title: Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. A Comparison between Robotic-assisted and Manual Implantation of Cementless Total Hip Arthroplasty Primary and Revision Total Hip Replacement Using the Robodoc® System [Clinical outcome following robotic assisted versus conventional total hip arthroplasty: a controlled and prospective study of seventy-one patients]. Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Robotic-assisted TKA Reduces Postoperative Alignment Outliers and Improves Gap Balance Compared to Conventional TKA Validity and Responsiveness of the Knee Society Clinical Rating System in Comparisonwith the SF-36 and WOMAC Comparison of robotic-assisted and manual implantation of a primary total hip replacement. A prospective study. Robot-assisted primary cementless total hip arthroplasty with a short femoral stem: a prospective randomized short-term outcome study.
abstract: This study was aim ed to compare robotic-assisted implantation of a total knee arthroplasty with conventional manual implantation . We controlled , r and omized , and review ed 72 patients for total knee arthroplasty assigned to undergo either conventional manual implantation ( excluding navigation-assisted implantation cases ) of a Zimmer LPS prosthesis ( Zimmer , Warsaw , Ind ) ( 30 patients : group 1 ) or robotic-assisted implantation of such a prosthesis ( 32 patients : group 2 ) . The femoral flexion angle ( gamma angle ) and tibial angle ( delta angle ) in the lateral x-ray of group 1 were 4.19 + /- 3.28 degrees and 89.7 + /- 1.7 degrees , and those of group 2 were 0.17 + /- 0.65 degrees and 85.5 + /- 0.92 degrees . The major complications were from improper small skin incision during a constraint attempt of minimally invasive surgery and during bulk fixation frame pins insertion . Robotic-assisted technology had definite advantages in terms of preoperative planning , accuracy of the intraoperative procedure , and postoperative follow-up , especially in the femoral flexion angle ( gamma angle ) and tibial flexion angle ( delta angle ) in the lateral x-ray , and in the femoral flexion angle ( alpha angle ) in the anteroposterior x-ray . But a disadvantage was the high complication rate in early stage Background The benefits of robotic techniques for implanting femoral components during THA are still controversial . Questions / Purpose sThe purpose of this study was to prospect ively compare the results and complications of robotic-assisted and h and -rasping stem implantation techniques . Method The minimum followup was 5 years ( mean , 67 months ; range , 60–85 months ) . One hundred forty-six primary THAs on 130 patients were included in this study .  Robot-assisted primary THA was performed on 75 hips and a h and -rasping technique was used on 71 hips . Results At 2 and 3 years postoperatively , the Japanese Orthopaedic Association ( JOA ) clinical score was slightly better in the robotic-assisted group . At 5 years followup , however , the differences were not significant . Postoperative limb lengths of the robotic-milling group had significantly less variance than the h and -rasping group . At 2 years postoperatively , there was significantly more stress shielding of the proximal femur in the h and -rasping group ; this difference was more significant 5 years postoperatively . Conclusions Substantially more precise implant positioning seems to have led to less variance in limb-length ine quality and less stress shielding of the proximal femur 5 years postoperatively . Level of Evidence Level II , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence The ROBODOC ® system was design ed to address potential human errors in performing cementless total hip replacement . The system consists of a preoperative planning computer workstation ( called ORTHODOC ) and a five-axis robotic arm with a high speed milling device as an end effector . The combined experience of the United States Food and Drug Administration multicenter trial and the German postmarket use of the system are reported . The United States study is controlled and r and omized with 136 hip replacements performed at three centers ( 65 ROBODOC ® and 62 control ) . Followup was 1 year on 127 hip replacements and 2 years on 93 hip replacements . No differences were found in the Harris hip scores or the Short Form Health Survey outcomes question naire . Length of stay also was not different , but the surgical time and blood loss were greater in the ROBODOC ® group . This was attributed to a learning curve at each center . Radiographs were evaluated by an independent bone radiologist and showed statistically better fit and positioning of the femoral component in the ROBODOC ® group . Complications were not different , except for three cases of intraoperative femoral fracture in the control group and none in the ROBODOC ® group . The German study reports on 858 patients , 42 with bilateral hip replacements and this includes 30 revision cases for a total of 900 hip replacements .  