Robotic Versus Manual Total Knee Arthroplasty in High Volume Surgeons: A Comparison of Cost and Quality Metrics

Published:December 21, 2021DOI:https://doi.org/10.1016/j.arth.2021.12.018

      Abstract

      Background

      Robotic-assisted total knee arthroplasty (RTKA) was introduced to improve surgical accuracy and patient outcomes. However, RTKA may also increase operating time and add cost to TKA. This study sought to compare the differences in cost and quality measures between manual TKA (MTKA) and RTKA

      Methods

      All MTKAs and RTKAs performed between January 1, 2017 and December 31, 2019, by 6 high volume surgeons in each cohort, were retrospectively reviewed. Cohorts were propensity score matched. Operative time, length of stay (LOS), total direct cost, 90-day complications, utilization of postacute services, and 30-day readmissions were studied.

      Results

      After one-to-one matching, 2392 MTKAs and 2392 RTKAs were studied. In-room/out-of-room operating time was longer for RTKA (139 minutes) than for MTKA (107 minutes) P < .0001, as was procedure time (RTKA 78 minutes; MTKA 70 minutes), P < .0001. Median LOS was equal for MTKA and RTKA (33 hours). Total cost per case was greater for RTKA ($11,615) than MTKA ($8674), P < .0001. Home health care was utilized more frequently after RTKA (38%) than MTKA (29%), P < .0001. There was no significant difference in 90-day complication rates. Thirty-day readmissions occurred more often after MTKA (4.9%) than RTKA (1.2%), P < .0001.

      Conclusion

      RTKA was a longer and costlier procedure than MTKA for experienced surgeons, without clinically significant differences in LOS or complications. Home health care was utilized more often after RTKA, but fewer readmissions occurred after RTKA. Longer term follow-up and functional outcome studies are required to determine if the greater cost of RTKA is offset by lower revision rates and/or improved functional results.

