Skip to main content
SpringerLink
Log in

Robotic-assisted TKA Reduces Postoperative Alignment Outliers and Improves Gap Balance Compared to Conventional TKA

  • Symposium: Papers Presented at the Annual Meetings of the Knee Society
  • Published:
Clinical Orthopaedics and Related Research®

An Erratum to this article was published on 14 July 2012

Abstract

Background

Several studies have shown mechanical alignment influences the outcome of TKA. Robotic systems have been developed to improve the precision and accuracy of achieving component position and mechanical alignment.

Questions/purposes

We determined whether robotic-assisted implantation for TKA (1) improved clinical outcome; (2) improved mechanical axis alignment and implant inclination in the coronal and sagittal planes; (3) improved the balance (flexion and extension gaps); and (4) reduced complications, postoperative drainage, and operative time when compared to conventionally implanted TKA over an intermediate-term (minimum 3-year) followup period.

Methods

We prospectively randomized 100 patients who underwent unilateral TKA into one of two groups: 50 using a robotic-assisted procedure and 50 using conventional manual techniques. Outcome variables considered were postoperative ROM, WOMAC scores, Hospital for Special Surgery (HSS) knee scores, mechanical axis alignment, flexion/extension gap balance, complications, postoperative drainage, and operative time. Minimum followup was 41 months (mean, 65 months; range, 41–81 months).

Results

There were no differences in postoperative ROM, WOMAC scores, and HSS knee scores. The robotic-assisted group resulted in no mechanical axis outliers (> ± 3° from neutral) compared to 24% in the conventional group. There were fewer robotic-assisted knees where the flexion gap exceeded the extension gap by 2 mm. The robotic-assisted procedures took an average of 25 minutes longer than the conventional procedures but had less postoperative blood drainage. There were no differences in complications between groups.

Conclusions

Robotic-assisted TKA appears to reduce the number of mechanical axis alignment outliers and improve the ability to achieve flexion-extension gap balance, without any differences in clinical scores or complications when compared to conventional manual techniques.

Level of Evidence

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Adam C, Eckstein F, Milz S, Putz R. The distribution of cartilage thickness within the joints of the lower limb of elderly individuals. J Anat. 1998;193:203–213.

    Article  PubMed  Google Scholar 

  2. Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty. J Arthroplasty. 2005;20:132–138.

    Article  PubMed  Google Scholar 

  3. Asano H, Hoshino A, Wilton TJ. Soft-tissue tension total knee arthroplasty. J Arthroplasty. 2004;19:558–561.

    Article  PubMed  Google Scholar 

  4. Ateshian GA, Soslowsky LJ, Mow CV. Quantitation of articular surface topography and cartilage thickness in knee joints using stereophotogrammetry. J Biomech. 1991;24:761–776.

    Article  PubMed  CAS  Google Scholar 

  5. Bardakos N, Cil A, Thompson B, Stocks G. Mechanical axis cannot be restored in total knee arthroplasty with a fixe valgus resection angle. J Arthroplasty. 2007;22:85–89.

    Article  PubMed  Google Scholar 

  6. Bathis H, Perlick L, Tingart M, Perlick C, Luring C, Grifka J. Intraoperative cutting errors in total knee arthroplasty. Arch Orthop Trauma Surg. 2005;125:16–20.

    Article  PubMed  CAS  Google Scholar 

  7. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinical important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840.

    PubMed  CAS  Google Scholar 

  8. Bellemans J, Vandenneucker H, Vanlauwe J. Robot-assisted total knee arthroplasty. Clin Orthop Relat Res. 2007;464:111–116.

    PubMed  Google Scholar 

  9. Börner M, Wiesel U, Ditzen W. Clinical experiences with ROBODOC and the Duracon total knee. In: Stiehl JB, Konermann W, Haaker RG, eds. Navigation and Robotics in Total Joint and Spine Surgery. Berlin, Germany: Springer-Verlag; 2004:362–366.

