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com
State of the Art
1
Orthopaedic Surgery, Hospital
Sotero del Rio, Santiago, Chile
2 Computer-assisted navigation was introduced as
Orthopaedic Surgery, Clinica
Alemana - Universidad del
Desarrollo, Santiago, Chile
3
Orthopaedic Surgery, Sydney
Orthopaedic Research Institute,
Sydney, New South Wales,
Australia
4
Orthopaedic Surgery, University
College London Hospitals NHS
Foundation Trust, London, UK
Correspondence to
Dr Francisco Figueroa, Hospital
Sotero del Rio, Santiago, Chile;
​franciscofigueroab@​gmail.​com
Received 15 August 2017
Revised 29 October 2017
Accepted 29 November 2017
Published Online First
23 January 2018
To cite: Figueroa F, Parker D,
Fritsch B, et al. JISAKOS
2018;3:46–54.
46
New and evolving technologies for knee
arthroplasty—computer navigation and robotics:
state of the art
Francisco Figueroa,1,2 David Parker,3 Brett Fritsch,3 Sam Oussedik4
Abstract
an adjunct to total knee arthroplasty (TKA) with the
potential of improving positioning and alignment of TKA
implants. Computer-assisted surgery (CAS) can be divided
into: passive (navigated TKA) or semiactive and active
(robotic TKA). Passive CAS has shown improved results
regarding alignment in TKA compared with conventional
instrumentation but it has several possible complications
such as registration errors, pin site complications, increased
surgical time and a potentially longer learning curve.
Robotic TKA has been developed to eliminate the possible
error in the preparation of bone surfaces by the surgeon.
There is still little evidence on these systems but the early
results are encouraging. Despite better results in accuracy
with both CAS systems, clinical benefits are still subject of
debate. Additional research is required to fully define the
costs and benefits of robotics in regular medical practice.
Introduction
For patients with disabling knee osteoarthritis,
total knee arthroplasty (TKA) is widely considered
a successful management option.1 Following TKA,
most patients can expect long-term reduction in
pain and improvements in quality of life,2 3 and
between 72% and 86% of patients report that they
are satisfied with their postoperative outcome.4–6
The stepwise improvements in implant tech-
nology and surgical technique have contributed
to broad success with TKA, though there remains
a significant proportion who do not achieve their
desired outcome. The introduction of newer TKA
designs has been largely unsuccessful in improving
functional outcomes, particularly among the highly
active, younger and higher demand patients.7
In a recent study of more than 60 000 revision
TKA in the USA, infection was identified as the
leading cause of revision (25.2%), followed by
mechanical loosening (16.1%) and implant failure/
breakage (9.7%).8 The most important predictors
of failure secondary to prosthesis loosening are
poor positioning of the prosthesis and subsequent
malalignment of the postoperative lower limb.1 A
meta-analysis found that as little as 3° of deviation
from mechanical alignment in the coronal plane
significantly increased the risk of TKA failure.9
Varus malalignment can lead to increased stress on
the bone of the medial tibial plateau and accelerated
failure.10 Avoidance of malalignment through strat-
egies that increase the accuracy of prosthesis posi-
tioning may improve long-term prosthesis survival
rates for patients.
Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146. Copyright © 2018 ISAKOS
Key articles on computer-assisted surgery 
(CAS) total knee arthroplasty (TKA)
1. Delp et al11 reported the first series of CAS TKA
in 1998.
2. Harvie et al36 published the results using a
surface-mounted CAS system.
3. Mayman16 made a comprehensive review on
handheld CAS TKA.
4. Gustke42 reported the first results using a
pressure-sensor in TKA.
5. de Steiger et al14 demonstrated a clinical
benefit in CAS TKA in patients younger than
65 years old.
6. Siebert et al51 reported the first series of
robotic TKA in 2002.
7. van der list et al28 did a systematic review on
CAS navigated and robotic TKA.
8. Jacofsky et al48 published a comprehensive
review on history and evolution of robotics in
arthroplasty.
9. Gholson et al45 reported on current rates of
adoption and complications on CAS TKA in
USA.
10. The Australian Orthopaedic Association
National Joint Replacement Registry70 is an
obligated source of data in navigation surgery
adoption rates and outcomes.
