Patient perception of computed tomography scans in robotic-assisted elective total knee and hip arthroplasty: A cross-sectional study

Carlos Guevara-Serra; Hector E. Sanchez-Fernandez; José I. Acosta Julbe; Miguel Girod Hoffman; Marcantonio V. Pinci; Norberto J. Torres Lugo; Hector Muñoz Miro; Fernando Arocho Oquendo; Antonio Otero-López

doi:10.1016/j.jor.2025.05.001

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70 (); 153-157

doi:

10.1016/j.jor.2025.05.001

Patient perception of computed tomography scans in robotic-assisted elective total knee and hip arthroplasty: A cross-sectional study

Carlos Guevara-Serra^a, Hector E. Sanchez-Fernandez^a, José I. Acosta Julbe^a,, Miguel Girod Hoffman^b,c, Marcantonio V. Pinci^a, Norberto J. Torres Lugo^a, Hector Muñoz Miro^d, Fernando Arocho Oquendo^b, Antonio Otero-López^a

a Department of Orthopedic Surgery, University of Puerto Rico, Puerto Rico, San Juan, USA

b School of Medicine, University of Puerto Rico, Medical Sciences Campus, Puerto Rico, San Juan, USA

c Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA

d Department of General Surgery, University of Puerto Rico, Puerto Rico, San Juan, USA

⁎Corresponding author: José I. Acosta Julbe. jose.acosta14@upr.edu

Received: 2025-2-7, Accepted: 2025-5-3, Published: 2025-5-14

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

This study evaluates patient perceptions of radiation exposure from preoperative CT scans in robotic-assisted total joint arthroplasty (raTJA). It examines awareness of radiation risks, the impact of prior raTJA experience, and the role of education and previous CT scans in knowledge acquisition. Additionally, it explores patient preferences for CT scans despite radiation exposure.

A cross-sectional study was conducted with patients 21 years of age and older who were candidates for a raTJA. A 21-item questionnaire was distributed in an arthroplasty clinic to assess patient demographics, prior CT scan exposure, knowledge of radiation risks, and opinions on preoperative CT scans in raTJA.

Of the 155 respondents, 72.9 % were female, with a mean age of 64. The majority (80.7 %) were candidates for TKA, and 16.8 % for THA. While 53.6 % of participants knew that CT scans involve radiation exposure, 81 % were unaware of how much radiation a CT scan produces compared to X-rays. Among patients with prior raTJA, 62 % were aware of radiation risks. Patient knowledge of radiation exposure was not significantly associated with education level or prior CT scans (P > 0.05). Notably, over 90 % of patients preferred a preoperative CT if it enabled robotic assistance, even after learning about radiation exposure.

As robotic-assisted TJA becomes more widespread, understanding patient views on preoperative CT scans is increasingly essential. While awareness of radiation exposure was limited, most patients preferred CT imaging if it enabled robotic assistance, highlighting the need for improved education and communication regarding the risks and benefits.

IV cross-sectional study.

Keywords

Robotic-assisted arthroplasty

Patient perception

Radiation exposure

CT scan

Total knee arthroplasty

Total hip arthroplasty

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1 Introduction

Total joint arthroplasty (TJA) is one of the most frequently performed procedures in orthopaedic surgery, with over one million TJAs conducted annually in the United States.¹ By 2030, the incidence of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) is projected to increase by 85 % and 71 %, respectively.² This surge is driven by population aging, the rising prevalence of obesity, and the increasing incidence of osteoarthritis (OA), the leading indication for TJAs.³

Over the past two decades, more surgeons have been using robotic-assisted technologies for TKA and THA because they allow for better fine-tuning of various intraoperative parameters and have been shown to increase the precision of implant positioning.^4–6 Furthermore, studies suggest that robotic assistance is linked to reduced postoperative length of stay, fewer in-hospital implant complications, and improved postoperative range of motion compared to manual TKA.^7–9 Specifically, the MAKO™—a computerized tomography (CT)-based robotic-assisted platform—utilizes preoperative three-dimensional (3D) CT models to optimize implant size and orientation before bone resection, enhancing surgical precision and minimizing human error.¹⁰ Studies have also found that radiographic parameters, such as alignment, component positioning, and soft tissue balancing, are significantly improved with robotic systems.⁵^,⁶ However, using CT scans in these procedures exposes patients to significantly high doses of radiation.¹¹ For instance, preoperative pelvic CT scans for THA deliver three times the radiation dose of a standard hip radiograph series.¹²^,¹³ Radiation exposure can cause a range of biological effects, from DNA damage and cell death to long-term risks such as cancer and cardiovascular disease, depending on the dose and duration.¹⁴^,¹⁵ Given its potential to disrupt cellular processes and compromise organ function, minimizing radiation exposure remains a clinically relevant goal in the care of the orthopedic patient.

