Assistant Professor

Faculty of Paramedical Sciences

Rama University

 Kanpur, UP, India 

Assistant Professor

School of Health Sciences

CSJM University

Kanpur, UP, India

The inflammation of your joint that results from arthritis can make it difficult to perform daily tasks. Knee arthritis can result from osteoarthritis, a degenerative disease that erodes bone and cartilage in joints. The largest and strongest joint in your body is your knee. Joint arthritis can be the cause of knee pain. The newest cutting-edge technique in knee surgery is robotic or robotic aided knee surgery.

Prior to surgery: Like most total knee replacement patients, you will have a similar preoperative experience. However, robotic knee surgery differs from conventional knee replacement techniques in that a three-dimensional (3D) model of your knee anatomy may be created using a series of x-rays. The surgeon will be able to prepare several details of knee replacement surgery prior to operations.

In the operating room: Robotic surgery functions exactly like manual surgery, with the assistance of a robot. With a robotic helper, the surgical process is comparable to a conventional total knee replacement. In order to tailor the surgical procedure for your particular anatomy, your surgeon has received specialised training in the use of robot technology during knee replacement. The robot is not a self-governing device; it requires your surgeon's commands to move. This makes it more likely that the strategy your surgeon implemented will be carried out as intended. Throughout the procedure, ROSA® Knee gives your surgeon information about your knee, enabling them to better position your implant according to your particular anatomy.

After surgery: Your surgeon will choose the appropriate recovery plan for you, and you will be admitted to the hospital based on that plan. While recovery times vary, most patients should be back to driving in two weeks or less. Your surgeon will advise you on what to avoid doing as well as when and what activities you can resume. Getting surgery of any kind can be frightening. You can anticipate less discomfort, a higher quality of life, and the restoration of your strength and mobility following robotically assisted knee surgery. Even though knee surgery is usually successful, some individuals may still have some mild discomfort and limitations on their activities. But most symptoms do get under control, and there is some improvement in mobility. [1]

Total knee replacement:

When all non-operative options for treating advanced arthritis patients have been exhausted, total knee arthroplasty (TKA) offers a potent way to relieve pain and restore function. Surgeons strive to enhance patient happiness and results through the advancement of technology and surgical techniques. With the help of robots, surgeons can do operations with the least amount of human error and the highest level of operative accuracy. 

Robots:

The word "robot" originates from the Czech word "robota," meaning work or activity that is forced.  In 1988, the first robot surgery was carried out to do neurosurgical biopsies. Since then, there has been a notable advancement in the use of robotics in surgery.

In addition to the sharp rise in TKA requirements in recent years, the number of robotic total knee arthroplasty (TKA) procedures has increased significantly. People require more total knee arthroplasty (TKA) as a result of a higher incidence of osteoarthritis brought on by ageing populations. Benefits include: fewer surgical incisions, more accuracy in managing soft tissues, a speedier recuperation and return to work following surgery, and a shorter hospital stay due to fewer errors related to bone cutting and prosthesis alignment and positioning. Compared to conventional TKR, robotic TKR yields superior surgical and clinical patient results. In the UK, the first robotically assisted total knee arthroplasty was carried out in 1988.

Objectives of TKA as opposed to robotic TKA: The goals of TKA are to realign the joint line, the mechanical axis, the Q angle for ideal patella tracking, and the equilibrium between the flexion and extension gaps. The surrounding soft tissue must be preserved in order to accomplish these objectives. Damage to the extensor mechanism, PCL, or collateral ligaments may shorten the life of a prosthesis, slow the healing process, and reduce joint stability. Reducing saw action using robotic TKA minimises iatrogenic bone and soft-tissue injury. Athroplasty success factors include: Optimal prosthesis positioning Precise flexion-extension gap balancing Perfect ligament tensioning Soft-tissue preservation.

The majority of these variables are tied to the surgeon, and they change depending on the knowledge and expertise of the actual surgeon. Therefore, methods combining soft tissue balance and bone excision in conventional total knee arthroplasty are linked to a risk of iatrogenic soft tissue injuries, poor repeatability, and the inability to fine-tune implant location. Inaccurate prosthesis positioning or gap balancing can result in longer rehabilitation times for patients, less satisfying recovery rates, and increased instability when the implant's lifespan is shortened.[2]

Robotic systems that are imaging or not imaging:

In robotic-assisted total knee arthroplasty, a virtual three-dimensional model of the patient's unique bone architecture is created using computer software. The surgeon uses this to plan ahead for bone cutting, component placement, and size. Navigation software is then used to map this surgical plan intra-operatively to the patient's bone architecture. This virtual 3D model is generated from pre-operative imaging using computed tomography or magnetic resonance imaging for image-dependent systems.

