Comparison of robot-assisted and conventional total knee arthroplasty: A controlled cadaver study using multiparameter quantitative three-dimensional CT assessment of alignment

Introduction: A functional total knee replacement has to be well aligned, which implies that it should lie along the mechanical axis and in the correct axial and rotational planes. Incorrect alignment will lead to abnormal wear, early mechanical loosening, and patellofemoral problems. There has been increased interest of late in total knee arthroplasty with robotic assistance. This study was conducted to determine whether robot-assisted total knee arthroplasty is superior to the conventional surgical method with regard to the precision of implant positioning. Materials and Methods: Twenty knee replacements, comprising ten robot-assisted procedures and ten conventional operations, were performed on ten cadavers. Two experienced surgeons performed the surgeries. Both procedures on each cadaver were performed by the same surgeon. The choice of which procedure was to be performed first was randomized. Following implantation of the prosthesis, the mechanical axis deviation, femoral coronal angle, tibial coronal angle, femoral sagittal angle, tibial sagittal angle, and femoral rotational alignment were measured via 3D CT scanning. These variables were then compared with the preoperatively planned values. Results: In the knees that underwent robot-assisted surgery, the mechanical axis deviation ranged from -1.94 degrees to 2.13 degrees (mean: -0.21 degrees), the femoral coronal angle from 88.08 degrees to 90.99 degrees (mean: 89.81 degrees), the tibial coronal angle from 89.01 degrees to 92.36 degrees (mean: 90.42 degrees), the tibial sagittal angle from 81.72 degrees to 86.24 degrees (mean: 83.20 degrees), and the femoral rotational alignment from 0.02 degrees to 1.15 degrees (mean: 0.52 degrees) in relation to the transepicondylar axis. In the knees that underwent conventional surgery, the mechanical axis deviation ranged from -3.19 degrees to 3.84 degrees (mean: -0.48 degrees), the femoral coronal angle from 88.36 degrees to 92.29 degrees (mean: 90.50 degrees), the tibial coronal angle from 88.15 degrees to 91.51 degrees (mean: 89.83 degrees), the tibial sagittal angle from 80.06 degrees to 87.34 degrees (mean: 84.50 degrees), and the femoral rotational alignment from 0.32 degrees to 4.13 degrees (mean: 2.76 degrees) in relation to the transepicondylar axis. In the conventional knee replacement group, there were two instances of outliers outside the range of 3 degrees varus/valgus for the mechanical axis deviation. The robot-assisted knee replacements showed significantly superior femoral rotational alignment results compared with conventional surgery (p = 0.006). There was no statistically significant difference between robot-assisted and conventional total knee arthroplasty with regard to the other variables. All the measurements showed high intra-observer and inter-observer reliability. Conclusion: Robot-assisted total knee arthroplasty showed excellent precision in the sagittal and coronal planes of the 3D CT scan. In particular, the robot-assisted technique showed better accuracy in femoral rotational alignment compared to the conventional surgery, despite the fact that the surgeons who performed the operations were more experienced and familiar with the conventional method than with robot-assisted surgery. It can thus be concluded that robot-assisted total knee arthroplasty is superior to conventional total knee arthroplasty.