Robotic-assisted Total Hip Arthroplasty Utilizing a Fluoroscopy-guided System Produced Similar Cup Accuracy and Precision Relative to a Computerized Tomography-based Robotic Platform

Robotic-assisted Total Hip Arthroplasty Utilizing a Fluoroscopy-guided System Produced Similar Cup Accuracy and Precision Relative to a Computerized Tomography-based Robotic Platform | 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 Robotic-assisted Total Hip Arthroplasty Utilizing a Fluoroscopy-guided System Produced Similar Cup Accuracy and Precision Relative to a Computerized Tomography-based Robotic Platform Christian B. Ong, Graham B.J. Buchan, Christian J. Hecht II, Arihiko Kanaji, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4314196/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction: Robotic assistance for total hip arthroplasty (THA) has been demonstrated to improve accuracy of acetabular cup placement relative to manual, unassisted technique. The purpose of this investigation was to compare the accuracy and precision between a fluoroscopy-based robotic total hip arthroplasty platform (FL-RTHA) and a computerized tomography-based (CT-RTHA) platform. Methods: The study included 98 consecutive FL-RTHA and 159 CT-RTHA procedures performed via direct anterior approach (DAA). All cases were performed for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included cup implantation accuracy and precision (variance). Implantation accuracy was calculated as the absolute value of the difference between pre-operative target cup angles (inclination and anteversion) and the same post-operative angles. Percentage placement in the Lewinnek safe zone was also measured for both cohorts. Results: The FL-RTHA and CT-RTHA cohorts demonstrated a 1.2° difference in absolute values for cup inclination accuracy (4.6° ± 3.6 vs. 3.4 ± 2.7; p=0.005), and no difference in absolute values for cup anteversion accuracy (4.7° ± 4.1 vs. 4.6 ± 3.4; p=0.991). Cohorts demonstrated similar precision for cup inclination and anteversion placement parameters, as well as equivalent Lewinnek safe zone placement. Conclusions: The use of a fluoroscopy-based robotic assistance platform for primary DAA THA resulted in similar accuracy and precision of acetabular cup placement when compared to a CT-based robotic assistance system. Hip Arthroplasty Robotic-Assisted Surgery Acetabulum Accuracy Figures Figure 1 Figure 2 INTRODUCTION Accurate positioning of the acetabular cup during total hip arthroplasty (THA) is an essential element in mitigating rates of premature component wear, impingement, and dislocation, while also promoting excellent joint mobility in the post-operative setting [1–5]. A common standard for cup positioning is the Lewinnek “safe” zone of 40° ± 10 inclination and 15° ± 10 anteversion [6]. Despite the importance of cup positioning, orthopaedic surgeons still inadvertently place cups outside of a safe zone in ~20-50% of THA procedures [7,8]. To promote consistent component positioning, many surgeons have begun to utilize intra-operative technologic assistance for THA [9]. The use of intra-operative robotic assistance has been correlated with improved outcomes over manual unassisted technique (mTHA) in terms of cup placement rates within safe zone [10], and resultant short-term functional outcomes [11]. Though the intra-operative use of robotics may improve component positioning, widespread adoption may be limited to certain factors. The most prevalent robotic THA technique utilizes a computerized tomography (CT) based workflow (CT-RTHA), and requires the use of costly per-case disposables ranging from $750-$1,300 [12]. A CT-based platform also increases operative and overall operating room times [13]. It also involves increased radiation through required pre-operative CT scans, compared to a fluoroscopy assisted mTHA workflow [14]. In an attempt to address these concerns, a novel, fluoroscopy-based robotic assistance platform (FL-RTHA) was developed and brought to U.S. market in 2021. While early results have demonstrated potentially improved cost-effectiveness [12,15], and reduced operative times and radiation exposure relative to CT-RTHA [16,17], there has yet to be a direct comparison of the intra-operative performance with regards to acetabular cup placement between these two workflows. Therefore, the purpose of this investigation was to compare both accuracy and precision outcomes for cup placement for primary THA between a FL-RTHA system and the predicate CT-RTHA platform. The authors hypothesized that the results would demonstrate a similar performance profile between systems. MATERIALS AND METHODS Institutional review board approval was obtained prior to the initiation of this investigation. A cohort analysis of a consecutive series of 98 FL-RTHA and 159 CT-RTHA patients who underwent primary, direct anterior approach (DAA) THA, during the same time period, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis was conducted. All procedures were performed by one of two high-volume arthroplasty surgeons (Surgeons 1 and 2), who have been in practice for greater than 10 years post-fellowship. All FL-RTHA procedures were performed with the Zimmer ROSA® Hip System (Zimmer Biomet, Warsaw IN, USA), while CT-RTHA procedures were performed with the Stryker MAKO® Hip System (Stryker, Kalamazoo MI, USA). Patients who were less than 18 years of age were excluded from the study. The primary means used to assess intra-operative performance with regards to acetabular cup placement included average cup inclination and anteversion angles, cup placement accuracy, cup placement precision (variance), and the proportion of cups placed within the Lewinnek safe zone of 40° ± 10 inclination and 15° ± 10 anteversion [6]. In line with previous investigations, accuracy was assessed by computing target discrepancy, which was defined as the absolute value (magnitude) of the difference between measured post-operatively radiographic cup angles, and pre-operative targeted cup placement angles for each case [18–20]. Cup placement precision was assessed by calculating variances for cup placement angles, which were the square of Standard Deviation (SD). Adopting the methodology of Buchan et al. [10], the Martell Hip Analysis Suite Software (version 8.0.4.5., Martell Hip Analysis Suite™, Chicago IL, USA) was used to measure cup angles from six-week post-operative standing antero-posterior radiographs. All radiographic measurements were executed by the first and second authors of this manuscript. An inter-observer reliability analysis was conducted, and demonstrated an average difference of 1.1° for inclination, and 0.2° for anteversion. Surgical technique: For the FL-RTHA cohort, all cases were performed with the ROSA® Hip System through a DAA [21,22]. Target cup inclination and anteversion angles were 40° and 15°, respectively, for all procedures. The G7® Acetabular System (Zimmer Biomet, Warsaw IN, USA) paired with the Avenir Complete® Femoral Stem (Zimmer Biomet, Warsaw IN, USA) was placed in all patients. For the CT-RTHA cohort, all cases were performed with the MAKO® Hip System, using a technique similar to those of Perazzini et al [23]. However, a truncated “express” workflow was adopted, which involved registration of the acetabulum only [24]. Components implanted were the Trident II® Acetabular System (Stryker, Kalamazoo MI, USA) paired with the Accolade II® Femoral Stem (Stryker, Kalamazoo MI, USA). In a majority of CT-RTHA cases, cup angles of 42°/18° (n=95; 55.88%) and 42°/20° (n=48; 28.24%) were targeted for inclination and anteversion, respectively. A full breakdown of target cup placement angles is included in Table 1 . Statistical analysis: Patient demographics and surgical data between cohorts were provided as descriptive statistics. Continuous variables were presented as means ± SD and medians with interquartile range (IQR), and categorical variables as frequencies and percentages. Independent samples student t-tests, Mann-Whitney U tests, and F-tests were used to compare the means and variances of continuous variables between