The learning curve of imageless robot-assisted total knee arthroplasty with standardised laxity testing requires the completion of nine cases, but does not reach time neutrality compared to conventional surgery

Int Orthop. 2023 Feb;47(2):503-509. doi: 10.1007/s00264-022-05630-8. Epub 2022 Nov 17.


Purpose: The assistance of robot technology is introduced into the operating theatre to improve the precision of a total knee arthroplasty. However, as with all new technology, new technology requires a learning curve to reach adequate proficiency. The primary aim of this study was to identify the learning curve of an imageless robotic system with standardised laxity testing. The secondary aim of this study was to evaluate the accuracy of the intra-operative coronal alignment during the learning curve.

Methods: A prospective study was performed on 30 patients undergoing robot-assisted total knee arthroplasty with an imageless robotic system (Corin, Massachusetts, USA) associated with a dedicated standardised laxity testing device. The learning curve of all surgical steps was assessed with intra-operative video monitoring. As comparison, the total surgical time of the last 30 patients receiving conventional total knee arthroplasty by the same surgeon and with the same implant was retrospectively assessed. Coronal lower limb alignment was evaluated pre- and post-operatively on standing full-leg radiographs.

Results: CUSUM (cumulative summation) analysis has shown inflexion points in multiple steps associated with robot-assisted surgery between one and 16 cases, which indicates the progression from the learning phase to the proficiency phase. The inflexion point for total operative time occurred after nine cases. Robot-assisted total knee surgery required significantly longer operative times than the conventional counterpart, with an average increase of 22 min. Post-operative limb and implant alignment was not influenced by a learning curve.

Conclusion: The introduction of an imageless robotic system with standardised laxity assessment for total knee arthroplasty results in a learning curve of nine cases based on operative time. Compared to conventional surgery, the surgeon is not able to reach time neutrality with the robotic platform. There is no learning curve associated with coronal limb or implant alignment. This study enables orthopaedic surgeons to understand the implementation of this surgical system and its specific workflow into clinical practice.

Keywords: Imageless robotics; Learning curve; Surgical efficiency; Total knee arthroplasty.

MeSH terms

  • Arthroplasty, Replacement, Knee* / methods
  • Humans
  • Knee Joint
  • Operative Time
  • Prospective Studies
  • Retrospective Studies
  • Robotic Surgical Procedures* / methods
  • Robotics*