Therefore, patients' limited understanding of the radiation exposure associated with robotic-assisted total joint arthroplasty (raTJA) CT scans must be addressed.¹⁶ While even low levels of radiation exposure increase cancer risk,^17–19 studies show that patients often underestimate the radiation from CT scans compared to radiographs and remain unaware of the potential hazards of radiation-induced cancer.²⁰^,²¹ Despite this, evaluating patient perceptions regarding radiation risks in TJAs has been limited.

Our study assesses patients' perceptions of preoperative CT scans in raTJA. Specifically, we sought to answer the following questions: How aware are patients of the radiation exposure involved in preoperative CT scans for robotic-assisted TJA? Does prior experience with robotic-assisted TJA influence patients' awareness of radiation exposure? Additionally, is the patient education level or prior CT scan history associated with their knowledge of radiation risks? We hypothesize that most patients possess limited knowledge about the significant radiation exposure related to preoperative CT scans and that prior robotic-assisted TJA experience, but not education level or prior CT scans, is associated with increased awareness of radiation risks. This study aims to enhance patient education and contribute to safer, more transparent clinical practices in robotic-assisted surgery by answering these questions.

2 Materials and methods

2.1

2.1 IRB Statement

This study was approved by the Institutional Review Board of the University of Puerto Rico (#2306115833). All participants provided informed consent before participation, and the study was conducted following the Declaration of Helsinki.

2.2

2.2 Study design

We conducted a cross-sectional study evaluating patients' perceptions regarding preoperative CT scans (Siemens Healthineers, Erlangen, Germany) for raTJA using the MAKO robotic system (Stryker Corporation, Kalamazoo, Michigan, USA). The inclusion criteria were patients 21 years or older and candidates for a primary TKA or THA. We excluded patients younger than 21, those undergoing revision TKA or THA, who were unable to consent, and those with diagnosed significant cognitive impairment.

2.3

2.3 Data collection

The authors of this study utilized a 22-item questionnaire, developed initially by Daramola et al., that was validated in a cohort of patients presenting to a tertiary care rhinology clinic with sinus and/or nasal complaints.²² The survey distributed to our patient cohort was modified to 21 items after a referral question was omitted, and the content was revised to reflect more pertinent questions asked at a preoperative clinic visit for TJA. The modified survey was distributed to participants meeting the inclusion criteria and can be accessed in the Appendix. The survey was provided to the patients at our arthroplasty clinic after they decided to proceed with surgery, but before the CT scan and surgery date, to ensure that perceived surgical outcomes did not affect the overall scope of the study, which was to determine the perceptions of the CT scan needed for this technology (Appendix F ig. 1). Research personnel were available to address any questions or concerns regarding the survey. The questionnaire covered demographics (i.e., age, sex, education level, symptom timing, prior TJA history, and prior robotic TJA history), exposure to previous CT scans, knowledge about radiation exposure, and opinions regarding preoperative CT scans and expected postoperative outcomes. To provide context for patient responses regarding radiation exposure, a supplemental table summarizing typical radiation doses for CT scans used in TJA planning (in millisieverts) and their equivalents in chest x-rays was included in the analysis.

