Knee pain is one of the most common orthopaedic complaints around the world, particularly among the elderly. Total Knee Replacement (TKR) has long been the standard treatment for advanced osteoarthritis and other degenerative knee conditions. While conventional TKR has shown excellent results, recent advancements in medical technology have paved the way for robotic assistance in orthopaedic surgery. Among these, the Robotic Surgical Assistant (ROSA) system has emerged as a significant innovation. This technological leap not only represents a shift in how orthopaedic surgeries are performed but also aims to address many of the limitations found in conventional techniques, offering patients the prospect of better functional outcomes and reduced complication rates. This article provides a comprehensive overview of ROSA-assisted total knee replacement, its technological aspects, clinical procedure, advantages, challenges, and its growing adoption in Malaysia.

Understanding Total Knee Replacement

Total Knee Replacement (TKR), also known as total knee arthroplasty (TKA), is a surgical procedure in which damaged or diseased parts of the knee joint are replaced with artificial components. This procedure aims to relieve pain, restore function, and improve quality of life for patients suffering from severe knee arthritis, rheumatoid arthritis, or traumatic injuries.

Traditional TKR involves manual alignment of the knee components by the surgeon, using anatomical landmarks, alignment jigs, and the surgeon’s experience. While this method has been successful for decades, it is associated with certain limitations, including variability in implant positioning, alignment errors, and post-operative complications.

When is Total Knee Replacement Necessary

Total Knee Replacement is generally recommended for patients who experience severe knee pain, stiffness, and functional limitations that significantly affect their daily activities and quality of life. It is most often considered when conservative treatments such as medications, physiotherapy, injections, and lifestyle modifications have failed to provide adequate relief. The procedure is particularly advised for individuals with advanced osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis, where there is extensive joint damage and deformity that cannot be managed by less invasive means. Additionally, persistent pain at rest or during sleep, and significant restriction in movement or instability of the knee joint, are common indications for considering Total Knee Replacement.

What is ROSA?

ROSA, which stands for Robotic Surgical Assistant, is a state-of-the-art robotic platform developed to assist surgeons in performing orthopaedic procedures with enhanced precision and accuracy. The ROSA Knee System is specifically designed for total knee replacement surgeries. It combines advanced computer navigation, real-time data analytics, and robotic assistance to help surgeons achieve optimal implant positioning and alignment.

By integrating robotic precision with the surgeon’s expertise, ROSA facilitates a more personalised approach to joint replacement, taking into account the unique anatomical variations of each patient. This advanced system enables surgeons to execute bone cuts and implant placements with remarkable accuracy, thereby minimising the risk of alignment errors commonly seen in conventional procedures.

Key Features of the ROSA Knee System

• Pre-operative Planning: The system allows detailed planning using patient-specific data, often incorporating X-rays, CT scans, or MRI images to create a 3D model of the patient’s knee.
• Intra-operative Guidance: During surgery, ROSA provides real-time feedback and guidance, helping the surgeon make precise bone cuts and adjust implant positioning.
• Data Analytics: The system collects and analyses intra-operative data to ensure accuracy and consistency in every step of the procedure.
• Robotic Arm Assistance: The robotic arm aids the surgeon in executing planned bone resections while compensating for any unintended movements.
• Minimally Invasive Approach: ROSA supports minimally invasive techniques, potentially reducing tissue trauma and facilitating faster recovery.

The ROSA-Assisted Total Knee Replacement Procedure

The ROSA-assisted TKR procedure is a blend of advanced technology and surgical expertise. The process can be broadly divided into three phases: pre-operative planning, intra-operative execution, and post-operative assessment.

1. Pre-operative Planning

Before the surgery, detailed imaging studies are performed to assess the patient’s knee anatomy. These images are uploaded into the ROSA system, which constructs a 3D model of the knee. The surgeon then uses this model to plan the optimal implant size, position, and alignment, tailored to the individual patient’s anatomy and biomechanics.

2. Intra-operative Execution

On the day of surgery, the patient is positioned, and the knee is prepared in the usual sterile manner. The ROSA system is set up in the operation theatre. Special trackers or sensors may be attached to the patient’s leg to provide real-time positional feedback to the system. The surgeon makes the necessary incisions and exposes the knee joint. The ROSA system continuously monitors the position of the femur and tibia, providing precise guidance for bone resections. The robotic arm assists in making highly accurate cuts, minimising the risk of human error. Throughout the procedure, the system offers real-time data and alerts the surgeon to any deviations from the planned course.

3. Implant Placement and Assessment

After bone preparation, the chosen implants are positioned as per the pre-operative plan. The ROSA system verifies the alignment and stability of the components, allowing for any final adjustments. Once the surgeon is satisfied with the placement, the wound is closed, and the patient is taken to recovery.

4. Post-operative Care

Post-surgery, patients are monitored for pain, mobility, and wound healing. The precision of the robotic system often allows for faster mobilisation, reduced pain, and shorter hospital stays. Rehabilitation protocols are tailored to help patients regain strength and function at the earliest.

Advantages of ROSA-Assisted Knee Replacement

The integration of robotic technology in knee replacement offers several distinct advantages over conventional methods:

• Enhanced Precision: The robotic arm, guided by computer navigation, ensures bone cuts and implant placement are consistently accurate, reducing the risk of alignment errors.
• Personalised Surgery: Pre-operative planning allows customisation based on the patient’s unique anatomy, improving functional outcomes.
• Reduced Human Error: Real-time data and feedback minimise the impact of fatigue or subjective judgement during lengthy procedures.
• Minimally Invasive: Smaller incisions and less soft tissue disruption are possible, leading to less pain and quicker recovery.
• Better Long-term Outcomes: Precise alignment and placement of implants are associated with improved longevity and performance of the prosthesis.
• Consistent Results: The standardisation provided by robotic systems reduces variability between cases and among different surgeons.