The Harris hip score rose from 43.7 to 91.5 . In these cases the surgical time declined quickly from 240 minutes for the first case to 90 minutes . No intraoperative femoral fractures occurred in 900 cases . Other complications were comparable with total hip replacements performed using conventional techniques . The ROBODOC ® system is thought to be safe and effective in producing radiographically superior implant fit and positioning while eliminating femoral fractures AIM Robotic assisted total hip arthroplasty  remains controversial , since wider exposure of the proximal femur and placement of the leg in maximal hip adduction and external rotation using a rigid leg-holder apparatus may impair significantly the hip abductors . Consequently , it is the purpose of this study to analyse and report both clinical outcome and hip abductor function following robotic assisted versus conventional total hip arthroplasty . MATERIAL AND METHODS 36 robotic-assisted ( CASPAR , Orto-Maquet , Rastatt , Germany ) and 35 conventional cementless total hip arthroplasties  were followed on average for 18 months regarding incidence of complications , Harris hip score , the scoring system according to Merle d'Aubigné and Postel , hip abductor function ( using a spring-balance ) , and incidence of Trendelenburg 's sign ( according to the Kuhfuss-classification ) . Statistical analysis was performed in case of continuous data using the t test and the Mann-Whitney test , respectively , and in case of categorical data using Fisher 's exact test and the chi-squared test , respectively . The level of significance was set as p < 0.05 . RESULTS Average duration of surgery ( CASPAR : 100.6 min ; conventional : 51.5 min ; p < 0.0001 ) as well as average loss of haemoglobin ( CASPAR : 4.5 mg/dL ; conventional : 3.3 mg/dL ; p = 0.0002 ) differed significantly , whereas the incidence of complications ( CASPAR : two dislocations , one sciatic paresis , one deep infection ; conventional : one dislocation , two fissures ) , revision rate ( CASPAR : 5.6 % ; conventional : 2.9 % ) , and incidence of heterotopic ossifications ( CASPAR : 30.6 % ; conventional : 17.1 % ) was comparable following both procedures ( p > 0.05 ) . Improvement of the Harris hip score also was comparable in both groups ( CASPAR : 40.9 to 86.1 points ; conventional : 39.5 to 88.0 points ; p = 0.21 ) , whereas improvement of the score according to Merle d'Aubigné and Postel was significantly greater following the manual procedure ( CASPAR : 10.1 to 16.0 points ; conventional : 8.3 to 16.6 points ; p < 0.0001 ) . Differences between the two groups were also significant regarding hip abductor function ( CASPAR : 76.1 % ; conventional : 93.8 % of the contralateral hip ; p < 0.0001 ) and incidence of Trendelenburg 's sign ( CASPAR : 61.1 % ; conventional : 25.7 % ; p = 0.0014 ) . CONCLUSION The significant functional impairment following robotic assisted THA should be taken critically into consideration prior to initiating such procedure Purpose Despite reduction in radiological outliers in previous r and omized trials comparing robotic-assisted versus conventional total knee arthroplasty ( TKA ) , no differences in short-term functional outcomes were observed . The aim of this study was to determine whether there was improvement in functional outcomes and quality -of-life ( QoL ) measures between robotic-assisted and conventional TKA . Methods All 60 knees ( 31 robotic-assisted ; 29 conventional ) from a previous r and omized trial were available for analysis . Differences in range of motion , Knee Society ( KSS ) knee and function scores , Oxford Knee scores ( OKS ) , SF-36 subscale and summative ( physical PCS/mental component scores MCS ) were analysed . In addition , patient satisfaction , fulfilment of expectations and the proportion attaining a minimum clinical ly important difference ( MCID ) in KSS , OKS and SF-36 were studied . Results Both robotic-assisted and conventional TKA displayed significant improvements in majority of the functional outcome scores at 2 years . Despite having a higher rate of complications , the robotic-assisted group displayed