The first computer-assisted knee replacement
was performed almost 20 years ago.11–13 Computer-
assisted navigation was introduced as an adjunct to
TKA surgery with the potential to improve posi-
tioning and alignment of the TKA prostheses.1
Despite numerous publications providing
supporting evidence of the advantages of this tech-
nology over conventional instrumentation, knee
arthroplasty navigation has yet to become main-
stream.14 Several reasons have been cited, including
cost, learning curve, additional incisions for pin
sites, increased operating room time, technical diffi-
culty and lack of evidence that clinical outcomes are
improved.15 16
This review will focus on the use of computer-
assisted surgery (CAS) in knee arthroplasty and will
cover the different types of CAS including naviga-
tion and robotic surgery.
Types of CAS
CAS systems are classified into three main
categories:13
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Figure 1  Process of anatomical landmarks registration.
►► Passive: the system assists the procedure under the direct
control of the surgeon. For example, CAS is used to posi-
tion the cutting blocks in the exact desired position, but the
surgeon uses conventional instruments to make the bone
cuts. Navigation is part of this category.
►► Semiactive: are controlled robotic tools where the system
restricts a task within a predetermined frame. In other
words, it is an enforced controlled robot.
►► Active: are robotic tools performing surgical tasks such as
drilling or milling without the direct intervention of the
surgeon.
­ sisted navigation improves alignment, controversy remains as to
Two different modalities are also available for these systems:13
►► Image-based modality: this modality consists of three-di-
mensional constructs created using images obtained from
preoperative CT or MRI.
►► Image-free modality: This technology does not require any
imaging. The patient’s anatomical landmarks are collected
directly during surgery (figure 1) to create the patient-spe-
cific model. This modality is the one most commonly used in
knee surgery. When using these systems, the surgeon obtains
anatomical registration points intraoperatively, which are
then used to create a 3D knee model based on a database of
knee CT scans (figure 2). The knee position and cutting jig
are then positioned according to the reference frame created
from the registered anatomical landmarks. The major advan-
tage of image-free systems is that they do not require the
Figure 2  3D model of the patient’s femur based on intraoperative
Copyright 2018 OMNI.
Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146
State of the Art
additional radiation, cost and planning associated with
preoperative CT scans.17 This is the most common form of
navigation in use for knee arthroplasty.
Passive CAS: navigated TKA
Accuracy of implant positioning
Navigation has been shown to reliably increase accuracy of align-
ment parameters. Residents’ ability to accurately place cutting
blocks for TKA in a plastic saw-bone knee model has been
studied, demonstrating alignment closer to a neutral mechan-
ical axis using navigation, therefore improving reproducibility in
inexperienced surgeons.18
In a randomised study, Zhang et al19 demonstrated that 28%
of conventional TKAs had mechanical axis deviation larger
than 3° , whereas none of the navigated knees were misaligned
by these criteria. Blakeney et al,20 Tolk et al,21 Cip et al22 and
Todesca et al23 supported these findings with studies suggesting
that CAS had fewer outliers than conventional TKA (table 1).
Thienpont et al24 aggregated the results of 10 meta-analyses
(comprising 239 studies, 118 of them randomised controlled
trials) and were able to compare the results for 28 763 patients
who had undergone either conventional or computer-assisted
navigational arthroplasty. The authors found that there was
a significantly lower likelihood of mechanical axis outliers
(defined as more than 2°) when computer-assisted navigation
was compared with conventional arthroplasty (OR from 0.21
to 0.76).
Clinical outcomes
While the majority of studies have indicated that computer-as-
whether this leads to any additional clinical benefit.
In a prospective randomised trial, Huang et al25 showed a
mechanical axis within 3° of neutral in more CAS TKAs than
conventional ones and that at 5 years there was a positive
correlation between alignment and better International Knee
Society and SF-12 scores.
In a meta-analysis of 21 studies involving 1713 knees that
were treated with either computer-assisted (n=869) or conven-
tional (n=844) arthroplasty, Rebal et al26 found that, in addition
to improving alignment, computer-assisted navigation was asso-
ciated with significantly greater increases in Knee Society Scores
at both 3 and 12 months postoperatively.
A major study of the Australian registry has more recently
shown evidence of a significant reduction in the revision rate
of TKA in patients younger than 65 years (7.8% revision rate
in non-navigated versus 6.3% revision rate in navigated TKA
at 9 years follow-up) and a trend to fewer revisions in older
patients.14
However, some studies have demonstrated no differences
between computer-assisted navigation and conventional arthro-
plasty in terms of functional or clinical outcomes at up to 10
years after TKA.17 Spencer et al,27 in a randomised controlled
trial of 71 patients with a minimum of 2 years of follow-up,
found no significant difference in functional outcome scores
between patients managed with computer-assisted navigation
and those managed with conventional arthroplasty. Zhang
et al,19 Blakeney et al20 and Cip et al22 were all able to demon-
strate better alignments in CAS TKA but not any improved clin-
ical outcomes.