      Keywords

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      References

        • Sloan M.
        • Premkumar A.
        • Sheth N.P.
        Projected volume of primary total joint arthroplasty in the U.S., 2014- to 2030.
        J Bone Joint Surg Am. 2018; 100: 1455-1460
        • Bourne R.B.
        • Chesworth B.M.
        • Davis A.M.
        • Mahomed N.N.
        • Charron K.D.J.
        Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?.
        Clin Orthop Relat Res. 2010; 468: 57-63
        • Culliton S.E.
        • Bryant D.M.
        • Overend T.J.
        • Macdonald S.J.
        • Chesworth B.M.
        The relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty.
        J Arthroplasty. 2012; 27: 490-492
        • Noble P.C.
        • Conditt M.A.
        • Cook K.F.
        • Mathis K.B.
        Patient expectations affect satisfaction with total knee arthroplasty.
        Clin Orthop Relat Res. 2006; 452: 35-42
        • Jeffery R.S.
        • Morris R.W.
        • Denham R.A.
        Coronal alignment after total knee replacement.
        J Bone Joint Surg Br. 1991; 73: 709-714
        • Ritter M.A.
        • Davis K.E.
        • Meding J.B.
        • Pierson J.L.
        • Berend M.E.
        • Malinzak R.A.
        The effect of alignment and BMI on failure of total knee replacement.
        J Bone Joint Surg Am. 2011; 93: 1588-1596
        • Parratte S.
        • Pagnano M.W.
        • Trousdale R.T.
        • Berry D.J.
        Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements.
        J Bone Joint Surg Am. 2010; 92: 2143-2149
        • Sires J.D.
        • Craik J.D.
        • Wilson C.J.
        Accuracy of bone resection in MAKO total knee robotic-assisted surgery.
        J Knee Surg. 2021; 34: 745-748https://doi.org/10.1055/s-0039-1700570
        • Parratte S.
        • Price A.J.
        • Jeys L.M.
        • Jackson W.F.
        • Clarke H.D.
        Accuracy of a new robotically assisted technique for total knee arthroplasty: a cadaveric study.
        J Arthroplasty. 2019; 34: 2799-2803
        • Hampp E.L.
        • Chughai M.
        • Scholl L.Y.
        • Sodhi N.
        • Bhowmik-Stoka M.
        • Jacofsky D.J.
        Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared with manual techniques.
        J Knee Surg. 2018; 32: 239-250
        • Park S.E.
        • Lee C.T.
        Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty.
        J Arthroplasty. 2007; 22: 1054-1059
        • Manning W.
        • Ghosh M.
        • Wilson I.
        • Hide G.
        • Longstaff L.
        • Deehan D.
        Improved mediolateral load distribution without adverse laxity pattern in robot-assisted knee arthroplasty compared to a standard manual measured resection technique.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 2835-2845
        • Shalhoub S.
        • Lawrence J.M.
        • Keggi J.M.
        • Randall A.L.
        • DeClaire J.H.
        • Plaskos C.
        • et al.
        Robotic-assisted total knee arthroplasty combined with a robotic tensioning system can help predict and achieve accurate postoperative ligament balance.
        J Arthroplasty. 2019; 5: 334-340
        • Kayani B.
        • Konan S.
        • Pietrzak J.R.T.
        • Haddad F.
        Iatrogenic bone and soft tissue trauma in robotic-arm assisted total knee arthroplasty compared with conventional jig-based total knee arthroplasty: a prospective cohort study and validation of a new classification system.
        J Arthroplasty. 2018; 33: 2496-2501
        • Hampp E.L.
        • Sodhi N.
        • Scholl L.
        • Deren M.E.
        • Yenna Z.
        • Westrich G.
        • et al.
        Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach.
        Bone Joint Res. 2019; 8: 495-501
        • Sodhi N.
        • Khlopas A.
        • Piuzzi N.S.
        • Sultan A.A.
        • Marchand R.C.
        • Malkani A.L.
        • et al.
        The learning curve associated with robotic total knee arthroplasty.
        J Knee Surg. 2018; 31: 17-21
        • Naziri Q.
        • Cusson B.C.
        • Chaudhri M.
        • Shah N.V.
        • 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: 364-368
        • Kayani B.
        • Konan S.
        • Tahmassebi J.
        • Pietrzak J.R.T.
        • Haddad F.S.
        Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty.
        Bone Joint J. 2018; 100-B: 930-937
        • Moschetti W.E.
        • Konopka J.F.
        • Rubash H.E.
        • Genuario J.W.
        Can robot-assisted unicompartmental knee arthroplasty Be cost-effective? A Markov decision analysis.
        J Arthroplasty. 2016; 31: 759-765
        • Childers C.
        • Maggard-Gibbons M.
        Understanding costs of care in the operating room.
        JAMA Surg. 2018; 153: e176233
        • Anis H.K.
        • Sodhi N.
        • Klika A.K.
        • Mont M.
        • Barsoum W.K.
        • Higuera C.A.
        • et al.