2.4

2.4 Data analyses

Descriptive statistics were used to summarize the sample data, including mean, standard deviation (SD), and percentages. Cross-tabulation analysis for categorical variables was performed to determine associations between patient demographics and responses utilizing chi-square tests. A power calculation determined the sample size required to detect meaningful differences in patient awareness regarding the preoperative CT scan. Based on prior literature suggesting that approximately 40–50 % of patients have limited knowledge of radiation exposure, we estimated that a sample size of at least 150 participants would be sufficient to detect differences in awareness levels with 95 % confidence and an assumed margin of error of 5 %. This sample size was calculated to provide adequate statistical power (80 %) for chi-square analyses to assess associations between awareness and demographic variables, including education level and prior CT scan history.¹⁶^,¹⁷ We also conducted a subgroup analysis, including patients who had previously undergone raTJA. We performed a cross-tabulation analysis to study whether having a previous raTJA was associated with the response to the question about radiation exposure during a CT. A P-value of <0.05 was considered statistically significant. All statistical analyses were conducted using IBM SPSS Statistics (IBM Corp., Armonk, New York, United States).

3 Results

Table 1 summarizes the baseline demographics of the cohort. Of the 200 responses, 155 patients were included in our analyses. The mean age was 64 (SD 11.4), and 72.9 % of respondents were women. 16.8 % were candidates for a THA, while 80.7 % were for a TKA. Among those who had undergone a previous arthroplasty procedure (41.3 % of the cohort), 42 (27.1 %) underwent a procedure assisted by robotic technology. Of these 42 patients, 39 (92.9 %) reported satisfactory outcomes. One hundred twenty-eight patients (82.6 %) had undergone a CT scan before completing the questionnaire. Over half of the cohort (57.4 %) had undergone multiple CT scans, whereas a quarter had undergone only one previous CT scan (25.2 %).

Table 1 Baseline characteristics of our cohort.

Characteristics	n (n=155)	Percentage (%) ^a
*Gender*
Women	113	72.9
Men	41	26.5
Prefer not to say	1	0.7
*Age*
21-50	21	13.6
51-64	57	36.8
> 65	77	50.0
*Type of surgery*
Total Knee Arthroplasty (TKA)	125	80.6
Total Hip Arthroplasty (THA)	30	19.4
*Previous total joint arthroplasty (TJA) procedure*
Yes	64	41.3
No	91	58.7
*If have had previous TJA, was it robotically-assisted?*
Yes	42	27.10
No	30	19.35
*If have had previous TJA, were you satisfied with the results?*
Yes - manual TJA	14	46.67
Yes – robotically-assisted TJA	39	92.86
No – manual TJA	8	26.67
No – robotically-assisted TJA	4	9.52
*Prior to answering this questionnaire, have you gotten a CT scan and if yes, how many?*
Yes	128	82.58
1	39	25.16
2-3	60	38.71
4-5	12	7.74
>5	17	10.97
No	27	17.42
*What is the highest level of education you have completed?*
Less than high school	13	8.39
High school	58	37.42
Undergraduate Degree	52	33.55
Graduate Studies	32	20.65

a Percentages may not round to 100 due to missing data in the responses.

Table 2 summarizes the questionnaire responses related to radiation exposure during a CT. Over half of the patients (53.6 %) knew that undergoing a CT scan involves exposure to ionizing radiation. In addition, 81 % of the patients were unsure of how many x-rays are equivalent to the radiation involved in one CT scan. Among those concerned about using CT scans to guide a raTJA, the most reported concern was the time required to perform a CT scan (10.3 %), followed by radiation exposure (8.4 %).

Table 2 Questionnaire responses related to radiation exposure during a pre-operative CT scan for robotic-assisted total joint arthroplasty and general beliefs regarding the benefits of pre-operative CT scans.

