessment for chronic pain and patient satisfaction after total knee arthroplasty.
        Orthopedics. 2016; 39: 55
        • Lavand'homme P.
        • Thienpont E.
        Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain.
        Bone Joint J. 2015; 97-B: 45
        • Liddle A.D.
        • Pandit H.
        • Judge A.
        • et al.
        Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales.
        Bone Joint J. 2015; 97-B: 793
        • Sisko A.M.
        • Truffer C.J.
        • Keehan S.P.
        • et al.
        National health spending projections: the estimated impact of reform through 2019.
        Health Aff. 2010; 29: 1933
        • Lee G.C.
        “Computer navigation for total knee arthroplasty reduces revision rate for patients less than sixty-five years of age”.
        J Bone Joint Surg Am. 2015; 97: e40
      3. Robot Institute of America. NBS/RIA robotics research workshop: proceedings of the NBS/RIA Workshop on Robotic Research held at Gaithersburg, MD.

      4. www.merriam-webster.com/dictionary/robot [accessed 06.01.15].

        • Kube C.R.
        • Parker C.A.
        • Wang T.
        • et al.
        Biologically inspired collective robots.
        in: De Castro L.N. VonZuben F.J. Recent developments in biologically inspired computing. Idea Group Publishing, Rochster2005: 369
      5. http://cs.stanford.edu/people/eroberts/courses/soco/projects/1998-99/robotics/history.html [accessed 06.01.15].

        • Davies B.
        A review of robotics in surgery.
        Proc Inst Mech Eng H. 2000; 214: 129
        • Murphy D.
        • Challacombe B.
        • Khan M.S.
        • et al.
        Robotic technology in urology.
        Postgrad Med J. 2006; 82: 743
        • Netravali N.A.
        • Shen F.
        • Park Y.
        • et al.
        A perspective on robotic assistance for knee arthroplasty.
        Adv orthopedics. 2013; 2013: 970703
        • DiGioia III, A.M.
        • Jaramaz B.
        • Picard F.
        • et al.
        Computer and robotic assisted hip and knee surgery.
        Oxford Univeristy Press, New York (NY)2004
        • Smith-Bindman R.
        • Lipson J.
        • Marcus R.
        • et al.
        Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.
        Arch Intern Med. 2009; 169: 2078
        • Gourin G.
        • Terris J.
        History of robotic surgery.
        in: Faust R.A. Robotics in surgery: history, current and future applications. Nova Science Publishers, Inc., New York (NY)2007: 3-12
      6. Jones B, Blyth MJ, MacLean A, et al. Accuracy of UKA implant positioning and early clinical outcomes in a RCT comparing robotic assisted and manual surgery. 13th annual CAOS Meeting, June 12-15, 2013, Orlando, FL, USA.

