Application and Postoperative Rehabilitation Effects of HURWA, Cori, and Brainlab Robots in TKA under the ERAS Concept

Application and Postoperative Rehabilitation Effects of HURWA, Cori, and Brainlab Robots in TKA under the ERAS Concept | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application and Postoperative Rehabilitation Effects of HURWA, Cori, and Brainlab Robots in TKA under the ERAS Concept Mingyou Wang, Zhuodong Tang, Yuping Lan, Ruiqi Lan, Mingli Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7198229/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract As science and technology continue to progress, the variety and number of robots used in assisted total knee arthroplasty (TKA) have steadily increased, allowing more surgeons and patients to benefit from enhanced medical precision and improved knee joint function, ultimately leading to a better quality of life. This study conducted a retrospective analysis of 164 knee osteoarthritis patients who underwent either traditional or robot-assisted TKA following the Enhanced Recovery After Surgery (ERAS) protocol. The patients were divided into four groups according to the surgical approach and robotic system employed: traditional TKA group, Brainlab navigation system group (BRATKA group), domestic Hehua robot group (HRATKA group), and Stryker Cori robot group (CRATKA group). Data collected included basic patient information, imaging data, blood indicators, knee function, pain scores, complication rates, and in-hospital satisfaction. The results showed that under the ERAS protocol, the incision length in the robotic groups was longer than that in the conventional group (P > 0.05). The surgery times in the BRATKA group was longer than HRATKA group, while the TKA and CRATKA groups were shorter than them (P < 0.05). The HRATKA group performed better in terms of FFC (femoral-femoral contact) compared to the other groups (P < 0.05). The LFC (lateral femoral condyle) was comparable to the TKA group, smaller than the BRATKA and CRATKA groups (P < 0.05), The LTC (lateral tibial condyle) angle in the HRATKA group was nearer to 90° compared to the TKA group. No statistically significant differences were found between the groups in terms of HKA (hip-knee-ankle angle) and FTC (femoral-tibial contact) angles. On the third postoperative day, no significant differences were observed in the rate of knee swelling, length of hospital stay, changes in WBC, NLR, ESR, and CRP levels among the groups, or perioperative blood loss (P > 0.05). However, patients in the Brainlab group had higher resting VAS (Visual Analog Scale) and movement VAS scores compared to the other groups on day 3 post-operation (P < 0.05). At 90 days postoperatively, no statistically significant differences were found in VAS scores across the four groups. Additionally, there were no notable differences in KSS (Knee Society Score) or ROM (Range of Motion) scores postoperatively (P > 0.05). All four groups encountered common complications, including lower limb intermuscular venous thrombosis and wound exudation. Satisfaction rates exceeded 95% in all groups (P > 0.05). Under the ERAS protocol, despite differences in surgical approach, operation time, certain imaging data, and pain scores at 3 days post-operation, the three robotic systems demonstrated effective knee function recovery and patient satisfaction, comparable to the conventional TKA group, without increasing perioperative blood loss, inflammatory responses, or surgical complications. These findings suggest that robotic-assisted TKA, when applied under the ERAS protocol, leads to satisfactory clinical outcomes, further validating its role in improving surgical precision and promoting faster recovery. Knee osteoarthritis Total knee arthroplasty Surgical robots Enhanced Recovery After Surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Knee osteoarthritis (KOA) is one of the most prevalent joint conditions among the elderly population. With the ongoing global trend of ageing populations, the incidence of knee osteoarthritis is increasing[1]. Total knee arthroplasty (TKA) has emerged as an effective treatment option to enhance knee joint function, alleviate pain, and improve quality of life. However, despite the growing sophistication of TKA technology, the postoperative recovery process still presents a number of challenges, including pain management, functional recovery, and postoperative complications[2]. In recent years, with the rapid advancement of precision medicine and surgical robotic technology, robot-assisted surgery in TKA has gradually become a new trend[3, 4]. Robot-assisted surgery not only offers greater precision and personalised surgical planning but also contributes to improved postoperative recovery, particularly in areas such as prosthesis positioning, bone resection accuracy, and soft tissue assessment, demonstrating significant advantages[5, 6, 7, 8]. However, the adoption of robotic technology in China began relatively later, with most robot-assisted surgeries being concentrated in major cities and hospitals. For many surgeons who are newly introduced to robotic surgery, there is a notable learning curve[9, 10]. During this phase, as technical skills are still developing, surgeries tend to take longer, leading to extended anesthesia and tourniquet application times, which could increase the risk of postoperative complications or adverse reactions[10, 11]. In light of this, the application of the Enhanced Recovery After Surgery (ERAS) concept is crucial in enhancing the postoperative recovery of patients undergoing robotic surgery[12]. The ERAS framework aims to optimise perioperative management and accelerate recovery by combining preoperative nutritional assessments and psychological interventions, precise intraoperative techniques, and early postoperative mobilisation and functional recovery[13, 14]. The implementation of the ERAS concept helps mitigate the potential negative impacts associated with the initial learning curve of robotic technology. Specifically, its benefits in reducing postoperative complications, shortening hospital stays, relieving postoperative pain, and enhancing functional recovery position it as a vital complement to robotic technology. The aim of this study is to explore the use of three robotic systems in TKA under the ERAS concept and assess their impact on promoting postoperative rehabilitation. Through this research, we intend to provide a more robust theoretical foundation for the integration of robotic technology with the ERAS concept, promote holistic rehabilitation in knee arthroplasty patients, and offer guidance for future clinical implementations. Methods 1.1 General Information The study included patients who received TKA for end-stage knee osteoarthritis at our hospital from December 2020 to May 2025. Based on the surgical approach and robotic assistance system, the patients were classified into four groups: 1. Conventional TKA group; 2. Brainlab navigation system group (BRATKA group); 3. Domestic HURWA robot group (HRATKA group); 4. Stryker Cori robot group (CRATKA group).Inclusion criteria included : ① Age ≥ 50 years with a diagnosis of end-stage KOA; ② Failure of conservative treatment; ③ All procedures were conducted by the same surgical team using primary unilateral knee arthroplasty with the same type of knee prosthesis; ④ Absence of local or systemic infection in the knee joint; ⑤ Full understanding of the study's risks and benefits, and provision of informed consent to participate. Exclusion criteria included: ① Presence of local knee infection or any active systemic infection; ② Severe cardiovascular or pulmonary impairment, liver or kidney dysfunction, or patients who were unable to tolerate surgery; ③ A history of knee joint aspiration or injection within the past month; ④ Neuromuscular disorders such as paralysis or muscle weakness; ⑤ Any other conditions deemed unsuitable by the investigators or patients who withdrew from the study. Ethical clearance for this study was granted by the Ethics Committee of Panzhihua Central Hospital (Approval No.: Pan Ke Lun Shen Zi No. 2024-008). 1.2 Surgical Method The procedure was carried out by the same group of experienced surgeons.All procedures were carried out under combined spinal and general anesthesia in the supine position. A tourniquet was applied during the procedure, and a standard anterior midline approach with a medial parapatellar incision was used for TKA. The surgical field was routinely disinfected and draped.Thirty minutes before surgery, a standard dose of 1.5g of cefuroxime sodium was administered. Fifteen minutes before skin incision, a routine intravenous injection of 1g of tranexamic acid was given. After the joint capsule was sutured, 3g of tranexamic acid was injected into the joint cavity, and a "cocktail" injection was used for periarticular injections around the joint. 1.2.1 Conventional TKA Group :Preoperative planning and bone resection were performed using the standard total knee arthroplasty (TKA) technique. A Stryker Legion knee prosthesis (USA) was inserted, and once the bone cement had set, the joint capsule was sutured. The subcutaneous tissue and skin were closed in layers, followed by the application of a sterile gauze dressing. The procedure was then concluded. 1.2.2 BRATKA Group [15, 16, 17] :For this group, the Brainlab Knee3 navigation system was employed. After exposing the knee joint, the anterior and posterior cruciate ligaments, along with osteophytes, were excised, and the patella was denervated, with its edges cleared of osteophytes. Robotic navigation trackers were positioned on the distal medial femur and the proximal medial tibia. The hip joint was mobilised to locate the centre of the femoral head, and the system was used to sequentially register the distal femoral cortex, the medial and lateral femoral condyles, the Whiteside line, the tibial medial and lateral platforms, the tibial intercondylar ridge, the tibial proximal centre, and the medial and lateral malleoli. The knee joint was flexed and extended, and valgus and varus stress tests were conducted. The robotic system recorded the sizes of the medial and lateral gaps, as well as the alignment of the lower limb. Following registration, the initial surgical plan was generated by the computer software, and parameters such as prosthesis size, resection thickness, and resection angle were adjusted based on the patient’s specific condition. Once the surgical plan was finalised, bone resection was carried out under the guidance of the robotic system. The distal femur and tibial platform were resected first, with each resection being followed by a verification of its accuracy. After the bone resection was completed, the flexion and extension gaps were reassessed to ensure balance between the medial-lateral and flexion-extension gaps. A trial prosthesis was then placed and tested, further confirming the flexion and extension of the knee joint. Varus and valgus stress tests were applied to assess both lower limb alignment and gap balance. Once satisfactory results were achieved, the navigation trackers were removed, and the final prosthesis was implanted. 1.2.3 CRATKA Group The Stryker CORI Orthopaedic Intelligent Robot was used for this group. After exposing the joint via the previously described incision, 3D infrared camera tracking arrays were positioned on the distal medial femur and the proximal medial tibia. A burr was then installed, and the flexible handheld robotic arm was calibrated. The system proceeded to guide the step-by-step registration of the anatomical landmarks of the knee and ankle joints. The hip joint was mobilised to locate the centre of the femoral head, and the alignment of the lower limb as well as the flexion-extension angles were assessed. Following system prompts, the femur and tibia were registered. Soft tissue tension was evaluated, and once the knee joint data were obtained, a surgical plan was formulated. Under the guidance of the robotic navigation system, the distal femur and tibial platform were resected. After resection, a trial knee prosthesis was inserted, and the balance of the medial-lateral and flexion-extension gaps was reassessed. Once satisfactory outcomes were achieved, the 3D infrared camera tracking arrays were removed, and the final prosthesis was implanted. 1.2.4 HRATKA Group Preoperatively, a hip-knee-ankle CT scan was conducted, and the CT data were imported into the HURWA robotic system to create a personalised surgical plan and identify safe bone resection areas. During the surgery, a standard anterior midline approach with a medial parapatellar incision was employed to dissect the soft tissues layer by layer and expose the knee joint. A knee fixation frame was used to stabilise the joint. The robotic positioning reflectors were securely attached to the distal femur and tibial platform. Registration was carried out following system prompts, including the distal femur, distal femoral anterior cortex, and tibial platform.Once registration was completed, the surgeon performed bone resections of the distal femur and tibial platform under the guidance of the robotic arm, continuously monitoring the thickness and angles of the resections. After the bone resections were finalised, a trial prosthesis was inserted to assess the flexion-extension gap and the balance of the medial-lateral gap in the knee joint. Once satisfactory outcomes were confirmed, the final prosthesis was implanted. 1.3 Perioperative Management All patients followed the same perioperative protocols, including anti-inflammatory, analgesic, anticoagulant, decongestive, and functional exercises based on the Chinese Expert Consensus on Accelerated Rehabilitation of Hip and Knee Arthroplasty. 