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Comparing a robotic imageless second-generation system to traditional instrumentation in total knee arthroplasty: A matched cohort analysis
⁎Corresponding author: Justin Leal. justin.leal@duke.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Robotic-assisted total knee arthroplasty (rTKA) has gained interest from patients and surgeons alike. Robotic systems assist with gap balancing and bone cut accuracy, which can theoretically minimize post-operative pain by decreasing soft tissue damage. This study compared perioperative results, 30- and 90-day complications, patient-reported outcomes (PROs), and survivorship to all-cause revisions between patients undergoing traditional versus rTKA.
A total of 430 TKAs (215 rTKA, 215 traditional) by two fellowship trained arthroplasty surgeons were retrospectively reviewed from 2017 to 2022. All rTKAs were performed using the CORI Surgical System (Smith & Nephew, Memphis, Tennessee). Cohorts were propensity score matched by age, sex, body mass index, and American Society of Anesthesiologist classification. Blood loss, surgical times, length of stays, 30- and 90-day complications, pain scores and PROs were compared with univariable analyses. Cox regression analyses evaluated survival to all-cause revisions.
Patients undergoing rTKA had a higher incidence of discharge home (86.5 %–60.0 %) (p < 0.01). There was no difference in blood loss or surgical time. rTKA pain scores were lower in-hospital mean 2 (range, 0 to 9) vs 3 (range, 0 to 9) (p = 0.02) as well as at one-year post-operatively, mean 1 (range, 0 to 7) vs 2 (range, 0 to 10) (p = 0.02). Cox hazard ratio demonstrated no difference in survival to all-cause revisions (HR 1.3; CI 0.5 to 3.7) (p = 0.64).
This matched cohort analysis demonstrated potential short-term benefits associated with imageless second generation rTKA including improved early post-operative pain, without compromising survivorship to all-cause revisions.
Keywords
Robotics
Navigation
Total knee arthroplasty
Patient-reported outcome measures
Propensity-score matching
1 Introduction
Total knee arthroplasty (TKA) has effectively treated knee pain and dysfunction for decades. Consequently, there is an expected increase in TKA incidence of 69 % by the year 2050.1,2 With the implementation of recent designs, implant survivorship has improved to greater than 90 % at ten years’ follow-up; however, dissatisfaction rates of up to 20 % after TKA have been reported.3–7 Certain surgeon-controlled intra-operative factors such as implant positioning, balancing of flexion-extension gaps, proper ligament tensioning, and overall limb alignment have been shown to influence implant survivorship and patient-reported outcomes. With traditional jig-based instrumentation for TKA, intraoperative data on gap measurements or ligamentous tensioning is limited and this can negatively affect patient-reported outcomes.8,9 Robotic-assisted arthroplasty total knee arthroplasty (rTKA) was created to provide solutions to these problems and, as a result, has attracted significant interest from both patients and surgeons alike.10–12
The incidence of robotic assisted total knee arthroplasty has increased by over 10 % since the early 2000s.10–12 rTKA was introduced to assist in bone cut accuracy, implant placement, and balancing of both flexion and extension gaps.13–15 Since its implementation, rTKA several reports in the literature have demonstrated improved implant position accuracy, restoration of the joint line, and limb alignment.13,14,14,16,17 In theory these improvement should minimize bony resection and damage to surrounding soft tissues, which can both generate blood loss and increase post-operative pain.18 Many studies have demonstrated improved pain scores and early return to function post-operatively in patients undergoing robotics versus conventional jig-based TKA.14,15,18–20
Most literature evaluating rTKA outcomes focus on surgeries performed with first generation, image-based software. There are limitations to this technology as it requires a pre-operative CT scan for planning of bone resection which results in additional cost, time, and radiation exposure for patients.13 More recently, second generation imageless systems have been developed that do not require pre-operative imaging. They instead rely on intraoperative surface mapping of the patient's anatomy to guide resection which has been shown to help execute more precise component placement radiographically.21 There remains limited data focused on outcomes after imageless rTKA in the literature.