    Chapter  Google Scholar 

  10. Chang CW, Yang CY. Kinematic navigation in total knee replacement—experience from the first 50 cases. J Formos Med Assoc. 2006;105:468–474.

    Article  PubMed  Google Scholar 

  11. Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthroplasty versus a conventional jig-based technique: a randomized, prospective trial. J Bone Joint Surg Br. 2004;86:372–377.

    Article  PubMed  CAS  Google Scholar 

  12. Chin PL, Yang KY, Yeo SJ, Lo NN. Randomized control trial comparing radiographic total knee arthroplasty implant placement using computer navigation versus conventional technique. J Arthroplasty. 2005;20:618–626.

    Article  PubMed  Google Scholar 

  13. Choong PF, Dowsey MM, Stoney JD. Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplasty. 2009;24:560–569.

    Article  PubMed  Google Scholar 

  14. Churchill DL, Incavo SJ, Johnson CC, Beynnon BD, The transepicondylar axis approximates the optimal flexion axis of the knee. Clin Orthop Relat Res. 1998;356:111–118.

    Article  PubMed  Google Scholar 

  15. Confalonieri N, Manzotti A, Pullen C, Ragone V. Computer-assisted technique versus intramedullary and extramedullary alignment systems in total knee replacement: a radiological comparison. Acta Orthop Belg. 2005;71:703–709.

    PubMed  Google Scholar 

  16. Decking J, Theis C, Achenbach T, Roth E, Nafe B, Eckardt A. Robotic total knee arthroplasty: the accuracy of CT-based component placement. Acta Orthop Scand. 2004;75:573–579.

    Article  PubMed  Google Scholar 

  17. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.

    Article  PubMed  Google Scholar 

  18. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12.

    PubMed  Google Scholar 

  19. Fadda M, Marcacci M, Toksvig-Larsen S, Wang T, Meneghello R. Improving accuracy of bone resections using robotics tool holder and a high speed milling cutting tool. J Med Eng Technol. 1998;22:280–284.

    Article  PubMed  CAS  Google Scholar 

  20. Fehring TK. Rotational malalignment of the femoral component in total knee arthroplasty. Clin Orthop Relat Res. 2000;380:72–79.

    Article  PubMed  Google Scholar 

  21. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg Am. 1976;58:754–765.

    PubMed  CAS  Google Scholar 

  22. Jakopec M, Harris SJ, Rodriguez y Baena F, Gomes P, Cobb J, Davies BL. The first clinical application of a “Hands-On” robotic knee surgery system. Comput Aided Surg. 2001;6:329–339.

    PubMed  CAS  Google Scholar 

  23. Jeffery RS, Morris RW, Denham RA. Coronal alignment after total knee replacement. J Bone Joint Surg Br. 1991;73:709–714.

    PubMed  CAS  Google Scholar 

  24. Jenny JY, Clemens U, Kohler S, Kiefer H, Kongermann W, Miehlke RK. Consistency of implantation of a total knee arthroplasty with a non-image-based navigation system: a case-control study of 235 cases compared with 235 conventionally implanted prostheses. J Arthroplasty. 2005;20:832–839

    Article  PubMed  Google Scholar 

  25. Kharwadkar N, Kent RE, Sharara KH, Naique S. 5° to 6° of distal femoral cut for uncomplicated primary total knee arthroplasty: is it safe? Knee. 2006;13:57–60.

    Article  PubMed  CAS  Google Scholar 

  26. Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2009;24:570–578.

    Article  PubMed  Google Scholar 

  27. Lotke PA, Ecker ML. Influence of positioning of the prosthesis in total knee replacement. J Bone Joint Surg Am. 1977;59:77–79.

    PubMed  CAS  Google Scholar 

  28. Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after total knee replacement: effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am. 1991;73:1037–1040.

    PubMed  CAS  Google Scholar 

  29. Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;22:1097–1106.

    Article  PubMed  Google Scholar 

  30. Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE. Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res. 2001;392:38–45.