1.4 Evaluation Criteria for Efficacy General data, including age, gender, height, weight, surgical site, Kellgren-Lawrence grade, preoperative HKA (hip-knee-ankle angle), preoperative functional assessment, incision length, surgery time, and total blood loss, were collected for all patients.Postoperative follow-up included X-rays of the knee joint in both the anteroposterior and lateral views, as well as full-length X-rays of both lower limbs. The prosthesis position was evaluated by measuring the following angles:Frontal tibia component angle (FTC, optimal value 90°, Fig. 1A)；Lateral femoral component angle (LFC, optimal value 0°, Fig. 1B)；Lateral tibia component angle (LTC, optimal value 87°, Fig. 1B)；Frontal femoral component angle (FFC, optimal value 90°, Fig. 3C).Additionally, the degree of deviation of the hip-knee-ankle angle (HKA, optimal value 180°, Fig. 1D) was used to evaluate lower limb alignment. An abnormal value was defined as a deviation of ≥3° from the optimal value [18]. Measurement methods are shown in Figure 1.Perioperative follow-up was conducted for 3 months, with a total of 5 visits: preoperative, postoperative day 1, day 3, day 5, and 3-month follow-up. The following parameters were collected: KSS (Knee Society Score), VAS (Visual Analogue Scale) score, range of motion (ROM), hemoglobin (HB), hematocrit (HCT), complication rates, and patient satisfaction during hospitalization.The Knee Society Score (KSS) includes a clinical score [pain (50 points), range of motion (25 points), stability (25 points), total 100 points] and a functional score [walking ability (50 points), stair climbing ability (50 points), total 100 points]. Total blood volume was calculated using the Nadler [19] equation. 1.5 Statistical Methods Statistical analysis was conducted using SPSS (version 26.0). Categorical variables were analyzed with the Pearson chi-square or Fisher's exact test, while continuous variables were assessed using the Student's t-test. Variables with multiple comparisons, such as perioperative changes in HB, HCT, WBC, NLR, ESR, and CRP, were analyzed with repeated-measures ANOVA and post-hoc Bonferroni tests. Results 2.1 General Results The study included 164 patients. The baseline characteristics, including age, gender distribution, BMI, surgical side, Kellgren-Lawrence grade, and preoperative HKA, were consistent across all groups (P > 0.05), indicating comparability, as shown in Table 1. All surgeries were completed successfully. The surgical incisions in the three robotic groups were longer than TKA Group (P < 0.05). The surgery times in the BRATKA group was longer than HRATKA group, while the TKA and CRATKA groups were shorter than them. No notable variations were observed in knee joint swelling rates on postoperative day 3 or the length of hospital stay (LOS) across the four groups (P > 0.05). All patients experienced primary wound healing (Tab. 1). Tab.1 Demographic characteristics of the four patient groups. Grouping Cases Age Sex (male/female) BMI Operation side(R/L) K-L Class PreoperativeHKA Length of incision time of operation The swelling rate of the knee joint（POD3） LOS III IV TKA Group（n=40） 40 65.50±8.90 15/25 25.18±2.78 21/19 14 26 174±4.9 12.7±1.2 81.45±6.79 5.92±0.92 10.30±1.55 BRATKA Group（n=40） 40 64.30±7.00 16/24 24.17±1.84 18/22 13 27 173.5±5.6 13.9±1.9 a 132.1±34.6 a 6.02±0.65 10.52±1.92 HRATKA Group（n=42） 42 64.70±8.30 16/26 25.10±2.30 21/21 15 27 172.5±4.1 14.13±0.74 a 96.80±7.10 ab 5.85±0.88 10.30±1.70 CRATKA Group（n=42） 42 65.60±7.50 14/28 24.50±2.70 20/22 11 31 173.3±4.1 14.02±0.54 a 90.10±8.80 abc 6.10±0.79 9.80±2.20 Note : a Compared with the conventional TKA group, P < 0.05; b Compared with the BRATKA group, P < 0.05; c Compared with the HRATKA group, P < 0.05. 2.2 Radiographic Measurement Results At the 3-month postoperative follow-up, all patients had well-aligned knee prostheses with no signs of loosening. No significant differences in FTC and HKA were found between the four groups (P > 0.05). The FFC in the HRATKA group was closer to 90° compared to the TKA, BRATKA, and CRATKA groups (P 0.05). The LFC angle in the HRATKA and TKA groups was similar, but smaller than that in the BRATKA and CRATKA groups (P < 0.05). The LTC angle in the HRATKA group was closer to 90° compared to the TKA group (P < 0.05) (Tab. 2). Tab.2 Comparison of Lower Limb Alignment and Prosthesis Position Postoperatively in the Four Groups (x̄±S) Grouping FFC LFC FTC LTC HKA TKA Group（n=40） 87.62±1.90 7.72±2.2 88.62±1.21 86.12±2.32 176.98±1.65 BRATKA Group（n=40） 87.92±1.02 9.98±1.54 a 88.51±0.85 86.52±1.02 177.45±1.39 HRATKA Group（n=42） 88.98±0.64 ab 7.00±1.41 b 88.62±0.80 86.74±1.50 a 178.05±1.29 CRATKA Group（n=42） 87.88±1.74 c 10.60±2.84 ac 88.45±1.31 86.36±1.86 177.33±1.65 Note :a Compared with the conventional TKA group, P < 0.05;b Compared with the BRATKA group, P < 0.05;c Compared with the HRATKA group, P 0.05). In all four groups, postoperative hemoglobin (HB) and hematocrit (HCT) levels initially decreased, reaching their lowest point on postoperative day 3 before beginning to rise. No statistically significant differences in HB and HCT were observed at any time point (P > 0.05) (Fig. 2). 3.4 Inflammatory Indicators The white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in all four groups showed an increasing trend starting from postoperative day 1 (POD1). Specifically, the WBC and NLR peaked on POD1 and then decreased, while the ESR and CRP reached their peak on POD3 before declining. No statistically significant differences were observed between the indexes at the respective time points (Fig. 3). 2.4 Clinical Efficacy Evaluation Results No statistically significant differences were found in preoperative knee pain, function, or range of motion (ROM) among the four groups (P > 0.05). On postoperative day 3, resting pain in the BRATKA group was higher than in the TKA, HRATKA, and CRATKA groups, with statistically significant differences (P < 0.05). The HRATKA group experienced higher resting pain than the CRATKA group, with a statistically significant difference (P 0.05). The exercise VAS scores in the BRATKA and HRATKA groups were similar, with no significant difference between them (P > 0.05). However, both groups had higher scores compared to the TKA and CRATKA groups, with statistically significant differences (P 0.05). There were no statistically significant differences in KSS scores and ROM between the groups at postoperative days 3 and 90 (P > 0.05). However, VAS scores, ROM, and KSS scores at 90 days postoperatively were significantly improved compared to those on postoperative day 3 (P < 0.05). Additionally, the VAS scores, ROM, and KSS scores at postoperative day 3 showed significant improvement compared to preoperative values (P < 0.05) (Tab. 3-4). Tab.3 Comparison of VAS and ROM of knee joint before and after surgery between four groups（x̄±S） Grouping Resting VAS（x̄±S） The VAS of motion（x̄±S） ROM pre-operation POD3 POD90 pre-operation POD3 POD90 pre-operation POD3 POD90 TKA Group（n=40） 6.20±1.02 3.95±0.89 1.48±0.77 7.02±1.05 4.35±0.87 2.01±0.99 100.01±9.71 110.51±8.52 119.52±8.87 BRATKA Group（n=40） 6.08±1.20 4.89±0.78 a 1.50±0.57 7.22±1.56 5.65±0.77 a 1.98±0.77 99.68±8.79 109.57±7.33 118.78±9.02 HRATKA Group（n=42） 6.23±1.05 4.33±1.08 b 1.45±0.85 7.33±1.52 5.56±1.23 a 2.00±0.85 101.50±12.33 108.33±5.65 118.00±9.05 CRATKA Group（n=42） 6.15±1.32 3.85±0.99 bc 1.52±0.86 6.90±1.33 4.25±0.89 bc 1.95±0.68 99.46±9.85 107.44±7.25 117.78±8.38 Note : a Compared with the conventional TKA group, P < 0.05; b Compared with the BRATKA group, P < 0.05; c Compared with the HRATKA group, P < 0.05 Tab.4 Comparison of KSS of knee joint between four groups during perioperative period Grouping KSS（x̄±S） Clinical score Function scores Total scores pre-operation POD3 POD90 pre-operation POD3 POD90 pre-operation POD3 POD90 TKA Group（n=40） 40.51±4.15 50.21±4.21 81.24±6.25 42.05±3.54 49.52±6.25 76.54±6.24 83.54±7.25 100.25±8.54 157.54±6.87 BRATKA Group（n=40） 41.25±4.21 51.24±3.68 80.54±7.55 41.25±3.65 47.54±5.64 75.01±5.87 82.54±8.22 99.84±9.25 156.85±6.54 HRATKA Group（n=42） 41.33±4.05 50.33±4.54 79.05±6.60 42.23±3.31 49.44±6.02 77.21±6.05 83.25±6.05 100.00±8.65 156.52±7.25 CRATKA Group（n=42） 42.42±4.60 52.05±3.59 80.28±6.09 41.33±3.78 48.33±5.22 75.35±6.22 84.23±7.89 99.00±7.58 155.00±6.85 2.5 Incidence of Complications and Patient Satisfaction Evaluation All four groups experienced complications such as lower limb deep vein thrombosis and wound exudation postoperatively, with no statistically significant differences (P > 0.05). No mechanical-related complications, deep vein thrombosis, pulmonary embolism, neurovascular injury, acute periprosthetic infection, or other severe complications occurred. Additionally, there were no instances of nausea, vomiting, or aspiration pneumonia. Patient satisfaction during hospitalisation showed no statistically significant differences across the groups (P > 0.05) (Tab. 5). Tab.5: Comparison of perioperative complication rates and patient satisfaction between the four groups. Grouping Complication rate (n,%) Satisfaction during hospitalization (%) Intermuscular vein thrombosis Wound exudate Others (mechanical-related complications, deep vein thrombosis, etc. TKA Group（n=40） 3 1 0 97.50（39/40） BRATKA Group（n=40） 5 2 0 95.00（38/40） HRATKA Group（n=42） 4 (9.52) 2（4.76） 0 95.24（40/42） CRATKA Group（n=42） 3 (7.14) 2（4.76） 0 92.86（39/42） Fisher 0.935 0.685 - 1.077 P 0.852 1.000 - 0.959 2.6 Typical cases Discussion 3.1 Current Status of Robot-Assisted TKA Development in China With the ageing population and the steadily rising life expectancy in China, the number of TKA will gradually increase in the future. As precision medicine and scientific technology continue to advance rapidly, surgical robots are expected to experience significant development potential in the coming years[21, 22]. According to statistics, in 2020, the total number of surgical robots worldwide, with the United States leading, accounted for over 50% of the global market share[23], followed by the European Union, while China accounted for 5.1%. The ROBODOC and the MAKO robotic systems are among the earlier robotic systems.[24,25, 26]. Patents related to surgical robots started to increase in 2000, with 41% of these patents focusing on positioning and navigation technologies, marking a new phase in China’s development and research into joint surgery robots.In 2022, several companies in China, including HURWA, MicroPort Robotics Honghu, Yuanhua Intelligent Technology’s Bone Saint Yuanhua, and Jianjia ARTHROBOT, were approved for market introduction. The number of robotic systems used in joint surgery increased from 17 in 2020 to 136 in 2023, with projections indicating it will reach 788 by 2026.[27]. However, the adoption of robot-assisted TKA remains relatively low at present, with the majority of installations concentrated in major cities and academic hospitals. The distribution follows a "south-heavy, north-light" pattern. Additionally, as the usage and maintenance costs of surgical robots have yet to be included in the medical insurance system, studies on the use of robots in TKA remains limited. Most regions are still in the early stages of development and integration. Nevertheless, with increasing interest and promotion from healthcare professionals, rapid advancements in this technology are anticipated in the near future. 3.2 Summary of the Advantages of the Three Robotic Systems In this study, we highlight the different characteristics of the three robotic systems used in TKA, as follows: Brainlab Knee 3 Navigation System [15, 16, 17] :① Imaging-guided and accurate bone resection positioning: The Brainlab Knee 3 navigation system employs advanced computer-assisted navigation technology to ensure precise bone positioning and resection planning by acquiring real-time three-dimensional imaging data of the patient's knee joint.② Dynamic gap balance feedback technology: This system integrates gap balance technology, allowing for the real-time monitoring and adjustment of the joint gap during the flexion-extension movements of the surgery.③ Intraoperative alignment optimisation and personalised bone resection planning: The Brainlab Knee 3 system enables surgeons to create a personalised bone resection and gap balancing plan based on dynamic assessments of lower limb alignment during the procedure.④ Streamlined registration process and quick operation: Preoperative CT scans are not necessary, as intraoperative registration reduces preparation time and minimises the financial burden on patients.⑤ Absence of resection components, providing only resection-related guidance: Resection is carried out with the aid of resection guides, but without robotic resection components.⑥ Accurate soft tissue tension evaluation and adjustment: The system prioritises soft tissue balance, enabling surgeons to precisely evaluate and modify soft tissue tension throughout the procedure. This is vital for achieving balanced flexion and extension, ensuring soft tissue stability throughout knee joint movement.⑦ Compact design, facilitating transportation and integration into operating room layouts: The system's compact size makes it easy to transport and integrate into operating rooms with various configurations. Dom estic HURWA Robot [28, 29] :① Precise robotic arm control and personalised surgical planning: The HURWA robotic system uses preoperative CT scan imaging data to develop a personalised surgical plan, assisting surgeons in accurately positioning the prosthesis and performing bone resections during surgery. The system offers precise assistance via the robotic arm, allowing real-time monitoring of bone resection thickness and angles to ensure surgical accuracy.② Localized technical support and service advantages: As a domestic robotic system, the HURWA robot provides quicker technical support and is more convenient for postoperative equipment maintenance and system updates. Compared to imported systems, this domestic robot is better suited to the local healthcare environment and can be customised to better align with the anatomical characteristics of Chinese patients.