Thus, this study sought to compare the following: 1) perioperative results 2) post-operative outcomes and survivorship to all-cause revisions, and 3) patient-reported outcomes (PROs) and pain scores between patients undergoing conventional versus rTKA with an imageless second-generation robotic system. The authors hypothesized that patients undergoing rTKA would have improved early post-operative outcomes with no difference in survival to all-cause revisions.
2 Methods
This is a retrospective review of patients undergoing TKA by two fellowship trained arthroplasty surgeons in one health system from January 1, 2017, until February 28, 2022. One surgeon (Surgeon A) practices at a tertiary academic center, while the other, (Surgeon B) practices at a community-based hospital within the participating health system. Institutional Review Board approval was obtained prior to study commencement. Inclusion criteria were met for patients undergoing unilateral robotic or traditional TKA during the above time frame – all primary TKAs were included regardless of complexity. Exclusion criteria were met for patients who had less than 90-day follow up, and those undergoing unicompartmental knee arthroplasty or revision TKA.
All rTKAs were performed using the CORI Surgical System (Smith & Nephew, Memphis, Tennessee). This is a semi-active, imageless system that uses intra-operative surface-mapping of the patient's anatomy in conjunction with balance assessment to guide bone resection. All resections were performed at the surgeon's discretion with a burr as the end-instrument. Both participating surgeons had significant experience using this surgical system.
Patients undergoing rTKA by the two participating surgeons were propensity score matched by age, sex, body mass index (BMI) and American Society of Anesthesiologist (ASA) scores to patients undergoing traditional TKA by the same two surgeons during the study window. Matching of patients was performed on a surgeon-specific basis. A total of 215 rTKA and 215 traditional TKA were included in the final cohorts (128 surgeon A to 87 surgeon B). Patient demographics were compared with univariable analyses. Mean follow up for the entire study population was 1.2 years.
2.1 Perioperative results
Perioperative variables recorded included the types of anesthesia administered (general versus spinal), the percentage of first-start cases, and pre-operative hematocrit levels. Intraoperative variables including blood loss, drain use, tranexamic acid (TXA) administration and surgical time were collected. Post-operative results including drain output, total length of stay in hours (LOS), and discharge location were recorded. In addition to recorded blood loss, the Brecher model ([k1(height3) + k2(weight) + k3] × ln([preoperative hematocrit/postoperative hematocrit]) was used to calculate intra-operative blood loss with pre- and post-operative hematocrit levels.22 All perioperative results were compared between the two cohorts with univariable analyses. A surgeon specific subgroup analysis was then performed to compare total hospital LOS and discharge location between the two cohorts. This was done to control for confounding variables, as the tertiary academic medical center began an outpatient arthroplasty program on March 1, 2020, and opened an outpatient surgery center for same-day discharges after total joint arthroplasty on August 1, 2021.
2.2 Post-operative outcomes
Both 30- and 90- day Emergency Department (ED) visits and readmissions were recorded and categorized by reasons for hospital return (medical versus surgical). All-cause revisions to final follow up were also recorded. 30- and 90-day ED visits and readmissions were compared between the two cohorts with univariable analyses. Adjusted cox regression analyses were performed while controlling for age, sex, BMI, and ASA scores to compare survival to all-cause revisions between the two cohorts.
