Khlopas Anton, Chughtai Morad, Hampp Emily L, Scholl Laura Y, Prieto Michael, Chang Ta-Cheng, Abbasi Abdullah, Bhowmik-Stoker Manoshi, Otto Jason, Jacofsky David J, Mont Michael A
Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.
Research Department, Stryker, Mahwah, New Jersey.
Surg Technol Int. 2017 Jul 25;30:441-446.
While total knee arthroplasty (TKA) procedures have demonstrated clinical success, occasionally intraoperative complications can occur. Collateral or posterior cruciate ligament injury, instability, extensor mechanism disruption, and tibiofemoral or patellofemoral dislocation are among a few of the intraoperatively driven adverse events prevalently ranked by The Knee Society. Robotic-arm assisted TKA (RATKA) provides a surgeon the ability to three-dimensionally plan a TKA and use intraoperative visual, auditory, and tactile feedback to ensure that only the desired bone cuts are made. The potential benefits of soft tissue protection in these surgeries need to be further evaluated. The purpose of this cadaver study was to assess the a) integrity of various knee soft tissue structures (medial collateral ligament [MCL], lateral collateral ligament [LCL], posterior cruciate ligament [PCL], and the patellar ligament), as well as b) the need for tibial subluxation and patellar eversion during RATKA procedures.
Six cadaver knees were prepared using RATKA by a surgeon with no prior clinical robotic experience. These were compared to seven manually performed cases as a control. The mean Kellgren-Lawrence score was 2.8 (range, 0 to 4) in RATKA and 2.6 (range, 1 to 4) in the manual cohort. The presence of soft tissue damage was assessed by having an experienced surgeon perform a visual evaluation and palpation of the PCL, MCL, LCL, and the patellar ligament after the procedures. In addition, leg pose and retraction were documented during all bone resections. The amount of tibial subluxation and patellar eversion was recorded for each case.
For all RATKA-assisted cases, there was no visible evidence of disruption of any of the ligaments. All RATKA cases were left with a bone island on the tibial plateau, which protected the PCL. Tibial subluxation and patella eversion were not required for visualization in any RATKA cases. In two of the seven MTKA cases, there was slight disruption noted of the PCL, although this did not lead to any apparent change in the functional integrity of the ligament. All MTKA cases required tibial subluxation and patellar revision to achieve optimal visualization.
Several aspects of soft tissue protection were noted during the study. During bone resections, the tibia in RATKA procedures did not require subluxation, which may reduce ligament stretching or decrease complication rates. Potential patient benefits for short-term recovery and decreased morbidity to reduce operative complications should be studied in a clinical setting. Since RATKA uses a stereotactic boundary to constrain the sawblade, which is generated based on the implant size, shape, and plan, and does not have the ability to track the patient's soft tissue structures, standard retraction techniques during cutting are recommended. Therefore, the retractor placement and potential for soft tissue protection needs to be further investigated. RATKA has the potential to increase soft tissue protection when compared to manual TKA.
虽然全膝关节置换术（TKA）已取得临床成功，但术中偶尔也会出现并发症。膝关节侧副韧带或后交叉韧带损伤、不稳定、伸肌机制破坏以及胫股或髌股关节脱位是膝关节协会普遍列出的一些术中不良事件。机器人手臂辅助全膝关节置换术（RATKA）使外科医生能够对TKA进行三维规划，并利用术中视觉、听觉和触觉反馈，确保只进行所需的骨切割。这些手术中软组织保护的潜在益处需要进一步评估。本尸体研究的目的是评估：a）各种膝关节软组织结构（内侧副韧带[MCL]、外侧副韧带[LCL]、后交叉韧带[PCL]和髌韧带）的完整性，以及b）RATKA手术过程中胫骨半脱位和髌骨外翻的必要性。
一名此前无机器人临床经验的外科医生使用RATKA对六个尸体膝关节进行操作。将其与七个手动操作病例作为对照。RATKA组的平均Kellgren-Lawrence评分为2.8（范围为0至4），手动操作组为2.6（范围为1至4）。术后由经验丰富的外科医生对PCL、MCL、LCL和髌韧带进行视觉评估和触诊，以评估软组织损伤情况。此外，在所有骨切除过程中记录腿部姿势和牵开情况。记录每个病例的胫骨半脱位和髌骨外翻程度。
在所有RATKA辅助病例中，未发现任何韧带断裂的明显迹象。所有RATKA病例在胫骨平台上都留下了一个骨岛，保护了PCL。在任何RATKA病例中，可视化都不需要胫骨半脱位和髌骨外翻。在七个手动全膝关节置换术（MTKA）病例中的两个病例中，PCL有轻微断裂，尽管这并未导致韧带功能完整性出现任何明显变化。所有MTKA病例都需要胫骨半脱位和髌骨复位以实现最佳可视化。
研究中注意到了软组织保护的几个方面。在骨切除过程中，RATKA手术中的胫骨不需要半脱位，这可能会减少韧带拉伸或降低并发症发生率。短期恢复和降低发病率以减少手术并发症对患者的潜在益处应在临床环境中进行研究。由于RATKA使用基于植入物尺寸、形状和规划生成的立体定向边界来约束锯片，且无法跟踪患者的软组织结构，因此建议在切割过程中采用标准的牵开技术。因此，牵开器的放置和软组织保护的潜力需要进一步研究。与手动TKA相比，RATKA有增加软组织保护的潜力。