③ Shorter learning curve and user-friendly interface: The HURWA robot system features a simple, intuitive interface, making the operating process straightforward. For surgeons in primary healthcare settings, the system allows for swift adaptation, thereby reducing the time needed to transition from traditional surgery to robot-assisted surgery.④ Bone resection characteristics: The system employs a robotic arm-controlled electric saw for bone resection, which enhances efficiency and significantly speeds up the surgery. However, if the safety lines are not appropriately designed or if the system does not precisely control the procedure, the speed and force of the electric saw could harm nearby vital soft tissues, such as ligaments, nerves, or blood vessels, leading to potential postoperative complications. Thus, it is essential to carefully plan the resection path and establish safety zones to prevent soft tissue injury when using the robotic arm electric saw for bone resection. Stryker Cori Robot [30, 31, 32] :① No preoperative CT required, uses intraoperative 3D registration technology: A standout feature of the Cori robotic system is that it eliminates the need for preoperative CT scans. During surgery, it reconstructs the patient's true bone surface anatomy in 3D, including cartilage details, and creates an optimal surgical plan in real-time, based on soft tissue tension and lower limb alignment. This reduces preoperative preparation time and alleviates the financial burden on patients.② Millimeter-level accuracy, ensuring optimal prosthesis alignment: The Cori robot continuously monitors the balance of knee ligaments and real-time soft tissue tension, helping surgeons adjust the surgical plan to maintain knee stability and improve postoperative recovery.③ Compact, portable design, adaptable to various hospital sizes: The Cori robot is designed to be compact and portable, minimising the space required in the operating room and providing flexible configurations that suit hospitals of different sizes. Additionally, it does not necessitate sterile preparation for the system or complex instrument assembly, saving both time and effort.④ Flexibility and adaptability: The Cori robot provides exceptional flexibility in real-time soft tissue assessment, 3D registration, and adjustments during surgery, making it particularly suitable for complex cases that require customised modifications. In contrast, the HURWA robot is more focused on precise bone resection and prosthesis positioning through robotic arm control, offering higher operational efficiency in standard cases.⑤ Burr bone resection characteristics: The burr is employed for grinding-type bone resection, which, although slower than electric saw resection, achieves higher efficiency by applying appropriate mechanical traction. The small size of the burr ensures minimal mechanical damage to soft tissues during resection. For patients with complex joint anatomies, the burr allows for finer adjustments of resection angles and depths, helping to preserve joint surface balance, maintain smooth bone surfaces, and reduce the risk of postoperative prosthesis wear. The use of the burr also diminishes intraoperative instrument tremor and prevents the loosening of positioning reflectors. However, during the grinding process, bone chips can be ejected, especially when grinding harder bone, potentially contaminating the surgical field and increasing the risk of local infection. This can be mitigated by using shields, controlling the water flow to the burr, and employing assistant suction techniques to reduce bone chip dispersion. 3.3 Clinical Efficacy Comparison of the Three Robotic Systems In this study, the three robotic systems (HURWA robot, CORI robot, and Brainlab robot) each displayed their unique advantages and differences in TKA. Unlike traditional TKA, the introduction of various robotic systems has made it more difficult for many surgeons new to robotic surgery to quickly acclimatise to the surgical environment[33]. During the learning phase, issues such as prolonged surgery durations, registration errors, and operational mistakes may occur, potentially leading to increased surgical trauma or adverse reactions that could impact the rehabilitation of the knee joint. Ensuring the surgical effectiveness and rehabilitation outcomes of robot-assisted TKA is a critical concern for clinical practitioners. The ERAS has already been successfully applied in joint surgeries, is a crucial strategy for ensuring these outcomes. In this study, we observed that in terms of surgical duration, all three robotic systems resulted in longer operation times compared to the conventional group.The Brainlab system lacks a resection component and requires resection to be performed using a guide, which makes the surgical process more complex and results in slightly longer operation times compared to the other two robotic systems. In contrast, the HURWA and CORI robotic systems had relatively shorter surgical durations. The HURWA robot, which employs a robotic arm electric saw for bone resection, demonstrated greater operational efficiency. On the other hand, the CORI robot uses a burr for grinding-type bone resection, which takes longer, but its strength lies in its ability to assess soft tissue tension in real-time, thereby optimising joint stability. However, as surgeons become more skilled with these systems, surgical time tends to decrease, which aligns with the findings of Weaver et al.[34].In terms of blood loss, the robotic groups exhibited similar perioperative blood loss to the conventional group, likely because all surgeries were conducted with a tourniquet. Additionally, no marrow opening was performed in the robotic groups, compensating for any potential hidden blood loss due to the longer surgical time when compared to the conventional group. Regarding radiographic assessments, the robotic systems demonstrated more consistent control over the prosthesis angles. The HURWA robot, in particular, showed superior postoperative recovery in terms of FFC and LFC angles compared to the other two systems, likely due to its precise preoperative CT planning for bone resection and intraoperative knee joint fixation. This significantly reduced the occurrence of postoperative joint angle deviations and mechanical axis misalignments. In contrast, the Brainlab and CORI robots focused more on soft tissue assessment to optimise joint stability, yet they maintained accurate control over parameters like FTC, LTC, and HKA.Regarding complications, all three groups experienced common issues, including bilateral lower limb deep vein thrombosis and wound exudation. However, all patients showed symptom improvement following anticoagulation therapy and wound dressing changes. No severe complications, such as pulmonary embolism, neurovascular injury, or acute periprosthetic infection, were reported, and there were no instances of nausea, vomiting, or aspiration. 3.4 Importance of the ERAS Concept in Perioperative Management of Robot-Assisted TKA Patients The development of robot-assisted technology seeks to enhance surgical precision and outcomes, as well as improve patient satisfaction[35]. International research has shown that robot-assisted TKA can effectively reduce hospital stays, alleviate pain, decrease short-term inflammatory responses, and lower the incidence of complications such as thrombosis, pneumonia, and wound infections. Long-term follow-up research has also demonstrated a decrease in revision rates and opioid usage[36], offering certain economic benefits. However, in this study, robot-assisted TKA did not show significant advantages in terms of hospital stay, short-term knee function, or complications. This discrepancy may be attributed to the relatively recent advancement of domestic robotic systems, which have a shorter clinical application history. As a result, they have not yet fully addressed complications or surgical risks associated with mechanical failures or the surgeon's inexperience. Moreover, due to the necessity of inserting fixation pins into the patient’s bone structures, placing femoral and tibial trackers, and the registration process, current robot-assisted TKA surgeries tend to involve longer operation times and larger incisions, which could increase the risk of surgical site infections[37]. Furthermore, due to the low prevalence and limited patient awareness of robot-assisted TKA in China, some patients remain doubtful about the technology and may experience anxiety or negative emotions, which can impact their rehabilitation process. Ensuring safety, surgical effectiveness, rapid recovery, and patient satisfaction during hospitalisation for robot-assisted TKA is essential to support the development of robotic technology[38, 39]. Since 2015, our department, as a pilot hospital for accelerated recovery orthopaedic surgery designated by the National Health Commission, has consistently implemented the ERAS concept in the perioperative management of traditional TKA patients, achieving positive outcomes. ERAS optimises perioperative management, reduces surgical stress responses, accelerates recovery, shortens hospital stay duration and decreases the occurrence of postoperative complications. For robot-assisted TKA, it is crucial to focus on preoperative education, psychological assessments, wound management, pain control, and postoperative rehabilitation exercises as key components of perioperative care[12]. Strict adherence to these measures in robot-assisted TKA patients can significantly promote rapid recovery and improve the overall patient experience.The close relationship between ERAS and robot-assisted TKA is evident in the following aspects[40]: ① In line with the ERAS concept, robot-assisted TKA offers enhanced surgical precision and minimally invasive techniques, without increasing intraoperative blood loss or postoperative pain, thereby minimising surgical trauma. ② Robot-assisted TKA employs preoperative 3D imaging and planning to develop a personalised surgical plan, which better preserves joint function while minimising the incidence of surgical complications. This approach reduces postoperative discomfort and complications, thereby accelerating recovery. ③ ERAS stresses early mobilisation and active rehabilitation. Robot-assisted TKA can offer personalised rehabilitation plans based on preoperative assessments and planning, providing timely guidance and supervision for recovery after surgery. ④ Robot-assisted TKA has the ability to collect and analyse large volumes of surgical data and parameters, offering valuable information and feedback to the surgeon. This helps evaluate surgical outcomes more effectively, predict recovery progress, and promptly adjust treatment plans. 3.5 Limitations of This Study Firstly, the study has a relatively small sample size and a short follow-up period. A longer follow-up duration is necessary to observe and compare the long-term efficacy of the three robotic systems. Secondly, this is a single-centre study, and regional variations and biases in surgical techniques may exist. The technical expertise of different hospitals and surgeons, as well as individual patient characteristics, could influence surgical outcomes. Lastly, as the robotic assistance systems were used in a sequential manner, there is a learning curve, which could lead to bias in the study outcomes. Conclusion The study assessed the effectiveness of three robotic systems (HURWA robot, CORI robot, and Brainlab robot) in TKA and explored the role of the ERAS concept in enhancing postoperative rehabilitation. Although, during the learning curve, the surgery duration for the three robotic systems was longer than that of conventional knee arthroplasty, and the incisions were larger, the support of the ERAS concept helped prevent any significant increase in postoperative knee joint swelling, extended hospital stay, pain, or complication rates. Moreover, the three robotic systems produced similar outcomes in terms of postoperative functional recovery, complication management, and patient satisfaction, each offering its own advantages. Looking ahead, as technology continues to progress and surgeons accumulate more experience, robot-assisted surgery is anticipated to have a growing impact on enhancing surgical efficiency, reducing complications, and expediting rehabilitation, providing more precise and tailored treatment options for knee arthroplasty. Abbreviations TXA tranexamic acid VAS Visual analogue scale TKA Total knee arthroplasty HB Hemoglobin HCT Hematocrit WBC White Blood Cell ESR Erythrocyte Sedimentation Rate CRP C-reactive Protein TBL total blood loss PBV patient’s blood volume BRATKA Brainlab navigation system assisted total knee arthroplasty HRATKA HURWA robot-assisted total knee arthroplasty CRATKA Stryker Cori robot-assisted total knee arthroplasty KSS American Knee Society Score ROM range of motion VAS visual analogue scale LOS length of stay. Declarations Acknowledgements This study adheres to CONSORT guidelines. We are thankful for the support of the nursing staffs from the Department of Orthopaedics, Panzhihua Municipal Central Hospital and the patients enrolled in this study. Authors’ contributions MYW and ZDT participated in the perioperative management, and postoperative follow-up and wrote the main manuscript; Yuping Lan was in charge of the whole preoperative planning, operation process and helped revise the article; HPW, XZS, MLW and RQL were in charge of the follow-up of the patients; All authors read and approved the final draft. Funding This research was funded by Sichuan Medical Association Orthopedics (Shang Antong) special research project (No.2023SAT14) , Research Project of Sichuan Society of Gerontology (No. 24SCLN092), Sichuan Provincial Primary Health Development Research Center in 2024, North Sichuan Medical College (No. SWFZ24-Q-86) and Chengdu High-tech Medical Association "2023 annual Flurbiprofen gel paste treatment of osteoarthritis special research fund" project (2024013), who is not involved in study design, data collection, analysis and interpretation or manuscript preparation. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was approved by The Institutional Review Board of Panzhihua Central Hospital (Pankelun Trial No. [2024-008]) and written informed consent to participate was obtained from all of the individual participants included in the study. Consent for publication Written informed consent was obtained from the patient for publication of this paper. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Author details Department of Orthopedics, Panzhihua Municipal Central Hospital, 34# Yikang road, Panzhihua 617000, People’s Republic of China. References Jang S, Lee K, Ju JH. Recent Updates of Diagnosis, Pathophysiology, and Treatment on Osteoarthritis of the Knee. INT J MOL SCI 2021 2021-03-05;22(5). 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Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022 2022-08-01;30(8):2677–95. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Oct, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 17 Sep, 2025 Reviews received at journal 17 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 12 Aug, 2025 Reviewers invited by journal 06 Aug, 2025 Editor assigned by journal 25 Jul, 2025 Submission checks completed at journal 24 Jul, 2025 First submitted to journal 23 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7198229","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498796895,"identity":"bdc2f991-2a6a-48ef-a40b-cd5138aad728","order_by":0,"name":"Mingyou Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIie3QMQrCMBTG8VcK0eHZbvJEoVdIEaSD6FWUglMHRydxcqp7S8EzFLxAStbOLl0KvUDAxUHEujnZjIL5b4HvR0gATKYfTSikBfMaIdRdT1hFMglCBzbrIo31iC1xvrPOEE1ln2ns+bXkAiOyGZRKAoLnDkUHqSIuqCSHWadcbgPw02z1nczexI/bW+xBLhOEFa90yPpJ1pFhLZHpEoEtQQQ9sqw22+KAFDJivP1k6n7LKAsvtwfuF15iN0rd55477iAAff55oq75u16tszKZTKZ/7gU3YEZeaLvoHQAAAABJRU5ErkJggg==","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mingyou","middleName":"","lastName":"Wang","suffix":""},{"id":498796896,"identity":"0d6b0e13-5705-4e4c-a60f-75ecb6d2cc5d","order_by":1,"name":"Zhuodong Tang","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhuodong","middleName":"","lastName":"Tang","suffix":""},{"id":498796897,"identity":"c702d45f-31fa-4c7e-b2c1-27083ddb7a00","order_by":2,"name":"Yuping Lan","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuping","middleName":"","lastName":"Lan","suffix":""},{"id":498796898,"identity":"de85e586-05a1-4b1d-a778-1970600ec00d","order_by":3,"name":"Ruiqi Lan","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruiqi","middleName":"","lastName":"Lan","suffix":""},{"id":498796899,"identity":"46a361c7-1deb-4d01-a595-b74f69eff224","order_by":4,"name":"Mingli Wang","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingli","middleName":"","lastName":"Wang","suffix":""},{"id":498796900,"identity":"b392808c-e06c-4935-b2d0-3a5a1c6ddfca","order_by":5,"name":"Xunzhou Song","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xunzhou","middleName":"","lastName":"Song","suffix":""},{"id":498796901,"identity":"bcca3853-0f95-4205-8c10-6a7bd1b0e925","order_by":6,"name":"Hongping Wang","email":"","orcid":"","institution":"Panzhihua Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hongping","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-07-23 15:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7198229/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7198229/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-025-02859-4","type":"published","date":"2025-10-09T15:58:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88948720,"identity":"b00f2d39-b433-4ab4-a893-59fd76fb542f","added_by":"auto","created_at":"2025-08-13 05:36:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":201344,"visible":true,"origin":"","legend":"\u003cp\u003eA.Hip-knee-ankle angle（HKA） B.Sagittal plane femoral component angle（LFC）and sagittal plane tibial component angles（LTC） C.Coronal plane femoral component angle（FFC）D.Coronal plane tibial component angle（FTC）\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/8873dece867b1b9a74c5535a.png"},{"id":88948722,"identity":"b761c6af-c934-4b69-9635-e278ea23a5a1","added_by":"auto","created_at":"2025-08-13 05:36:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162298,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the trends in perioperative HB, HCT, and TBL between the four groups. (A) Trend of HB changes; (B) Trend of HCT changes; (C) Trend of total blood loss.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/a48b40c5a89f18406f49507a.png"},{"id":88948721,"identity":"1de50416-46d5-409a-81d4-bbebd40518e4","added_by":"auto","created_at":"2025-08-13 05:36:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":63388,"visible":true,"origin":"","legend":"\u003cp\u003eInflammatory indicators. (A) Trend of WBC changes; (B) Trend of NLR changes; (C) Trend of ESR changes; (D) Trend of CRP changes.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/2cd6ab07496c4d6e15fd188f.png"},{"id":88948725,"identity":"822fe8ff-cd31-44cd-8474-965eeae03ed0","added_by":"auto","created_at":"2025-08-13 05:36:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":468296,"visible":true,"origin":"","legend":"\u003cp\u003eA typical case（HURWA Robot）. A 61-year-old female patient with left knee osteoarthritis (K-L IV), undergoing robot-assisted TKA using the HURWA system. (A1-A3) Preoperative X-rays; (B) The robotic control console and mechanical arm of the HURWA robot-assisted TKA system; (C1-C2) Preoperative osteotomy planning; (C3-C4) Verification of the flexion-extension gap after osteotomy; (D1-D3) Intraoperative good alignment of the joint prosthesis with the osteotomy surface; (E1-E3) Postoperative X-rays.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/a85b0b83930d7e6967deb6f1.png"},{"id":88948737,"identity":"a8ba3a55-01e1-440a-8a3d-23c36724bab6","added_by":"auto","created_at":"2025-08-13 05:36:03","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":484744,"visible":true,"origin":"","legend":"\u003cp\u003eA typical case（CORI Robot）. A 65-year-old female patient with right knee osteoarthritis (K-L IV), undergoing robot-assisted TKA using the Stryker Cori system. (A1-A3) Preoperative \u0026nbsp;X-rays; (B) The Stryker Cori handheld drill-type orthopaedic robot; (C) Preoperative osteotomy planning; (D1-D2) Intraoperative femoral and tibial osteotomies; (E1-E2) After osteotomy, the prosthesis trial aligns well with the femoral bone surface; (E2) Verification of the flexion-extension gap and soft tissue balance after final prosthesis placement; (F1-F3) Postoperative X-rays.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/5d77927105ed23b233c4b595.png"},{"id":88948730,"identity":"4d50c82b-95e2-4b32-b5ee-762677ad65f3","added_by":"auto","created_at":"2025-08-13 05:36:02","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":326464,"visible":true,"origin":"","legend":"\u003cp\u003eFig.5: A typical case（Brainlab navigation system）.A 61-year-old female patient with right knee osteoarthritis (K-L IV), undergoing robot-assisted TKA using the Brainlab navigation system. (A1-A3) Preoperative full-length X-rays of both lower limbs and anteroposterior and lateral views of the knee joint; (B) Preoperative osteotomy planning; (C1-C2) Intraoperative femoral osteotomies; (D) Operation report; (E1-E3) Postoperative anteroposterior and lateral X-rays of the knee joint and full-length X-rays of both lower limbs.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/8f0a424a3b43cc27295b1cde.png"},{"id":93419782,"identity":"2d302499-781a-4c6f-bf3e-03afc7c3566c","added_by":"auto","created_at":"2025-10-13 16:07:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2997684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7198229/v1/58791c0f-4af8-4d9e-ae49-c667561268d3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application and Postoperative Rehabilitation Effects of HURWA, Cori, and Brainlab Robots in TKA under the ERAS Concept","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is one of the most prevalent joint conditions among the elderly population. With the ongoing global trend of ageing populations, the incidence of knee osteoarthritis is increasing[1]. Total knee arthroplasty (TKA) has emerged as an effective treatment option to enhance knee joint function, alleviate pain, and improve quality of life. However, despite the growing sophistication of TKA technology, the postoperative recovery process still presents a number of challenges, including pain management, functional recovery, and postoperative complications[2]. In recent years, with the rapid advancement of precision medicine and surgical robotic technology, robot-assisted surgery in TKA has gradually become a new trend[3, 4]. Robot-assisted surgery not only offers greater precision and personalised surgical planning but also contributes to improved postoperative recovery, particularly in areas such as prosthesis positioning, bone resection accuracy, and soft tissue assessment, demonstrating significant advantages[5, 6, 7, 8]. However, the adoption of robotic technology in China began relatively later, with most robot-assisted surgeries being concentrated in major cities and hospitals. For many surgeons who are newly introduced to robotic surgery, there is a notable learning curve[9, 10]. During this phase, as technical skills are still developing, surgeries tend to take longer, leading to extended anesthesia and tourniquet application times, which could increase the risk of postoperative complications or adverse reactions[10, 11]. In light of this, the application of the Enhanced Recovery After Surgery (ERAS) concept is crucial in enhancing the postoperative recovery of patients undergoing robotic surgery[12]. The ERAS framework aims to optimise perioperative management and accelerate recovery by combining preoperative nutritional assessments and psychological interventions, precise intraoperative techniques, and early postoperative mobilisation and functional recovery[13, 14]. The implementation of the ERAS concept helps mitigate the potential negative impacts associated with the initial learning curve of robotic technology. Specifically, its benefits in reducing postoperative complications, shortening hospital stays, relieving postoperative pain, and enhancing functional recovery position it as a vital complement to robotic technology. The aim of this study is to explore the use of three robotic systems in TKA under the ERAS concept and assess their impact on promoting postoperative rehabilitation. Through this research, we intend to provide a more robust theoretical foundation for the integration of robotic technology with the ERAS concept, promote holistic rehabilitation in knee arthroplasty patients, and offer guidance for future clinical implementations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e1.1 General Information\u003c/strong\u003e\u003cbr\u003eThe study included patients who received TKA for end-stage knee osteoarthritis at our hospital from December 2020 to May 2025. Based on the surgical approach and robotic assistance system, the patients were classified into four groups: 1. Conventional TKA group; 2. Brainlab navigation system group (BRATKA group); 3. Domestic HURWA robot group (HRATKA group); 4. Stryker Cori robot group (CRATKA group).Inclusion criteria included\u003cstrong\u003e:\u003c/strong\u003e ① Age \u0026ge; 50 years with a diagnosis of end-stage KOA; ② Failure of conservative treatment; ③ All procedures were conducted by the same surgical team using primary unilateral knee arthroplasty with the same type of knee prosthesis; ④ Absence of local or systemic infection in the knee joint; ⑤ Full understanding of the study\u0026apos;s risks and benefits, and provision of informed consent to participate. Exclusion criteria included: ① Presence of local knee infection or any active systemic infection; ② Severe cardiovascular or pulmonary impairment, liver or kidney dysfunction, or patients who were unable to tolerate surgery; ③ A history of knee joint aspiration or injection within the past month; ④ Neuromuscular disorders such as paralysis or muscle weakness; ⑤ Any other conditions deemed unsuitable by the investigators or patients who withdrew from the study. Ethical clearance for this study was granted by the Ethics Committee of Panzhihua Central Hospital (Approval No.: Pan Ke Lun Shen Zi No. 2024-008).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Surgical Method\u003c/strong\u003e\u003cbr\u003eThe procedure was carried out by the same group of experienced surgeons.All procedures were carried out under combined spinal and general anesthesia in the supine position. A tourniquet was applied during the procedure, and a standard anterior midline approach with a medial parapatellar incision was used for TKA. The surgical field was routinely disinfected and draped.Thirty minutes before surgery, a standard dose of 1.5g of cefuroxime sodium was administered. Fifteen minutes before skin incision, a routine intravenous injection of 1g of tranexamic acid was given. After the joint capsule was sutured, 3g of tranexamic acid was injected into the joint cavity, and a \u0026quot;cocktail\u0026quot; injection was used for periarticular injections around the joint.