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

Total knee arthroplasty (TKA) is on the verge of being revolutionized by artificial intelligence (AI), which will make it possible for robots to have a clinical influence in areas where navigation systems have been rendered ineffective. Navigation has been shown to increase surgical accuracy; nevertheless, it has not been shown to provide major gains in terms of clinical outcome for the patient. On the other hand, robotic systems that are powered by artificial intelligence have the potential to improve functional outcomes, boost precision, and tailor procedures to the specific anatomy of each unique patient. Through the utilization of real‐time data and prediction algorithms, artificial intelligence‐guided robots have the potential to overcome the limits of conventional approaches, thereby establishing a new benchmark for TKA.

AI may enable robots to make a clinical impact in total knee arthroplasty, where navigation has not!

Hirschmann,

von Eisenhart‐Rothe,

Graichen

et al. 2024

Same same but different—Image‐based versus imageless robotic‐assisted total knee arthroplasty!

Hirschmann,

Avram,

Graichen

et al. 2024

Robotic‐assisted total knee arthroplasty (RTKA) has gained widespread acceptance due to its demonstrated ability to improve surgical accuracy compared to conventional total knee arthroplasty (CTKA). While the precise impact of RTKA on postoperative patient‐reported outcome measures (PROMs) remains inconclusive, the increased accuracy in alignment and joint kinematics suggests potential improvements in patient satisfaction and functional outcomes. Two primary RTKA systems exist: image‐based, which uses preoperative CT scans for detailed 3D modeling, and image‐less, which relies on intra‐operative digitization of anatomical landmarks. Both systems aim to achieve accurate implant placement and soft‐tissue balancing, yet they differ in methodology and reliance on preoperative data.Despite RTKA's theoretical advantages, there is ongoing debate about whether accuracy alone is sufficient to achieve optimal postoperative outcomes, particularly concerning joint kinematics and alignment strategies. Literature reveals no significant difference in coronal plane alignment between image‐based and image‐less systems, though image‐less systems may be more prone to varus errors due to the reliance on intra‐articular landmarks. Additionally, image‐free systems may face challenges in replicating native knee anatomy, especially in the sagittal plane, leading to potential limitations in achieving ideal tibial slope reconstruction.The future of RTKA may lie in refining implant positioning strategies that minimize postoperative alterations to pre‐arthritic knee kinematics, particularly with standardized off‐the‐shelf implants. As robotic technology evolves, there is potential to enhance surgical outcomes by combining accuracy with personalized alignment approaches that better address individual patient anatomy. Further research is needed to assess the long‐term clinical benefits of RTKA and its capacity to improve patient‐specific functional outcomes.Level of evidencelevel 5

Comparison of the accuracy and efficacy of different assistive techniques in primary total knee arthroplasty: A network meta‐analysis

Zheng,

Li,

Yuan

et al. 2024

PurposeVarious assistive techniques, such as conventional cutting instruments (CON), computer‐assisted navigation systems (CAS), patient‐specific instruments (PSI) and robot‐assisted systems (RAS), have been developed and applied in primary total knee arthroplasty (TKA). In this study, we aimed to assess the relative accuracy and efficacy of several assistive techniques for TKA through a network meta‐analysis (NMA) based on multiple published randomized controlled trials (RCTs).MethodsThe PubMed, EMBASE and Cochrane databases were searched for RCTs to conduct this NMA from inception to 1 January 2024. We combined direct and indirect comparisons using a Bayesian NMA framework to assess and compare the effects of different assistive techniques on radiological and clinical outcomes. An NMA was conducted, and the study protocol was published online at PROSPERO (CRD42023402882).ResultsOne hundred and twelve RCTs involving 14,968 TKAs with four different assistive techniques (CON, CAS, PSI and RAS) were evaluated. Inconsistency and heterogeneity were acceptable for most outcomes. Based on the surface under the cumulative ranking curve, RAS could be the best technique for accurate mechanical axis alignment and component position, followed by CAS, PSI and CON. We observed no difference in clinical outcome scores. Additionally, CAS was the best intervention for visual analogue scale scores, and PSI had the shortest operative time. No significant differences were observed in postoperative complications, range of motion or total blood loss.ConclusionRAS was most likely to achieve an accurate alignment, followed by CAS, PSI and CON. No differences were observed in clinical outcome scores and postoperative complications among the four assistive techniques.Level of EvidenceLevel I (systematic review of Level‐I randomized controlled studies).