        • Bargar W.L.
        • Bauer A.
        • Börner M.
        Primary and revision total hip replacement using the Robodoc system.
        Clin Orthop Relat Res. 1998; 354: 82
        • Bargar W.L.
        Robots in orthopedic surgery.
        Clin Orthop Relat Res. 2007; 463: 31
        • Chun Y.S.
        • Kim K.I.
        • Cho Y.J.
        • et al.
        Causes and patterns of aborting a robot-assisted arthroplasty.
        J Arthroplasty. 2011; 26: 621
        • Jakopec M.
        • Harris S.J.
        • Rodriguez y Baena F.
        • et al.
        The first clinical application of a “hands-on” robotic knee surgery system.
        Computer Aided Surg. 2001; 6: 329
        • Park S.E.
        • Lee C.T.
        Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty.
        J Arthroplasty. 2007; 22: 1054
        • Bach C.
        • Winter P.
        • Nogler M.
        • et al.
        No functional impairment after Robodoc total hip arthroplasty.
        Acta Orthop Scand. 2002; 73: 386
        • Haigo K.
        • Sugano N.
        • Takashina M.
        • et al.
        Effectiveness of the Robodoc system in preventing intraoperative pulmonary embolism.
        Acta Orthop Scand. 2003; 74: 264
        • Börner M.
        • Wiesel U.
        • Ditzen W.
        “Clinical experiences with Robodoc and the Duracon total knee”.
        in: Stiehl J.B. Konermann W. Haaker R.G. Navigation and robotics in total joint and spine surgery. Springer-Verlag, Berlin, Germany2004: 362-366
        • Song E.K.
        • Seon J.K.
        • Park S.J.
        • et al.
        Simultaneous bilateral total knee arthroplasty with robotic and conventional techniques: a prospective, randomized study.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1069
        • Song E.K.
        • Seon J.K.
        • Yim J.H.
        • et al.
        Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA.
        Clin Orthop Relat Res. 2013; 471: 118
        • Pugely A.J.
        • Martin C.T.
        • Gao Y.
        • et al.
        The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty.
        J Arthroplasty. 2015; 30: 47
        • Davies B.L.
        • Rodriguez y Baena F.M.
        • Barrett A.R.
        • et al.
        Robotic control in knee joint replacement surgery.
        Proc Inst Mech Eng H. 2007; 221: 71
        • Schulz A.P.
        • Seide K.
        • Queitsch C.
        • et al.
        Results of total hip replacement using the Robodoc surgical assistant system: clinical outcome and evaluation of complications for 97 procedures.
        Int J Med Robot. 2007; 3: 301
        • Kazanzides P.
        Robots for orthopaedic joint reconstruction.
        in: Faust R.A. Robotics in surgery: history, current and future applications. Nova Science Publishers, Inc, New York2007
        • Tew M.
        • Waugh W.
        Tibiofemoral alignment and the results of knee replacement.
        J Bone Joint Surg Br. 1985; 67: 551
        • Bellemans J.
        • Vandenneucker H.
        • Vanlauwe J.
        Robot-assisted total knee arthroplasty.
        Clin Orthop Relat Res. 2007; 464: 111
        • Siebert W.
        • Mai S.
        • Kober R.
        • et al.
        Technique and first clinical results of robot assisted total knee replacement.
        Knee. 2002; 9: 173
        • Wu L.
        • Hahne H.
        • Hassenpflug J.
        The dimensional accuracy of preparation of femoral cavity in cementless total hip arthroplasty.
        J Zhejiang Univ Sci. 2004; 5: 1270
        • Mazoochian F.
        • Pellengahr C.
        • Huber A.
        • et al.
        Low accuracy of stem implantation in THR using the CASPAR-system: anteversion measurements in 10 hips.
        Acta Orthop Scand. 2004; 75: 261
        • Siebel T.
        • Kafer W.
        Clinical outcome following robotic assisted versus conventional total hip arthroplasty: a controlled and prospective study of seventy-one patients.
        Z Orthop Ihre Grenzgeb. 2005; 143: 391
      7. NavioPFS FDA. http://www.accessdata.fda.gov/cdrh_docs/pdf12/K121936.pdf [accessed 06.01.15].

        • Lonner J.
        • Smith J.
        • Picard F.
        • et al.
        High degree of accuracy of a novel image-free handheld robot for unicondylar knee arthroplasty in a cadaveric study.
        Clin Orthop Relat Res. 2015; 473: 206
      8. Gregori A, Picard F, Bellemans J, et al. Handheld precision sculpting tool for unicondylar knee arthroplasty. A clinical review. 15th EFORT Congress 2014, June 4-6, London, UK.

      9. Wallace D, Gregori A, Picard F, et al. The learning curve of a novel handheld robotic system for unicondylar knee arthroplasty. International Society of Computer Assisted Orthopaedic Surgery 2014, June 18-21. Milan, Italy.