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.1 Conventional TKA Group\u003c/strong\u003e:Preoperative planning and bone resection were performed using the standard total knee arthroplasty (TKA) technique. A Stryker Legion knee prosthesis (USA) was inserted, and once the bone cement had set, the joint capsule was sutured. The subcutaneous tissue and skin were closed in layers, followed by the application of a sterile gauze dressing. The procedure was then concluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.2 BRATKA Group [15, 16, 17]\u003c/strong\u003e:For this group, the Brainlab Knee3 navigation system was employed. After exposing the knee joint, the anterior and posterior cruciate ligaments, along with osteophytes, were excised, and the patella was denervated, with its edges cleared of osteophytes. Robotic navigation trackers were positioned on the distal medial femur and the proximal medial tibia. The hip joint was mobilised to locate the centre of the femoral head, and the system was used to sequentially register the distal femoral cortex, the medial and lateral femoral condyles, the Whiteside line, the tibial medial and lateral platforms, the tibial intercondylar ridge, the tibial proximal centre, and the medial and lateral malleoli. The knee joint was flexed and extended, and valgus and varus stress tests were conducted. The robotic system recorded the sizes of the medial and lateral gaps, as well as the alignment of the lower limb. Following registration, the initial surgical plan was generated by the computer software, and parameters such as prosthesis size, resection thickness, and resection angle were adjusted based on the patient\u0026rsquo;s specific condition. Once the surgical plan was finalised, bone resection was carried out under the guidance of the robotic system. The distal femur and tibial platform were resected first, with each resection being followed by a verification of its accuracy. After the bone resection was completed, the flexion and extension gaps were reassessed to ensure balance between the medial-lateral and flexion-extension gaps. A trial prosthesis was then placed and tested, further confirming the flexion and extension of the knee joint. Varus and valgus stress tests were applied to assess both lower limb alignment and gap balance. Once satisfactory results were achieved, the navigation trackers were removed, and the final prosthesis was implanted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.3 CRATKA Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Stryker CORI Orthopaedic Intelligent Robot was used for this group. After exposing the joint via the previously described incision, 3D infrared camera tracking arrays were positioned on the distal medial femur and the proximal medial tibia. A burr was then installed, and the flexible handheld robotic arm was calibrated. The system proceeded to guide the step-by-step registration of the anatomical landmarks of the knee and ankle joints. The hip joint was mobilised to locate the centre of the femoral head, and the alignment of the lower limb as well as the flexion-extension angles were assessed. Following system prompts, the femur and tibia were registered. Soft tissue tension was evaluated, and once the knee joint data were obtained, a surgical plan was formulated. Under the guidance of the robotic navigation system, the distal femur and tibial platform were resected. After resection, a trial knee prosthesis was inserted, and the balance of the medial-lateral and flexion-extension gaps was reassessed. Once satisfactory outcomes were achieved, the 3D infrared camera tracking arrays were removed, and the final prosthesis was implanted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2.4 HRATKA Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperatively, a hip-knee-ankle CT scan was conducted, and the CT data were imported into the HURWA robotic system to create a personalised surgical plan and identify safe bone resection areas. During the surgery, a standard anterior midline approach with a medial parapatellar incision was employed to dissect the soft tissues layer by layer and expose the knee joint. A knee fixation frame was used to stabilise the joint. The robotic positioning reflectors were securely attached to the distal femur and tibial platform. Registration was carried out following system prompts, including the distal femur, distal femoral anterior cortex, and tibial platform.Once registration was completed, the surgeon performed bone resections of the distal femur and tibial platform under the guidance of the robotic arm, continuously monitoring the thickness and angles of the resections. After the bone resections were finalised, a trial prosthesis was inserted to assess the flexion-extension gap and the balance of the medial-lateral gap in the knee joint. Once satisfactory outcomes were confirmed, the final prosthesis was implanted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Perioperative Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients followed the same perioperative protocols, including anti-inflammatory, analgesic, anticoagulant, decongestive, and functional exercises based on the Chinese Expert Consensus on Accelerated Rehabilitation of Hip and Knee Arthroplasty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Evaluation Criteria for Efficacy\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eGeneral data, including age, gender, height, weight, surgical site, Kellgren-Lawrence grade, preoperative HKA (hip-knee-ankle angle), preoperative functional assessment, incision length, surgery time, and total blood loss, were collected for all patients.Postoperative follow-up included X-rays of the knee joint in both the anteroposterior and lateral views, as well as full-length X-rays of both lower limbs. The prosthesis position was evaluated by measuring the following angles:Frontal tibia component angle (FTC, optimal value 90\u0026deg;, Fig. 1A)；Lateral femoral component angle (LFC, optimal value 0\u0026deg;, Fig. 1B)；Lateral tibia component angle (LTC, optimal value 87\u0026deg;, Fig. 1B)；Frontal femoral component angle (FFC, optimal value 90\u0026deg;, Fig. 3C).Additionally, the degree of deviation of the hip-knee-ankle angle (HKA, optimal value 180\u0026deg;, Fig. 1D) was used to evaluate lower limb alignment. An abnormal value was defined as a deviation of \u0026ge;3\u0026deg; from the optimal value [18]. Measurement methods are shown in Figure 1.Perioperative follow-up was conducted for 3 months, with a total of 5 visits: preoperative, postoperative day 1, day 3, day 5, and 3-month follow-up. The following parameters were collected: KSS (Knee Society Score), VAS (Visual Analogue Scale) score, range of motion (ROM), hemoglobin (HB), hematocrit (HCT), complication rates, and patient satisfaction during hospitalization.The Knee Society Score (KSS) includes a clinical score [pain (50 points), range of motion (25 points), stability (25 points), total 100 points] and a functional score [walking ability (50 points), stair climbing ability (50 points), total 100 points]. Total blood volume was calculated using the Nadler [19] equation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5 Statistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was conducted using SPSS (version 26.0). Categorical variables were analyzed with the Pearson chi-square or Fisher\u0026apos;s exact test, while continuous variables were assessed using the Student\u0026apos;s t-test. Variables with multiple comparisons, such as perioperative changes in HB, HCT, WBC, NLR, ESR, and CRP, were analyzed with repeated-measures ANOVA and post-hoc Bonferroni tests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e2.1 General Results\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study included 164 patients. The baseline characteristics, including age, gender distribution, BMI, surgical side, Kellgren-Lawrence grade, and preoperative HKA, were consistent across all groups (P \u0026gt; 0.05), indicating comparability, as shown in Table 1. All surgeries were completed successfully. The surgical incisions in the three robotic groups were longer than TKA Group (P \u0026lt; 0.05). The surgery times in the BRATKA group was longer than HRATKA group, while the TKA and CRATKA groups were shorter than them. No notable variations were observed in knee joint swelling rates on postoperative day 3 or the length of hospital stay (LOS) across the four groups (P \u0026gt; 0.05). All patients experienced primary wound healing (Tab. 1).\u003c/p\u003e\n\u003cp\u003eTab.1 Demographic characteristics of the four patient groups.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"784\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 79px;\"\u003e\n \u003cp\u003eGrouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003eCases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 80px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003eSex (male/female)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 79px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003eOperation side(R/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003eK-L Class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003ePreoperativeHKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003eLength of incision\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003etime of operation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003eThe swelling rate of the knee joint（POD3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003eLOS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eTKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e65.50\u0026plusmn;8.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e15/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e25.18\u0026plusmn;2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e21/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e174\u0026plusmn;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e12.7\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e81.45\u0026plusmn;6.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e5.92\u0026plusmn;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e10.30\u0026plusmn;1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eBRATKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e64.30\u0026plusmn;7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e16/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e24.17\u0026plusmn;1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e18/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e173.5\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e13.9\u0026plusmn;1.9\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e132.1\u0026plusmn;34.6\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e6.02\u0026plusmn;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e10.52\u0026plusmn;1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eHRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e64.70\u0026plusmn;8.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e16/26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e25.10\u0026plusmn;2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e21/21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e172.5\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e14.13\u0026plusmn;0.74\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e96.80\u0026plusmn;7.10\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e5.85\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e10.30\u0026plusmn;1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eCRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e65.60\u0026plusmn;7.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e14/28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e24.50\u0026plusmn;2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e20/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e173.3\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e14.02\u0026plusmn;0.54\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e90.10\u0026plusmn;8.80\u003csup\u003eabc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e6.10\u0026plusmn;0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e9.80\u0026plusmn;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e:\u003csup\u003ea\u003c/sup\u003e Compared with the conventional TKA group, P \u0026lt; 0.05;\u003csup\u003eb\u0026nbsp;\u003c/sup\u003eCompared with the BRATKA group, P \u0026lt; 0.05;\u003csup\u003ec\u003c/sup\u003e Compared with the HRATKA group, P \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Radiographic Measurement Results\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;At the 3-month postoperative follow-up, all patients had well-aligned knee prostheses with no signs of loosening. No significant differences in FTC and HKA were found between the four groups (P \u0026gt; 0.05). The FFC in the HRATKA group was closer to 90\u0026deg; compared to the TKA, BRATKA, and CRATKA groups (P \u0026lt; 0.05). However, no significant differences were found among the three robotic groups (P \u0026gt; 0.05). The LFC angle in the HRATKA and TKA groups was similar, but smaller than that in the BRATKA and CRATKA groups (P \u0026lt; 0.05). The LTC angle in the HRATKA group was closer to 90\u0026deg; compared to the TKA group (P \u0026lt; 0.05) (Tab. 2).