2.3 Patient reported outcomes
Patient-reported outcomes (PRO) using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 Short Form, categorical PROMIS scores including physical function, pain interference, and depression, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) forms were collected pre-operatively, at three months post-operatively and again at final follow-up appointments. Only patients who had both pre- and post-operative scores were included in final analysis. The PROMIS Global-10 short form consists of 10 items that assess physical health, mental health, social health, pain, fatigue, and overall perceived quality of life. The responses are combined and reported as two scores: the global physical and global mental health scores. Of the 430 patients in the cohort, 158 (37 %) had both pre- and post-operative PROMIS short form scores recorded. Categorical PROMIS scores are collected separately from the short form and focus on one specific assessment area. The raw PROMIS scores obtained were reported as a T-score metric, which allows for comparison to the United States general population (mean: 50, SE: 10). Of the 430 patients in the cohort, 254 (59 %) had both pre- and post-operative categorical PROMIS scores recorded. The KOOS JR was developed from the original long version of the Knee injury and Osteoarthritis Outcome Score (KOOS) to assess functionality after joint replacement. Raw scores were reported for the seven items scored zero to four, with a lower raw score corresponding to improved knee health. Of the 430 patients in the cohort, 183 (43 %) had both pre- and post-operative KOOS JR scores recorded. PRO results, as well as change in score between the time points were compared. Finally, pain scores were collected pre-operatively, post-operatively while the patient was in the recovery room, and again at three months, six months, and one year after surgery. These were compared at all time points, and the differences in pain scores were also calculated and compared with univariable analyses.
The mean age of all study participants was 65 (range, 48 to 83), and the mean BMI was 32.9 (range 19.7–42.8). Of the entire study population, 42.6 % were men. There was no significant difference in patient age, sex, BMI or ASA scores between the two cohorts (see Table 1).
| Demographic | Robotic TKA (n = 215) | Conventional TKA (n = 215) | p-value |
| Age in years (range) | 66 (38–87) | 65 (41–92) | 0.470 |
| Men, n (%) | 91 (42.3) | 92 (42.8) | 1.000 |
| BMI, mean (range) | 33.0 (19.7–42.8) | 32.8 (20.2–42.6) | 0.752 |
| ASA, n (%) | 0.685 | ||
| 1 | 1 (0.5) | 2 (0.9) | – |
| 2 | 94 (43.7) | 90 (41.9) | – |
| 3 | 119 (55.3) | 123 (57.2) | – |
| 4 | 1 (0.5) | 0 (0.0) | – |
3 Results
3.1 Perioperative results
A higher percentage of patients undergoing conventional TKA were completed as the first case (72–51) (p = 0.033) (see Table 2), however, a higher percentage of patients in the rTKA cohort were discharged home post-operatively (86.5 %–60.0 %) (p < 0.001). The percentage of patients who had a drain post-operatively was significantly lower in the rTKA cohort (12.6 %–34.4 %) (p < 0.001). Hospital LOS was significantly less in the rTKA cohort mean 42 h (range, 6 to 476) to 54 (range, 7 to 485) (p < 0.001). Subgroup analysis demonstrated rTKA patients of Surgeon A had a significantly shorter LOS, mean 40 h (range, 6 to 476) to 60 (range, 8 to 485) (p = 0.008), while there was no difference in LOS between the two cohorts for Surgeon B, mean 44 (range, 10 to 386) to 44 (range, 7 to 216) (p = 0.985). Subgroup analysis also demonstrated both surgeons had a significantly higher percentage of rTKA patients discharged home (Surgeon A; 89.1 %–72.7 %) (p < 0.001) (Surgeon B; 82.8 %–41.4 %) (p < 0.001). The remainder of perioperative results can be seen in Table 2.
