Does Robotic-Assisted Total Knee Arthroplasty Improve Outcomes of Adult Osteoarthritis Patients—A Systematic Review and Trial Sequential Meta-Analysis

Abstract

Background and Objectives: Total knee arthroplasty (TKA) is a standard treatment for end-stage knee osteoarthritis (KOA). While conventional TKA (cTKA) is widely used, robotic-assisted TKA (rTKA) has gained attention for its potential precision and improved outcomes. However, the comparative efficacy and safety of rTKA versus cTKA remain unclear due to inconsistent findings in existing studies. This study aims to systematically review and compare the efficacy and safety of rTKA and cTKA in patients with KOA.

Methods: A total of seven databases were searched. Only randomized controlled trials (RCTs) were included in this systematic review. Subgroup analysis, sensitivity analysis, and trial sequential analysis (TSA) were used to evaluate the stability of the results.

Results: Twenty-five RCTs involving 3156 patients with KOA were included. The only statistically significant clinical difference between patients who received rTKA and cTKA was that the rTKA group was associated with a longer operative duration (MD = 22.38 mins; 95% confidence interval [CI] [12.86, 31.91]; p < 0.00001; I² = 98%). As for functional parameters, the two groups had similar results in postoperative Knee Society Score (KSS), the Western Ontario and McMaster Universities (WOMAC), and Hospital for Special Surgery Score (HSS). Regarding the tibiofemoral angle and the coronal femoral component angle, no significant difference was observed between the two groups. Patients in the rTKA group had a higher hip–knee–ankle angle (HKA) (MD = 0.63; 95% CI [0.23, 1.03]; p = 0.002; I² = 52%), lower HKA deviation (MD = −0.99; 95% CI [−1.24, −0.74]; p < 0.00001; I² = 0%), and a higher coronal tibial component angle (MD = 0.46; 95% CI [0.07, 0.85]; p = 0.02; I² = 81%) after the surgery.

Conclusions: While rTKA appears to be a feasible and safe alternative to cTKA, the mixed evidence from our study highlights the need for further research to fully understand its clinical implications and long-term outcomes.

Trial Registration: PROEPERO: CRD42024541052

Keywords

conventional total knee arthroplasty / knee osteoarthritis / robot-assisted total knee arthroplasty / TKA

References

[1] K. D. Allen, L. M. Thoma, and Y. M. Golightly, “Epidemiology of Osteoarthritis,” Osteoarthritis and Cartilage 30, no. 2 (2022): 184-195, https://doi.org/10.1016/j.joca.2021.04.020.

[2] V. L. Johnson and D. J. Hunter, “The Epidemiology of Osteoarthritis,” Best Practice & Research. Clinical Rheumatology 28, no. 1 (2014): 5-15, https://doi.org/10.1016/j.berh.2014.01.004.

[3] N. Arden and M. C. Nevitt, “Osteoarthritis: Epidemiology,” Best Practice & Research. Clinical Rheumatology 20, no. 1 (2006): 3-25, https://doi.org/10.1016/j.berh.2005.09.007.

[4] L. Murphy and C. G. Helmick, “The Impact of Osteoarthritis in the United States: A Population-Health Perspective,” American Journal of Nursing 112, no. 3 Suppl 1 (2012): S13-S19, https://doi.org/10.1097/01.NAJ.0000412646.80054.21.

[5] H. Alizai, W. Walter, I. Khodarahmi, and C. J. Burke, “Cartilage Imaging in Osteoarthritis,” Seminars in Musculoskeletal Radiology 23, no. 5 (2019): 569-578, https://doi.org/10.1055/s-0039-1695720.

[6] W. J. Scheuing, A. M. Reginato, M. Deeb, and S. Acer Kasman, “The Burden of Osteoarthritis: Is It a Rising Problem?,” Best Practice & Research. Clinical Rheumatology 37, no. 2 (2023): 101836, https://doi.org/10.1016/j.berh.2023.101836.

[7] Y. Lu and X. Shi, “Current Status and Progress of Domestic and International Epidemiological Studies on Osteoarthritis of the Knee,” Chinese Journal of Traditional Medical Traumatology & Orthopedics 20, no. 6 (2012): 81-84.

[8] “China Health and Retirement Longitudinal Study (CHARLS),” https://charls.pku.edu.cn/.

[9] W. B. Lim and O. Al-Dadah, “Conservative Treatment of Knee Osteoarthritis: A Review of the Literature,” World Journal of Orthopedics 13, no. 3 (2022): 212-229, https://doi.org/10.5312/wjo.v13.i3.212.