In a meta-analysis of seven studies and three registries, van
der List et al28 reported the difference in the annual revision rate
(ARR) of computer navigation versus conventional TKA surgery
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State of the Art

Table 1  Recent studies comparing mechanical axis outliers in navigated total knee arthroplasty versus conventional instrumentation
Study Year Number of patients Outliers conventional Outliers navigation
19
Zhang et al 2011 32 (bilateral) 28% 0%
Blakeney et al20 2011 107 36%–38% (intramedullary and extramedullary) 19%
Tolk et al21 2012 100 50% 26%
Cip et al22 2014 200 19% 10%
Todesca et al23 2017 225 11% 4%

alignment, range of motion) is provided by the system. Despite

Essential features of computer-assisted surgery  (CAS) this, it is regarded as being less invasive (with no risk of fracture
total knee arthroplasty associated with bicortical tracker pin placement) and a faster
system to use than the fully navigated system.
1. CAS systems can be passive (navigated), semiactive or active There are four published studies in the literature reporting the
(robotics). outcome of ASM navigation for TKA. A randomised controlled
2. They can have an image-based modality (usually CT) or an trial by Harvie et al36 in a study with 40 patients, demonstrated
image-free modality. ASM navigation to be as accurate as full navigation regarding
3. Most of the systems are optically based and they rely on pin coronal and sagittal femoral and tibial cuts and that the oper-
trackers in femur and tibia for registration. ative time was significantly reduced. A retrospective compara-
4. Other options like surface-mounted and handheld CAS tive study37 of 200 knees illustrated that the femoral component
navigation have been developed. alignment was more accurate with ASM navigation compared
5. Regarding robotic systems, currently four platforms are with conventional intramedullary instrumentation (90% within
available. 3° of mechanical axis vs 74%). Singisetti et al38 reported on
the clinical outcomes using ASM navigation versus conven-
tional instrumentation and did not find clinical differences in
in 4 70 231 patients. Analysis showed an ARR of 0.55 in patients
WOMAC, SF-36 and Quality of life scores. Finally Clement
who underwent computer-navigated TKA surgery and an ARR
et al39 concluded that ASM navigation significantly reduces the
of 0.56 in patients who underwent conventional TKA surgery
number of outliers for the femoral and tibial components when
(P=0.58).
compared with conventional non-navigation alignment. (4% vs
11%, respectively)
Cost-effectiveness
The cost-effectiveness of these systems depends on many factors.
Hand-held navigation
The most commonly used assessment is to look at the cost savings
Trying to solve some of the problems associated with optical
associated with a reduced revision rate for arthroplasties that are
CAS has led to newer, hand-held accelerometer-based navigation
more accurately performed with navigation surgery.
However, the cost-effectiveness of computer-assisted naviga-
tion depends on the hospital volume of TKA procedures. Using
a Markov decision model, Slover et al29 found that hospitals
performing a high volume of TKA procedures (more than 150
TKAs a year) would experience a cost benefit in association with
the use of computer-assisted navigation as only modest reduc-
tions in the revision rate would make the technology cost-ef-
fective. On the other side, when clinical outcomes are taken
into account, there are several studies supporting that the insti-
tutional costs of computer-assisted navigation for TKA are not
justified with regard to improved clinical outcomes.30–32

Surface-mounted navigation
Navigated TKA does have specific complications associated with
the use of tracker pins. There have been several reports of peri-
prosthetic fractures from the tracker pin sites.33 34 There has also
been concerns regarding tracker movement during surgery espe-
cially in osteoporotic bone.35
The OrthoMap Express Knee Software (previously known
as ASM system) (Stryker, Mahwah, New Jersey, USA) (figure 3)
avoids the use of femoral and tibial pins by using mini jigs with
trackers that are attached to the femoral and tibial joint surfaces.
The process of mapping the knee is similar to other naviga-
tion systems but the ASM system only allows the planning of
the femoral and tibial cuts in the coronal and sagittal planes.
No checking of the bone cuts and no guidance to rotation are Figure 3  The OrthoMap Express Knee Software (Stryker, Mahwah, New
provided. After cuts are performed, the TKA proceeds a conven- Jersey, USA) surface mounted navigation system. Copyright Stryker 1998-
tional non-navigated procedure. No more information (limb 2018.
