ROBOTICS IN TOTAL KNEE ARTHROPLASTY
Evidence suggests no significant difference in function, outcomes, or complications in the short term between robotic assisted and conventional total knee arthroplasty (TKA).

Rationale

This statement was downgraded due to the varying treatments (robots used) between studies. One high quality study (Kim, 2020) evaluating robotic assisted total knee arthroplasty (TKA) with conventional technique found no clinical benefits to robotic surgery, but another higher quality study (Cho, 2019) demonstrates improved accuracy and fewer outliers with robotics.

However, numerous low-quality studies demonstrate improved outcomes with robotic assisted TKA.  King (2020) favored MAKO robotic assisted TKA to conventional jig technique for MUA. Jeon (2019) favored ROBODOC to conventional technique for periprosthetic fracture at 9 years with decreased outliers. Shaw (2021) favors robotic technique for 90-day revisions. Kayani (2018) finds robotic assisted TKA had benefits over conventional technology in early post op VAS pain and improved early functional recovery and discharge. Bollars (2020) image free robot decreased outliers. Hamilton (2021) robotic group had earlier discharge and more likely to go home. King (2020) showed MAKO robotic assisted TKA lead to shorter length of stay and reduction in pain. However, average procedure time was nine minutes longer in this group. While Liow (2014, 2017) showed that ROBODOC lead to similar short term clinical outcomes, the robotic assisted group showed better restore joint line and mechanical axis. Two-year outcomes showed subtle improvements with robotic assisted TKA. Marchand (2021) showed MAKO robotic assisted TKA improved two-year functional scores and lower aseptic revision rates. Marchand (2017) showed MAKO robotic assisted TKA improved short term pain, physical function, and total satisfaction. In Mitchell’s (2021) retrospective review, robotics demonstrated significant early clinical benefits with reduced length of stay, opioids, and re-admission. Park (2007) showed that ROBODOC improved accuracy, despite the risk of higher complications with inexperienced practitioners. Song’s (2013) ROBODOC procedure reduced outliers and lead to better balancing. Yang (2017) showed that ROBODOC reduced outliers and radiolucency. Bendich (2021) showed lower re-admission rate with robotic assisted TKA.

Benefits/ Harms of Implementation

Robotic assisted surgery may require preoperative imagery exposing the patient to radiation and its potential harm.

Outcome Importance

Practitioners should carefully examine the presented evidence during decision making, especially in the presence of robotic assisted surgery’s growing popularity for TKA.

Cost Effectiveness / Resource Utilization

Robotic assisted surgery, although more expensive, may cut cost by improving pain, decreased LOS, and readmissions. Long term outcomes may reduce revision burden.

Feasibility

This recommendation faces no feasibility challenge.

Future Research

Recent studies of this new and constantly improving and evolving technology show improved early short-term outcomes and pain scores. Novel robotic technologies will need to conduct long term randomized controlled trials to demonstrate clinical advantage (i.e., safety and efficacy) over conventional surgical techniques.