| Perioperative Results | Robotic TKA (n = 215) | Conventional TKA (n = 215) | p-value |
| Spinal anesthesia, n (%) | 196 (91.2) | 194 (90.2) | 0.868 |
| First Case, n (%) | 51 (23.7) | 72 (33.5) | 0.033 |
| Change in Hematocrit, mean (range) | 6.3 (0–11.9) | 6.0 (0–11.4) | 0.234 |
| Blood Volume Loss (mL), mean (range) | 868.3 (753.6–907.4) | 821.8 (710.5–932.4) | 0.291 |
| Drain use, n (%) | 27 (12.6) | 74 (34.4) | <0.001 |
| Drain output (mL), mean (range) | 372.9 (8-1100) | 379.6 (5-1490) | 0.927 |
| TXA use, n (%) | 204 (94.9) | 200 (93.0) | 0.544 |
| TXA IV use, n (%) | 196 (91.2) | 198 (92.1) | 0.862 |
| TXA Topical use, n (%) | 9 (4.2) | 3 (1.4) | 0.143 |
| Procedure Time (min), mean (range) | 114.8 (75–251) | 113.9 (66–294) | 0.729 |
| Hospital LOS (hours), mean (range) | 41.7 (6–476) | 53.7 (8–485) | 0.022 |
| Discharge Destination, n (%) | <0.001 | ||
| Home or Self Care | 186 (86.5) | 129 (60.0) | <0.001 |
| Home Health Service | 16 (7.4) | 70 (32.6) | <0.001 |
| Skilled Nursing Facility | 13 (6.0) | 16 (7.4) | 1.000 |
3.2 Post-operative outcomes
The rTKA cohort trended towards a lower incidence of 30-day ED visits and readmissions, as well as 90-day ED visits. There was a significantly lower percentage of 90-day readmissions (4.2 %–13.5 %) (p < 0.001) in the rTKA cohort (see Table 3). When stratified by reason for 90-day complications, there was a lower incidence of post-operative deep venous thromboses (0–1) and prosthetic joint infections (PJI) (4–5) in the robotic cohort (see Table 4). Adjusted cox hazard ratio demonstrated no difference in three-year survival to all-cause revision between the two cohorts (HR 1.3; CI 0.5 to 3.7) (p = 0.638) (see Fig. 1).
| Short-term Outcome | Robotic TKA (n = 215) | Conventional TKA (n = 215) | p-value |
| 30-day ED visits, n (%) | 16 (7.4) | 25 (11.6) | 0.135 |
| 30-day Readmissions, n (%) | 5 (2.3) | 14 (6.5) | 0.058 |
| 90-day ED visits, n (%) | 25 (11.6) | 38 (17.7) | 0.102 |
| 90-day Readmissions, n (%) | 9 (4.2) | 29 (13.5) | 0.001 |
| 90-day Emergency Department Visit | Robotic TKA (n = 215) | Conventional TKA (n = 215) |
| Non-Orthopedic | 12 | 20 |
| Deep Venous Thrombosis | 0 | 1 |
| Prosthetic Joint Infection | 2 | 4 |
| Post-Operative Pain | 7 | 9 |
| Periprosthetic Fracture | 0 | 2 |
| Superficial Wound Care | 4 | 1 |
| 90-day Readmission | Robotic TKA (n = 215) | Conventional TKA (n = 215) |
| Non-Orthopedic | 3 | 14 |
| Prosthetic Joint Infection | 4 | 5 |
| Post-Operative Pain | 2 | 0 |
| Periprosthetic Fracture | 0 | 3 |
3.3 Patient reported outcomes
There was no difference in pre-operative pain scores between the rTKA, mean 5 (range, 0 to 10) and traditional TKA, mean 6 (range, 0 to 10); (p = 0.700) cohorts. Patients in the rTKA cohort had significantly lower pain scores reported in both the post-operative care unit, mean 2 (range, 0 to 9) vs 3 (range, 0 to 9) (p = 0.016); and at one-year post-operatively mean 1 (range, 0 to 7) vs 2 (range, 0 to 10) (p = 0.022) (see Fig. 2). There were no differences in pain scores at three (p = 0.726) and six months (p = 0.850) post-operatively. Finally, when comparing changes in pain scores at each time point there was no significant difference between the cohorts.