48 Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146
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Figure 4  KneeAlign Technology (OrthAlign, Aliso Viejo, California, USA)
handheld navigation system. Copyright 2014 OrthAlign, Inc.
systems to be developed. These incorporate dynamic motion
sensors and radiofrequency communication systems within the
surgical field. The idea of a handheld easy-to-use navigation
system was conceived in 2008, and the first system became clin-
ically available in 2009.16 The goal was a navigation system that
included no additional incisions, no pins in the femur or tibia,
no external computer or device that would require line of sight
or a non-sterile operator, no capital equipment cost, little to no
additional operating room time, a fast learning curve and accu-
racy equivalent to or better than currently available large console
navigation systems. Two systems are currently approved by the
US Food and Drug Administration (FDA) and on the market.
These systems are the KneeAlign Technology (OrthAlign, Aliso
Viejo, California, USA) (figure 4) and the iASSIST Knee System
(Zimmer, Warsaw, Indiana, USA). Both systems work in similar
fashion using accelerometer technology.
The few studies available on these systems have shown
improved alignment when compared with optically based CAS
systems. Nam et al40 reported a 92.5% of patients getting an
alignment within 3° of the neutral mechanical axis compared
with 86.3% when using an optical CAS system. Goh et al41 at 6
months after the surgery obtained mild improvements regarding
alignment (with neutral mechanical axis as the target) with the
accelerometer-based CAS system, but they did not find any
differences in clinical outcomes scores or patient satisfaction.
The reduced equipment and cheaper costs of these systems
make them attractive and may contribute to easier availability
compared with optical CAS systems. However, current litera-
ture has not substantiated a clinical superiority of these systems
over conventional TKA instrumentation even though there is a
trend to better alignment results than optically based navigation
systems (and conventional instrumentation too) but still with
shortage of data to support this affirmation.
Pressure sensors
Studies reporting on the use of intraoperative sensing technology
are being increasingly published.42 These sensors can eliminate
the effect of inexperience on the judgement of amount of gap
balance. The model with most evidence available is Verasense
(OrthoSensor, Dania Beach, Florida, USA) (figure 5). This device
has miniaturised integrated circuits and microprocessors that are
similar to those used in cell phones, and it communicates to a
computer via a wireless link. The computer has a graphical inter-
face which shows the pressures that are present and the loca-
tion of maximal contact between the medial and lateral femoral
condyles. In this way, they provide feedback on contact pressures
and inferred kinematics from the contact points.
Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146
State of the Art
Figure 5  Pressure sensor data obtained during surgery using Verasense
(OrthoSensor, Dania Beach, Florida, USA). 
These trials have the shape of standard implant trial devices,
so it can be designed for use in different total knee systems.
Currently, four major total knee systems make use of this
product.
In the first study reporting clinical data related to Verasense,
Gustke et al42 showed the 1-year data results from 135 knees in
135 patients in a multicentre study. The quantitatively ‘balanced’
knees showed statistical improvement over the 6-month and
1-year follow-ups compared with the ‘unbalanced’ group. The
American Knee Society Score of the ‘balanced’ group was 23.3
points higher than the ‘unbalanced’ group at 1-year follow-up.
Amundsen et al43 reported that the use of a constrained insert
was significantly lower when doing an algorithmic pie-crusting
of the medial collateral ligament guided by Verasense comparing
to a classic release technique assessed using laminar spreaders,
spacer blocks, manual stress and a ruler (5.3 vs 13.8%; P=0.049).
Despite promising results, the literature is still limited and
with short follow-ups. Further studies using intraoperative
sensing technology are necessary to determine if the quantitative
balancing of the knee translates to long-term improvements in
function or implant survivorship.
Limitations
Although TKA performed with navigation is associated with
improved radiographic alignment, the use of computer-assisted
navigation is associated with a number of potential drawbacks.
Complications unique to navigated TKA have been reported
and may occur in up to 17% of cases compared with conven-
tional TKA.44 Complications can be divided into registration
errors, pin site complications, increased surgical time and longer
learning curve.45
Registration errors: many navigation systems rely on the
intraoperative registration of various anatomical landmarks,
which, if marked incorrectly, may lead to component malposi-
tion. The most common registration errors occur at the femoral
epicondyles; such errors may lead to malrotation of the femoral
component.46
Pin site complications: component malposition also may occur
when markers that are drilled into the femur or tibia move during
the course of surgery, particularly in patients with osteoporosis.
This emphasises the importance of the surgeon being aware of
this and checking the stability of these markers as well as not
49
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State of the Art
Tips and tricks in computer-assisted surgery total knee
arthroplasty (TKA)
1. Avoid registration errors, especially femoral epicondyles
which may lead to malrotation of the femoral component.
