Value of robotic total knee arthroplasty in residency training: perceptions of orthopaedic surgery residents

INTRODUCTION The aim of total knee arthroplasty (TKA) is the creation of a balanced joint with optimal flexion and extension gaps.[1] As part of this procedure, appropriate bone and soft tissue releases must be made to ensure adequate alignment of both the femoral and tibial components.[2] The developments in robotic TKA over the last few decades have shown favourable results as compared to the conventional jig-based TKA, including greater accuracy in limb alignment, decreased postoperative pain and earlier functional rehabilitation.[3] The computer software used in robotic TKA allows the surgeon to create a virtual 3-dimensional (3D) reconstruction of the patient's knee joint. When this is coupled with intraoperative real-time ligament-balancing feedback, the surgeon can carry out patient-specific planning for bony resection and implant placement for optimal functional alignment.[4,5] Although robotic TKA is not currently available at all institutions in Singapore, the surgical procedure is commonly used across many countries. At our institution, we have incorporated this method of surgery in the training of young surgeons, including orthopaedic residents, since mid-2018. Majority of the orthopaedic residents at our centre have had the opportunity to experience robotic TKA procedures in their adult reconstruction postings. The residents have two 3-month rotations in adult reconstruction, one as a junior resident and the as a senior resident where they may be the first or second surgeon, or the first or second assistant, depending on the complexity of the case and the competency of the resident. On average, residents would have experienced 24–36 TKA procedures during the 3-month rotation, with an average of 3–4 conventional TKAs, 18–28 navigated TKAs and three or four robotic TKAs. We hope that by including robotic TKA as part of their training, orthopaedic surgery residents will gain increased exposure to the technique and a better understanding of how to perform TKA by the time they graduate from residency. In this study, we aimed to investigate the perceptions of residents about the use of robotics in TKA during their residency training, as well as the value of robotics in the education of residents in TKA procedures. METHODS A cross-sectional descriptive survey was conducted in 2021 to assess the perception of gap balancing among orthopaedic residents who had the opportunity to participate in robotic-assisted TKA during their residency training. We selected residents who had completed at least one rotation in the adult reconstruction division and had previously performed or assisted in a robotic TKA procedure. The robot used in our institution for this purpose is the Mako Robot (Stryker, Mahwah, NJ, USA). The study was reviewed by the National Healthcare Group Domain Specific Review Board, Singapore and an exemption was granted (reference no. 2020/01270). A five-part questionnaire [see Supplemental Digital Appendix at https://links.lww.com/SGMJ/A89] was created and sent out to the residents who fulfilled the selection criteria. Completion of the questionnaire was on a voluntary basis, and the submission of a response was interpreted as implied consent to participation in the study. The questionnaire used both general and Likert scale-based questions. The questions were used to measure the residents' perceptions of the use of robotic-assisted surgery in their training. The residents gave their level of agreement to the statements provided on a 5-point Likert scale, where 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree. The first part of the questionnaire was related to the residents' level of exposure to the various methods of TKA (conventional, navigated and robotic), as well as their involvement in knee gap balancing. The second part of the questionnaire used Likert scale-based questions to quantify the residents' confidence in carrying out a robotic TKA procedure and achieving an optimal gap balance with this method. The third part investigated the participants' perceptions of robotic TKA during their training, as well as their current perceptions of the various methods of TKA procedures. Descriptive variables were reported as mean ± standard deviation (SD) or n (%). All analyses were performed using IBM SPSS Statistics version 11.5 (IBM Corp, Armonk, NY, USA). A rho (ρ) value > 0 was considered a positive correlation, while values closer to 1 indicated stronger positive correlation and values closer to −1 indicated stronger negative correlation. A P value < 0.05 was considered statistically significant. RESULTS A total of 19 out of 22 (86.4%) orthopaedic residents from years 2 to 6 of training responded to the survey. Of these, only 17 residents who had previously been involved in robotic TKAs and had at least one rotation through the adult reconstruction division were included in this study. During their rotation through the division, the residents were exposed to TKAs performed using conventional, navigated and robotic methods. Among the residents, navigated TKA was the most familiar method (n=16, 94.1%), followed by other robotic TKA procedures (n=7, 41.2%). The mean Likert scale score for statements included in the first part of the questionnaire showed a positive agreement for all included questions [Table 1], except for resident's comfort in the use of robotic technology in TKA surgery, where it was rated at a mean of 2.88 ± 1.05. All other questions regarding robotic TKA surgery received positive responses.Table 1: Responses to questionnaire.The overall perception of residents towards their competency of achieving a balanced flexion and extension gap using robotic TKA surgery was 3.35 ± 0.79 on the 5-point Likert scale. A lack of exposure to robotic TKA surgery was the unanimous reason given in cases where residents reported low confidence. Most residents (76.5%) were largely favourable towards the use of robotic TKA as a teaching tool in their programme, and all residents (100%) agreed that robotic TKA procedures should be included in the orthopaedic surgery residency training. The top two reported advantages for the use of robotic TKA were its use in difficult cases, such as severe valgus or varus malalignments, and its ability to achieve a better alignment of the knee postoperatively. The top two reported disadvantages were the learning curve and cost of robotic TKAs, although all residents agreed that robotic TKA procedures should be included in the orthopaedic surgery residency training. Residents were asked which method of TKA they thought was the best and their procedure of choice if they were