There was no significant difference found in the KOOS JR scores (see Fig. 3) at any time points. The post-operative PROMIS global mental scores were significantly higher one-year post-operatively in the rTKA cohort mean 52 (range, 36 to 68) vs 48 (range, 25 to 63) (see Fig. 4). There were no differences in PROMIS categorical scores at any time point (see Fig. 5). The differences in KOOS, PROMIS Global Health-Physical Function and PROMIS Global Health-Mental Function scores at three months and final follow up trended to have a greater improvement in the rTKA cohort at final follow up, however these results were not significant (see Table 5).
| Patient-Reported Outcome | Follow-Up Range | Robotic TKA (n = 215) | Conventional TKA (n = 215) | p-value |
| KOOS JR | Pre-op –Post-op (3 months) | 8.6 (5.4) | 4.4 (5.3) | 0.059 |
| Pre-op - Post-op (final follow-up) | 8.6 (5.8) | 5.9 (3.7) | 0.195 | |
| PROMIS Global Health - Physical Function | Pre-op –Post-op (3 months) | 4.0 (6.0) | 0.3 (3.4) | 0.061 |
| Pre-op - Post-op (final follow-up) | 4.8 (7.5) | 3.8 (6.8) | 0.726 | |
| PROMIS Global Health - Mental | Pre-op –Post-op (3 months) | 0.3 (4.5) | 1.4 (4.4) | 0.365 |
| Pre-op - Post-op (final follow-up) | 0.3 (7.4) | 2.0 (3.0) | 0.524 |
4 Discussion
Despite being considered one of the most successful procedures in orthopedics with excellent survivorship, postoperative patient satisfaction rates after TKA remain lower than expected.3,7 Robotic assisted TKA provides a potential solution to this problem, and thus, should be critically evaluated and compared to conventional TKA. To the authors’ knowledge, the present study is one of the first and largest to provide a matched cohort analysis comparing perioperative results, short-term outcomes, and PROs of an imageless second-generation robotic system to conventional TKA.
4.1 Perioperative results
Certain studies cite longer operative time as a potential drawback of rTKA.13,23,24 Tompkins et al.23 evaluated a matched cohort of 2392 conventional TKAs to rTKA done with the MAKO surgical system (Stryker, Kalamazoo, Michigan) and found that both operative and procedure time were significantly longer in the rTKA cohort. Deceky et al.24 evaluated 220 consecutive conventional and rTKAs using the MAKO surgical system (Stryker, Kalamazoo, Michigan) and demonstrated that rTKAs had a significantly longer tourniquet time. Others have mentioned no difference in operative time once overcoming the learning curve, and opined the use of rTKA may ultimately improve intraoperative efficiency.13,25,26 In the present study, there is no difference in procedure time between the two cohorts. This could potentially be an added benefit of a second-generation imageless system when compared to first-generation systems, and should be further investigated. However, it is important to note that both surgeons had extensive experience using the CORI Surgical System (Smith & Nephew, Memphis, Tennessee) which could account for the similar procedure time between rTKA and traditional TKA.
Many authors have reported earlier hospital discharge associated with rTKA when compared to conventional TKA. Tompkins et al.23 reported a shorter hospital LOS by 1.9 h in the rTKA cohort, however, the authors felt this result was not clinically significant. Kayani et al.15 reported a much larger difference between rTKA and conventional TKA patients, with rTKA cohort averaging a 28-h shorter time to hospital discharge. The present study demonstrates an approximately 12-h shorter LOS in the rTKA cohort. However, it should be acknowledged that subgroup analysis demonstrated patients undergoing rTKA with Surgeon A had a significantly shorter hospital LOS, while Surgeon B showed no difference between the cohorts. Surgeon A works at the tertiary academic center, which developed a program for short stay arthroplasty in spring 2020. All rTKA patients of Surgeon An underwent surgery after implementation of the short stay arthroplasty program, which certainly introduces bias into the results.