2. Be aware of pin site complications. In patients with
osteoporosis, the stability of these markers should be checked
during surgery as well as not relying only on technological
aids alone to achieve proper component position and
alignment.
3. When using closed robotic TKA systems, decide if the benefits
of robotics outweigh the benefits you believe exist in the
implant system. In the case of open systems, you may need to
decide if the benefits of the open implant options outweigh
the loss of certain functionality in the robotic system.
relying on technological aids alone to achieve proper component
position and alignment.
Fractures have been reported to occur around pin sites used
in navigated TKA and are unique to this procedure, occurring
approximately 1% of the time.33 34 Other non-fracture pin site
complications have been described including multiple pin inser-
tion attempts, aborting navigated TKA as a result of pin loos-
ening, haematoma, infection and nerve injury.15 These problems
should however be avoidable in experienced hands and with the
appropriate training.
Increased surgical time: an increase in operating room time
for navigated TKA could be required as a result of the additional
computer processing, pin and tracker placement, array registering
of data points and analysis of intraoperative data. This increase
in operating room time is variable and ranges between increases
of 8 and 63 min depending on the publication.15 However, it
has been suggested that time efficiency in navigated TKA may
be gained by customising the navigation protocol to eliminate
certain steps.15 In the authors’ experience, once surgeons have
become familiar with and competent with their preferred navi-
gation system, the additional time is negligible.
Longer learning curve: as with any new surgical procedure,
navigation involves a learning curve until the steady state is
obtained. Common sense dictates that the more sophisticated
the procedure is, the longer the learning curve will be. Navi-
gation systems are generally considered by non-user surgeons
as adding complexity to the procedure, especially as computer
use is still uncommon in the operative field. However, Jenny
et al47 in a review article assessed several studies regarding this
topic and concluded that all studies support the hypothesis that
computer-navigated TKA involves only a short learning curve
and that beginners can obtain good results from the beginning
of their experience, as navigation provides continuous feedback
during all phases of the knee replacement surgery and allows for
correcting any bone cut errors. Interestingly, there is no compa-
rable research on the learning curve of TKA with standard,
manual instrumentation. One might postulate that this learning
curve might be longer than with navigation, with potentially a
higher rate of outliers.47
Active and semiactive CAS: robotics
Although computer-assisted navigation may improve component
alignment, errors can still occur during the process of making
the bone cuts, leading to component malposition. This limitation
has led to the development of robotic-assisted knee arthroplasty
in an effort to facilitate the preparation of bone surfaces.48 The
50
term robot refers to any mechanical device that is accurately
controlled by a computer with the use of intelligent software.17
These robots can be classified into two main categories: active
and semiactive.49 50 Active systems act without the direct involve-
ment of the surgeon. On the other hand, in semiactive systems,
the surgeon performs the procedure but with feedback from
the robot to prevent errors during the process of making bony
cuts. The adequate term for this type of technology is ‘haptic
system’. Haptic feedback can be provided to the surgeon as
auditory (beeping), tactile (vibratory) or visual (colour changes
in the computer screen). Other forms of semiactive technology
control the speed and deepness of the working instrument. In
that way, if the surgeons are driving the bone cuts outside of
the previous established margins, the system retracts the cutting/
burring instrument or decreases the speed of it so changes into
the planning are prevented.
All orthopaedic robotic systems currently require a platform
and ‘preapproved’ plan on which to base the surgical procedure.
The surgical planning can be created from preoperative imaging
or from intraoperative landmark registration without the need
for specific imaging. In both systems, the patients’ anatomy must
be registered via mapping points on the bone with a navigated
tool creating a three-dimensional frame of reference based on
the patient’s anatomy.
Robotic systems can have ‘closed’ or ‘open’ platforms
depending on if they allow only one manufacturer to be
implanted (closed) or different companies (open). Most plat-
forms are essentially open in nature, but commercial issues tend
to make them locked to a particular implant. In the case of a
closed platform, a surgeon will need to decide if the benefits of
using a robotic system outweigh the benefits they believe exist in
the implant (in the case the surgeon is not familiar to the implant
‘closed’ to the platform). In the case of open systems, potential
drawbacks are that some specificity and functionality are gener-
ally lost for the system to be able to become more universal. As
an example, many open systems cannot optimally predict kine-
matics for implant positioning.
Since Siebert et al51 published on the first series of robotic
TKA (using a system that is not currently in use), several systems
have been developed for TKA and unicompartmental knee
arthroplasty (UKA). Currently, there are four robotic platforms
available. Each of them will be discussed separately.