the primary surgeon. There were mixed responses; navigated TKA was chosen as the best technique and the choice of surgery if they were the primary surgeon by 64.8% and 70.7% of the residents, respectively. The reason for this choice was unanimously reported as the residents' familiarity with navigated TKAs. Residents (23.5%) who chose to use a robotic technique cited its accuracy as the reason. There was a strong positive correlation between residents who reported to be currently comfortable with robotic TKAs and their perceived competency towards performing robotic TKAs at the end of their training (ρ = 0.63, P = 0.01). However, there were weak correlations between the residents' perceived competency in robotic TKAs at the end of their training and their current understanding of conventional TKAs (ρ = 0.06, P = 0.81) and navigated TKAs (ρ = 0.22, P = 0.40) [Table 2]. Residents who assisted in more robotic TKA procedures were more confident in their ability to achieve a balanced flexion and extension gap in robotic TKA surgery (ρ = 0.66, P ≤ 0.01).Table 2: Spearman's correlation matrix for responses regarding resident's exposure to robotic TKA, confidence in TKA procedures and understanding of gap balancing.DISCUSSION With the progress in technology available for TKA, robotic TKA surgeries have become more readily available and have shown strong results compared to conventional TKA procedures.[6] With greater accuracy and consistency, robotic TKA provides greater target alignment.[7-9] In addition to better precision and accuracy, some studies show that robotic TKA confers less postoperative pain, reduce length of stay and improves function, which increases patient satisfaction postoperatively.[10] Due to its growing availability, young orthopaedic surgeons are now exposed to this form of TKA procedure from the early stages of their training, and they can learn how to perform robotic TKA as part of their training programme. From our survey, it is evident that residents have generally positive attitudes towards robotic TKA as a teaching tool and as a method of TKA . All residents agreed that robotic TKA should be included as part of their training programme, with a majority of them seeing an advantage in its use as a teaching tool. Being able to leverage technology to improve surgical outcomes has caused a paradigm shift globally, where more advanced technology is simultaneously being developed with a general trend towards its acceptance.[11-16] While robotic technology may provide greater benefits to patients in comparison to conventional or navigated methods, an important consideration for this method of TKA would be its ease of use.[17] Current literature has discussed the many potential advantages of robotic TKAs over other methods, with reasons ranging from reduction in postoperative alignment outliers to improvements in gap balance.[18] Residents included in this survey agreed with these advantages. Interestingly, when asked on their preferred choice of TKA modality, most chose to use navigated TKAs over robotic TKAs, likely due to their exposure and familiarity with navigated TKA due to its current high usage in the department. The dissonance between the existing literature and the response from this study provides some insight into the issues that residents may have regarding robotic surgery. While they could identify the theoretical benefits of a robotic surgery, most were still more comfortable with more traditional methods of TKA. This may be attributed to the perceived steep learning curve associated with robotic surgeries, which they had highlighted in the survey. Exacerbated by a lack of opportunities to engage in robotic surgeries, it is understandable that most residents are not comfortable with robotic TKA, and hence, would not consider the use of robotics at this stage of their training. Despite this, all residents surveyed agreed that robotic TKA should be a part of their residency programme and education, as they considered it an important and beneficial aspect of their training. One possible way to improve residents' uptake and confidence in robotic TKAs is by increasing their exposure to these procedures and incorporating the teaching of robotic TKA to the earlier stages of training. In this way, they will have more time to learn the skills required in robotic TKA. This is supported by our finding that residents who assisted in more robotic TKA procedures were more confident in their ability to achieve balanced flexion and extension gap. In addition, the technology associated with robotic surgery can also help to bridge the initial learning curve for important principles such as gap balancing. With 3D visualisation of the knee model using robotic technology, residents would be able to visualise planned implants in situ and also obtain real-time feedback on gap balancing. Vermue et al. reported that there is no learning curve for gap balancing with the use of robotic TKA surgery.[19] This would make it a viable choice for even junior surgeons to learn gap balancing principles and be able to practise it using the computer software. To the best of our knowledge, this study is the first of its kind to examine the perceptions of orthopaedic residents on robotic TKA. However, the study does have its limitations. As residents were exposed to conventional, navigated and robotic TKAs from the start of their residency training, it was not possible to compare their knowledge or competency before exposure to robotic TKAs. This prevented any analysis to determine if there was a significant change in the resident's competency after exposure to robotic TKA. Furthermore, our results may have been subject to reporting bias, as the findings were largely dependent on the residents' personal perceptions of their comfort level, confidence and perceived future competency. Finally, as this is a single-centre study, it would not reflect the perception of orthopaedic residents in general. To follow up on the findings of this study, residents can be further surveyed on how the curriculum can be improved to optimise their confidence and competence in robotic TKA. As technology improves, a follow-up study can be conducted to evaluate whether their perceptions of robotic TKA has changed over time. In conclusion, while most residents surveyed have generally favourable perceptions towards robotic surgery, a lack of exposure and opportunity has led to difficulty in learning and practising robotic surgeries. To overcome this perceived difficulty, robotic TKA can be incorporated early in residents' education, and it can also serve as a valuable teaching tool in orthopaedic residency training. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.