    Article  PubMed  Google Scholar 

  31. Nagachinta T, Stephens M, Reitz M, Polk BF. Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis. 1987;156:967–973.

    Article  PubMed  CAS  Google Scholar 

  32. Nagamine R, Miura H, Bravo CV, Urabe K, Matsuda S, Miyanishi K, Hirata G, Iwamoto Y. Anatomic variations should be considered in total knee arthroplasty. J Orthop Sci. 2000;5:232–237.

    Article  PubMed  CAS  Google Scholar 

  33. Oberst M, Berstch C, Wurstlin S, Holz U. CT analysis of leg alignment after conventional vs. navigated knee prosthesis implantation: initial results of a controlled, prospective, and randomized study. Unfallchirurg. 2003;106:941–948.

    PubMed  CAS  Google Scholar 

  34. Park SE, Lee CT. Comparison of ROBODOC-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty. 2007;22:1054–1059.

    Article  PubMed  Google Scholar 

  35. Parratte S, Pagnano MW, Trousdale RT, Berry DJ. 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.

    Article  PubMed  Google Scholar 

  36. Peersman G, Laskin R, Davis J, Person GE, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J. 2006;2:70–72.

    Article  PubMed  CAS  Google Scholar 

  37. Perillo-Marcone A, Barrett DS, Taylor M. The importance of tibial alignment: finite element analysis of tibial malalignment. J Arthroplasty. 2000;15:1020–1027.

    Article  PubMed  CAS  Google Scholar 

  38. Perlick L, Bathis H, Tingart M, Perlick C, Grifka J. Navigation in total-knee arthroplasty: CT-based implantation compared with the conventional technique. Acta Orthop Scand. 2004;75:464–470.

    Article  PubMed  Google Scholar 

  39. Plaskos C, Hodgson AJ, Inkpen K, McGraw RW. Bone cutting errors in total knee arthroplasty. J Arthroplasty. 2002;17:698–705.

    Article  PubMed  Google Scholar 

  40. Rand JA, Coventry MB. Ten-year evaluation of geometric total knee arthroplasty. Clin Orthop Relat Res. 1988;232:168–173.

    PubMed  Google Scholar 

  41. Reed SC, Gollish J. The accuracy of femoral intramedullary guides in total knee arthroplasty. J Arthroplasty. 1997;12:677–682.

    Article  PubMed  CAS  Google Scholar 

  42. Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am. 2011;93:1588–1596.

    Article  PubMed  Google Scholar 

  43. Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement: its effect on survival. Clin Orthop Relat Res. 1994;299:153–156.

    PubMed  Google Scholar 

  44. Rodriguez JA, Bhende H, Ranawat CT. Total condylar knee replacement: a 20-year follow-up study. Clin Orthop Relat Res. 2001;388:10–17.

    Article  PubMed  Google Scholar 

  45. Saragaglia D, Picard F, Chaussard C, Montbarbon E, Leitner F, Cinquin P. Computer-assisted knee arthroplasty: comparison with a conventional procedure. Results of 50 cases in a prospective, randomized study. Rev Chir Orthop Reparatrice Appar Mot. 2001;87:18–28.

    PubMed  CAS  Google Scholar 

  46. Sasanuma H, Sekiya H, Takatoku K, Takada H, Sugimoto N. Evaluation of soft-tissue balance during total knee arthroplasty. J Orthop Surg (Hong Kong). 2010;18:26–30.

    Google Scholar 

  47. Sekiya H, Takatoku K, Takada H, Sasanuma H, Sugimoto N. Postoperative lateral ligamentous laxity diminishes with time after TKA in the varus knee. Clin Orthop Relat Res. 2009;467:1582–1586.

    Article  PubMed  Google Scholar 

  48. Seon JK, Park SJ, Lee KB, Li G, Kozanek M, Song EK. Functional comparison of total knee arthroplasty performed with and without a navigation system. Int Orthop. 2009;33:987–990.

