Learning Curve in Robotic-Assisted Total Knee Arthroplasty: A Systematic Review of the Literature

Abstract

Several innovations have been introduced in recent years to improve total knee arthroplasty (TKA). Robotic-assisted surgery is gaining popularity for more precise implant placement while minimizing soft tissue injury. The main concerns are increased cost, operative time, and a significant learning curve. This systematic review aims to analyze the surgical time learning curve, implant placement accuracy, and complications related to robotic-assisted TKA (raTKA). A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The research was conducted up to September 2022 in four databases (PubMed/MEDLINE, Embase, Scopus, and the Cochrane Database of Systematic Reviews), with the following key terms: “robotic-assisted”, “total knee arthroplasty”, “robotic”, “TKA”, “learning”, and “TKR”. The methodology quality of the studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO), ID: CRD42022354797, in August 2022. Fifteen clinical studies that analyzed the raTKA learning curve of 29 surgeons and 2300 raTKAs were included in the systematic review. Fourteen surgeons reported the presence of an inflection point during the learning curve. Few studies have reported the learning curve of raTKA regarding lower limb alignment, component position, and intraoperative and postoperative complications. The main finding of this systematic review is that the procedure number required to reach the learning plateau is about 14.9 cases. Furthermore, an average decrease in surgical time of 23.9 min was described between the initial and proficiency phases; the average surgical time in the two phases was 98.8 min and 74.4 min, respectively. No learning curve was observed for implant placement and lower limb alignment because the implants were correctly placed from the first raTKAs. No significant complication rates were reported during the raTKA learning curve.