[10] A. Postler, A. L. Ramos, J. Goronzy, et al., “Prevalence and Treatment of Hip and Knee Osteoarthritis in People Aged 60 Years or Older in Germany: An Analysis Based on Health Insurance Claims Data,” Clinical Interventions in Aging 13 (2018): 2339-2349, https://doi.org/10.2147/CIA.S174741.

[11] A. M. Weinstein, B. N. Rome, W. M. Reichmann, et al., “Estimating the Burden of Total Knee Replacement in the United States,” Journal of Bone and Joint Surgery. American Volume 95, no. 5 (2013): 385-392, https://doi.org/10.2106/JBJS.L.00206.

[12] F. R. Nelson, “A Background for the Management of Osteoarthritic Knee Pain,” Pain Management 4, no. 6 (2014): 427-436, https://doi.org/10.2217/pmt.14.40.

[13] Z. Yan, Y. Wu, M. Liu, et al., “Heterogeneous Trajectories of Kinesiophobia and Their Effects on Rehabilitation Outcomes After Total Knee Arthroplasty: A Prospective Cohort Study,” Journal of Orthopaedic Surgery and Research 18, no. 1 (2023): 449, https://doi.org/10.1186/s13018-023-03881-8.

[14] E. K. Song, J. K. Seon, S. J. Park, W. B. Jung, H. W. Park, and G. W. Lee, “Simultaneous Bilateral Total Knee Arthroplasty With Robotic and Conventional Techniques: A Prospective, Randomized Study,” Knee Surgery, Sports Traumatology, Arthroscopy 19, no. 7 (2011): 1069-1076, https://doi.org/10.1007/s00167-011-1400-9.

[15] S. J. Bhimani, R. Bhimani, A. Smith, C. Eccles, L. Smith, and A. Malkani, “Robotic-Assisted Total Knee Arthroplasty Demonstrates Decreased Postoperative Pain and Opioid Usage Compared to Conventional Total Knee Arthroplasty,” Bone & Joint Open 1, no. 2 (2020): 8-12, https://doi.org/10.1302/2633-1462.12.BJO-2019-0004.R1.

[16] C. Batailler, M. B. Anderson, X. Flecher, M. Ollivier, and S. Parratte, “Is Sequential Bilateral Robotic Total Knee Arthroplasty a Safe Procedure? A Matched Comparative Pilot Study,” Archives of Orthopaedic and Trauma Surgery 143, no. 3 (2023): 1599-1609, https://doi.org/10.1007/s00402-022-04455-9.

[17] M. J. Page, J. E. McKenzie, P. M. Bossuyt, et al., “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” International Journal of Surgery 88 (2021): 105-906.

[18] B. J. Shea, B. C. Reeves, G. Wells, et al., “AMSTAR 2: A Critical Appraisal Tool for Systematic Reviews That Include Randomised or Non-Randomised Studies of Healthcare Interventions, or Both,” British Medical Journal 358 (2017): j4008, https://doi.org/10.1136/bmj.j4008.

[19] “Yiigle Database,” https://www.yiigle.com/index.

[20] “Online Tool to Evaluate the Certainty of the Evidence-GRADEpro,” https://www.gradepro.org/.

[21] S. E. Park and C. T. Lee, “Comparison of Robotic-Assisted and Conventional Manual Implantation of a Primary Total Knee Arthroplasty,” Journal of Arthroplasty 22, no. 7 (2007): 1054-1059, https://doi.org/10.1016/j.arth.2007.05.036.

[22] E. K. Song, J. K. Seon, J. H. Yim, N. A. Netravali, and W. L. Bargar, “Robotic-Assisted TKA Reduces Postoperative Alignment Outliers and Improves Gap Balance Compared to Conventional TKA,” Clinical Orthopaedics and Related Research 471, no. 1 (2013): 118-126, https://doi.org/10.1007/s11999-012-2407-3.

[23] M. H. Liow, Z. Xia, M. K. Wong, K. J. Tay, S. J. Yeo, and P. L. Chin, “Robot-Assisted Total Knee Arthroplasty Accurately Restores the Joint Line and Mechanical Axis. A Prospective Randomized Study,” Journal of Arthroplasty 29, no. 12 (2014): 2373-2377, https://doi.org/10.1016/j.arth.2013.12.010.

[24] Y. H. Kim, S. H. Yoon, and J. W. Park, “Does Robotic-Assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial,” Clinical Orthopaedics and Related Research 478, no. 2 (2020): 266-275, https://doi.org/10.1097/CORR.0000000000000916.