 This surgical plan is created using non-imaging technologies using a more thorough registration of the bony articulating surfaces and joint kinematics recorded intra-operatively post arthrotomy. Systems that rely on images provide surgeons enough time to prepare for surgery, including selecting the orientation and size of implants. This advantage should be weighed against the higher radiation risk and pre-operative imaging costs, though. Furthermore, the intra-operative registration of bone landmarks that imageless systems require depends on the accuracy with which the operating surgeon enters the proper data points—a human error that can occur.

Robotic variants:

passive	semi-active	active
Limited use in TKA	More used than passive one	Often used and operate autonomously under surgical supervision
Based on computer assisted or navigation	same	robotic software is used to configure the surgical plan offline
Provide positional guidance to surgeon	Require constant input from surgeon	surgeon performs the initial surgical approach
Potential of human error remains	Allow surgeon to guide the robotic arm to carry-out bony cut	robotic arm is initiated and performs the femoral and tibial bony resections independently
Constraints for implant positioning and surfacing	Needs surgeon involvement most of the time	Once activated, the surgeon maintains control via an emergency manual override button

[3]

Reasons for revision TKR surgeries: Research indicates that osteolysis, polyethylene wear, septic or aseptic loosening, and instability are often the causes of revision procedures. The results of a revision total knee arthroplasty may be impacted by surgical technique challenges such as precise preoperative planning, managing bone deficit, balancing soft tissues, and restoring the joint line. It has been demonstrated that the use of robotic-assisted systems can increase preoperative planning accuracy and improve reproducibility in primary arthroplasty procedures. This research aimed to discuss the surgical procedure for second-stage revision knee arthroplasty, unicompartmental knee arthroplasty (UKA), or robotic-assisted revision total knee arthroplasty following total knee arthroplasty (TKA). [9]

Comparison table: highlighting the key differences between robotic and computer-assisted surgery for knee replacement:

Robotic Surgery	Computer-Assisted Surgery
Utilizes robotic arms and instruments	Uses computerized navigation and imaging
Offers high precision and real-time adjustments	Provides guidance but less precise in real-time
Robotic arms are controlled by a surgeon at a console	Surgeon performs the surgery with assistance from computerized data
Robotic arms execute precise movements based on surgeon's commands	Surgeon manually performs the procedure guided by computer data
Creates 3D models for personalized surgical plans	Relies on preoperative imaging for guidance
Provides real-time feedback and adjustments	Offers guidance but less immediate adjustments
Allows for personalized and adaptive procedures	Offers guidance but with limited adaptability
Provides training modules for robotic system	Assists surgeons with visualization and planning training
May lead to quicker recovery and improved outcomes	May offer better outcomes compared to traditional surgery
Often involves smaller incisions	Can facilitate minimally invasive techniques
Widely used in orthopedic surgeries including knee replacements	Used in various surgical specialties

 

Manual Surgery	Robotic Surgery
Relies on manual instruments and surgeon's expertise	Utilizes robotic arms and advanced technology
Precision depends on surgeon's skill and experience	Offers high precision and real-time adjustments
Relies on surgeon's visual assessment and experience	Provides real-time guidance and feedback
Surgeon's experience shapes procedure	Creates personalized surgical plans based on patient anatomy
Surgeon performs the procedure manually	Surgeon controls robotic arms from a console
Limited real-time adaptability during surgery	Offers real-time adjustments based on feedback
Relies on preoperative imaging for planning	Creates 3D models for precise surgical planning
Surgeon's expertise developed through experience	Provides training modules for robotic system
Incision size varies based on surgeon's technique	Often involves smaller, more precise incisions
Recovery time and outcomes vary based on surgeon's skill	May lead to quicker recovery and improved outcomes
Outcomes may vary based on surgeon's proficiency	Offers consistency in precision and execution
Relies solely on surgeon's manual skills	Integrates advanced technology for precision

Later in the 1980s, robotic surgical systems were introduced to the field of orthopaedic surgery. Originally designed for total hip arthroplasty procedures, ROBODOC (Integrated Surgical Systems, Davis, CA) has been used in over 15,000 TKAs globally. Robotic arm-assisted, robot-guided cutting jigs, and robotic milling systems with an active, semiactive, or passive control system are among the many platforms used today. Several studies have demonstrated that using robotic arms during total knee arthroplasty (TKA) surgeries improves accuracy in implant location and limb alignment. Nonetheless, there is no assurance that utilising robotic arms for TKA will result in better precision or fewer postoperative problems, and there may be additional costs and surgical time involved. In spite of divergent opinions and data on robotics in TKA, the use of robot arm-assisted TKA has been growing vastly. [10]

Comprehensive data and matrices regarding complete knee replacement procedures:

Following TKR operations, a small number of individuals still report dissatisfaction. That is the only method available, nevertheless, to deal with the issues brought on by end-stage osteoarthritis. These figures may be as high as 20% or somewhat lower. Since every fact, as we all know, has both positive and negative aspects, this is also true. The inadequate percentages of the population undergoing total knee replacement (TKR) procedures incite both producers and surgeons to innovate their technology and implants in addition to their applied approaches. It is evident that greater outcomes are associated with a surgeon performing a higher volume of knee procedures. The way that surgeons perform traditional knee replacement surgery versus robotically aided knee replacement surgery ultimately differs in results.

