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Robotic-arm assisted unicompartmental knee arthroplasty system has a learning curve of 11 cases and increased operating time

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

UKA has higher revision risk, particularly for lower volume surgeons. While robotic-arm assisted systems allow for increased accuracy, introduction of new systems has been associated with learning curves. The aim of this study was to determine the learning curve of a UKA robotic-arm assisted system. The hypothesis was that this may affect operative times, patient outcomes, limb alignment, and component placement.

Methods

Between 2017 and 2021, five surgeons performed 152 consecutive robotic-arm assisted primary medial UKA, and measurements of interest were recorded. Patient outcomes were measured with Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score at 6 weeks, 1 year, and 2 years. Surgeons were grouped into ‘low’ and ‘high’ usage groups based on total UKA (manual and robotic) performed per year.

Results

A learning curve of 11 cases was found with operative time (p < 0.01), femoral rotation (p = 0.02), and insert sizing (p = 0.03), which highlighted areas that require care during the learning phase. Despite decreased 6-week EQ-5D-5L VAS in the proficiency group (77 cf. 85, p < 0.01), no difference was found with implant survival (98.2%) between phases (p = 0.15), or between ‘high’ and ‘low’ usage surgeons (p = 0.23) at 36 months. This suggested that the learning curve did not lead to early adverse effects in this patient cohort.

Conclusion

Introduction of a UKA robotic-arm assisted system showed learning curves for operative times and insert sizing but not for implant survival at early follow-up. The short learning curve regardless of UKA usage indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons.

Level of evidence

Level III, Retrospective cohort study.

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References

  1. Akagi M, Oh M, Nonaka T, Tsujimoto H, Asano T, Hamanishi C (2004) An Anteroposterior axis of the tibia for total knee arthroplasty. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-200403000-00030

    Article  PubMed  Google Scholar 

  2. Australian Orthopaedic Association (2019) Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2019 Annual Report. Adelaide, AUS. https://aoanjrr.sahmri.com/. Accessed 7 July 2020

  3. Banger M, Doonan J, Rowe P, Jones B, MacLean A, Blyth MJB (2021) Robotic arm-assisted versus conventional medial unicompartmental knee arthroplasty: five-year clinical outcomes of a randomized controlled trial. Bone Jt J. https://doi.org/10.1302/0301-620X.103B6.BJJ-2020-1355.R2

    Article  Google Scholar 

  4. Batailler C, Bordes M, Lording T, Nigues A, Servien E, Calliess T, Lustig S (2021) Improved sizing with image-based robotic-assisted system compared to image-free and conventional techniques in medial unicompartmental knee arthroplasty. Bone Jt J. https://doi.org/10.1302/0301-620X.103B4.BJJ-2020-1453.R1

    Article  Google Scholar 

  5. Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK, Barker K, Murray G, Simpson H, Dodwell D, Donell S, Warner K (2019) The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. Lancet 394:746–756

    Article  PubMed  PubMed Central  Google Scholar 

  6. Behrend H, Giesinger K, Giesinger JM, Kuster MS (2012) The ‘forgotten joint’ as the ultimate goal in joint arthroplasty. Validation of a new patient-reported outcome measure. J Arthroplasty 27:430-436.e1

    Article  PubMed  Google Scholar 

  7. Bell SW, Frcs T, Anthony I, Jones B, Frcs T, Maclean A, Frcs T, Rowe P, Blyth M, Frcs T (2016) Improved accuracy of component positioning. J Bone Jt Surg 98:627–635

    Article  Google Scholar 

  8. Bergeson AG, Berend KR, Lombardi AV, Hurst JM, Morris MJ, Sneller MA (2013) Medial mobile bearing unicompartmental knee arthroplasty. Early survivorship and analysis of failures in 1000 consecutive cases. J Arthroplasty 28:172–175

    Article  PubMed  Google Scholar 

  9. Bini S, Khatod M, Cafri G, Chen Y, Paxton EW (2013) Surgeon, implant, and patient variables may explain variability in early revision rates reported for unicompartmental arthroplasty. J Bone Jt Surg. https://doi.org/10.2106/JBJS.L.01006

    Article  Google Scholar 

  10. Clement ND, MacDonald D, Simpson AHRW (2014) The minimal clinically important difference in the Oxford knee score and short form 12 score after total knee arthroplasty. Knee Surg Sport Traumatol Arthrosc 22:1933–1939

    Article  CAS  Google Scholar 

  11. Collier MB, Eickmann TH, Sukezaki F, McAuley JP, Engh GA (2006) Patient, implant, and alignment factors associated with revision of medial compartment unicondylar arthroplasty. J Arthroplasty 21:108–115

    Article  PubMed  Google Scholar 

  12. Gaudiani MA, Nwachukwu BU, Baviskar JV, Sharma M, Ranawat AS (2017) Optimization of sagittal and coronal planes with robotic-assisted unicompartmental knee arthroplasty. Knee 24:837–843