Questionnaire Item	n	%∗∗
*Would you prefer a pre-operative CT scan prior to your TKA or THA if your surgeon will be assisted by a robot?*
Yes	145	93.55
No	10	6.45
*If your answer to previous question was “yes”, choose the best reason why:*
It will improve the clinical outcome	87	56.13
The recovery time will be less	31	20.00
Less risk of infection	10	6.45
The operating time will be less	19	12.26
Missing	8	5.16
*How comfortable would you feel if your surgeon told you that he/she would need a CT scan to prepare for your surgery?*
I'd need to ask questions, but I'd probably an.	49	31.61
Comfortable and willing to proceed without asking questions	92	59.35
Concerned and would proceed if questions are answered properly	13	8.39
Unwilling to continue under any circumstances	1	0.65
*According to your knowledge, during a CT scan you are exposed to radiation*
Yes	83	53.55
No	19	12.26
Not sure	53	34.19
*A CT scan involves radiation exposure. In terms of radiation exposure, how many x-rays are equivalent to the CT scan you will get in the radiology department?*
1-10	26	16.77
10-50	3	1.94
Not sure	126	81.29
*How many lower extremity CT scans would you be willing to have in one year if this were necessary to fully treat your osteoarthritis?*
0	5	3.23
1	48	30.97
2-5	50	32.26
>5	1	0.65
Not sure	51	32.90
*Would you be willing to undergo a CT scan of the lower extremity for research purposes?*
Yes	103	66.45
No	52	33.55
*If you knew that a history, physical examination findings, and x-ray images alone were enough to surgically treat a hip or knee with osteoarthritis, would you prefer to:*
Proceed with surgery without further intervention	54	34.84
Proceed with surgery only after analyzing the limb with a CT scan even if this implies additional expenses for the scan and the radiation exposure involved with the CT scan	101	65.16
*Do you have any concerns regarding the use of lower extremity CT scans to guide a TKA or THA?*
Yes	48	30.97
No	107	69.03
*If your answer to the previous question was “yes”, please choose your biggest concern:*
The time required to perform a CT scan	16	10.32
Radiation exposure	13	8.39
Anxiety related to lying within the gantry	9	5.81
Possible adverse effects	5	3.23
Cost	3	1.94
Missing	109	70.32

Fig. 1 summarizes the factors potentially associated with patient awareness regarding radiation exposure in CT scans. A history of prior CT scans and education level were not related to knowledge of radiation exposure (χ2 = 3.7; P = 0.16 and χ6 = 7.7; P = 0.3, respectively). Among the patients with a prior raTJA, 62 % knew that CT scans involved radiation exposure (χ2 = 7.2; P = 0.03). Table 3 summarizes the effective radiation dose for CT scans used in TJA planning.

Factors that could confound patient awareness regarding radiation exposure in computed tomography. ∗raTJA = robotic-assisted total joint arthroplasty.

Table 3 Radiation exposure and chest X-Ray equivalents for imaging modalities in total hip and total knee arthroplasty planning.

Imaging Type	Effective Dose (mSv)	Chest X-Ray Equivalent	Reference (PubMed ID)
CT for THA Planning (Pelvis)	4 ± 1	50 (based on 0.1 mSv)	20022723
CT for TKA Planning (Knee)	3–9	38–106	25840872
Standard Hip X-Ray Series	0.7–1.0	9–12	20022723
Standard Knee X-Ray Series	0.2	2	19651945
CT Abdomen and Pelvis	10	122	19651945

4 Discussion

Robotic-assisted total joint arthroplasty is increasingly used in the United States, with growing evidence supporting its benefits in implant alignment and radiographic outcomes.²³ Despite this growing utilization, limited research has explored patients' perspectives on raTJA, particularly regarding preoperative CT scans—a common requirement for specific robotic systems.²⁴^,²⁵ This study is the first to examine patients’ awareness and perceptions of the radiation exposure associated with these scans.

Our findings reveal that approximately half of the patients surveyed recognized that CT scans involve radiation exposure, yet 38 % of those with prior raTJA remained unaware. Interestingly, prior CT experience and education level were not associated with greater awareness of radiation risks, suggesting variability in how information is communicated during clinical encounters.

These findings align with those in other medical specialties. For instance, Daramola et al. found that fewer than half of patients undergoing evaluation for nasal symptoms knew that CT imaging involved radiation.²² Like our study, they found no association between education level or prior surgical experience and radiation awareness. The consistency of these findings across specialties highlights a broader gap in patient education and informed consent regarding imaging-related radiation exposure. This is particularly important given the potential risks associated with ionizing radiation. While the effective dose (ED) from preoperative CT scans used in RA-TJA is generally within recommended safety limits, typically ranging from 3 to 8.5 mSv, the radiation burden is cumulative. Even low-dose exposure may carry long-term biological consequences, including DNA damage, organ dysfunction, and increased cancer risk.^13–16^,^26–28 With the average age of arthroplasty patients declining, the lifetime radiation risk becomes even more relevant.²⁹^,³⁰

Moreover, ED provides a standardized method to compare radiation exposure across imaging modalities. Costello et al. reported that a 10 mSv ED may increase the lifetime fatal cancer risk by 1 in 2000—highlighting the need for judicious use of CT imaging.³¹ While the average ED for raTHA planning is approximately 4.0 mSv,¹³ these values are equivalent to dozens of chest X-rays, underscoring the importance of patient education and transparency in imaging-related decisions.