ROBODOC (Curexo Technology, Fremont, California, USA)
The ROBODOC system debuted in 1992 focused on total hip
arthroplasty (THA). The system obtained FDA approval in 2008
but only for THA.52 Recently, the system has been expanded to
TKA. ROBODOC is an image-based (CT), autonomous, milling
robotic system.
The preoperative CT data are imported into the ORTHODOC
Preoperative Planning Workstation and converted into a 3D
virtual bone image which the surgeon can manipulate to view
bone and joint anatomy and bone density. ORTHODOC has
an extensive library of many commonly used knee implants and
ultimately can incorporate any manufacturer’s implant. Using
point and click controls, the surgeon selects and positions a 3-D
image of an implant within the reconstructed CT bone image
to achieve optimal fit and alignment for the patient’s anatomy.
Using controlled, gentle pressure (2–2.5 lbs), ROBODOC mills
the bone as specified by the ORTHODOC plan.
Its clinical success and utility has been demonstrated in a
series of clinical trials. In a study of 72 knees, Park and Lee53
compared outcomes of robotic assisted with conventional knee
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State of the Art

arthroplasty at mean follow-up of approximately 4 years. The
authors demonstrated better accuracy in the coronal femoral
component angles, sagittal femoral angle and sagittal tibial
angles between the robotic-assisted and conventional cohorts.
In this particular study, however, no differences in Knee Society
Scores were demonstrated.
Song et al54 55 performed two randomised clinical trials
comparing ROBODOC robotic-assisted and conventional
TKA. They found more reliable mechanical axis alignment and
femoral and tibial component positioning using ROBODOC and
also found that 12 out of 18 patients had a preference for the
ROBODOC-assisted TKA leg, while only six in the conventional
leg. In a follow-up study, they assessed soft tissue balancing
and found that more patients   with robotic-assisted TKA had
well-matched (within 2 mm) flexion-extension gap and more
satisfactory posterior cruciate ligament tension compared with
conventional TKA. In both studies, the ROBODOC-assisted
TKA procedures averaged 25 min longer than the manual proce-
dures but demonstrated less postoperative blood loss.
In another prospective randomised study consisting of 60
patients, Liow et al56 found no mechanical axis outliers (more
than 3° from neutral) or notching in the robot-assisted group as
compared with 19.4% (P=0.049) and 10.3% (P=0.238), respec-
tively in the conventional group. The robot-assisted group had
3.23% joint-line height outliers (>5 mm, using the Kawamura
and Bourne57 method) as compared with 20.6% in the conven-
tional group (P=0.049). Clinical outcomes were similar between
groups.
Disadvantages of this system are that the time needed for
registration and milling is greater than other robotics platforms.
Also, milling compared with cutting creates excessive heat that
could damage the surrounding bone. In addition, intraoperative
flexibility, and therefore surgeon’s involvement, is very limited.
Lastly, the software does not allow for live kinematic joint assess-
ment or final implant position information.

NAVIO (Blue Belt Technologies, Plymouth, Minnesota, USA)

NAVIO (figure 6) is an imageless, semiautonomous, burring
system that was designed originally to provide freehand
sculpting for unicompartmental (UKR) and patellofemoral knee
arthroplasty. The system obtained FDA approval in 2012. The
handheld cutting tool has an end-cutting burr that extends and
retracts so that only the planned bone is removed. The light-
weight robotic tool combines image-free intraoperative regis-
tration, planning and navigation with bone preparation. The
NAVIO software platform was formerly open to different UKR
Figure 6  NAVIO (Blue Belt Technologies, Plymouth, Minnesota, USA)
designs but right now is closed to one company implants. The
robotic-assisted total knee arthroplasty system. Copyright 2016 Smith
system is semiautonomous and works monitoring the surgeon
& Nephew.
movements of the burring tool using as feedback the retraction
of the burring tip when the surgeon goes out of the boundaries
of the planned resection. However, if the burr is moved too planned position guided by robotic assistance. There are no
quickly, bone outside the planned volume is able to be removed publications on this system to date.
before burr retraction. The system does not provide any haptic
feedback. iBlock
Lonner et al58 and Smith et al59 are the only published studies The iBlock robotic cutting guide (OMNIlife Science, East
to date and report reliable component positioning using the Taunton, Massachusetts, USA) (figure 7) is a motorised, bone-
NAVIO System in cadaveric and synthetic samples respectively. mounted cutting guide that positions the saw guide for all
No clinical studies regarding NAVIO have been published in femoral resections according to the surgeon’s plan, allowing the
PUBMED-indexed journals to this date. surgeon to then complete the resections with a standard oscil-
Recently, a new NAVIO system for TKR has been developed lating saw. It can be used in conjunction with the NanoBlock,
and obtained FDA approval in 2016 with the first procedure a separate, adjustable, resection block used for tibial resection.
