Comparison of robotic-assisted total knee arthroplasty: an updated systematic review and meta-analysis

Journal of Robotic Surgery (2024) 18:292 https://doi.org/10.1007/s11701-024-02045-y REVIEW Comparison of robotic‑assisted total knee arthroplasty: an updated systematic review and meta‑analysis Xinyu Fu1 · Yiming She2 · Guangwen Jin1 · Chengri Liu1 · Ze Liu1 · Wei Li1 · Ri Jin1 Received: 14 June 2024 / Accepted: 7 July 2024 © The Author(s) 2024 Abstract This study was conducted to compare the changes in different clinical scores and imaging indexes of patients who underwent robot-assisted total knee arthroplasty (RA-TKA) and manual total knee arthroplasty (M-TKA). PubMed, Web of Science, Cochrane Library and Embase were searched according to PRISMA guidelines in June 2024. Search terms included “robotassisted”, “manual” and “total knee arthroplasty”. Outcome indicators included American Knee Society Score (KSS), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), range of motion (ROM), Hospital for Special Surgery (HSS) score, Forgotten Joint Score (FJS), 36-Item Short Form Health Survey (SF-36), operation duration (min), intraoperative blood loss (ml), pain score, patient’s satisfaction scores, hip–knee–ankle (HKA) angle, frontal femoral component angle, frontal tibia component angle, lateral femoral component angle and lateral tibia component angle. A total of 1,033 articles were obtained after removing duplicates, and 12 studies involving 2,863 patients (1,449 RATKAs and 1,414 M-TKAs) were finally meta-analyzed (22–32). The baseline data of both groups were similar in all results. Meta-analysis suggested a better performance of the RA-TKA group than the M-TKA group regarding the HKA angle. The manual TKA reduced the operation time and significantly improved the range of motion. The results of > 6 months followup showed that M-TKA was better than RA-TKA in terms of KSS score and WOMAC. Compared with M-TKA, RA-TKA can produce more accurate prosthetic alignment, but it does not lead to better clinical results. Orthopedic surgeons should choose between two surgical procedures according to their own experience and patients’ characteristics. Keywords Robot assisted · Manual · Total knee arthroplasty · Knee Introduction Total knee arthroplasty (TKA) is highly effective for treating advanced knee osteoarthritis [1]. Despite its great success and rapid development over the past two decades, 20% of patients experience unsatisfactory clinical outcomes after surgery [2, 3]. The precise positioning of components and alignment of the limb are critical factors influencing patient satisfaction and functional results following TKA [4]. In practice, achieving these standards manually can be very challenging for surgeons. The development of orthopedic robots has facilitated the widespread * Ri Jin 1 Department of Orthopedics, Yanbian University Hospital, 1327 Juzi Street, Yanji Jilin 133002, China 2 Department of Nephrology, Yanbian University Hospital, Yanji, Jilin 133002, China adoption of robot-assisted total knee replacement systems in clinical settings [5–8]. Many reports have indicated that robotic-assisted total knee arthroplasty (RA-TKA) enables more accurate bone cutting and implant placement and achieves balanced extension and flexion gaps tailored to the patient's skeletal anatomy and natural ligament balance, reducing the probability of detrimental stress and wear [9, 10]. The approach can theoretically promise more significant improvements in clinical outcomes. However, controversy persists regarding whether RA-TKA yields superior functional and clinical outcomes compared to manual TKA (M-TKA). Multiple studies report no statistically significant difference in clinical outcomes, despite favorable radiological outcomes during follow-up visits [11–13]. Based on that, many scholars have disputed its clinical significance. Therefore, we collected relevant articles and performed a meta-analysis. The study aims to compare the clinical outcomes and radiological results of RA-TKA and M-TKA through the analysis of relevant Vol.:(0123456789) 292 Page 2 of 14 studies, thus providing a basis for physicians’ decisionmaking processes. The hypothesis of this study is that RATKA yields significantly superior outcomes than M-TKA, both clinically and radiologically. Materials and methods Literature retrieval This study complied with the standards for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA 2020) [14] and registered in PROSPERO prospectively (CRD420234731153). Articles published in English were systematically retrieved from PubMed, Web of Science, Cochrane Library and Embase up to June 1, 2024 to comprehensively compare the efficacy and/or safety of RATKA and M-TKA in treating knee osteoarthritis. The following terms were searched in the database: "robot-assisted", "robotic-assisted", "robot", "robotic", “Arthroplasty”, "Knee Replacement Arthroplasties", "Robotic Assisted Surgery" and "Total Knee Arthroplasty” (Table S1). Two authors independently and impartially examined the articles that met the inclusion criteria according to the search strategy, performed data extraction and manually examined the reference list of all included studies. Inclusion and exclusion criteria Studies that contained the following features were included: 1. studies with a randomized control, cohort or case–control design; 2. patients with end-stage knee osteoarthritis; 3. studies that compared RA-TKA and M-TKA; 4. evaluations including no less than one of the following indicators: American Knee Society Score (KSS), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), joint range of motion (ROM), 36-Item Short Form Health Survey (SF-36) score, Hospital for Special Surgery (HSS) score, Forgotten Joint Score (FJS), pain score, patient satisfaction score, operation length (min), intraoperative blood loss (ml), hip–knee–ankle (HKA) angle, frontal femoral component angle, frontal tibia component angle, lateral femoral component angle and lateral tibia component angle; 5. articles containing enough data for calculating odds ratio (OR) or weighted mean difference (WMD). Studies were excluded if they were reviews, letters, comments, case reports, abstracts for conference presentation, articles on pediatrics and unpublished articles. We included studies on patients who underwent unilateral RA-TKA or M-TKA, and also excluded studies involving single-compartment knee arthroplasty. Journal of Robotic Surgery (2024) 18:292 Data extraction Data was extracted systematically and independently by two investigators (Fu Xinyu and She Yiming). Disagreements were finally resolved by the third researcher (Jin Ri). We extracted the data on first author and publication year of the article, research duration, research country, research design, sample size, patient’s age and body mass index (BMI), follow-up time and interventions. Continuous variables in the included studies presented as the median and inte (...truncated)