    Article  PubMed  Google Scholar 

  13. Gilmour A, MacLean AD, Rowe PJ, Banger MS, Donnelly I, Jones BG, Blyth MJG (2018) Robotic-arm–assisted vs conventional unicompartmental knee arthroplasty. The 2-year clinical outcomes of a randomized controlled trial. J Arthroplasty 33:S109–S115

    Article  PubMed  Google Scholar 

  14. Goodfellow J, O’Connor J, Pandit H, Dodd C, Murray D (2011) Unicompartmental arthroplasty with the Oxford knee. Goodfellow Publishers Ltd, Woodeaton

    Google Scholar 

  15. Hamilton WG, Ammeen D, Engh CA, Engh GA (2010) Learning curve with minimally invasive unicompartmental knee arthroplasty. J Arthroplasty 25:735–740

    Article  PubMed  Google Scholar 

  16. Harris IA, Cashman K, Lorimer M, Peng Y, Ackerman I, Heath E, Graves SE (2021) Are responders to patient health surveys representative of those invited to participate? An analysis of the patient-reported outcome measures pilot from the Australian orthopaedic association national joint replacement registry. PLoS ONE 16:1–11

    Article  Google Scholar 

  17. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X (2011) Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 20:1727–1736

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Hernigou P, Deschamps G (2004) Alignment influences wear in the knee after medial unicompartmental arthroplasty. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000128285.90459.12

    Article  PubMed  Google Scholar 

  19. Inui H, Yamagami R, Kono K, Kawaguchi K, Taketomi S, Tanaka S (2021) Prosthetic alignment and clinical outcomes of navigation-assisted unicompartmental knee arthroplasty by an experienced surgeon compared with inexperienced surgeons. J Arthroplasty 36:2435–2439

    Article  PubMed  Google Scholar 

  20. Kayani B, Konan S, Huq SS, Tahmassebi J, Haddad FS (2019) Robotic-arm assisted total knee arthroplasty has a learning curve of seven cases for integration into the surgical workflow but no learning curve effect for accuracy of implant positioning. Knee Surg Sport Traumatol Arthrosc 27:1132–1141

    Article  Google Scholar 

  21. Kayani B, Konan S, Pietrzak JRT, Huq SS, Tahmassebi J, Haddad FS (2018) The learning curve associated with robotic-arm assisted unicompartmental knee arthroplasty. Bone Jt J 100B:1033–1042

    Article  Google Scholar 

  22. Kayani B, Konan S, Tahmassebi J, Rowan FE, Haddad FS (2019) An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty. Bone Jt J 101B:24–33

    Article  Google Scholar 

  23. Kazarian GS, Barrack TN, Okafor L, Barrack RL, Nunley RM, Lawrie CM (2020) High prevalence of radiographic outliers and revisions with unicompartmental knee arthroplasty. J Bone Jt Surg Am 102:1151–1159

    Article  Google Scholar 

  24. Klasan A, Carter M, Holland S, Young SW (2020) Low femoral component prominence negatively influences early revision rate in robotic unicompartmental knee arthroplasty. Knee Surg Sport Traumatol Arthrosc 28:3906–3911

    Article  Google Scholar 

  25. Klasan A, Parker DA, Lewis PL, Young SW (2021) Low percentage of surgeons meet the minimum recommended unicompartmental knee arthroplasty usage thresholds: analysis of 3037 Surgeons from Three National Joint Registries. Knee Surg Sport Traumatol Arthrosc. https://doi.org/10.1007/s00167-021-06437-7 (Advance online publication)

    Article  Google Scholar 

  26. Klasan A, Tay ML, Frampton C, Young SW (2021) High usage of medial unicompartmental knee arthroplasty negatively influences total knee arthroplasty revision rate. Knee Surg Sport Traumatol Arthrosc. https://doi.org/10.1007/s00167-021-06650-4 (Advance online publication)

    Article  Google Scholar 

  27. Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW (2017) Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res 475:2194–2201

    Article  PubMed  PubMed Central  Google Scholar 

  28. Kozinn SC, Scott R (1989) Current concepts review: unicondylar knee arthroplasty. J Bone Jt Surg Ser A 71-A:145–150

    Article  Google Scholar 

  29. Liddle AD, Judge A, Pandit H, Murray DW (2014) Adverse outcomes after total and unicompartmental knee replacement in 101330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet 384:1437–1445

    Article  PubMed  Google Scholar 

  30. Millar LJ, Banger M, Rowe PJ, Blyth M, Jones B, Maclean A (2018) A five-year follow up of gait in robotic assisted vs conventional unicompartmental knee arthroplasty. Gait Posture 65:31–32

    Article  Google Scholar 

  31. Mittal A, Meshram P, Kim WH, Kim TK (2020) Unicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA. J Orthop Traumatol 21:15–23

    Article  PubMed  PubMed Central  Google Scholar 

  32. Mofidi A, Plate JF, Lu B, Conditt MA, Lang JE, Poehling GG, Jinnah RH (2014) Assessment of accuracy of robotically assisted unicompartmental arthroplasty. Knee Surg Sport Traumatol Arthrosc 22:1918–1925

