Implementing Robot-assisted knee arthroplasty at a high-volume, peripheral hospital

In 2015, an estimated 30 million adults suffered from osteoarthritis (OA).
Thereby, this disease accounts for 3% of all hospitalizations and for 20% of
all health care expenditures.1 Advanced OA requires total knee arthroplasty
(TKA). In developed countries, the mean utilization rate of TKA is estimated to
be 150-200 cases per 100.000 population in 2019,2 and the trend for annual knee
arthroplasties is increasing.3
Modern technology applied during surgeries is designed to further improve
placement and alignment of the implants, and thereby reducing short- and
long-term complications as well as improving patient-reported outcomes. While
patient-specific instrumentation has demonstrated promising, yet not convincing
results, newest technologies combine the development of surgical plans with
peri-operative assessments of outcomes. The first studies of robot-assisted
TKAs (RA-TKA) indeed demonstrated better short-term clinical outcomes when
compared to conventional manual technique with reduction in radiographic
outliers and reduced risks of iatrogenic soft tissues injuries (reduced blood
loss and postoperative drainage)4. Few studies suggest that costs and operative
time were higher for RA-TKA, but these costs may be offset by clinical
improvement and reduced health care utilization in the 90-day period after
surgery.5, 6 From a health care provider perspective, purchase of these
systems, utilization within institutions required to accompany a variety of
surgeries, and manpower to maintain and utilize these systems still adds
significant costs. These costs may be reduced by efficient utilization, eg
appropriate utilization of the variety of programs offered by these
technologies and scheduling.
To our knowledge, no study has assessed the logistics of utilizing RA-TKA in a
high-volume, peripheral hospital. Therefore, our aims are to describe
logistical, infrastructural costs of utilizing RA-TKA at Zuyderland Medical
Center of two programs offered by the ROSA-robot which are image-based and
image-less procedures. To understand the causes of efficient utilization, we
will perform a detailed characterization of RA-TKA, including the learning
curve for maximally efficient surgery duration, and durations and personnel
required for ROSA-implementation. Additionally, we will collect data on
procedural, clinical and economic outcomes for 90 days, in order to inform
cost-efficacy of utilizing ROSA over a relevant period of time.

Primary Objective: to investigate whether image-based ROSA procedures, which
require more preparation time from the surgeon, reduce operation duration and
required materials in the operation ward, as compared to imageless procedures,
for which ROSA will only be used during the operation to assist in placement of
the prothesis.

This is a randomized study, in which one orthopedic surgeon will perform 8
image-based and 8 image-less ROSA-assisted TKAs. Patients are recruited at
Zuyderland Medical Center, enrolled pre-operatively and followed up for 90 days
post-surgery.

Use or Not-use of an surgery-plan, developed usingt he ROSA-software

The clinical benefit of ROSA-assisted surgery has yet only been demonstrated in
cadaveric studies; the risks associated with this study or group allocation are
minimal, because only additional information is offered, and all decisions are
made by the operating surgeons. All procedures are deemed safe for clinical
practice.