cohorts. Pearson’s chi-squared tests and Fisher’s exact tests were used to compare categorical variables. Shapiro-Wilk tests of normality were used to assess the distributions of data. p < 0.05 was considered statistically significant. All analyses were performed using JMP Version 16.2.98 (SAS Institute Inc., Cary, NC, 1989–2021) and Microsoft Excel (Microsoft Corporation 2023, Redmond WA, USA) software. RESULTS Cohorts were similar in their distributions of patient Body Mass Index (BMI), procedure laterality, and pre-operative American Society of Anesthesiologists (ASA) score. However, compared to the CT-RTHA cohort, the FL-RTHA cohort was younger (60.5 ± 13.1 years vs. 66.1 ± 8.7 years; p<0.001), more predominately female (46.9% vs. 63.5%; p=0.009), had a smaller proportion of Caucasian patients (80.6% vs. 95.6%; p<0.001), and less likely to have a pre-operative diagnosis of osteoarthritis (85.7% vs. 98.1%; p<0.001). Full demographic and treatment information is included in Table 1 . The FL-RTHA and CT-RTHA cohorts had similar average cup inclination (42.8° ± 5.2 vs. 42.5° ± 4.4; p=0.695) and anteversion (18.5 ± 5.1 vs. 18.9 ± 5.9; p=0.618) angles, as well as similar degrees of cup inclination (26.8 vs. 19.4; p=0.069) and anteversion (26.0 vs. 34.3; p=0.137) precision. Full comparisons of cup inclination and anteversion angle distributions between cohorts are provided in Figures 1 and 2 . In comparing cup placement accuracies, patients in the FL-RTHA cohort demonstrated a 1.2° difference for inclination (4.6° ± 3.6 vs. 3.4 ± 2.7; p=0.005), but similar outcomes for anteversion. Cohorts were also similar in their proportions of cups placed within the Lewinnek safe zone. Full accuracy comparisons are provided in Table 2 . DISCUSSION The use of intra-operative technological assistance has increased dramatically over the past decade, with estimates showing a 10-fold increase in utilization rates between 2008 to 2015 in the United States alone [9]. The use of robotic assistance for THA has been shown to benefit the accuracy of cup implantation, which is an important factor in ensuring favorable outcomes in the post-operative setting. The results of our investigation demonstrated that the use of a fluoroscopy-based robotic assistance system for primary THA resulted in similar accuracy and precision outcomes relative to a CT-based robotic workflow. To the authors’ knowledge, this is the first investigation which has directly compared the intra-operative performance of this specific FL-RTHA platform to that of an existing robotic system. The first significant finding of our investigation was that both cohorts demonstrated similar average cup implantation angles and distributions for inclination and anteversion. Though this is the first investigation which has directly compared the accuracy profiles of these two robotic platforms, our findings are in line with existing literature which has demonstrated excellent intra-operative performance for both systems [10,21,25–29]. Prior studies involving the FL-RTHA platform have shown improved cup implantation accuracy relative to mTHA in a number of clinical scenarios [10,21,25,26], with comparable findings having also been reported in the CT-RTHA literature [27–29]. Furthermore, the averages and variances for cup inclination and anteversion angles obtained in this study are similar to those reported by these previous authors [10,21,25–29]. Though not statistically significant, it appeared that the FL-RTHA system trended towards greater precision for cup anteversion. This finding is especially significant, considering orthopaedic surgeons have a tendency to misjudge and subsequently misalign cup anteversion angles during impaction as opposed to inclination angles [25]. There are potentially a number of contributing factors to the improved anteversion precision in the FL-RTHA cohort, though a primary driver is likely the differences in acetabular registration workflows between systems. As discussed in Kamath et al, the FL-RTHA platform utilizes intra-operative fluoroscopic images obtained from a standard C-arm to execute pin-less digital navigation and fluoroscopy-based robotic registration of the acetabulum [21,22]. The CT-RTHA platform requires the insertion of individual navigation tracker pins, in conjunction with physical probe contact with a number of bony landmarks around the acetabular rim to perform acetabular registration [23,24]. Requiring direct probe contact with the acetabulum can prove to be challenging especially in minimally invasive DAA THA, where access to the joint space is limited. This difficulty can be further compounded by patient anatomical factors such as bony deformity and an obese body habitus [30,31]. Because image-based registration is a consistent approach that is relatively indifferent to patient anatomy [17], the FL-RTHA system may offer alternate advantages to achieve similarly precise cup implantation. The second significant finding of this study was that the FL-RTHA and CT-RTHA platforms had similar accuracy outcomes, and also had similar proportions of cups placed within the Lewinnek zone. The authors surmise that the observed 1.2° difference in inclination accuracy between systems is a result of the FL-RTHA cohort including cases from the surgeon’s learning period with the system, which is traditionally associated with inferior surgical performance compared to the post-proficiency stage [32,33]. One investigation reported an average cup implantation angle difference of 2.8° for inclination, and 3.5° for anteversion between pre- and post-proficiency procedures when adopting an intra-operative assistance system for THA [34]. The CT-RTHA cohort only included post-proficiency procedures. Overall, it is unlikely that this small difference (1.2°) in accuracy would have meaningful clinical impact on post-operative results with regards to complication rates, functionality, or patient-reported outcomes, especially given the equal rates at which cups were placed within the Lewinnek zone in either cohort [6]. The 81.6% of cups placed within the Lewinnek zone in the FL-RTHA cohort is comparable to the 87% reported in a recent study by Stewart et al, who utilized the CT-RTHA system for DAA THA [35]. When considering the overall net benefits to the patient, this ~1° difference in accuracy should be weighed against the potential for improved cost-effectiveness [12,15], reduced operative times and pin-less workflow, and radiation exposure in the FL-RTHA cohort relative to the CT-RTHA cohort [16,17]. Our findings have several limitations. First, the retrospective nature of this study introduced the possibility of documentation biases. To mitigate this likelihood, all data were directly obtained from a rigorous review of standardized institutional electronic health records. Second, the two surgeons involved in this investigation are high-volume robotic arthroplasty surgeons, potentially limiting the generalizability of these findings to surgeons who perform lower case volumes or who have less expertise in robotic THA. Third, all FL-RTHA procedures were performed by one surgeon, and all CT-RTHA procedures were performed by a different surgeon. While both surgeons are of similar levels of arthroplasty experience, surgeon-related factors could have biased the results. To create comparable cohorts, only primary cases with a pre-operative diagnosis of osteoarthritis, avascular necrosis or rheumatoid arthritis were considered. Fourth, this was an unmatched investigation, and there were various demographic differences between cohorts that could have biased the results. In order to mitigate this limitation, we used consecutive series of patients in either cohort. However, a recent study by Barrack et al found that patient BMI and surgeon annual case volume were the two strongest predictors of cup positioning, and that patient age, sex and pre-operative diagnosis were not significant predictors of placement outcomes [36]. Lastly, cup angle comparisons could have confounded by differences in target inclination and anteversion angles between cohorts. While this may have theoretically influenced comparisons of cup placement precision, by-case adjustments of pre-operative target implantation angles for accuracy calculations would have controlled for this discrepancy. Overall, the authors do not believe that these limitations significantly biased the results. CONCLUSION The use of a fluoroscopy-based robotic assisted platform for THA yielded similar accuracy and precision outcomes with regards to acetabular cup positioning when compared to a CT-based robotic system. The observed ~1° difference in inclination accuracy between systems is likely clinically insignificant with regards to its overall impact on post-operative patient outcomes. Additional research among an expanded and matched cohort is still needed to validate these findings. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing interests: Authors C.B.O., G.B.J.B., C.J.H., and A.K. declare that they have no relevant competing interests. Author D.O.K. serves on the speakers bureau and receives royalties from Zimmer Biomet. Author A.F.K. serves on the speakers bureau, is a paid consultant, and owns stock or stock options in Zimmer Biomet. Author contributions: Christian B. Ong: [Writing – original draft/review & editing; Data review; Formal analysis; Investigation] Graham B.J. Buchan: [Writing – original draft/review & editing; Data review; Investigation] Christian J. Hecht II: [Writing – original draft/review & editing; Data review; Investigation] Arihiko Kanaji: [Writing – original draft/review & editing; Formal analysis; Investigation] Daniel O. Kendoff: [Writing – original draft/review & editing; Formal analysis; Investigation] Atul F. Kamath: [Supervision; Methodology; Writing – review & editing] Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board (06/03/2022; IRB#: 22-528). Data availability statement: The data that support the findings of this study are available upon reasonable request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. References Scheerlinck T. Cup positioning in total hip arthroplasty. Acta Orthop Belg . 2014;80(3):336-347. Patil S, Bergula A, Chen PC, Colwell CW Jr, D'Lima DD. Polyethylene wear and acetabular component orientation. 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Cup positioning in primary total hip arthroplasty using an imageless navigation device: is there a learning curve?. Orthopedics . 2009;32(10 Suppl):14-17. doi:10.3928/01477447-20090915-52 Stewart NJ, Stewart JL, Brisbin A. A Comparison of Component Positioning Between Fluoroscopy-Assisted and Robotic-Assisted Total Hip Arthroplasty. J Arthroplasty . 2022;37(8):1602-1605.e3. doi:10.1016/j.arth.2022.03.056 Barrack RL, Krempec JA, Clohisy JC, et al. Accuracy of acetabular component position in hip arthroplasty. J Bone Joint Surg Am . 2013;95(19):1760-1768. doi:10.2106/JBJS.L.01704 Tables Table 1: Patient demographic and treatment data between fluoroscopy-based and CT-based robotic THA cohorts. Technique FL-RTHA n=98 CT-RTHA n=159 p-value Age at Surgery (Years) 60.5 ± 13.1 66.1 ± 8.7 <0.001* Gender (% Female) 46.9% 63.5% 0.009* Body Mass Index (BMI) 29.6 ± 4.8 29.3 ± 5.4 0.686 Race <0.001* (% Caucasian) 80.6% 95.6% (% Black) 18.4% 4.4% (% Other) 1.0% 0.0% Side (% Left) 44.9% 44.0% 0.889 Preoperative Diagnosis (% Osteoarthritis) 85.7% 98.1% (% Avascular Necrosis) 12.3% 1.3% <0.001* (% Rheumatoid Arthritis) 2.0% 0.6% ASA Score 0.492 (% Class I) 1.0% 1.3% (% Class II) 48.0% 55.3% (% Class III) 51.0% 43.4% Cup Implantation Target 40° inc./15° ant. 42° inc./18° ant. 42° inc./20° ant. Other 100% 0% 0% 0% 0% 56.6% 30.2% 13.2% <0.001* Note: * = p < 0.05; Categorical variables expressed as percentages; Quantitative variables expressed as mean ± standard deviation; FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty; DAA = Direct anterior approach; ASA = American Society of Anesthesiologists risk score; inc. = Inclination; ant. = Anteversion Table 2 : A comparison of acetabular cup placement accuracy for inclination and anteversion based on pre-operative target angles for the fluoroscopy-based and computerized tomography-based robotic cohorts. Technique FL-RTHA n=98 CT-RTHA n=159 p-value Absolute accuracy Inclination (˚) 4.6 ± 3.6 3.4 ± 2.7 0.005* Anteversion (˚) 4.7 ± 4.1 4.6 ± 3.4 0.991 Lewinnek Safe Zone placement (%) 81.6% 81.8% 0.968 Note: * = p<0.05; Categorical variables expressed as percentages; Quantitative variables expressed as mean ± standard deviation; FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty Additional Declarations Competing interest reported. Author D.O.K. serves on the speakers bureau and receives royalties from Zimmer Biomet. Author A.F.K. serves on the speakers bureau, is a paid consultant, and owns stock or stock options in Zimmer Biomet. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Jun, 2024 Reviews received at journal 10 Jun, 2024 Reviewers agreed at journal 12 May, 2024 Reviewers invited by journal 11 May, 2024 Editor assigned by journal 11 May, 2024 Submission checks completed at journal 10 May, 2024 First submitted to journal 23 Apr, 2024 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4314196","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":303366447,"identity":"634972c0-bd56-4c60-8db1-366b4f9aa18c","order_by":0,"name":"Christian B. Ong","email":"","orcid":"","institution":"Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"B.","lastName":"Ong","suffix":""},{"id":303366448,"identity":"5d17e797-20c0-476f-8d7e-146c6bc1bec6","order_by":1,"name":"Graham B.J. Buchan","email":"","orcid":"","institution":"Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation","correspondingAuthor":false,"prefix":"","firstName":"Graham","middleName":"B.J.","lastName":"Buchan","suffix":""},{"id":303366449,"identity":"2b4e5ce3-79fb-4ae2-8a6a-4618a8dc0902","order_by":2,"name":"Christian J. Hecht II","email":"","orcid":"","institution":"Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"J. Hecht","lastName":"II","suffix":""},{"id":303366450,"identity":"bca03cd7-771d-480e-abed-60f61e395028","order_by":3,"name":"Arihiko Kanaji","email":"","orcid":"","institution":"Fujita Health University Bantane Hospital","correspondingAuthor":false,"prefix":"","firstName":"Arihiko","middleName":"","lastName":"Kanaji","suffix":""},{"id":303366451,"identity":"b3f9c236-1135-4eb2-b8e1-7f686cb7ab41","order_by":4,"name":"Daniel O. Kendoff","email":"","orcid":"","institution":"Chefarzt Zentrum für Orthopädie und Unfallchirurgie, HELIOS Kliniken Berlin-Buch","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"O.","lastName":"Kendoff","suffix":""},{"id":303366452,"identity":"befb1732-b5c1-46d9-83c4-bb4d0ed1e61f","order_by":5,"name":"Atul F. Kamath","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACCRDB2MAgByQfkKDlYAODMQMDswFpWhIbiNYi2X468fPHHXbp/e2HGRg+7qklrEWaJ3ezxMEzybkzziQzMM54dpywFjmG3A0SB9uYgST/AWaeA8eI0ML/dvOPg2316QYSzAzEaZGWyN0GtOVwAlRLDWEtkjPebrM423bcEOSXgzMOHCCsReJ87uYblW3V8vzthxkffDhQR1gLCgBacZhELUBAqi2jYBSMglEwEgAAbuI9bExRaUAAAAAASUVORK5CYII=","orcid":"","institution":"Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation","correspondingAuthor":true,"prefix":"","firstName":"Atul","middleName":"F.","lastName":"Kamath","suffix":""}],"badges":[],"createdAt":"2024-04-23 20:21:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4314196/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4314196/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57297049,"identity":"8752bd97-fd87-4e2a-8c3b-02904fc53b98","added_by":"auto","created_at":"2024-05-28 20:06:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34616,"visible":true,"origin":"","legend":"\u003cp\u003eBox-and-whisker plots comparing cup inclination angles between the fluoroscopy-based and computerized tomography-based robotic cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty; The horizontal line within each box represents the data Median, while the upper and lower borders of each box represent the 3\u003c/em\u003e\u003csup\u003e\u003cem\u003erd\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e (75\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentile) and 1\u003c/em\u003e\u003csup\u003e\u003cem\u003est\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e (25\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentile) Quartiles, respectively. The upper and lower stem borders represent the maximum and minimum data values, respectively.