        • Simons M.
        • Riches P.
        The learning curve of robotically-assisted unicondylar knee arthroplasty.
        Bone Joint J Orthopaedic Proc Suppl. 2014; 96: 152
        • Plaskos C.
        • Cinquin P.
        • Lavallee S.
        • et al.
        Praxiteles: a miniature bone-mounted robot for minimal access total knee arthroplasty.
        Int J Med Robot. 2005; 1: 67
        • Koulalis D.
        • O’Loughlin P.
        • Plaskos C.
        • et al.
        Sequential versus automated cutting guides in computer-assisted total knee arthroplasty.
        Knee. 2011; 18: 436
        • Suero E.
        • Plaskos C.
        • Dixon P.
        • et al.
        Adjustable cutting blocks improve alignment and surgical time in computer-assisted total knee replacement.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1736
        • Ponder C.
        • Plaskos C.
        • Cheal E.
        Press-fit total knee arthroplasty with a robotic-cutting guide: proof of concept and initial clinical experience.
        Bone Joint J. 2013; 95-B: 61
        • Koenig J.
        • Suero E.
        • Plaskos C.
        Surgical accuracy and efficiency of computer navigated TKA with a robotic cutting guide—report on first 100 cases.
        J Bone Joint Surg Br. 2012; 94-B: 301
        • Lang J.E.
        • Mannava S.
        • Floyd A.J.
        • et al.
        Robotic systems in orthopaedic surgery.
        J Bone Joint Surg Br. 2011; 93: 1296
        • Lonner J.H.
        Indications for unicompartmental knee arthroplasty and rationale for robotic arm-assisted technology.
        Am J Orthop (Belle Mead NJ). 2009; 38 (Review): 3
        • Sinha R.K.
        Outcomes of robotic arm-assisted unicompartmental knee arthroplasty.
        Am J Orthop. 2009; 38: 20
        • Pearle A.D.
        • O'Loughlin P.F.
        • Kendoff D.O.
        Robot-assisted unicompartmental knee arthroplasty.
        J Arthroplasty. 2010; 25: 230
        • Hamilton W.G.
        • Ammeen D.
        • Engh Jr., C.A.
        • et al.
        Learning curve with minimally invasive unicompartmental knee arthroplasty.
        J Arthroplasty. 2010; 25: 735
        • Lonner J.H.
        Indications for unicompartmental knee arthroplasty and rationale for robotic arm-assisted technology.
        Am J Orthop. 2009; 38: 3
        • Coon T.M.
        Integrating robotic technology into the operating room.
        Am J Orthop. 2009; 38: 7
      10. Jinnah R, Horowitz S, Lippincott C, et al. The learning curve of robotically assisted UKA. 22nd annual Congress of ISTA, October 22-24, 2009, Big Island, HI.

        • Lonner J.H.
        • John T.K.
        • Conditt M.A.
        Robotic arm-assisted UKA improved tibial component alignment: a pilot study.
        Clin Orthop Relat Res. 2010; 468: 141
        • Citak M.
        • Suero E.M.
        • Citak M.
        • et al.
        Unicompartmental knee arthroplasty: is robotic technology more accurate than conventional technique?.
        Knee. 2013; 20: 268
        • Tamam C.
        • Plate J.F.
        • Augart M.
        • et al.
        Retrospective clinical and radiological outcomes after robotic assisted bicompartmental knee arthroplasty.
        Adv Orthop. 2015; 2015: 747309
        • Conditt M.A.
        • Coon T.
        • Hernandez A.
        • et al.
        Short term survivorship and outcomes of robotically assisted bicompartmental arthroplasty.
        Bone Joint J. 2016; 98-B: 49
      11. Coon T, Roche M, Buechel F, et al. Short to mid term survivorship of robotic arm assisted UKA: a multicenter study. Pan Pacific Orthopaedic Congress. July 16-19, 2014, Kona, HI.

      12. Coon T. MAKOplasty medial UKA demonstrates low two-year revision rate in multicenter study. From short to mid term survivorship of robotically assisted UKA: a multicenter study. Ista 27th annual Congress, Sept. 24-27, 2014, Kyoto, Japan.

      13. Coon T, Roche M, Pearle A, et al. Short to mid term survivorship of robotically assisted UKA: a multicenter study. Icjr 2nd annual Pan Pacific orthopaedic Congress, July16-29, 2015, Kona, HI.