Tompkins et al.23 found no difference in percentage of patients discharged home in their study. However, they demonstrated greater usage of home health services by the rTKA cohort. Mont et al.26 showed lower healthcare utilization in the form of home health visits and discharge to skilled nursing facility in their rTKA cohort. The present study demonstrates a significantly higher percentage of patients discharged home in the rTKA cohort, and a significantly higher percentage of patients in the conventional TKA cohort requiring home health services. There was no difference in discharge to skilled nursing facility between the two cohorts. This adds value to the existing literature as the cohorts in this study were matched by age, sex, BMI and ASA score, eliminating bias that could predispose one cohort to require additional services post-operatively.
4.2 Post-operative outcomes
There are numerous studies in the literature that report improved 30- and 90-day outcomes in the form of ED visits and hospital readmissions after rTKA. This study mirrors those findings, with the rTKA cohort trending towards decreased 30- and 90-day ED visits and 30-day readmissions. There were significantly fewer 90-day readmissions in the rTKA cohort. However, it must be taken into consideration that most ED visits and readmissions in the traditional cohort were for medical reasons, and there was no clear difference in orthopedic readmissions between the two cohorts. Further analysis of 90-day ED visits demonstrated the rTKA cohort had a higher incidence of patients returning for superficial wound care. Pin site complications are unique to rTKA, and have previously been reported as a reason for short-term hospital return.23 Despite these findings, there was no difference between the cohorts in patients returning to the hospital at 90-days for prosthetic joint infection.
4.3 Patient reported outcomes
Scott et al.7 found that post-operative pain is an important prognostic indicator for patient dissatisfaction after TKA. Numerous studies have reported improved post-operative pain scores in patients undergoing robotic versus conventional TKA.13–16,18–20,26–29 The present study adds to this data as patients in the rTKA cohort had significantly improved pain scores in both the post-operative recovery area, and at one year post-operatively. The early benefit of these results is clear, with a higher percentage of patients discharged home in the rTKA cohort; however, the results demonstrated at one-year could also provide benefits for long-term patient satisfaction.
4.4 Limitations
The most significant limitation to this study includes sample size and lack of long-term follow-up. While this study cannot comment on the long-term results of rTKA, the institution at which the study was performed is, to the author's knowledge, one of the first to use this second-generation system. Thus, the follow up reported in this study is the most robust seen in the literature. Additionally, while the number of patients in each cohort is limited, the authors feel the ability to match control cohorts improves our findings. Matching was done via propensity scoring, and not done on a 1:1 ratio. This decreases this specificity of patient matching; however, the authors feel the benefits of a larger final cohort outweighs the limitations. Finally, this study was a retrospective review of each cohort, and comes with the inherent disadvantages of this study design. Further prospective trials should be completed to truly compare outcomes between the cohorts.
5 Conclusion
The present study provides a large, matched cohort analysis demonstrating rTKA with an imageless second-generation robotic system is safe, without increased operative time or unanticipated complications. Furthermore, this study demonstrated that patients may benefit from improved early post-operative pain, with a trend toward greater improvement margin of PROs, without compromising survivorship to all cause revision.
Ethical approval
IRB approval was obtained prior to initiating this study.
Consent
None.
6 Conflicts of interest and source of funding
Disclosures related to conflict of interest be each author can be found on the disclosure website at www.aaos.org.
CRediT authorship contribution statement
Niall H. Cochrane: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Billy I. Kim: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Justin Leal: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Rhett K. Hallows: Conceptualization, Methodology, Supervision, Writing – review & editing. Thorsten M. Seyler: Conceptualization, Methodology, Supervision, Writing – review & editing.
References
- Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage. 2017;25(11):1797-1803.
- [Google Scholar]
- Prevalence of total Hip and knee replacement in the United States. J Bone Jt Surg-Am. 2015;97(17):1386-1397.
- [Google Scholar]
- Survival analysis of total knee arthroplasty at a minimum 10 years' follow-up: a multicenter French nationwide study including 846 cases. Orthop Traumatol Surg Res. 2013;99(4):385-390.