    Article  Google Scholar 

  33. Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J (2007) The use of the Oxford hip and knee scores. J Bone Jt Surg Ser B 89:1010–1014

    Article  CAS  Google Scholar 

  34. National Joint Registry (2019) National joint registry for England, wales, northern Ireland and the isle of man: 16th annual report 2019. Hemel Hempstead

    Google Scholar 

  35. New Zealand Orthopaedic Association (2019) The New Zealand Joint Registry Twenty-one Year Report January 1999 to December 2019. https://nzoa.org.nz/nzoa-joint-registry. Accessed 22 Apr 2020

  36. Noticewala MS, Geller JA, Lee JH, Macaulay W (2012) Unicompartmental knee arthroplasty relieves pain and improves function more than total knee arthroplasty. J Arthroplasty 27:99–105

    Article  PubMed  Google Scholar 

  37. Pearle AD, van der List JP, Lee L, Coon TM, Borus TA, Roche MW (2017) Survivorship and patient satisfaction of robotic-assisted medial unicompartmental knee arthroplasty at a minimum two-year follow-up. Knee 24:419–428

    Article  PubMed  PubMed Central  Google Scholar 

  38. Tay ML, McGlashan SR, Monk AP, Young SW (2021) Revision indications for medial unicompartmental knee arthroplasty: a systematic review. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-03827-x (Advance online publication)

    Article  PubMed  Google Scholar 

  39. Vermue H, Lambrechts J, Tampere T, Arnout N, Auvinet E, Victor J (2020) How should we evaluate robotics in the operating theatre? Bone Jt J. https://doi.org/10.1302/0301-620X.102B4.BJJ-2019-1210.R1

    Article  Google Scholar 

  40. Vermue H, Luyckx T, Winnock de Grave P, Ryckaert A, Cools AS, Himpe N, Victor J (2020) Robot-assisted total knee arthroplasty is associated with a learning curve for surgical time but not for component alignment, limb alignment and gap balancing. Knee Surg Sport Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06341-6 (Advance online publication)

    Article  Google Scholar 

  41. Whittaker JP, Dwyer KA, Howard J, Huey V, Lesko J, Nunley RM, Verdonk P (2018) Learning curve with a new primary total knee arthroplasty implant: a multicenter perspective with more than 2000 patients. Arthroplast Today 4:348–353

    Article  PubMed  PubMed Central  Google Scholar 

  42. Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP (2009) Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee 16:473–478

    Article  PubMed  Google Scholar 

  43. Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson WF, Bottomley N, Hopewell S, Price AJ (2019) Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis. BMJ 364:1–17

    Google Scholar 

  44. Zhang Q, Zhang Q, Guo W, Liu Z, Cheng L, Yue D, Zhang N (2014) The learning curve for minimally invasive Oxford phase 3 unicompartmental knee arthroplasty: cumulative summation test for learning curve (LC-CUSUM). J Orthop Surg Res 9:1–9

    Article  Google Scholar 

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Acknowledgements

The authors would like to thank Dr. Sherina Holland for assistance with data collection and Mr. Greg Gamble for statistical advice for this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Surgery, Faculty of Medical and Health Sciences (FMHS), University of Auckland, 85 Park Road, Grafton, 1023, Auckland, New Zealand

    Mei Lin Tay, Scott M. Bolam & Simon W. Young

  2. Department of Orthopaedic Surgery, North Shore Hospital, Waitematā DHB, Auckland, New Zealand

    Mei Lin Tay, Nina Zeng & Simon W. Young

  3. Stryker New Zealand, Auckland, New Zealand

    Matthew Carter

  4. Department of Orthopaedic Surgery, Auckland City Hospital, Auckland DHB, Auckland, New Zealand

    Scott M. Bolam

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Contributions

MLT, SWY, and MC conceived this research and participated in concept and study methodology design. MLT, MC, and NZ performed data collection and data validation. MLT performed data analysis. MLT, SMB, and SWY participated in interpretation of the data. MLT wrote the original draft and all authors reviewed manuscript and participated in revisions. All authors read and approved the final manuscript.

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Correspondence to Mei Lin Tay.

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Conflict of interest

SWY receives research support and is a paid consultant for Stryker Orthopaedics NZ. MC is a senior product specialist at Stryker Orthopaedics. These affiliations did not influence study design or data collection, analysis, or interpretation of data. Stryker Orthopaedics did not influence any decisions for manuscript preparation or publication. MLT, SMB, and NZ declare no conflict of interest.

Ethical approval

This study received ethics approval from the national New Zealand Health and Disability Ethics Committees (17/NTB/174) and the local institution.

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Participants included in this study were informed of, and provided consent for, the collection and use of their data for the study.

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Tay, M.L., Carter, M., Bolam, S.M. et al. Robotic-arm assisted unicompartmental knee arthroplasty system has a learning curve of 11 cases and increased operating time. Knee Surg Sports Traumatol Arthrosc 31, 793–802 (2023). https://doi.org/10.1007/s00167-021-06814-2

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