Challenges and Limitations

While ROSA-assisted TKR offers many benefits, there are certain challenges and limitations that must be considered:

• Cost: The technology and equipment involved in robotic surgery may be expensive compared to traditional surgery, potentially increasing the overall cost of the procedure.
• Learning Curve: Surgeons and operating room staff require specialised training to operate the ROSA system effectively. This may initially lead to longer surgery times.
• Infrastructure Requirements: Hospitals need dedicated infrastructure and technical support for robotic systems, which may not be available in all centres.
• Patient Selection: Not all patients are ideal candidates for robotic-assisted TKR. Severe deformities, bone loss, or other complicating factors may limit its applicability.
• Technology Dependence: Over-reliance on technology may lead to skill atrophy among surgeons if not balanced with conventional surgical training.

ROSA vs Conventional Knee Replacement

Adoption of ROSA in Malaysia

Malaysia has witnessed a gradual integration of ROSA technology within its healthcare system, particularly in major urban medical centres. While the availability of ROSA-assisted knee replacement is currently limited to select advanced hospitals, its presence is steadily expanding as awareness and demand rise among both surgeons and patients. Malaysian orthopaedic surgeons are increasingly adopting this technology to provide enhanced precision and improved patient outcomes.

The adoption of robotic surgery, including ROSA, is being driven by a combination of patient demand, surgeon interest, and hospital investment in cutting-edge technology.

Malaysia’s commitment to advancing healthcare technology is evident in its investment in ROSA systems. Training programmes and workshops for surgeons are also being organised to ensure the safe and effective use of this technology.

Case Studies and Clinical Evidence

Early Malaysian case studies and international research suggest that ROSA-assisted TKR leads to improved accuracy in implant positioning, better alignment, and potentially superior functional outcomes compared to conventional methods. Patients often report less post-operative pain, quicker mobilisation, and higher satisfaction scores.

The Patient Experience

For Malaysian patients, the concept of a robot assisting in surgery may initially spark curiosity or even apprehension. It is important to clarify that the ROSA system does not replace the surgeon; rather, it serves as a sophisticated tool to enhance the surgeon’s capabilities and ensure greater surgical precision.

The typical patient journey for ROSA-assisted total knee replacement (TKR) involves several key steps:

• Consultation and Assessment: Patients undergo a comprehensive evaluation, including detailed imaging and functional assessments, to determine suitability for the procedure.
• Pre-operative Planning: Personalised surgical plans are developed and discussed with the patient, often utilising 3D models to help explain the procedure in an accessible manner.
• Surgery: The operation is conducted with the aid of the ROSA robotic system, allowing for enhanced accuracy and safety throughout the procedure.
• Recovery and Rehabilitation: Early mobilisation is encouraged, with physiotherapy programmes tailored to each patient’s needs, frequently leading to a quicker recovery process.
• Follow-up: Regular follow-up appointments are scheduled to monitor knee function, implant alignment, and overall patient satisfaction.

Many Malaysian patients who have undergone ROSA-assisted TKR report high levels of satisfaction, reduced post-operative pain, and a faster return to everyday activities compared to those who underwent traditional surgical methods.

Rehabilitation and Long-Term Follow-Up

Rehabilitation following ROSA-assisted knee replacement is a structured and integral part of the recovery process. Patients typically begin gentle movement and weight-bearing exercises soon after surgery, under the supervision of a physiotherapist. Customised rehabilitation plans focus on restoring strength, flexibility, and range of motion, with regular assessments to track progress and address any concerns promptly.

Long-term follow-up is essential to ensure the continued success of the procedure. Patients are encouraged to attend scheduled check-ups, where clinicians use advanced imaging and clinical evaluations to monitor implant performance and overall knee health. These follow-ups also provide an opportunity for patients to discuss any issues, ensuring ongoing support and optimal functional outcomes.

Future Trends in Robotic Orthopaedic Surgery

As the field continues to evolve, emerging trends in robotic orthopaedic surgery include the adoption of advanced navigation systems, integration of real-time data analytics, and the use of augmented reality to assist surgeons during procedures. Continuous improvements in artificial intelligence, machine learning, and robotics are expected to further enhance surgical outcomes. Integration with electronic medical records, remote monitoring, and tele-rehabilitation may become routine, making the entire patient journey more seamless.

These innovations not only enhance surgical precision but also contribute to improved patient safety and overall outcomes. Additionally, ongoing research in biomaterials and implant design aims to further increase the longevity and biocompatibility of knee replacements, ensuring better long-term results for patients.

Summary

Robotic Assisted Surgery (ROSA) represents a major leap forward in the field of total knee replacement. By combining the skill of the surgeon with the precision of robotics, ROSA offers the potential for safer, more accurate, and more personalised knee replacement surgery.

As technology continues to evolve and awareness spreads, ROSA and similar systems are poised to play a transformative role in orthopaedic surgery, redefining standards of care for generations to come.

Sources:

• https://int.livhospital.com/robotic-knee-replacement-vs-traditional-7-key-advantages-and-disadvantages/
• https://orthoinfo.aaos.org/en/treatment/total-knee-replacement/
• https://biologyinsights.com/rosa-robotic-knee-replacement-reviews-what-to-expect/