a trend towards higher scores in SF-36 QoL measures , with significant differences in SF-36 vitality ( p = 0.03 ) , role emotional ( p = 0.02 ) and a larger proportion of patients achieving SF-36 vitality MCID ( 48.4 vs 13.8 % , p = 0.009 ) . No significant differences in KSS , OKS or satisfaction/expectation rates were noted . ConclusionS ubtle improvements in patient QoL measures were observed in robotic-assisted TKA when compared to conventional TKA . This finding suggests that QoL measures may be more sensitive and clinical ly important than surgeon-driven objective scores in detecting subtle functional improvements in  robotic-assisted TKA  patients .Level of evidence II OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity 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 / purpose sWe 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 prospect ively r and omized 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 result ed 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 Background : The aim of this study was to vali date the Knee Society Clinical Rating System ( knee and function scores ) and to compare its responsiveness with that of the Western Ontario and McMaster University Osteoarthritis Index ( WOMAC ) and the Medical Outcomes Study Short Form-36 ( SF-36 ) . Methods : Patients were recruited as part of a prospect i ve observational study of the outcomes of primary total knee arthroplasty for the treatment of osteoarthritis in four centers in the United States , six centers in the United Kingdom , and two centers in Australia . Independent research assistants at each site collected the Knee Society clinical data . The WOMAC , SF-36 , patient satisfaction , and demographic data were obtained with self-administered question naires . Results : A total of 862 eligible patients were recruited , and complete preoperative and twelve-month data were available for 697 ( 80.9 % ) of them . The mean age was seventy years ( range , thirty-eight to ninety years ) , and the majority of the patients ( 58.9 % ) were women . Low correlations were found among the items of both the knee and the function score at both assessment times . The Knee Society pain and function scores had moderate-to-strong correlations with the corresponding pain and function domains of the WOMAC and SF-36 ( r = 0.31 to 0.72 ) . Measurement of the st and ardized response mean showed the  Knee Society knee score to be more responsive ( st and ardized response mean , 2.2 ) than the WOMAC ( st and ardized response means , 2.0 for pain and 1.4 for function ) and the SF-36 ( st and ardized response means , 1.0 for bodily pain and 1.1 for physical functioning ) . The Knee Society function score was the least responsive measure ( st and ardized response mean , 0.8 ) . Correlation of changes in scores at twelve months with patient reports of satisfaction and improvement in health status showed the WOMAC and SF-36 to be more responsive than the Knee Society scores . Conclusions : There is a poor correlation among the items of the Knee Society Clinical Rating System , but the rating system has adequate convergent construct validity . The WOMAC and SF-36 are more responsive measures of outcome of total knee arthroplasty . As they are less labor-intensive for research ers to use and as use of these instruments removes observer bias from the study design , they are preferable for knee arthroplasty outcome studies BACKGROUND Robotic-assisted total hip replacement  has become a common method of implantation , especially in Europe . It frequently has been postulated that robotic reaming would result in an improved clinical outcome due to the better fit of the prosthesis , but that has never been demonstrated in a prospect i ve study , to our knowledge . The purpose of this study was to compare robotic-assisted implantation of a total hip replacement with conventional manual implantation . METHODS One hundred and fifty-four patients scheduled for total hip replacement were r and omly assigned to undergo either conventional manual implantation of an S-ROM prosthesis ( eighty patients ) or robotic-assisted implantation of such a prosthesis ( seventy-four patients ) . The five-axis ROBODOC was used for the robotic-assisted procedures . Preoperatively as well as at three , six , twelve , and twenty-four months after surgery , the scores according to the Harris and Merle d'Aubigné systems and the Mayo clinical score were determined . Radiographs made at these intervals were analyzed for evidence of loosening , prosthetic alignment , and heterotopic