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4314196/v1/89dc9b474cf495bfcb322821.jpg"},{"id":57297048,"identity":"fa33e855-b9ca-4d48-8d7a-12c2804db36e","added_by":"auto","created_at":"2024-05-28 20:06:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26779,"visible":true,"origin":"","legend":"\u003cp\u003eBox-and-whisker plots comparing cup anteversion angles between the fluoroscopy-based and computerized tomography-based robotic cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty; The horizontal line within each box represents the data Median, while the upper and lower borders of each box represent the 3\u003c/em\u003e\u003csup\u003e\u003cem\u003erd\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e (75\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentile) and 1\u003c/em\u003e\u003csup\u003e\u003cem\u003est\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e (25\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentile) Quartiles, respectively. The upper and lower stem borders represent the maximum and minimum data values, respectively.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4314196/v1/b53c88c99c88e79f83b82388.jpg"},{"id":57297050,"identity":"00883776-e258-4ebb-a1de-c802cc01e09f","added_by":"auto","created_at":"2024-05-28 20:06:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":478163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4314196/v1/7fe6a9d5-2dd0-4edb-b963-7f986ad957ef.pdf"}],"financialInterests":"Competing interest reported. Author D.O.K. serves on the speakers bureau and receives royalties from Zimmer Biomet. Author A.F.K. serves on the speakers bureau, is a paid consultant, and owns stock or stock options in Zimmer Biomet.","formattedTitle":"Robotic-assisted Total Hip Arthroplasty Utilizing a Fluoroscopy-guided System Produced Similar Cup Accuracy and Precision Relative to a Computerized Tomography-based Robotic Platform","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAccurate positioning of the acetabular cup during total hip arthroplasty (THA) is an essential element in mitigating rates of premature component wear, impingement, and dislocation, while also promoting excellent joint mobility in the post-operative setting [1\u0026ndash;5]. A common standard for cup positioning is the Lewinnek \u0026ldquo;safe\u0026rdquo; zone of 40\u0026deg;\u0026nbsp;\u0026plusmn;\u0026nbsp;10 inclination and 15\u0026deg;\u0026nbsp;\u0026plusmn;\u0026nbsp;10 anteversion [6]. Despite the importance of cup positioning, orthopaedic surgeons still inadvertently place cups outside of a safe zone in ~20-50% of THA procedures [7,8]. To promote consistent component positioning, many surgeons have begun to utilize intra-operative technologic assistance for THA [9]. The use of intra-operative robotic assistance has been correlated with improved outcomes over manual unassisted technique (mTHA) in terms of cup placement rates within safe zone [10], and resultant short-term functional outcomes [11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThough the intra-operative use of robotics may improve component positioning, widespread adoption may be limited to certain factors. The most prevalent robotic THA technique utilizes a computerized tomography (CT) based workflow (CT-RTHA), and requires the use of costly per-case disposables ranging from $750-$1,300 [12]. A CT-based platform also increases operative and overall operating room times [13]. It also involves increased radiation through required pre-operative CT scans, compared to a fluoroscopy assisted mTHA workflow [14].\u003c/p\u003e\n\u003cp\u003eIn an attempt to address these concerns, a novel, fluoroscopy-based robotic assistance platform (FL-RTHA) was developed and brought to U.S. market in 2021. While early results have demonstrated potentially improved cost-effectiveness [12,15], and reduced operative times and radiation exposure relative to CT-RTHA [16,17], there has yet to be a direct comparison of the intra-operative performance with regards to acetabular cup placement between these two workflows. Therefore, the purpose of this investigation was to compare both accuracy and precision outcomes for cup placement for primary THA between a FL-RTHA system and the predicate CT-RTHA platform. The authors hypothesized that the results would demonstrate a similar performance profile between systems.\u0026nbsp;\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eInstitutional review board approval was obtained prior to the initiation of this investigation. A cohort analysis of a consecutive series of 98 FL-RTHA and 159 CT-RTHA patients who underwent primary, direct anterior approach (DAA) THA, during the same time period, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis was conducted. All procedures were performed by one of two high-volume arthroplasty surgeons (Surgeons 1 and 2), who have been in practice for greater than 10 years post-fellowship. All FL-RTHA procedures were performed with the Zimmer ROSA® Hip System (Zimmer Biomet, Warsaw IN, USA), while CT-RTHA procedures were performed with the Stryker MAKO® Hip System (Stryker, Kalamazoo MI, USA). Patients who were less than 18 years of age were excluded from the study.\u003c/p\u003e\n\u003cp\u003eThe primary means used to assess intra-operative performance with regards to acetabular cup placement included average cup inclination and anteversion angles, cup placement accuracy, cup placement precision (variance), and the proportion of cups placed within the Lewinnek safe zone of 40° ± 10 inclination and 15° ± 10 anteversion [6]. In line with previous investigations, accuracy was assessed by computing target discrepancy, which was defined as the absolute value (magnitude) of the difference between measured post-operatively radiographic cup angles, and pre-operative targeted cup placement angles for each case [18–20]. Cup placement precision was assessed by calculating variances for cup placement angles, which were the square of Standard Deviation (SD). Adopting the methodology of Buchan et al. [10], the Martell Hip Analysis Suite Software (version 8.0.4.5., Martell Hip Analysis Suite™, Chicago IL, USA) was used to measure cup angles from six-week post-operative standing antero-posterior radiographs. All radiographic measurements were executed by the first and second authors of this manuscript. An inter-observer reliability analysis was conducted, and demonstrated an average difference of 1.1° for inclination, and 0.2° for anteversion.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical technique:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor the FL-RTHA cohort, all cases were performed with the ROSA® Hip System through a DAA [21,22]. Target cup inclination and anteversion angles were 40°\u0026nbsp;and 15°, respectively, for all procedures. The G7® Acetabular System (Zimmer Biomet, Warsaw IN, USA) paired with the Avenir Complete® Femoral Stem (Zimmer Biomet, Warsaw IN, USA) was placed in all patients. For the CT-RTHA cohort, all cases were performed with the MAKO® Hip System, using a technique similar to those of Perazzini et al [23]. However, a truncated “express” workflow was adopted, which involved registration of the acetabulum only [24]. Components implanted were the Trident II® Acetabular System (Stryker, Kalamazoo MI, USA) paired with the Accolade II® Femoral Stem (Stryker, Kalamazoo MI, USA). In a majority of CT-RTHA cases, cup angles of 42°/18°\u0026nbsp;(n=95; 55.88%) and 42°/20°\u0026nbsp;(n=48; 28.24%) were targeted for inclination and anteversion, respectively. A full breakdown of target cup placement angles is included in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatient demographics and surgical data between cohorts were provided as descriptive statistics. Continuous variables were presented as means ± SD and medians with interquartile range (IQR), and categorical variables as frequencies and percentages. Independent samples student t-tests, Mann-Whitney U tests, and F-tests were used to compare the means and variances of continuous variables between cohorts. Pearson’s chi-squared tests and Fisher’s exact tests were used to compare categorical variables. Shapiro-Wilk tests of normality were used to assess the distributions of data. p \u0026lt; 0.05 was considered statistically significant. All analyses were performed using JMP Version 16.2.98 (SAS Institute Inc., Cary, NC, 1989–2021) and Microsoft Excel (Microsoft Corporation 2023, Redmond WA, USA) software.