[25] B. Kayani, J. Tahmassebi, A. Ayuob, S. Konan, S. Oussedik, and F. S. Haddad, “A Prospective Randomized Controlled Trial Comparing the Systemic Inflammatory Response in Conventional Jig-Based Total Knee Arthroplasty Versus Robotic-Arm Assisted Total Knee Arthroplasty,” Bone & Joint Journal 103, no. 1 (2021): 113-122, https://doi.org/10.1302/0301-620X.103B1.BJJ-2020-0602.R2.

[26] S. Thiengwittayaporn, P. Uthaitas, C. Senwiruch, N. Hongku, and R. Tunyasuwanakul, “Imageless Robotic-Assisted Total Knee Arthroplasty Accurately Restores the Radiological Alignment With a Short Learning Curve: A Randomized Controlled Trial,” International Orthopaedics 45, no. 11 (2021): 2851-2858, https://doi.org/10.1007/s00264-021-05179-y.

[27] M. Sun, L. Yang, L. Guo, and R. He, “Effect of Robotic-Arm Assisted Total Knee Arthroplasty on Femoral Rotation Alignment and its Short-Term Effectiveness,” Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 35, no. 7 (2021): 807-812, https://doi.org/10.7507/1002-1892.202102043.

[28] M. Yuan, X. Shi, Q. Su, X. Wan, and Z. Zhou, “A Prospective Randomized Controlled Trial on the Short-Term Effectiveness of Domestic Robot-Assisted Total Knee Arthroplasty,” Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 35, no. 10 (2021): 1251-1258, https://doi.org/10.7507/1002-1892.202106047.

[29] Z. Li, X. Chen, X. Wang, et al., “HURWA Robotic-Assisted Total Knee Arthroplasty Improves Component Positioning and Alignment—A Prospective Randomized and Multicenter Study,” Journal of Orthopaedic Translation 33 (2022): 31-40, https://doi.org/10.1016/j.jot.2021.12.004.

[30] A. Lychagin, M. Elizarov, A. Gritsyuk, et al., “Robot-Assisted Knee Arthroplasty: Randomized Clinical Trial,” Open Access Macedonian Journal of Medical Sciences 10, no. B (2022): 559-564, https://doi.org/10.3889/oamjms.2022.8685.

[31] N. V. Vaidya, A. N. Deshpande, T. Panjwani, R. Patil, T. Jaysingani, and P. Patil, “Robotic-Assisted TKA Leads to a Better Prosthesis Alignment and a Better Joint Line Restoration as Compared to Conventional TKA: A Prospective Randomized Controlled Trial,” Knee Surgery, Sports Traumatology, Arthroscopy 30, no. 2 (2022): 621-626, https://doi.org/10.1007/s00167-020-06353-2.

[32] J. Xu, L. Li, J. Fu, et al., “Early Clinical and Radiographic Outcomes of Robot-Assisted Versus Conventional Manual Total Knee Arthroplasty: A Randomized Controlled Study,” Orthopaedic Surgery 14, no. 9 (2022): 1972-1980, https://doi.org/10.1111/os.13323.

[33] Z. Xu, H. Li, Z. Liu, et al., “Robot-Assisted Surgery in Total Knee Arthroplasty: Trauma Maker or Trauma Savior? A Prospective, Randomized Cohort Study,” Burns & Trauma 10 (2022): tkac034, https://doi.org/10.1093/burnst/tkac034.

[34] G. Rong, J. Zhang, H. Zhang, et al., “Clinical Study of Domestic Robot-Assisted Total Knee Arthroplasty for Knee Osteoarthritis,” Journal of Practical Orthopaedics 28, no. 11 (2022): 976-981, https://doi.org/10.13795/j.cnki.sgkz.2022.11.004.

[35] O. Adamska, K. Modzelewski, J. Szymczak, et al., “Robotic-Assisted Total Knee Arthroplasty Utilizing NAVIO, CORI Imageless Systems and Manual TKA Accurately Restore Femoral Rotational Alignment and Yield Satisfactory Clinical Outcomes: A Randomized Controlled Trial,” Medicina 59, no. 2 (2023): 236, https://doi.org/10.3390/medicina59020236.

[36] P. Bollars, D. Janssen, W. De Weerdt, et al., “Improved Accuracy of Implant Placement With an Imageless Handheld Robotic System Compared to Conventional Instrumentation in Patients Undergoing Total Knee Arthroplasty: A Prospective Randomized Controlled Trial Using CT-Based Assessment of Radiological Outcomes,” Knee Surgery, Sports Traumatology, Arthroscopy 31, no. 12 (2023): 5446-5452, https://doi.org/10.1007/s00167-023-07590-x.