\u003c/p\u003e\n\u003cp\u003eTab.2 Comparison of Lower Limb Alignment and Prosthesis Position Postoperatively in the Four Groups (x̄\u0026plusmn;S)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"679\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eGrouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eFFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eLFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eFTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eLTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eHKA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eTKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e87.62\u0026plusmn;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e7.72\u0026plusmn;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e88.62\u0026plusmn;1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e86.12\u0026plusmn;2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e176.98\u0026plusmn;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eBRATKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e87.92\u0026plusmn;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e9.98\u0026plusmn;1.54\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e88.51\u0026plusmn;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e86.52\u0026plusmn;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e177.45\u0026plusmn;1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eHRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e88.98\u0026plusmn;0.64\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e7.00\u0026plusmn;1.41\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e88.62\u0026plusmn;0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e86.74\u0026plusmn;1.50\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e178.05\u0026plusmn;1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eCRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e87.88\u0026plusmn;1.74\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e10.60\u0026plusmn;2.84\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e88.45\u0026plusmn;1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e86.36\u0026plusmn;1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e177.33\u0026plusmn;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e:a Compared with the conventional TKA group, P \u0026lt; 0.05;b Compared with the BRATKA group, P \u0026lt; 0.05;c Compared with the HRATKA group, P \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Evaluation of Hemoglobin Changes and Blood Loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe blood loss (TBL) in the TKA, BRATKA, HRATKA, and CRATKA groups was 152.56\u0026plusmn;47.45, 158.91\u0026plusmn;57.79, 152.27\u0026plusmn;41.20, and 156.21\u0026plusmn;53.76 ml (P \u0026gt; 0.05). In all four groups, postoperative hemoglobin (HB) and hematocrit (HCT) levels initially decreased, reaching their lowest point on postoperative day 3 before beginning to rise. No statistically significant differences in HB and HCT were observed at any time point (P \u0026gt; 0.05) (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Inflammatory Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in all four groups showed an increasing trend starting from postoperative day 1 (POD1). Specifically, the WBC and NLR peaked on POD1 and then decreased, while the ESR and CRP reached their peak on POD3 before declining. No statistically significant differences were observed between the indexes at the respective time points (Fig. 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Clinical Efficacy Evaluation Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were found in preoperative knee pain, function, or range of motion (ROM) among the four groups (P \u0026gt; 0.05). On postoperative day 3, resting pain in the BRATKA group was higher than in the TKA, HRATKA, and CRATKA groups, with statistically significant differences (P \u0026lt; 0.05). The HRATKA group experienced higher resting pain than the CRATKA group, with a statistically significant difference (P \u0026lt; 0.05), while no significant difference was observed between the TKA and CRATKA groups (P \u0026gt; 0.05). The exercise VAS scores in the BRATKA and HRATKA groups were similar, with no significant difference between them (P \u0026gt; 0.05). However, both groups had higher scores compared to the TKA and CRATKA groups, with statistically significant differences (P \u0026lt; 0.05). No significant difference was found between the TKA and CRATKA groups (P \u0026gt; 0.05). There were no statistically significant differences in KSS scores and ROM between the groups at postoperative days 3 and 90 (P \u0026gt; 0.05). However, VAS scores, ROM, and KSS scores at 90 days postoperatively were significantly improved compared to those on postoperative day 3 (P \u0026lt; 0.05). Additionally, the VAS scores, ROM, and KSS scores at postoperative day 3 showed significant improvement compared to preoperative values (P \u0026lt; 0.05) (Tab. 3-4).\u003c/p\u003e\n\u003cp\u003eTab.3 Comparison of VAS and ROM of knee joint before and after surgery between four groups（x̄\u0026plusmn;S）\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"776\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003eGrouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 234px;\"\u003e\n \u003cp\u003eResting VAS（x̄\u0026plusmn;S）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 234px;\"\u003e\n \u003cp\u003eThe VAS of motion（x̄\u0026plusmn;S）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 240px;\"\u003e\n \u003cp\u003eROM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eTKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6.20\u0026plusmn;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e3.95\u0026plusmn;0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.48\u0026plusmn;0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e7.02\u0026plusmn;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e4.35\u0026plusmn;0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e2.01\u0026plusmn;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e100.01\u0026plusmn;9.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e110.51\u0026plusmn;8.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e119.52\u0026plusmn;8.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eBRATKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6.08\u0026plusmn;1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e4.89\u0026plusmn;0.78\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.50\u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e7.22\u0026plusmn;1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e5.65\u0026plusmn;0.77\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.98\u0026plusmn;0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e99.68\u0026plusmn;8.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e109.57\u0026plusmn;7.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e118.78\u0026plusmn;9.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eHRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6.23\u0026plusmn;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e4.33\u0026plusmn;1.08\u003csup\u003eb\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.45\u0026plusmn;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e7.33\u0026plusmn;1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e5.56\u0026plusmn;1.23\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e2.00\u0026plusmn;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e101.50\u0026plusmn;12.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e108.33\u0026plusmn;5.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e118.00\u0026plusmn;9.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eCRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6.15\u0026plusmn;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e3.85\u0026plusmn;0.99\u003csup\u003ebc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.52\u0026plusmn;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6.90\u0026plusmn;1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e4.25\u0026plusmn;0.89\u003csup\u003ebc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e1.95\u0026plusmn;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e99.46\u0026plusmn;9.85 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e107.44\u0026plusmn;7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e117.78\u0026plusmn;8.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e:\u003csup\u003ea\u003c/sup\u003e Compared with the conventional TKA group, P \u0026lt; 0.05;\u003csup\u003eb\u003c/sup\u003e Compared with the BRATKA group, P \u0026lt; 0.05;\u003csup\u003ec\u003c/sup\u003e Compared with the HRATKA group, P \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003eTab.4 Comparison of KSS of knee joint between four groups during perioperative period\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"774\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 3.8236%;\"\u003e\n \u003cp\u003eGrouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" style=\"width: 37.1244%;\"\u003e\n \u003cp\u003eKSS（x̄\u0026plusmn;S）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 12.8031%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eClinical score\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 12.8031%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFunction scores\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 13.73%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTotal\u0026nbsp;scores\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003epre-operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003ePOD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003ePOD90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 3.8236%;\"\u003e\n \u003cp\u003eTKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e40.51\u0026plusmn;4.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e50.21\u0026plusmn;4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e81.24\u0026plusmn;6.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e42.05\u0026plusmn;3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e49.52\u0026plusmn;6.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e76.54\u0026plusmn;6.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e83.54\u0026plusmn;7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e100.25\u0026plusmn;8.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e157.54\u0026plusmn;6.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 3.8236%;\"\u003e\n \u003cp\u003eBRATKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e41.25\u0026plusmn;4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e51.24\u0026plusmn;3.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e80.54\u0026plusmn;7.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e41.25\u0026plusmn;3.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e47.54\u0026plusmn;5.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e75.01\u0026plusmn;5.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e82.54\u0026plusmn;8.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e99.84\u0026plusmn;9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e156.85\u0026plusmn;6.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 3.8236%;\"\u003e\n \u003cp\u003eHRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e41.33\u0026plusmn;4.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e50.33\u0026plusmn;4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e79.05\u0026plusmn;6.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e42.23\u0026plusmn;3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e49.44\u0026plusmn;6.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e77.21\u0026plusmn;6.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e83.25\u0026plusmn;6.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e100.00\u0026plusmn;8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e156.52\u0026plusmn;7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 3.8236%;\"\u003e\n \u003cp\u003eCRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e42.42\u0026plusmn;4.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e52.05\u0026plusmn;3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e80.28\u0026plusmn;6.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e41.33\u0026plusmn;3.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e48.33\u0026plusmn;5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e75.35\u0026plusmn;6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.287%;\"\u003e\n \u003cp\u003e84.23\u0026plusmn;7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e99.00\u0026plusmn;7.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7505%;\"\u003e\n \u003cp\u003e155.00\u0026plusmn;6.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Incidence of Complications and Patient Satisfaction Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll four groups experienced complications such as lower limb deep vein thrombosis and wound exudation postoperatively, with no statistically significant differences (P \u0026gt; 0.05). No mechanical-related complications, deep vein thrombosis, pulmonary embolism, neurovascular injury, acute periprosthetic infection, or other severe complications occurred. Additionally, there were no instances of nausea, vomiting, or aspiration pneumonia. Patient satisfaction during hospitalisation showed no statistically significant differences across the groups (P \u0026gt; 0.05) (Tab. 5).\u003c/p\u003e\n\u003cp\u003eTab.5: Comparison of perioperative complication rates and patient satisfaction between the four groups.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"129%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003eGrouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003eComplication rate (n,%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 18px;\"\u003e\n \u003cp\u003eSatisfaction during hospitalization (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eIntermuscular vein thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003eWound exudate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eOthers (mechanical-related complications, deep vein thrombosis, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eTKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e97.50（39/40）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eBRATKA Group（n=40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e95.00（38/40）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eHRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (9.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2（4.76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e95.24（40/42）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eCRATKA Group（n=42）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (7.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2（4.76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e92.86（39/42）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eFisher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.685\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e1.