carried out less than 1 year ago. The system is imageless, semi- The system obtained FDA approved in 2010. The OmniBiotics
autonomous and helps the surgeon to put the cutting jigs in the computer station is an imageless closed software package that
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State of the Art
Figure 7  iBlock robotic cutting guide (OMNIlife Science, East Taunton,
Massachusetts, USA). Copyright 2018 OMNI.
uses intraoperative registration to generate a unique 3D digital
model of the patient’s knee. The system allows for planning of
implant positioning and sizing intraoperatively and visualising
planned bone cuts before they are made. It also has good intra-
operative flexibility and the possibility of making recuts in an
easy manner. In a cadaveric study,60 iBlock’s automated cutting
guide resulted in more efficient and more accurate femoral cuts
in comparison to the conventional navigation method.
There is limited clinical data available for this system; however,
the evidence available is promising. Suero et al61 performed a
study in 94 patients who underwent TKA using either Nano-
Block (n=30) or conventional cutting blocks (CCB) (n=64) for
the tibial cut. They found that postoperative mechanical align-
ment variability was significantly less in the NanoBlock group
(SD=1.7°) than in the CCB group (SD=2.7°). Tourniquet time
was significantly reduced by 14.8 min in the NanoBlock group
compared with the CCB. Differences in component alignment
were not significant.
Clark and Schmidt62 compared iBlock with computer-assisted
navigation in primary TKA. In their study, iBlock navigation
times were, on average, 9.0 min shorter compared with navi-
gation after adjustment. The average absolute intraoperative
malalignment was 0.5° less in the iBlock procedures compared
with the navigated procedures after adjustment. Patients in the
iBlock group tended to be discharged 0.6 days earlier compared
with patients in the navigation group after adjustment.
Mako
The Robotic Arm Interactive Orthopaedic System (Rio; Mako
Stryker, Fort Lauderdale, Florida, USA) (figure 8) is available
in clinical practice for UKR, THA and TKA. As an image-based
system, a preoperative CT is used to determine a surgical plan;
this can be adjusted intraoperatively depending on the in-vivo
registration before making any bone cut. Mako provides haptic
feedback to prevent any errors during cuts.
The Mako system is currently available for robotic assisted
UKA and THA procedures, and the total knee platform has
recently been FDA approved. The cutting tool is attached to
the haptic arm. For the UKR, it is a high-speed burr and for
the TKR an oscillating saw. The arm provides haptic feedback
and constrains the movement of the cutting instrument which is
guided by the surgeon.
At this stage, published data have focused on the accuracy of
the Mako system in implant positioning and alignment. Pearle
52
Figure 8  Intraoperative image showing usage of the Mako (Rio; Mako
Stryker, Fort Lauderdale, Florida, USA) robot.
et al63 showed the first 10 patients with UKA treated with the
Mako system (Mako Surgical, Fort Lauderdale, Florida, USA)
were within 1.6° of the mechanical axis. The mean tourniquet
time was 87.4 min (68–113 min) and overall operation time
132 min (118–152 min) in the study. In a series of 20 patients,
Dunbar et al64 showed reliable positioning of both components
comparing to the preoperative planning using this system.
Furthermore, Plate et al65 showed in 52 knees undergoing UKA
using the Mako system that soft tissue balancing was accurate up
to 0.53 mm compared with the preoperative plan and 83% of
the cases were within 1 mm of soft tissue balance comparing to
the preoperative plan throughout the range of motion (ROM).
Several comparisons have been made between Mako and
manual instruments for UKR. Lonner et al66 showed in a clin-
ical study using the Mako system, that robotic-assisted surgery
had increased mechanical axis accuracy and more accurate tibial
component alignment compared with manual UKA. MacCallum
et al67 showed in a clinical study that robotic-assisted surgery
with the Mako system was more precise in the coronal and
tibial planes for baseplate positioning when compared with
manual UKA.
In the only level I study regarding Mako, Bell et al68 randomised
139 patients to either Mako-assisted or conventional surgery. A
postoperative CT was performed at 3 months to assess the accu-
racy of the axial, coronal and sagittal component positioning.