The observed knowledge gaps in our cohort support the need for a standardized approach to radiation education in orthopaedics. A model similar to the radiation accountability framework developed by the American College of Cardiology could be adapted for surgical disciplines.³² This would ensure that patients are consistently informed of the risks associated with imaging, especially in fields like orthopaedics, where imaging plays a central role in diagnosis and surgical planning. Notably, not all robotic platforms require preoperative CT imaging. Systems such as ROSA™, Velys™, and NAVIO™ rely on intraoperative data or other imaging modalities, offering comparable clinical outcomes without exposing patients to preoperative CT-related radiation.¹⁶^,³³ As such, system selection may provide an opportunity for radiation stewardship in joint arthroplasty, especially in younger or higher-risk populations.

Despite limited knowledge of CT radiation, most patients in our study still preferred to undergo a preoperative CT scan, even after being informed of the associated risks. This aligns with findings from other studies where patients associated advanced imaging with improved diagnostic accuracy and surgical outcomes.²⁰ When asked about their preference, 93.6 % of patients favored preoperative CT imaging, with many believing it would lead to better outcomes, quicker recovery, or shorter procedures. Similarly, Jassim et al. found that nearly half of the patients perceived robotic surgery as more accurate, and many believed it would result in a faster method.³⁴ These perceptions suggest that patients place significant value on technological advancements and associate them with improved care, likely influencing their willingness to accept associated risks.

This study has several limitations. Our sample consisted of patients already scheduled for robotic-assisted TJA, who may be more familiar with preoperative imaging than the general population. Additionally, as a single-institution study involving one surgeon's urban practice, generalizability may be limited. Recent counseling may also have influenced responses, although survey timing was designed to minimize recall bias. Finally, while many participants had prior CT experience, creating a CT-naïve sample would be impractical given the widespread use of CT imaging in healthcare.³⁵^,³⁶ Nonetheless, our findings emphasize enhancing the informed consent process and developing educational strategies to improve patient understanding of imaging-related risks. While preoperative CT scans are essential for specific robotic systems, clinicians should remain mindful of the cumulative nature of radiation exposure and consider alternative systems when appropriate. Future studies should focus on long-term clinical outcomes across different robotic systems and further assess the cumulative effects of radiation exposure in this evolving patient population.

5 Conclusion

Due to the increasing popularity and adoption of raTJA, we considered it essential to understand the patient perspective regarding the preoperative CT scan for some raTJA systems. Approximately half of our cohort was aware that undergoing a CT scan involves radiation exposure. Notably, after being educated about exposure to radiation during CT, over 90 % of patients would prefer to undergo a preoperative CT if it meant their surgeon would have robotic assistance. Our results will inform surgeons about areas where communication can be improved and identify key drivers for why patients choose to undergo raTJA despite the increased costs and radiation exposure associated with the preoperative CT scans.

CRediT authorship contribution statement

Carlos Guevara-Serra: Conceptualization, Methodology, Writing – original draft Preparation. Hector E. Sanchez-Fernandez: Data curation, Investigation, Writing – Reviewing and Editing. José I. Acosta Julbe: Writing – Reviewing and Editing. Miguel Girod Hoffman: Software, Data curation, Formal analysis. Marcantonio V. Pinci: Visualization, Formal analysis. Norberto J. Torres Lugo: Methodology, Validation. Hector Muñoz Miro: Investigation, Writing – Reviewing and Editing. Fernando Arocho Oquendo: Data curation, Visualization. Antonio Otero-López: Supervision, Validation, Writing – Reviewing and Editing.

Acknowledgment and funding sources

No financial support was received for this study.

Financial support

No financial support or sponsorship was received.

Ethical statement

This study followed the moral principles outlined in the Declaration of Helsinki. Before data collection, Institutional Review Board (IRB) approval was obtained (IRB #2306115833), and all participants provided informed consent before completing the questionnaire.

Guardian/parent's consent

No pediatric patients were included in the study. Our study was also approved by the IRB #2306115833.

Funding

This study received no specific grant from any funding agency.

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