- [Google Scholar]
- Total knee arthroplasty with an oxidised zirconium femoral component: ten-year survivorship analysis. Bone Jt J. 2016;98-B(1):58-64.
- [Google Scholar]
- Patient-specific cutting blocks: of unproven value. Bone Jt J. 2016;98-B(1_Supple_A):78-80.
- [Google Scholar]
- The influence of body mass index on functional outcome and quality of life after total knee arthroplasty. Bone Jt J. 2016;98-B(6):780-785.
- [Google Scholar]
- Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br. 2010;92-B(9):1253-1258.
- [Google Scholar]
- The epidemiology of failure in total knee arthroplasty: avoiding your next revision. Bone Jt J. 2016;98-B(1_Supple_A):105-112.
- [Google Scholar]
- Accuracy of intramedullary versus extramedullary tibial alignment cutting systems in total knee arthroplasty. Clin Orthop. 1995;321:106-110.
- [Google Scholar]
- Trends in computer navigation and robotic assistance for total knee arthroplasty in the United States: an analysis of patient and hospital factors. Arthroplasty Today. 2019;5(1):88-95.
- [Google Scholar]
- Patient interest in robotic total joint arthroplasty is exponential: a 10-year google trends analysis. Arthroplasty Today. 2022;15:13-18.
- [Google Scholar]
- Trends of utilization and 90-day complication rates for computer-assisted navigation and robotic assistance for total knee arthroplasty in the United States from 2010 to 2018. Arthroplasty Today. 2021;11:134-139.
- [Google Scholar]
- Robotic total knee arthroplasty: clinical outcomes and directions for future research. Bone Jt Res. 2019;8(10):438-442.
- [Google Scholar]
- 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: a prospective cohort study. Bone Jt J. 2018;100-B(7):930-937.
- [Google Scholar]
- An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study. Bone Jt J. 2019;101-B(1):24-33.
- [Google Scholar]
- Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2022;30(8):2677-2695.
- [Google Scholar]
- Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop. 2013;471(1):118-126.
- [Google Scholar]
- Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach: a blinded assessment. Bone Jt Res. 2019;8(10):495-501.
- [Google Scholar]
- Robotic-assisted total knee arthroplasty demonstrates decreased postoperative pain and opioid usage compared to conventional total knee arthroplasty. Bone Jt Open. 2020;1(2):8-12.
- [Google Scholar]
- Robotic arm-assisted versus manual total knee arthroplasty: a propensity score-matched analysis. J Knee Surg. 2023;36(1):105-114.
- [Google Scholar]
- Robotic-assisted total knee arthroplasty utilizing navio, CORI imageless systems and manual TKA accurately restore femoral rotational alignment and yield satisfactory clinical outcomes: a randomized controlled trial. Medicina (Mex). 2023;59(2):236.
- [Google Scholar]
- A standardized method for calculating blood loss. Transfusion (Paris). 1997;37(10):1070-1074.
- [Google Scholar]
- Robotic versus manual total knee arthroplasty in high volume surgeons: a comparison of cost and quality metrics. J Arthroplasty. 2022;37(8):S782-S789.
- [Google Scholar]
- Robotic-assisted total knee arthroplasty allows for trainee involvement and teaching without lengthening operative time. J Arthroplasty. 2022;37(6):S201-S206.
- [Google Scholar]
- Simultaneous bilateral total knee arthroplasty with robotic and conventional techniques: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2011;19(7):1069-1076.
- [Google Scholar]
- 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(3):328-337.
- [Google Scholar]
- Results of robotic-assisted versus manual total knee arthroplasty at 2-year follow-up. J Knee Surg. 2023;36(2):159-166.
- [Google Scholar]
- Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study. Eur J Orthop Surg Traumatol. 2022;33(4):1231-1236.
- [Google Scholar]
- Navigated and robot-assisted technology in total knee arthroplasty: do outcome differences achieve minimal clinically important difference? J Arthroplasty. 2022;37(8):1562-1569.
- [Google Scholar]