    Article  PubMed  Google Scholar 

  49. Shepherd DE, Seedhom BB. Thickness of human articular cartilage in joints of the lower limb. Ann Rheum Dis. 1999;58:27–34.

    Article  PubMed  CAS  Google Scholar 

  50. Siebert W, Mai S, Kober R, Heeckt PF. Technique and first clinical results of ROBODOC-assisted total knee replacement. Knee. 2002;9:173–180.

    Article  PubMed  Google Scholar 

  51. Song EK, Seon JK, Park SJ, Jung WB, Park HW, Lee GW. Simultaneous bilateral total knee arthroplasty with robotic and conventional techniques: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2011;19:1069–1076.

    Article  PubMed  Google Scholar 

  52. Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A. Positioning of total knee arthroplasty with and without navigation support: a prospective, randomized study. J Bone Joint Surg Br. 2003;85:830–835.

    PubMed  CAS  Google Scholar 

  53. Sugama R, Kadoya Y, Kobayashi A, Takaoka K. Preparation of the flexion gap affects the extension gap in total knee arthroplasty. J Arthroplasty. 2005;20:602–607.

    Article  PubMed  Google Scholar 

  54. Takahashi T, Wada Y, Yamamoto H. Soft-tissue balancing with pressure distribution during total knee arthroplasty. J Bone Joint Surg Br. 1997;79:235–239.

    Article  PubMed  CAS  Google Scholar 

  55. Taylor R, Mittelstadt BD, Paul HA, Hanson W, Kazanzides P, Zuhars JF, Williamson B, Musits B, Glassman E, Bargar WL. An image-directed robotic system for precise orthopaedic surgery. IEEE Trans Robotics Automation. 1994;10:261–275.

    Article  Google Scholar 

  56. Tew M, Waugh W. Tibiofemoral alignment and the results of knee replacement. J Bone Joint Surg Br. 1985;67:551–556.

    PubMed  CAS  Google Scholar 

  57. Wasielewski RG, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG. Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res. 1994;299:31–43.

    PubMed  Google Scholar 

  58. Winemaker MJ. Perfect balance in total knee arthroplasty: the elusive compromise. J Arthroplasty. 2002;17:2–10.

    Article  PubMed  CAS  Google Scholar 

  59. Zumstein MA, Frauchiger L, Wyss D, Hess R, Ballmer PM. Is restricted femoral navigation sufficient for accuracy of total knee arthroplasty? Clin Orthop Relat Res. 2006;451:80–86.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam, Korea

    Eun-Kyoo Song MD, PhD, Jong-Keun Seon MD, PhD & Ji-Hyeon Yim MD, PhD

  2. Curexo Technology Corp, Fremont, CA, USA

    Nathan A. Netravali PhD

  3. Department of Orthopaedics, University of California at Davis School of Medicine, Sutter General Hospital, 1020 29th Street, #450, Sacramento, CA, 95816, USA

    William L. Bargar MD

Authors
  1. Eun-Kyoo Song MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jong-Keun Seon MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ji-Hyeon Yim MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nathan A. Netravali PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. William L. Bargar MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to William L. Bargar MD.

Additional information

One or more of the authors (WLB, JKS, NAN), or a member of their immediate family, have received or may receive payments or benefits, in any 1 year, an amount in excess of $10,000, from a commercial entity (Curexo Technology Corp) related to this work. The remaining authors certify that they (EKS, JHY), or a member of their immediate family, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

This study was performed at Chonnam National University Hwasun Hospital (Chonnam, Korea).

About this article

Cite this article

Song, EK., Seon, JK., Yim, JH. et al. Robotic-assisted TKA Reduces Postoperative Alignment Outliers and Improves Gap Balance Compared to Conventional TKA. Clin Orthop Relat Res 471, 118–126 (2013). https://doi.org/10.1007/s11999-012-2407-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2407-3

Keywords

Search

Navigation