ossification . RESULTS Thirteen ( 18 % ) of the seventy-four attempted robotic implantations had to be converted to manual implantations as a result of failure of the system . The duration of the robotic procedures  was longer than that of the manual procedures ( mean and st and ard deviation,107.1 + /- 29.1 compared with 82.4 + /- 23.4 minutes , p < 0.001 ) . Limb-length e quality ( mean discrepancy , 0.18 + /- 0.30 compared with 0.96 + /- 0.93 cm , p < 0.001 ) and varus-valgus orientation of the stem ( mean angle between the femur and the shaft of the prosthesis , 0.34 degrees + /- 0.67 degrees compared with 0.84 degrees + /- 1.23 degrees , p < 0.001 ) were better after the robotic procedures . At six months , slightly more heterotopic ossification was seen in the group treated with robotic implantation . The group treated with robotic implantation had a better Mayo clinical score at six and twelve months and a better Harris score at twelve months ; however , by twenty-four months , no difference was found between the groups with regard to any of the three scores . Dislocation was more frequent in the group treated with robotic implantation : it occurred in eleven of the sixty-one patients in that group compared with three of eighty in the other group ( p < 0.001 ) . Recurrent dislocation and pronounced limping were indications for revision surgery in eight of the sixty-one patients treated with robotic implantation compared with none of the seventy-eight ( excluding two with revision for infection ) treated with manual insertion ( p < 0.001 ) . Rupture of the gluteus medius tendon was observed during all of the revision operations . CONCLUSIONS The robotic-assisted technology had advantages in terms of preoperative planning and the accuracy of the intraoperative procedure . Disadvantages were the high revision rate ; the amount of muscle damage , which we believe was responsible for the higher dislocation rate ; and the longer duration of surgery . This technology must be further developed before its widespread usage can be justified BACKGROUND Recently , two topical issues in total hip arthroplasty ( THA ) have been robot-assisted surgery and use of a short stem . The purpose of this study was to evaluate the effects of robotic milling on the accuracy of short femoral stem positioning and on the short-term clinical outcome in THA using a prospect i ve , r and omized design . METHODS We r and omized 54 patients into two groups , either robotic milling group or manual rasping group .  The patients were assessed clinical ly and radiographically at 8 weeks , 5 months , 12 months , and 24 months . RESULTS Robotic milling group had a significantly longer operation time , requiring on average 8.9 min for registration and 11.2 min for milling . On the other h and , robotic milling group showed superior results in terms of stem alignment and leg length e quality . Two intraoperative femoral fractures occurred only in manual rasping group . Harris hip scores and WOMAC scores at 24 months postoperatively were similar in both groups . No complications including stem loosening , infection , nerve palsy , or dislocation were encountered in either group during the follow-up period . CONCLUSIONS The present study suggested that robot-assisted short stem THA could increase the accuracy of stem alignment , improve leg length e quality , and help reduce the risk of intraoperative femoral fracture as compared with manual rasping . However , the clinical outcome scores did not differ between the two groups at the time of short-term follow-up . Long-term follow-up is needed to determine whether there will be a long-term clinical relevance of robot-assisted implantation of short femoral stems in THA
target: R and om-effects meta-analyses showed that post-operative functional outcomes were comparable between active robotic and conventional total hip and knee arthroplasty at the short- , medium- and long-term follow-up .
  Conclusions This systematic and meta-analyses indicates that functional outcomes for patients undergoing active robotic total hip and knee arthroplasty were comparable to conventional surgery .
  Whether semi-active or active robotic hip or knee arthroplasty is effective in improving post-operative pain , quality of life and satisfaction with surgery is unclear .
background: Purpose The purpose of the study is to determine the effectiveness of semi-active and active robotic hip and knee arthroplasty on post-operative patient-reported outcomes of function , pain , quality of life and satisfaction with surgery .