        Is operative time a predictor for post-operative infection in primary total knee arthroplasty?.
        J Arthroplasty. 2019; 34: 5331-5336
        • Duchman K.R.
        • Pugely A.J.
        • Martin C.T.
        • Gao Y.
        • Bedard N.A.
        • Callaghan J.J.
        Operative time affects short-term complications in total joint arthroplasty.
        J Arthroplasty. 2016; 32: 1285-1291
        • Bohl D.D.
        • Ondeck N.T.
        • Darrith B.
        • Hannon C.P.
        • Fillingham Y.A.
        • Della Valle C.J.
        Impact of operative time on adverse events following primary total joint arthroplasty.
        J Arthroplasty. 2018; 33: 2256-2262
        • Mont M.A.
        • Khlopas A.
        • Chugtai M.
        • Newman J.M.
        • Deren M.
        • Sultan A.A.
        Value proposition of robotic total knee arthroplasty: what can robotic technology deliver in 2018 and beyond?.
        Expert Rev Med Devices. 2018; 15: 619-630
        • Parsley B.S.
        Robotics in orthopedics: a brave new world.
        J Arthroplasty. 2018; 33: 2355-2357
        • Jacofsky D.J.
        • Allen M.
        Robotics in arthroplasty: a comprehensive review.
        J Arthroplasty. 2016; 31: 2353-2363
        • Liow M.H.L.
        • Goh G.S.H.
        • Wong M.K.
        • Chin P.L.
        • Tay D.K.J.
        • Yeo S.J.
        Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2942-2951
        • Marchand R.C.
        • Sodhi N.
        • Anis H.K.
        • Ehiorobo J.
        • Newman J.M.
        • Taylor K.
        • et al.
        One-year patient outcomes for robotic-arm-assisted versus manual total knee arthroplasty.
        J Knee Surg. 2019; 32: 1063-1068
        • Khlopas A.
        • Sodhi N.
        • Hozack W.J.
        • Chen A.F.
        • Mahoney O.M.
        • Kinsey T.
        • et al.
        Patient-reported functional and satisfaction outcomes after robotic-arm-assisted total knee arthroplasty: early results of a prospective multicenter investigation.
        J Knee Surg. 2020; 33: 685-690
        • Shaw J.H.
        • Lindsay-Rivera K.G.
        • Buckley P.J.
        • Weir R.M.
        • Banka T.R.
        • Davis J.J.
        Minimal clinically important difference in robotic-assisted total knee arthroplasty versus standard manual total knee arthroplasty.
        J Arthroplasty. 2021; 36: S233-S241
        • Jeon S.W.
        • Kim K.I.
        • Song S.J.
        Robot-assisted total knee arthroplasty does not improve long-term clinical and radiologic outcomes.
        J Arthroplasty. 2019; 34: 1656-1661
        • Song E.K.
        • Seon J.K.
        • Yim J.H.
        • Netravali N.A.
        • Bargar W.L.
        Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA.
        Clin Orthop Relat Res. 2013; 471: 118-126
        • Kayani B.
        • Konan S.
        • Huq S.S.
        • Tahmessebi J.
        • Haddad F.S.
        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. 2019; 27: 1132-1141
        • DeFrance M.J.
        • Yayac M.F.
        • Courtney P.M.
        • Squire M.W.
        The impact of author financial conflicts on robotic-assisted joint arthroplasty research.
        J Arthroplasty. 2021; 36: 1462-1469
        • Naziri Q.
        • Burekhovic S.A.
        • Mixa P.J.
        • Pived R.
        • Newman J.M.
        • Shah N.
        • et al.
        The trends in robotic-assisted arthroplasty: a statewide database study.
        J Orthop. 2019; 16: 298-301
        • Sherman W.F.
        • Wu V.J.
        Robotic surgery in total joint arthroplasty: a survey of the AAHKS membership to understand the utilization, motivations, and perceptions of total joint surgeons.
        J Arthroplasty. 2020; 35: 3474-3481
        • Wilson S.
        • Marx R.G.
        • Pan T.-J.
        • Lyman S.
        Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty.
        J Bone Joint Surg Am. 2016; 98: 1683-1690
        • Lau R.C.
        • Perruccio A.V.
        • Gandhi R.
        • Mahomed N.M.
        The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature.
        BMC Musculoskelet Disord. 2012; 13: 250
        • Khlopas A.
        • Sodhi N.
        • Sultan A.A.
        • Chugtai M.
        • Molloy R.M.
        • Mont M.M.
        Robotic arm-assisted total knee arthroplasty.
        J Arthroplasty. 2018; 33: 2002-2006
        • Mont M.A.
        • Cool C.
        • Gregory D.
        • Coppolecchia
        • Sodhi N.
        • Jacofsky D.J.
        Health care utilization and payer cost analysis of robotic arm assisted total knee arthroplasty at 30, 60, and 90 days.
        J Knee Surg. 2021; 34: 328-337
        • Tompkins G.
        • Neighorn C.
        • Li H.-F.
        • Fleming K.
        • Lorish T.
        • Duwelius P.
        • et al.
        Extremes of body mass have significant impacts on complications, readmissions, and utilization of post-acute services after primary total hip arthroplasty.
        Bone Joint J. 2020; 102-B: 62-70