        • Lewinnek G.E.
        • Lewis J.L.
        • Tarr R.
        • et al.
        Dislocations after total hip-replacement arthroplasties.
        J Bone Joint Surg Am. 1978; 60: 217
        • Callanan M.C.
        • Jarrett B.
        • Bragdon C.R.
        • et al.
        The John Charnley Award; risk factors for cup malpositioning quality improvement through a joint registry at a tertiary hospital.
        Clin Orthop Rel Res. 2011; 469: 319
        • Domb B.G.
        • El Bitar Y.F.
        • Sadik B.S.
        • et al.
        Comparison of robotic-assisted and conventional acetabular cup placement in THA: a matched-pair controlled study.
        Clin Orthop Relat Res. 2014; 472: 329
      14. Elson L, Dounchis J, Illgren R, et al. A multi-centric evaluation of acetabular cup positioning in robotic-arm assisted total hip arthroplasty. 13th annual CAOS Meeting, June 12-15, 2013, Orlando, FL, USA.

        • Nawabi D.H.
        • Conditt M.A.
        • Ranawat A.S.
        • et al.
        Haptically guided robotic technology in total hip arthroplasty: a cadaveric investigation.
        J Eng Med. 2012; 227: 302
      15. Jerabek SA, Carroll KM, Maratt JD, et al. Accuracy of cup positioning and achieving desired hip length and offset following robotic THA. 14th annual CAOS Meeting, June 18-21, 2014, Milan, Italy.

      16. Suarez-Ahedo C, Gui C, Martin TJ, et al. Preservation of acetabular bone stock in total hip arthroplasty using conventional vs. Robotic techniques, a matched-pair controlled study. World Arthroplasty Congress, April 15-18, 2015, Paris, France.

        • Malik A.
        • Maheshwari A.
        • Dorr L.D.
        Impingement with total hip replacement.
        J Bone Joint Surg Am. 2007; 89: 1832
      17. Bukowski B, Abiola R, Illgen R. Outcomes after primary total hip arthroplasty: manual compared with robotic assisted techniques. 44th annual advances in arthroplasty, Cambridge, MA, October 7-10 2014.

        • Wolf A.
        • Jaramaz B.
        • Lisien B.
        • et al.
        MBARS: mini bone-attached robotic system for joint arthroplasty.
        Int J Med Robot. 2005; 1: 101
        • Song S.
        • Mor A.
        • Jaramaz B.
        HyBAR: hybrid bone-attached robot for joint arthroplasty.
        Int J Med Robotics Computer Assisted Surg. 2009; 5: 223
        • Moschetti W.E.
        • Konopka J.F.
        • Rubash H.E.
        • et al.
        Robot-assisted UKA can be cost effective compared to manual UKA: can robot-assisted unicompartmental knee arthroplasty be cost-effective? A Markov decision analysis.
        J Arthroplasty. 2016; 31: 759
        • Bozic K.J.
        • Kurtz S.M.
        • Lau E.
        • et al.
        The epidemiology of revision total hip arthroplasty in the United States.
        J Bone Joint Surg. 2009; 91: 128
        • Kurtz S.M.
        • Lau E.
        • Watson H.
        • et al.
        Economic burden of periprosthetic joint infection in the United States.
        J Arthroplasty. 2012; 27: 61
        • Conditt M.A.
        • Roche M.W.
        Minimally invasive robotic-arm-guided unicompartmental knee arthroplasty.
        J Bone Joint Surg Am. 2009; 91: 63
        • Liow M.H.
        • Xia Z.
        • Wong M.K.
        • et al.
        Robot-assisted total knee arthroplasty accurately restores the joint line and mechanical axis. A prospective randomised study.
        J Arthroplasty. 2014; 29: 2373
        • Yildirim G.
        • Fernandez-Madrid I.
        • Schwarzkopf R.
        • et al.
        Comparison of robot surgery modular and total knee arthroplasty kinematics.
        J Knee Surg. 2014; 27: 157
        • Plate J.F.
        • Mofidi A.
        • Mannava S.
        • et al.
        Achieving accurate ligament balancing using robotic-assisted unicompartmental knee arthroplasty.
        Adv Orthop. 2013; 2013: 837167