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.959\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e2.6 Typical cases\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e3.1 Current Status of Robot-Assisted TKA Development in China\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith the ageing population and the steadily rising life expectancy in China, the number of TKA will gradually increase in the future. As precision medicine and scientific technology continue to advance rapidly, surgical robots are expected to experience significant development potential in the coming years[21, 22]. According to statistics, in 2020, the total number of surgical robots worldwide, with the United States leading, accounted for over 50% of the global market share[23], followed by the European Union, while China accounted for 5.1%. The ROBODOC and the MAKO robotic systems are among the earlier robotic systems.[24,25, 26]. Patents related to surgical robots started to increase in 2000, with 41% of these patents focusing on positioning and navigation technologies, marking a new phase in China\u0026rsquo;s development and research into joint surgery robots.In 2022, several companies in China, including HURWA, MicroPort Robotics Honghu, Yuanhua Intelligent Technology\u0026rsquo;s Bone Saint Yuanhua, and Jianjia ARTHROBOT, were approved for market introduction. The number of robotic systems used in joint surgery increased from 17 in 2020 to 136 in 2023, with projections indicating it will reach 788 by 2026.[27]. However, the adoption of robot-assisted TKA remains relatively low at present, with the majority of installations concentrated in major cities and academic hospitals. The distribution follows a \u0026quot;south-heavy, north-light\u0026quot; pattern. Additionally, as the usage and maintenance costs of surgical robots have yet to be included in the medical insurance system, studies on the use of robots in TKA remains limited. Most regions are still in the early stages of development and integration. Nevertheless, with increasing interest and promotion from healthcare professionals, rapid advancements in this technology are anticipated in the near future.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Summary of the Advantages of the Three Robotic Systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In this study, we highlight the different characteristics of the three robotic systems used in TKA, as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBrainlab Knee 3 Navigation System [15, 16, 17]\u003c/strong\u003e:① Imaging-guided and accurate bone resection positioning: The Brainlab Knee 3 navigation system employs advanced computer-assisted navigation technology to ensure precise bone positioning and resection planning by acquiring real-time three-dimensional imaging data of the patient\u0026apos;s knee joint.② Dynamic gap balance feedback technology: This system integrates gap balance technology, allowing for the real-time monitoring and adjustment of the joint gap during the flexion-extension movements of the surgery.③ Intraoperative alignment optimisation and personalised bone resection planning: The Brainlab Knee 3 system enables surgeons to create a personalised bone resection and gap balancing plan based on dynamic assessments of lower limb alignment during the procedure.④ Streamlined registration process and quick operation: Preoperative CT scans are not necessary, as intraoperative registration reduces preparation time and minimises the financial burden on patients.⑤ Absence of resection components, providing only resection-related guidance: Resection is carried out with the aid of resection guides, but without robotic resection components.⑥ Accurate soft tissue tension evaluation and adjustment: The system prioritises soft tissue balance, enabling surgeons to precisely evaluate and modify soft tissue tension throughout the procedure. This is vital for achieving balanced flexion and extension, ensuring soft tissue stability throughout knee joint movement.⑦ Compact design, facilitating transportation and integration into operating room layouts: The system\u0026apos;s compact size makes it easy to transport and integrate into operating rooms with various configurations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDom\u003c/strong\u003e\u003cstrong\u003eestic\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHURWA\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Robot\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[28, 29]\u003c/strong\u003e:① Precise robotic arm control and personalised surgical planning: The HURWA robotic system uses preoperative CT scan imaging data to develop a personalised surgical plan, assisting surgeons in accurately positioning the prosthesis and performing bone resections during surgery. The system offers precise assistance via the robotic arm, allowing real-time monitoring of bone resection thickness and angles to ensure surgical accuracy.② Localized technical support and service advantages: As a domestic robotic system, the HURWA robot provides quicker technical support and is more convenient for postoperative equipment maintenance and system updates. Compared to imported systems, this domestic robot is better suited to the local healthcare environment and can be customised to better align with the anatomical characteristics of Chinese patients.③ Shorter learning curve and user-friendly interface: The HURWA robot system features a simple, intuitive interface, making the operating process straightforward. For surgeons in primary healthcare settings, the system allows for swift adaptation, thereby reducing the time needed to transition from traditional surgery to robot-assisted surgery.④ Bone resection characteristics: The system employs a robotic arm-controlled electric saw for bone resection, which enhances efficiency and significantly speeds up the surgery. However, if the safety lines are not appropriately designed or if the system does not precisely control the procedure, the speed and force of the electric saw could harm nearby vital soft tissues, such as ligaments, nerves, or blood vessels, leading to potential postoperative complications. Thus, it is essential to carefully plan the resection path and establish safety zones to prevent soft tissue injury when using the robotic arm electric saw for bone resection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStryker Cori Robot [30, 31, 32]\u003c/strong\u003e:① No preoperative CT required, uses intraoperative 3D registration technology: A standout feature of the Cori robotic system is that it eliminates the need for preoperative CT scans. During surgery, it reconstructs the patient\u0026apos;s true bone surface anatomy in 3D, including cartilage details, and creates an optimal surgical plan in real-time, based on soft tissue tension and lower limb alignment. This reduces preoperative preparation time and alleviates the financial burden on patients.② Millimeter-level accuracy, ensuring optimal prosthesis alignment: The Cori robot continuously monitors the balance of knee ligaments and real-time soft tissue tension, helping surgeons adjust the surgical plan to maintain knee stability and improve postoperative recovery.③ Compact, portable design, adaptable to various hospital sizes: The Cori robot is designed to be compact and portable, minimising the space required in the operating room and providing flexible configurations that suit hospitals of different sizes. Additionally, it does not necessitate sterile preparation for the system or complex instrument assembly, saving both time and effort.④ Flexibility and adaptability: The Cori robot provides exceptional flexibility in real-time soft tissue assessment, 3D registration, and adjustments during surgery, making it particularly suitable for complex cases that require customised modifications. In contrast, the HURWA robot is more focused on precise bone resection and prosthesis positioning through robotic arm control, offering higher operational efficiency in standard cases.⑤ Burr bone resection characteristics: The burr is employed for grinding-type bone resection, which, although slower than electric saw resection, achieves higher efficiency by applying appropriate mechanical traction. The small size of the burr ensures minimal mechanical damage to soft tissues during resection. For patients with complex joint anatomies, the burr allows for finer adjustments of resection angles and depths, helping to preserve joint surface balance, maintain smooth bone surfaces, and reduce the risk of postoperative prosthesis wear. The use of the burr also diminishes intraoperative instrument tremor and prevents the loosening of positioning reflectors. However, during the grinding process, bone chips can be ejected, especially when grinding harder bone, potentially contaminating the surgical field and increasing the risk of local infection. This can be mitigated by using shields, controlling the water flow to the burr, and employing assistant suction techniques to reduce bone chip dispersion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Clinical Efficacy Comparison of the Three Robotic Systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, the three robotic systems (HURWA robot, CORI robot, and Brainlab robot) each displayed their unique advantages and differences in TKA. Unlike traditional TKA, the introduction of various robotic systems has made it more difficult for many surgeons new to robotic surgery to quickly acclimatise to the surgical environment[33]. During the learning phase, issues such as prolonged surgery durations, registration errors, and operational mistakes may occur, potentially leading to increased surgical trauma or adverse reactions that could impact the rehabilitation of the knee joint. Ensuring the surgical effectiveness and rehabilitation outcomes of robot-assisted TKA is a critical concern for clinical practitioners. The ERAS has already been successfully applied in joint surgeries, is a crucial strategy for ensuring these outcomes. In this study, we observed that in terms of surgical duration, all three robotic systems resulted in longer operation times compared to the conventional group.The Brainlab system lacks a resection component and requires resection to be performed using a guide, which makes the surgical process more complex and results in slightly longer operation times compared to the other two robotic systems. In contrast, the HURWA and CORI robotic systems had relatively shorter surgical durations. The HURWA robot, which employs a robotic arm electric saw for bone resection, demonstrated greater operational efficiency. On the other hand, the CORI robot uses a burr for grinding-type bone resection, which takes longer, but its strength lies in its ability to assess soft tissue tension in real-time, thereby optimising joint stability. However, as surgeons become more skilled with these systems, surgical time tends to decrease, which aligns with the findings of Weaver et al.[34].In terms of blood loss, the robotic groups exhibited similar perioperative blood loss to the conventional group, likely because all surgeries were conducted with a tourniquet. Additionally, no marrow opening was performed in the robotic groups, compensating for any potential hidden blood loss due to the longer surgical time when compared to the conventional group. Regarding radiographic assessments, the robotic systems demonstrated more consistent control over the prosthesis angles. The HURWA robot, in particular, showed superior postoperative recovery in terms of FFC and LFC angles compared to the other two systems, likely due to its precise preoperative CT planning for bone resection and intraoperative knee joint fixation. This significantly reduced the occurrence of postoperative joint angle deviations and mechanical axis misalignments. In contrast, the Brainlab and CORI robots focused more on soft tissue assessment to optimise joint stability, yet they maintained accurate control over parameters like FTC, LTC, and HKA.Regarding complications, all three groups experienced common issues, including bilateral lower limb deep vein thrombosis and wound exudation. However, all patients showed symptom improvement following anticoagulation therapy and wound dressing changes. No severe complications, such as pulmonary embolism, neurovascular injury, or acute periprosthetic infection, were reported, and there were no instances of nausea, vomiting, or aspiration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Importance of the ERAS Concept in Perioperative Management of Robot-Assisted TKA Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe development of robot-assisted technology seeks to enhance surgical precision and outcomes, as well as improve patient satisfaction[35]. International research has shown that robot-assisted TKA can effectively reduce hospital stays, alleviate pain, decrease short-term inflammatory responses, and lower the incidence of complications such as thrombosis, pneumonia, and wound infections. Long-term follow-up research has also demonstrated a decrease in revision rates and opioid usage[36], offering certain economic benefits. However, in this study, robot-assisted TKA did not show significant advantages in terms of hospital stay, short-term knee function, or complications. This discrepancy may be attributed to the relatively recent advancement of domestic robotic systems, which have a shorter clinical application history. As a result, they have not yet fully addressed complications or surgical risks associated with mechanical failures or the surgeon\u0026apos;s inexperience. Moreover, due to the necessity of inserting fixation pins into the patient\u0026rsquo;s bone structures, placing femoral and tibial trackers, and the registration process, current robot-assisted TKA surgeries tend to involve longer operation times and larger incisions, which could increase the risk of surgical site infections[37].