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eCohorts were similar in their distributions of patient Body Mass Index (BMI), procedure laterality, and pre-operative American Society of Anesthesiologists (ASA) score. However, compared to the CT-RTHA cohort, the FL-RTHA cohort was younger (60.5 \u0026plusmn; 13.1 years vs. 66.1 \u0026plusmn; 8.7 years; p\u0026lt;0.001), more predominately female (46.9% vs. 63.5%; p=0.009), had a smaller proportion of Caucasian patients (80.6% vs. 95.6%; p\u0026lt;0.001), and less likely to have a pre-operative diagnosis of osteoarthritis (85.7% vs. 98.1%; p\u0026lt;0.001). Full demographic and treatment information is included in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe FL-RTHA and CT-RTHA cohorts had similar average cup inclination (42.8\u0026deg; \u0026plusmn; 5.2 vs. 42.5\u0026deg; \u0026plusmn; 4.4; p=0.695) and anteversion (18.5 \u0026plusmn; 5.1 vs. 18.9 \u0026plusmn; 5.9; p=0.618) angles, as well as similar degrees of cup inclination (26.8 vs. 19.4; p=0.069) and anteversion (26.0 vs. 34.3; p=0.137) precision. Full comparisons of cup inclination and anteversion angle distributions between cohorts are provided in \u003cstrong\u003eFigures 1 and 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eIn comparing cup placement accuracies, patients in the FL-RTHA cohort demonstrated a 1.2\u0026deg; difference for inclination (4.6\u0026deg; \u0026plusmn; 3.6 vs. 3.4 \u0026plusmn; 2.7; p=0.005), but similar outcomes for anteversion. Cohorts were also similar in their proportions of cups placed within the Lewinnek safe zone. Full accuracy comparisons are provided in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe use of intra-operative technological assistance has increased dramatically over the past decade, with estimates showing a 10-fold increase in utilization rates between 2008 to 2015 in the United States alone [9]. The use of robotic assistance for THA has been shown to benefit the accuracy of cup implantation, which is an important factor in ensuring favorable outcomes in the post-operative setting. The results of our investigation demonstrated that the use of a fluoroscopy-based robotic assistance system for primary THA resulted in similar accuracy and precision outcomes relative to a CT-based robotic workflow. To the authors\u0026rsquo; knowledge, this is the first investigation which has directly compared the intra-operative performance of this specific FL-RTHA platform to that of an existing robotic system.\u003c/p\u003e\n\u003cp\u003eThe first significant finding of our investigation was that both cohorts demonstrated similar average cup implantation angles and distributions for inclination and anteversion. Though this is the first investigation which has directly compared the accuracy profiles of these two robotic platforms, our findings are in line with existing literature which has demonstrated excellent intra-operative performance for both systems [10,21,25\u0026ndash;29]. Prior studies involving the FL-RTHA platform have shown improved cup implantation accuracy relative to mTHA in a number of clinical scenarios [10,21,25,26], with comparable findings having also been reported in the CT-RTHA literature [27\u0026ndash;29]. Furthermore, the averages and variances for cup inclination and anteversion angles obtained in this study are similar to those reported by these previous authors [10,21,25\u0026ndash;29]. Though not statistically significant, it appeared that the FL-RTHA system trended towards greater precision for cup anteversion. This finding is especially significant, considering orthopaedic surgeons have a tendency to misjudge and subsequently misalign cup anteversion angles during impaction as opposed to inclination angles [25]. \u0026nbsp;There are potentially a number of contributing factors to the improved anteversion precision in the FL-RTHA cohort, though a primary driver is likely the differences in acetabular registration workflows between systems. As discussed in Kamath et al, the FL-RTHA platform utilizes intra-operative fluoroscopic images obtained from a standard C-arm to execute pin-less digital navigation and fluoroscopy-based robotic registration of the acetabulum [21,22]. The CT-RTHA platform requires the insertion of individual navigation tracker pins, in conjunction with physical probe contact with a number of bony landmarks around the acetabular rim to perform acetabular registration [23,24]. Requiring direct probe contact with the acetabulum can prove to be challenging especially in minimally invasive DAA THA, where access to the joint space is limited. This difficulty can be further compounded by patient anatomical factors such as bony deformity and an obese body habitus [30,31]. Because image-based registration is a consistent approach that is relatively indifferent to patient anatomy [17], the FL-RTHA system may offer alternate advantages to achieve similarly precise cup implantation.\u003c/p\u003e\n\u003cp\u003eThe second significant finding of this study was that the FL-RTHA and CT-RTHA platforms had similar accuracy outcomes, and also had similar proportions of cups placed within the Lewinnek zone. The authors surmise that the observed 1.2\u0026deg;\u0026nbsp;difference in inclination accuracy between systems is a result of the FL-RTHA cohort including cases from the surgeon\u0026rsquo;s learning period with the system, which is traditionally associated with inferior surgical performance compared to the post-proficiency stage [32,33]. One investigation reported an average cup implantation angle difference of 2.8\u0026deg;\u0026nbsp;for inclination, and 3.5\u0026deg;\u0026nbsp;for anteversion between pre- and post-proficiency procedures when adopting an intra-operative assistance system for THA [34]. The CT-RTHA cohort only included post-proficiency procedures. Overall, it is unlikely that this small difference (1.2\u0026deg;) in accuracy would have meaningful clinical impact on post-operative results with regards to complication rates, functionality, or patient-reported outcomes, especially given the equal rates at which cups were placed within the Lewinnek zone in either cohort [6]. The 81.6% of cups placed within the Lewinnek zone in the FL-RTHA cohort is comparable to the 87% reported in a recent study by Stewart et al, who utilized the CT-RTHA system for DAA THA [35]. When considering the overall net benefits to the patient, this ~1\u0026deg;\u0026nbsp;difference in accuracy should be weighed against the potential for improved cost-effectiveness [12,15], reduced operative times and pin-less workflow, and radiation exposure in the FL-RTHA cohort relative to the CT-RTHA cohort [16,17].