[37] N. D. Clement, S. Galloway, Y. J. Baron, K. Smith, D. J. Weir, and D. J. Deehan, “Robotic Arm-Assisted Versus Manual (ROAM) Total Knee Arthroplasty: A Randomized Controlled Trial,” Bone & Joint Journal 105-B, no. 9 (2023): 961-970, https://doi.org/10.1302/0301-620X.105B9.BJJ-2023-0006.R3.

[38] R. Tian, X. Duan, N. Kong, et al., “Robotic-Assisted Total Knee Arthroplasty Is More Advantageous for Knees With Severe Deformity: A Randomized Controlled Trial Study Design,” International Journal of Surgery 109, no. 3 (2023): 287-296, https://doi.org/10.1097/JS9.0000000000000002.

[39] M. Du, Z. Li, Y. Jiang, et al., “Early Clinical and Radiographic Outcomes of Domestic Robot-Assisted Total Knee Arthroplasty,” Journal of Practical Orthopaedics 29, no. 6 (2023): 502-508, https://doi.org/10.13795/j.cnki.sgkz.2023.06.011.

[40] Y. Li, X. Zhang, L. Cao, et al., “A Multicenter Randomized Controlled Trial of Domestic Robot-Assisted and Conventional Total Knee Arthroplasty,” Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 37, no. 11 (2023): 1326-1334, https://doi.org/10.7507/1002-1892.202307078.

[41] H. Shao, L. Wu, G. Cao, et al., “Accuracy of Total Knee Arthroplasty Assisted by a Kind of Homemade Robot: A Multicenter Randomized Controlled Trial,” Chinese Journal of Bone and Joint Surgery 16, no. 4 (2023): 310-316.

[42] F. Wang, “Randomized Controlled Trial and Learning Curve Analysis of Robot-Assisted Total Knee Arthroplasty Compared With Conventional Total Knee Arthroplasty,”2023, http://link--cnki--net--https.cnki.scrm.scsycy.vip:2222/doi/10.27272/d.cnki.gshdu.2023.006520.

[43] Z. Xia, W. Hu, R. Wu, et al., “Short Term Efficacy and Safety Evaluation of Robot Assisted Total Knee Arthroplasty,” Chinese Journal of Medicine 58, no. 3 (2023): 276-279.

[44] S. Zhang, “Comparison of Early Clinical Results of Robot-Assisted TKA and Conventional TKA,”2023, http://link--cnki--net--https.cnki.scrm.scsycy.vip:2222/doi/10.26921/d.cnki.ganyu.2023.00160710.26921/d.cnki.ganyu.2023.001607.

[45] G. Liu, Q. Liu, R. Tian, K. Wang, and P. Yang, “Associations of Postoperative Outcomes With Geriatric Nutritional Risk Index After Conventional and Robotic-Assisted Total Knee Arthroplasty: A Randomized Controlled Trial,” International Journal of Surgery 110, no. 4 (2024): 2115-2121, https://doi.org/10.1097/JS9.0000000000001048.

[46] R. Alrajeb, M. Zarti, Z. Shuia, O. Alzobi, G. Ahmed, and A. Elmhiregh, “Robotic-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” European Journal of Orthopaedic Surgery and Traumatology 34, no. 3 (2024): 1333-1343, https://doi.org/10.1007/s00590-023-03798-2.

[47] Y. Lin, M. Jiang, C. Liao, Q. Wu, and J. Zhao, “Duloxetine Reduces Opioid Consumption and Pain After Total Hip or Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 181, https://doi.org/10.1186/s13018-024-04648-5.

[48] M. Hasegawa, Y. Hattori, Y. Naito, S. Tone, and A. Sudo, “Comparing an Imageless Hand-Held Robotic-Assisted System Versus Conventional Technique for Component Positioning and Early Clinical Outcomes in Total Knee Arthroplasty,” International Journal of Medical Robotics 20 (2024): e2564, https://doi.org/10.1002/rcs.2564.

[49] Z. A. Fozo, A. H. Ghazal, M. Hesham Gamal, S. G. Matar, I. Kamal, and K. M. Ragab, “A Systematic Review and Meta-Analysis of Conventional Versus Robotic-Assisted Total Knee Arthroplasty,” Cureus 15, no. 10 (2023): e46845, https://doi.org/10.7759/cureus.46845.

[50] P. Ruangsomboon, O. Ruangsomboon, C. Pornrattanamaneewong, R. Narkbunnam, and K. Chareancholvanich, “Clinical and Radiological Outcomes of Robotic-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Acta Orthopaedica 94 (2023): 60-79, https://doi.org/10.2340/17453674.2023.9411.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.