\u003c/p\u003e\n\u003cp\u003eFurthermore, due to the low prevalence and limited patient awareness of robot-assisted TKA in China, some patients remain doubtful about the technology and may experience anxiety or negative emotions, which can impact their rehabilitation process. Ensuring safety, surgical effectiveness, rapid recovery, and patient satisfaction during hospitalisation for robot-assisted TKA is essential to support the development of robotic technology[38, 39]. Since 2015, our department, as a pilot hospital for accelerated recovery orthopaedic surgery designated by the National Health Commission, has consistently implemented the ERAS concept in the perioperative management of traditional TKA patients, achieving positive outcomes. ERAS optimises perioperative management, reduces surgical stress responses, accelerates recovery, shortens hospital stay duration and decreases the occurrence of postoperative complications. For robot-assisted TKA, it is crucial to focus on preoperative education, psychological assessments, wound management, pain control, and postoperative rehabilitation exercises as key components of perioperative care[12]. Strict adherence to these measures in robot-assisted TKA patients can significantly promote rapid recovery and improve the overall patient experience.The close relationship between ERAS and robot-assisted TKA is evident in the following aspects[40]: ① In line with the ERAS concept, robot-assisted TKA offers enhanced surgical precision and minimally invasive techniques, without increasing intraoperative blood loss or postoperative pain, thereby minimising surgical trauma. ② Robot-assisted TKA employs preoperative 3D imaging and planning to develop a personalised surgical plan, which better preserves joint function while minimising the incidence of surgical complications. This approach reduces postoperative discomfort and complications, thereby accelerating recovery. ③ ERAS stresses early mobilisation and active rehabilitation. Robot-assisted TKA can offer personalised rehabilitation plans based on preoperative assessments and planning, providing timely guidance and supervision for recovery after surgery. ④ Robot-assisted TKA has the ability to collect and analyse large volumes of surgical data and parameters, offering valuable information and feedback to the surgeon. This helps evaluate surgical outcomes more effectively, predict recovery progress, and promptly adjust treatment plans.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Limitations of This Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirstly, the study has a relatively small sample size and a short follow-up period. A longer follow-up duration is necessary to observe and compare the long-term efficacy of the three robotic systems. Secondly, this is a single-centre study, and regional variations and biases in surgical techniques may exist. The technical expertise of different hospitals and surgeons, as well as individual patient characteristics, could influence surgical outcomes. Lastly, as the robotic assistance systems were used in a sequential manner, there is a learning curve, which could lead to bias in the study outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study assessed the effectiveness of three robotic systems (HURWA robot, CORI robot, and Brainlab robot) in TKA and explored the role of the ERAS concept in enhancing postoperative rehabilitation. Although, during the learning curve, the surgery duration for the three robotic systems was longer than that of conventional knee arthroplasty, and the incisions were larger, the support of the ERAS concept helped prevent any significant increase in postoperative knee joint swelling, extended hospital stay, pain, or complication rates. Moreover, the three robotic systems produced similar outcomes in terms of postoperative functional recovery, complication management, and patient satisfaction, each offering its own advantages. Looking ahead, as technology continues to progress and surgeons accumulate more experience, robot-assisted surgery is anticipated to have a growing impact on enhancing surgical efficiency, reducing complications, and expediting rehabilitation, providing more precise and tailored treatment options for knee arthroplasty.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTXA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;tranexamic acid\u003c/p\u003e\n\u003cp\u003eVAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Visual analogue scale\u003c/p\u003e\n\u003cp\u003eTKA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total knee arthroplasty\u003c/p\u003e\n\u003cp\u003eHB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hemoglobin\u003c/p\u003e\n\u003cp\u003eHCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hematocrit\u003c/p\u003e\n\u003cp\u003eWBC\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;White Blood Cell\u003c/p\u003e\n\u003cp\u003eESR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Erythrocyte Sedimentation Rate\u003c/p\u003e\n\u003cp\u003eCRP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C-reactive Protein\u003c/p\u003e\n\u003cp\u003eTBL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;total blood loss\u003c/p\u003e\n\u003cp\u003ePBV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;patient\u0026rsquo;s blood volume\u003c/p\u003e\n\u003cp\u003eBRATKA \u0026nbsp; Brainlab navigation system assisted total knee arthroplasty\u003c/p\u003e\n\u003cp\u003eHRATKA \u0026nbsp;\u0026nbsp;HURWA\u0026nbsp;robot-assisted total knee arthroplasty\u003c/p\u003e\n\u003cp\u003eCRATKA \u0026nbsp; Stryker Cori robot-assisted total knee arthroplasty\u003c/p\u003e\n\u003cp\u003eKSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Knee Society Score\u003c/p\u003e\n\u003cp\u003eROM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;range of motion\u003c/p\u003e\n\u003cp\u003eVAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;visual analogue scale\u003c/p\u003e\n\u003cp\u003eLOS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; length of stay.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adheres to CONSORT guidelines. We are thankful for the support of the nursing staffs from the Department of Orthopaedics, Panzhihua Municipal Central Hospital and the patients enrolled in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMYW and ZDT participated in the perioperative management, and postoperative follow-up and wrote the main manuscript; Yuping Lan was in charge of the whole preoperative planning, \u0026nbsp;operation process and helped revise the article; HPW, XZS, MLW and RQL were in charge of the follow-up of the patients; All authors read and approved the final draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by Sichuan Medical Association Orthopedics (Shang Antong) special research project (No.2023SAT14) , Research Project of Sichuan Society of Gerontology (No. 24SCLN092), Sichuan Provincial Primary Health Development Research Center in 2024, North Sichuan Medical College (No. SWFZ24-Q-86) and Chengdu High-tech Medical Association \u0026quot;2023 annual Flurbiprofen gel paste treatment of osteoarthritis special research fund\u0026quot; project (2024013), who is not involved in study design, data collection, analysis and interpretation or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by The Institutional Review Board of Panzhihua Central Hospital \u0026nbsp;(Pankelun Trial No. [2024-008]) and written informed consent to participate was obtained from all of the individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopedics, Panzhihua Municipal Central Hospital, 34# Yikang road, Panzhihua 617000, People\u0026rsquo;s Republic of China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJang S, Lee K, Ju JH. 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Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022 2022-08-01;30(8):2677\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Knee osteoarthritis, Total knee arthroplasty, Surgical robots, Enhanced Recovery After Surgery","lastPublishedDoi":"10.21203/rs.3.rs-7198229/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7198229/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAs science and technology continue to progress, the variety and number of robots used in assisted total knee arthroplasty (TKA) have steadily increased, allowing more surgeons and patients to benefit from enhanced medical precision and improved knee joint function, ultimately leading to a better quality of life. This study conducted a retrospective analysis of 164 knee osteoarthritis patients who underwent either traditional or robot-assisted TKA following the Enhanced Recovery After Surgery (ERAS) protocol. The patients were divided into four groups according to the surgical approach and robotic system employed: traditional TKA group, Brainlab navigation system group (BRATKA group), domestic Hehua robot group (HRATKA group), and Stryker Cori robot group (CRATKA group). Data collected included basic patient information, imaging data, blood indicators, knee function, pain scores, complication rates, and in-hospital satisfaction.\u003c/p\u003e\u003cp\u003eThe results showed that under the ERAS protocol, the incision length in the robotic groups was longer than that in the conventional group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The surgery times in the BRATKA group was longer than HRATKA group, while the TKA and CRATKA groups were shorter than them (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The HRATKA group performed better in terms of FFC (femoral-femoral contact) compared to the other groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The LFC (lateral femoral condyle) was comparable to the TKA group, smaller than the BRATKA and CRATKA groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), The LTC (lateral tibial condyle) angle in the HRATKA group was nearer to 90\u0026deg; compared to the TKA group. No statistically significant differences were found between the groups in terms of HKA (hip-knee-ankle angle) and FTC (femoral-tibial contact) angles.\u003c/p\u003e\u003cp\u003eOn the third postoperative day, no significant differences were observed in the rate of knee swelling, length of hospital stay, changes in WBC, NLR, ESR, and CRP levels among the groups, or perioperative blood loss (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, patients in the Brainlab group had higher resting VAS (Visual Analog Scale) and movement VAS scores compared to the other groups on day 3 post-operation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At 90 days postoperatively, no statistically significant differences were found in VAS scores across the four groups. Additionally, there were no notable differences in KSS (Knee Society Score) or ROM (Range of Motion) scores postoperatively (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eAll four groups encountered common complications, including lower limb intermuscular venous thrombosis and wound exudation. Satisfaction rates exceeded 95% in all groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Under the ERAS protocol, despite differences in surgical approach, operation time, certain imaging data, and pain scores at 3 days post-operation, the three robotic systems demonstrated effective knee function recovery and patient satisfaction, comparable to the conventional TKA group, without increasing perioperative blood loss, inflammatory responses, or surgical complications. These findings suggest that robotic-assisted TKA, when applied under the ERAS protocol, leads to satisfactory clinical outcomes, further validating its role in improving surgical precision and promoting faster recovery.\u003c/p\u003e","manuscriptTitle":"Application and Postoperative Rehabilitation Effects of HURWA, Cori, and Brainlab Robots in TKA under the ERAS Concept","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 05:35:57","doi":"10.21203/rs.3.rs-7198229/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-17T11:17:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T09:08:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245835446740963940999928476534172532735","date":"2025-09-12T11:15:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177248357974188056584616449800228538728","date":"2025-09-12T02:53:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30678483869738762340409970850390350978","date":"2025-08-30T08:59:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2788903293357169768603186081453555615","date":"2025-08-19T05:16:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53929112562922091982014617394009859536","date":"2025-08-16T15:43:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166877617295664559977983365239689857760","date":"2025-08-12T20:01:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T01:34:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T11:15:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T11:36:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-07-23T15:50:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8567b356-1667-430e-9dbc-db7ef6f8c926","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:02:43+00:00","versionOfRecord":{"articleIdentity":"rs-7198229","link":"https://doi.org/10.1007/s11701-025-02859-4","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-10-09 15:58:11","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-08-13 05:35:57","video":"","vorDoi":"10.1007/s11701-025-02859-4","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02859-4","workflowStages":[]},"version":"v1","identity":"rs-7198229","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7198229","identity":"rs-7198229","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}