\u003c/p\u003e\n\u003cp\u003eOur findings have several limitations. First, the retrospective nature of this study introduced the possibility of documentation biases. To mitigate this likelihood, all data were directly obtained from a rigorous review of standardized institutional electronic health records. Second, the two surgeons involved in this investigation are high-volume robotic arthroplasty surgeons, potentially limiting the generalizability of these findings to surgeons who perform lower case volumes or who have less expertise in robotic THA. Third, all FL-RTHA procedures were performed by one surgeon, and all CT-RTHA procedures were performed by a different surgeon. While both surgeons are of similar levels of arthroplasty experience, surgeon-related factors could have biased the results. To create comparable cohorts, only primary cases with a pre-operative diagnosis of osteoarthritis, avascular necrosis or rheumatoid arthritis were considered. Fourth, this was an unmatched investigation, and there were various demographic differences between cohorts that could have biased the results. In order to mitigate this limitation, we used consecutive series of patients in either cohort. However, a recent study by Barrack et al found that patient BMI and surgeon annual case volume were the two strongest predictors of cup positioning, and that patient age, sex and pre-operative diagnosis were not significant predictors of placement outcomes [36]. Lastly, cup angle comparisons could have confounded by differences in target inclination and anteversion angles between cohorts. While this may have theoretically influenced comparisons of cup placement precision, by-case adjustments of pre-operative target implantation angles for accuracy calculations would have controlled for this discrepancy. Overall, the authors do not believe that these limitations significantly biased the results.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe use of a fluoroscopy-based robotic assisted platform for THA yielded similar accuracy and precision outcomes with regards to acetabular cup positioning when compared to a CT-based robotic system. The observed ~1\u0026deg; difference in inclination accuracy between systems is likely clinically insignificant with regards to its overall impact on post-operative patient outcomes. Additional research among an expanded and matched cohort is still needed to validate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Authors C.B.O., G.B.J.B., C.J.H., and A.K. declare that they have no relevant competing interests.\u0026nbsp;Author D.O.K. serves on the speakers bureau and receives royalties from Zimmer Biomet.\u0026nbsp;Author A.F.K. serves on the speakers bureau, is a paid consultant, and owns stock or stock options in Zimmer Biomet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChristian B. Ong: [Writing – original draft/review \u0026amp; editing; Data review; Formal analysis; Investigation]\u003c/p\u003e\n\u003cp\u003eGraham B.J. Buchan: [Writing – original draft/review \u0026amp; editing; Data review; Investigation]\u003c/p\u003e\n\u003cp\u003eChristian J. Hecht II: [Writing – original draft/review \u0026amp; editing; Data review; Investigation]\u003c/p\u003e\n\u003cp\u003eArihiko Kanaji: [Writing – original draft/review \u0026amp; editing; Formal analysis; Investigation]\u003c/p\u003e\n\u003cp\u003eDaniel O. Kendoff: [Writing – original draft/review \u0026amp; editing; Formal analysis; Investigation]\u003c/p\u003e\n\u003cp\u003eAtul F. Kamath:\u0026nbsp;[Supervision; Methodology; Writing – review \u0026amp; editing]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board (06/03/2022; IRB#: 22-528).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e The data that support the findings of this study are available upon reasonable request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eScheerlinck T. Cup positioning in total hip arthroplasty. \u003cem\u003eActa Orthop Belg\u003c/em\u003e. 2014;80(3):336-347. \u003c/li\u003e\n\u003cli\u003ePatil S, Bergula A, Chen PC, Colwell CW Jr, D\u0026apos;Lima DD. Polyethylene wear and acetabular component orientation. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e. 2003;85-A Suppl 4:56-63. doi:10.2106/00004623-200300004-00007 \u003c/li\u003e\n\u003cli\u003eFontalis A, Kayani B, Thompson JW, Plastow R, Haddad FS. Robotic total hip arthroplasty: past, present and future. \u003cem\u003eOrthop Trauma\u003c/em\u003e. 2022 Feb 1;36(1):6\u0026ndash;13. doi:10.1016/j.mporth.2021.11.002\u003c/li\u003e\n\u003cli\u003eIllgen RL Nd, Bukowski BR, Abiola R, et al. Robotic-Assisted Total Hip Arthroplasty: Outcomes at Minimum Two-Year Follow-Up. \u003cem\u003eSurg Technol Int\u003c/em\u003e. 2017;30:365-372. \u003c/li\u003e\n\u003cli\u003eLittle NJ, Busch CA, Gallagher JA, Rorabeck CH, Bourne RB. Acetabular polyethylene wear and acetabular inclination and femoral offset. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 2009;467(11):2895-2900. doi:10.1007/s11999-009-0845-3\u003c/li\u003e\n\u003cli\u003eLewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e. 1978;60(2):217-220. \u003c/li\u003e\n\u003cli\u003eBosker BH, Verheyen CC, Horstmann WG, Tulp NJ. Poor accuracy of freehand cup positioning during total hip arthroplasty. \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e. 2007;127(5):375-379. doi:10.1007/s00402-007-0294-y \u003c/li\u003e\n\u003cli\u003eCallanan MC, Jarrett B, Bragdon CR, et al. The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 2011;469(2):319-329. doi:10.1007/s11999-010-1487-1 \u003c/li\u003e\n\u003cli\u003eBoylan M, Suchman K, Vigdorchik J, Slover J, Bosco J. Technology-Assisted Hip and Knee Arthroplasties: An Analysis of Utilization Trends. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2018;33(4):1019-1023. doi:10.1016/j.arth.2017.11.033 \u003c/li\u003e\n\u003cli\u003eBuchan GBJ, Hecht CJ 2nd, Liu D, Mokete L, Kendoff D, Kamath AF. Improved accuracy of a novel fluoroscopy-based robotically assisted THA system compared to manual THA. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2023;17(5):2073-2079. doi:10.1007/s11701-023-01623-w \u003c/li\u003e\n\u003cli\u003eNg N, Gaston P, Simpson PM, Macpherson GJ, Patton JT, Clement ND. Robotic arm-assisted versus manual total hip arthroplasty : a systematic review and meta-analysis. \u003cem\u003eBone Joint J\u003c/em\u003e. 2021;103-B(6):1009-1020. doi:10.1302/0301-620X.103B6.BJJ-2020-1856.R1 \u003c/li\u003e\n\u003cli\u003eOng CB, Buchan GBJ, Acu\u0026ntilde;a AJ, et al. Cost-effectiveness of a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system: A Markov analysis. \u003cem\u003eInt J Med Robot\u003c/em\u003e. Published online September 30, 2023. doi:10.1002/rcs.2582 \u003c/li\u003e\n\u003cli\u003eKunze KN, Bovonratwet P, Polce EM, Paul K, Sculco PK. Comparison of Surgical Time, Short-term Adverse Events, and Implant Placement Accuracy Between Manual, Robotic-assisted, and Computer-navigated Total Hip Arthroplasty: A Network Meta-analysis of Randomized Controlled Trials. \u003cem\u003eJ Am Acad Orthop Surg Glob Res Rev\u003c/em\u003e. 2022;6(4):e21.00200. Published 2022 Apr 1. doi:10.5435/JAAOSGlobal-D-21-00200\u003c/li\u003e\n\u003cli\u003ePonzio DY, Lonner JH. Preoperative Mapping in Unicompartmental Knee Arthroplasty Using Computed Tomography Scans Is Associated with Radiation Exposure and Carries High Cost. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2015;30(6):964-967. doi:10.1016/j.arth.2014.10.039 \u003c/li\u003e\n\u003cli\u003eMaldonado DR, Go CC, Kyin C, et al. Robotic Arm-assisted Total Hip Arthroplasty is More Cost-Effective Than Manual Total Hip Arthroplasty: A Markov Model Analysis. \u003cem\u003eJ Am Acad Orthop Surg\u003c/em\u003e. 2021;29(4):e168-e177. doi:10.5435/JAAOS-D-20-00498 \u003c/li\u003e\n\u003cli\u003eBuchan G, Ong C, Hecht C, et al. Equivalent radiation exposure with robotic total hip replacement using a novel, fluoroscopic-guided (CT-free) system: case-control study versus manual technique [published correction appears in J Robot Surg. 2023 Apr 15;:]. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2023;17(4):1561-1567. doi:10.1007/s11701-023-01554-6 \u003c/li\u003e\n\u003cli\u003eOng CB, Buchan GBJ, Hecht Ii CJ, et al. Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2023;17(6):2841-2847. doi:10.1007/s11701-023-01723-7 \u003c/li\u003e\n\u003cli\u003eOng CB, Chiu YF, Premkumar A, Gonzalez Della Valle A. Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study. \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e. 2023;143(5):2739-2745. doi:10.1007/s00402-022-04520-3 \u003c/li\u003e\n\u003cli\u003eBradley MP, Benson JR, Muir JM. Accuracy of Acetabular Component Positioning Using Computer-assisted Navigation in Direct Anterior Total Hip Arthroplasty. \u003cem\u003eCureus\u003c/em\u003e. 2019;11(4):e4478. Published 2019 Apr 16. doi:10.7759/cureus.4478 \u003c/li\u003e\n\u003cli\u003eRyan JA, Jamali AA, Bargar WL. Accuracy of computer navigation for acetabular component placement in THA. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 2010;468(1):169-177. doi:10.1007/s11999-009-1003-7 \u003c/li\u003e\n\u003cli\u003eKamath AF, Durbhakula SM, Pickering T, et al. Improved accuracy and fewer outliers with a novel CT-free robotic THA system in matched-pair analysis with manual THA [published correction appears in J Robot Surg. 2021 Dec 6;:]. \u003cem\u003eJ Robot Surg\u003c/em\u003e. 2022;16(4):905-913. doi:10.1007/s11701-021-01315-3 \u003c/li\u003e\n\u003cli\u003eZimmer Biomet TV [Internet]. [cited 2023 Aug 11]. ROSA\u0026reg; Hip System V1.0 Surgical Technique (Extended Version). Available from: https://zimmerbiomet.tv/videos/2858?version=3515\u003c/li\u003e\n\u003cli\u003ePerazzini P, Trevisan M, Sembenini P, et al. The Mako \u0026trade; robotic arm-assisted total hip arthroplasty using direct anterior approach: surgical technique, skills and pitfals. \u003cem\u003eActa Biomed\u003c/em\u003e. 2020;91(4-S):21-30. Published 2020 May 30. doi:10.23750/abm.v91i4-S.9659 \u003c/li\u003e\n\u003cli\u003eStryker MedEd [Internet]. Mako\u003csup\u003eTM\u003c/sup\u003e Total Hip Direct anterior approach: Surgical reference guide. Available from: https://www.strykermeded.com/media/2040/mako-tha-direct-anterior-approach-surgical-technique.pdf\u003c/li\u003e\n\u003cli\u003eOng CB, Buchan GBJ, Hecht Ii CJ, Kendoff DO, Homma Y, Kamath AF. Fluoroscopy-based robotic assistance for total hip arthroplasty improves acetabular cup placement accuracy for obese patients compared to the manual, fluoroscopic- assisted technique. \u003cem\u003eTechnol Health Care\u003c/em\u003e. Published online November 9, 2023. doi:10.3233/THC-231127 \u003c/li\u003e\n\u003cli\u003eOng CB, Buchan GBJ, Hecht Ii CJ, et al. Fluoroscopy-based robotics in total hip arthroplasty mitigates laterality-based differences in acetabular cup placement when compared to the manual, fluoroscopic- assisted technique. \u003cem\u003eTechnol Health Care\u003c/em\u003e. Published online November 9, 2023. doi:10.3233/THC-231126 \u003c/li\u003e\n\u003cli\u003eKong X, Yang M, Li X, et al. Impact of surgeon handedness in manual and robot-assisted total hip arthroplasty. \u003cem\u003eJ Orthop Surg Res\u003c/em\u003e. 2020;15(1):159. Published 2020 Apr 21. doi:10.1186/s13018-020-01671-0 \u003c/li\u003e\n\u003cli\u003eGupta A, Redmond JM, Hammarstedt JE, Petrakos AE, Vemula SP, Domb BG. Does Robotic-Assisted Computer Navigation Affect Acetabular Cup Positioning in Total Hip Arthroplasty in the Obese Patient? A Comparison Study. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2015;30(12):2204-2207. doi:10.1016/j.arth.2015.06.062 \u003c/li\u003e\n\u003cli\u003eEmara AK, Samuel LT, Acu\u0026ntilde;a AJ, Kuo A, Khlopas A, Kamath AF. Robotic-arm assisted versus manual total hip arthroplasty: Systematic review and meta-analysis of radiographic accuracy. \u003cem\u003eInt J Med Robot\u003c/em\u003e. 2021;17(6):e2332. doi:10.1002/rcs.2332 \u003c/li\u003e\n\u003cli\u003ePost ZD, Orozco F, Diaz-Ledezma C, Hozack WJ, Ong A. Direct anterior approach for total hip arthroplasty: indications, technique, and results. \u003cem\u003eJ Am Acad Orthop Surg\u003c/em\u003e. 2014;22(9):595-603. doi:10.5435/JAAOS-22-09-595 \u003c/li\u003e\n\u003cli\u003eLiu Z, Bell CD, Ong AC, Wu S, Li Z, Zhang Y. Direct anterior approach total hip arthroplasty for Crowe III and IV dysplasia. \u003cem\u003eArthroplast Today\u003c/em\u003e. 2020;6(2):251-256. Published 2020 Mar 31. doi:10.1016/j.artd.2020.02.008 \u003c/li\u003e\n\u003cli\u003eChang JD, Kim IS, Bhardwaj AM, Badami RN. The Evolution of Computer-Assisted Total Hip Arthroplasty and Relevant Applications. \u003cem\u003eHip Pelvis\u003c/em\u003e. 2017;29(1):1-14. doi:10.5371/hp.2017.29.1.1 \u003c/li\u003e\n\u003cli\u003eBuchan GBJ, Hecht CJ 2nd, Lawrie CM, Sculco PK, Kamath AF. The learning curve for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system. \u003cem\u003eInt J Med Robot\u003c/em\u003e. 2023;19(4):e2518. doi:10.1002/rcs.2518 \u003c/li\u003e\n\u003cli\u003eThorey F, Klages P, Lerch M, Floerkemeier T, Windhagen H, von Lewinski G. Cup positioning in primary total hip arthroplasty using an imageless navigation device: is there a learning curve?. \u003cem\u003eOrthopedics\u003c/em\u003e. 2009;32(10 Suppl):14-17. doi:10.3928/01477447-20090915-52 \u003c/li\u003e\n\u003cli\u003eStewart NJ, Stewart JL, Brisbin A. A Comparison of Component Positioning Between Fluoroscopy-Assisted and Robotic-Assisted Total Hip Arthroplasty. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2022;37(8):1602-1605.e3. doi:10.1016/j.arth.2022.03.056 \u003c/li\u003e\n\u003cli\u003eBarrack RL, Krempec JA, Clohisy JC, et al. Accuracy of acetabular component position in hip arthroplasty. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e. 2013;95(19):1760-1768. doi:10.2106/JBJS.L.01704 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePatient demographic and treatment data\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ebetween fluoroscopy-based and CT-based robotic THA cohorts.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.964401294498384%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.812297734627832%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.57281553398058%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.84403669724771%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.220183486238533%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFL-RTHA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.724770642201836%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCT-RTHA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.211009174311927%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge at Surgery (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e60.5\u0026nbsp;\u0026plusmn;\u0026nbsp;13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e66.1\u0026nbsp;\u0026plusmn;\u0026nbsp;8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGender (% Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e46.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e63.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBody Mass Index (BMI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e29.6\u0026nbsp;\u0026plusmn;\u0026nbsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e29.3\u0026nbsp;\u0026plusmn;\u0026nbsp;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e0.686\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.15384615384615%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Caucasian)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.175824175824175%\" valign=\"top\"\u003e\n \u003cp\u003e80.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.67032967032967%\" valign=\"top\"\u003e\n \u003cp\u003e95.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.15384615384615%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Black)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.175824175824175%\" valign=\"top\"\u003e\n \u003cp\u003e18.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.67032967032967%\" valign=\"top\"\u003e\n \u003cp\u003e4.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSide (% Left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e44.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e44.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Osteoarthritis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e85.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e98.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Avascular Necrosis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e12.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Rheumatoid Arthritis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e2.