The success of conventional knee surgery depends on the surgeon's ability to balance soft tissues like ligaments while making precise incisions and implant placement. On the other hand, robotic-assisted knee replacement surgery makes use of cutting-edge technology to generate a 3D computer model of the patient's knee joint. This can lead to reduced variability and more accurate surgical planning and execution. Based on the CT scans, a robotic arm is then trained to direct the surgeon's cuts. Recent years have seen a number of studies carried out to assess the efficacy of robotic knee replacement surgery. In comparison to traditional knee replacement surgery, robotic-assisted knee replacement surgery produced better alignment and fewer problems, according to a 2020 comprehensive review and meta-analysis of 18 research. The study came to the conclusion that, with precision producing slightly better clinical outcomes, robotically aided knee replacement surgery was a safe and effective substitute for traditional knee replacement surgery. According to a 2021 EFORT Open Review titled "The current state of robotics in total knee arthroplasty," patients who underwent robotic-assisted treatments reported shorter hospital stays and improved joint range of motion following their procedures. A robotic knee improves early functional outcomes while providing precise mechanical alignment.

Long-term functional results and implant survivability haven't been confirmed yet, though. The word "promising results" can be included into robotic surgery. Although it is a more successful technology, these processes could not completely prevent certain shortcomings or downsides. All things considered, both manual and robotic TKR techniques are regarded as effective ways to treat end-stage osteoarthritis in the knee joint. After TKA procedures, patients are largely satisfied with both nearly equal and safe tactics. The surgeon's flexibility and the locations of the planned surgeries each play a special role in the TKR procedures in this sequence. A FINAL IDEA is that since both sensor-based systems, such as 3D imaging technology, and hand-operated or robotically aided systems based on computer technologies depend on the expertise and experience of the surgeon. When choosing to have TKR surgery, it's important to remember that the surgeon should have a well-established, busy practise performing robotic or manual knee replacements. [11]

References

1.     rosa robotic knee replacement - Google Search. (n.d.). https://www.google.com/search?q=rosa+robotic+knee+replacement&rlz

2.     Saber, A. Y. (2023, August 14). Robotic-Assisted total knee arthroplasty. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK564396/

3.      St Mart JP, Goh EL. The current state of robotics in total knee arthroplasty. EFORT Open Rev. 2021 Apr 1;6(4):270-279. doi: 10.1302/2058-5241.6.200052. PMID: 34040804; PMCID: PMC8142057.

4.     Ngim, H. J., Van Bavel, D., De Steiger, R., & Tang, A. W. W. (2023). Robotic-assisted revision total knee arthroplasty: a novel surgical technique. Arthroplasty, 5(1). https://doi.org/10.1186/s42836-022-00160-5

5.     Pailhé, R. (2021). Total knee arthroplasty: Latest robotics implantation techniques. Orthopaedics & Traumatology: Surgery & Research, 107(1), 102780. https://doi.org/10.1016/j.otsr.2020.102780

6.     Nogalo, C., Meena, A., Abermann, E., & Fink, C. (2022). Complications and downsides of the robotic total knee arthroplasty: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 31(3), 736–750. https://doi.org/10.1007/s00167-022-07031-1

7.     Lei, K., Li, L., & Guo, L. (2022). Robotic systems in total knee arthroplasty: current surgical trauma perspectives. Burns & Trauma, 10. https://doi.org/10.1093/burnst/tkac049

8.     Shatrov, J., & Parker, D. (2020). Computer and robotic – assisted total knee arthroplasty: a review of outcomes. Journal of Experimental Orthopaedics, 7(1). https://doi.org/10.1186/s40634-020-00278-y

9.      Kayani, B., Konan, S., Ayuob, A., Onochie, E., Al-Jabri, T., & Haddad, F. S. (2019). Robotic technology in total knee arthroplasty: a systematic review. EFORT Open Reviews, 4(10), 611–617. https://doi.org/10.1302/2058-5241.4.190022

10.   Shatrov, J., & Parker, D. (2020). Computer and robotic – assisted total knee arthroplasty: a review of outcomes. Journal of Experimental Orthopaedics, 7(1). https://doi.org/10.1186/s40634-020-00278-y

11.   Compare my Care - Is robotic surgery achieving better results for knee replacement patients? (By M. Miles). (8 C.E., June). Compare My Care. Retrieved June 1, 2023, from https://www.comparemycare.com/articles/is-robotic-surgery-achieving-better-results-for-knee-replacement-patients