All component positioning parameters were more accurate with
the robot compared with conventional surgery (P<0.01). The
proportion of patients with component implantation within
2° of the target position was significantly greater in the group
who underwent robotic-assisted arthroplasty compared with the
group who underwent conventional arthroplasty with regard
to the femoral component sagittal position (57% vs 26%,
P=0.0008), femoral component coronal position (70% vs 28%,
P=0.0001), femoral component axial position (53% vs 31%,
P=0.0163), tibial component sagittal position (80% vs 22%,
P=0.0001) and tibial component axial position (48% vs 19%,
P=0.0009).
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Limitations
Robot-assisted surgery shares most of its disadvantages with
navigated surgery including the additional duration of the
surgery, cost, radiation associated with a preoperative CT (when
it is needed by the platform) and pin tracker related problems
(fractures, loosening and so on).
On the other hand, disadvantages of robotic-assisted proce-
dures compared with navigated-assisted surgery are the lack of
versatility intraoperatively with the first one, which can result
in the abandonment of the robotic procedure and conversion
to a conventional procedure. Other disadvantage is the high
start-up cost and learning curve associated with the use of any
new technology, which may be prohibitive for many surgeons
and hospital systems.
Cost-effectiveness
The added costs of using robotics-assisted surgery can be justi-
fied by improved outcomes such as fewer complications, implant
longevity with improving prosthetic alignment, better clin-
ical outcomes and earlier hospital discharge. Moschetti et al69
have shown that when more than 94 operations are performed
annually, robotic-assisted UKA is cost-effective compared with
manual surgery. Low-volume centres may take longer to demon-
strate cost-effectiveness of introducing robotic surgery.
Future perspectives
Computer-assisted navigation has been shown to improve
surgeon accuracy and precision in TKA. The goals of these
technologies are to consistently place the component exactly
where the surgeon wants it and to create the desired alignment
depending on the philosophy of the user. There are situations
where navigation could be preferred in TKA, such as intra-ar-
ticular correction of extra-articular deformity, presence of
hardware blocking femoral canal (making impossible to use
intramedullary gigs) and for the purpose of research.
While several studies have demonstrated that mechanical
axis alignment is routinely improved for coronal and sagittal
planes, the benefit of CAS in terms of rotational positioning
is still in question. In addition, computer-assisted navigation
does not directly address soft-tissue balancing. The use of
contact load sensors or soft tissue laxity measures in conjunc-
tion with computer navigation may assist in achieving soft-
tissue balance. The widespread adoption of computer-assisted
navigation will depend on its further development and cost.
Data from the Australian registry of joint replacements show
a progressive increase in the use of CAS in TKR from 2.4%
in 2003 to 28.6% in 2015.70 The same is happening in some
European countries as Norway with values around 20%.71
On the other hand regarding South American surgeons, only
4.5% of them use computer navigation routinely in their
practices (Figueroa D, unpublished data). In the same way,
in USA navigation use is only close to 1%.8 As the procedure
becomes faster and less expensive, it may become adopted on
a larger scale.
In the case of robotic surgery, the capacity of adding supple-
mental control of bony cuts and ligament balancing is now
starting to gain traction. To date, robotic aids have improved
consistency and decreased variability at the cost of increased
operative times at the onset with only some emerging evidence
supporting improved clinical outcomes. Difficulty arises in
showing clinical benefits to the patient because of the large
number of confounding factors, including the diligence with
which soft tissue balancing is carried out; however, there is
Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146
State of the Art
reasonable evidence of the bony accuracy of these systems.48
In the future, robotics is moving towards becoming a valuable
adjunct to the surgeon in delivering patient-specific arthroplasty
with patient-specific alignment targets. Although additional
research will be required to fully define the costs and benefits of
robotics in regular medical practice.
Contributors  FF: writing process. DP and SO: reviewing and editing process. BF:
writing, reviewing and editing process.
Competing interests  None declared.
Patient consent  Obtained.
Provenance and peer review  Commissioned; externally peer reviewed.
© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports
Medicine (unless otherwise stated in the text of the article) 2018. All rights reserved.
No commercial use is permitted unless otherwise expressly granted.
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Figueroa F, et al. JISAKOS 2018;3:46–54. doi:10.1136/jisakos-2017-000146
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New and evolving technologies for knee

arthroplasty−−computer navigation and
robotics: state of the art
Francisco Figueroa, David Parker, Brett Fritsch and Sam Oussedik

J ISAKOS2018 3: 46-54 originally published online January 23, 2018

doi: 10.1136/jisakos-2017-000146

Updated information and services can be found at:

http://jisakos.bmj.com/content/3/1/46

These include:

References This article cites 66 articles, 10 of which you can access for free at:
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