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.77669902912621%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eASA Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.359223300970875%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.21359223300971%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.650485436893204%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.492\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.15384615384615%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Class I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.175824175824175%\" valign=\"top\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.67032967032967%\" valign=\"top\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.15384615384615%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Class II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.175824175824175%\" valign=\"top\"\u003e\n \u003cp\u003e48.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.67032967032967%\" valign=\"top\"\u003e\n \u003cp\u003e55.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.15384615384615%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(% Class III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.175824175824175%\" valign=\"top\"\u003e\n \u003cp\u003e51.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.67032967032967%\" valign=\"top\"\u003e\n \u003cp\u003e43.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCup Implantation Target\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;40\u0026deg; inc./15\u0026deg; ant.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;42\u0026deg; inc./18\u0026deg; ant.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;42\u0026deg; inc./20\u0026deg; ant.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003cp\u003e56.6%\u003c/p\u003e\n \u003cp\u003e30.2%\u003c/p\u003e\n \u003cp\u003e13.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: * = p \u0026lt; 0.05; Categorical variables expressed as percentages; Quantitative variables expressed as mean\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026plusmn;\u003c/em\u003e\u003cem\u003e\u0026nbsp;standard deviation; FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty; DAA = Direct anterior approach; ASA = American Society of Anesthesiologists risk score; inc. = Inclination; ant. = Anteversion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e:\u0026nbsp;A comparison of acetabular cup placement accuracy for inclination and anteversion based on pre-operative target angles for the fluoroscopy-based and computerized tomography-based robotic cohorts.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.41269841269841%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.73015873015873%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.22222222222222%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.634920634920634%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.130434782608695%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.217391304347824%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;FL-RTHA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCT-RTHA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.652173913043478%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.142857142857146%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAbsolute accuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.555555555555557%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.634920634920634%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.142857142857146%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Inclination (˚)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4.6\u0026nbsp;\u0026plusmn;\u0026nbsp;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.555555555555557%\" valign=\"top\"\u003e\n \u003cp\u003e3.4\u0026nbsp;\u0026plusmn;\u0026nbsp;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.634920634920634%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.142857142857146%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Anteversion (˚)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4.7\u0026nbsp;\u0026plusmn;\u0026nbsp;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.555555555555557%\" valign=\"top\"\u003e\n \u003cp\u003e4.6\u0026nbsp;\u0026plusmn;\u0026nbsp;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.634920634920634%\" valign=\"top\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.142857142857146%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLewinnek Safe Zone placement (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e81.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.555555555555557%\" valign=\"top\"\u003e\n \u003cp\u003e81.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.634920634920634%\" valign=\"top\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: * = p\u0026lt;0.05; Categorical variables expressed as percentages; Quantitative variables expressed as mean\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026plusmn;\u003c/em\u003e\u003cem\u003e\u0026nbsp;standard deviation; FL-RTHA = Fluoroscopy-based robotic assisted total hip arthroplasty; CT-RTHA = Computerized tomography-based robotic assisted total hip arthroplasty\u003c/em\u003e\u003c/p\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":"Hip, Arthroplasty, Robotic-Assisted Surgery, Acetabulum, Accuracy","lastPublishedDoi":"10.21203/rs.3.rs-4314196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4314196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/em\u003e Robotic assistance for total hip arthroplasty (THA) has been demonstrated to improve accuracy of acetabular cup placement relative to manual, unassisted technique. The purpose of this investigation was to compare the accuracy and precision between a fluoroscopy-based robotic total hip arthroplasty platform (FL-RTHA) and a computerized tomography-based (CT-RTHA) platform.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e The study included 98 consecutive FL-RTHA and 159 CT-RTHA procedures performed via direct anterior approach (DAA). All cases were performed for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included cup implantation accuracy and precision (variance). Implantation accuracy was calculated as the absolute value of the difference between pre-operative target cup angles (inclination and anteversion) and the same post-operative angles. Percentage placement in the Lewinnek safe zone was also measured for both cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e The FL-RTHA and CT-RTHA cohorts demonstrated a 1.2° difference in absolute values for cup inclination accuracy (4.6° ± 3.6 vs. 3.4 ± 2.7; p=0.005), and no difference in absolute values for cup anteversion accuracy (4.7° ± 4.1 vs. 4.6 ± 3.4; p=0.991). Cohorts demonstrated similar precision for cup inclination and anteversion placement parameters, as well as equivalent Lewinnek safe zone placement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/em\u003e The use of a fluoroscopy-based robotic assistance platform for primary DAA THA resulted in similar accuracy and precision of acetabular cup placement when compared to a CT-based robotic assistance system.\u003c/p\u003e","manuscriptTitle":"Robotic-assisted Total Hip Arthroplasty Utilizing a Fluoroscopy-guided System Produced Similar Cup Accuracy and Precision Relative to a Computerized Tomography-based Robotic Platform","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-28 20:06:21","doi":"10.21203/rs.3.rs-4314196/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-10T15:34:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-10T14:37:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338109912981934074342528478321496737763","date":"2024-05-12T13:10:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-11T17:26:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-11T17:24:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-10T05:47:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-04-23T20:19:43+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":"8d5a615b-a8ed-42b1-8990-3d0c010b7a7d","owner":[],"postedDate":"May 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T22:23:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-28 20:06:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4314196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4314196","identity":"rs-4314196","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}