
==== Front
Eur J Orthop Surg Traumatol
Eur J Orthop Surg Traumatol
European Journal of Orthopaedic Surgery & Traumatology
1633-8065
1432-1068
Springer Paris Paris

39026078
4043
10.1007/s00590-024-04043-0
Original Article
Early and delayed periprosthetic joint infection in robot-assisted total knee arthroplasty: a multicenter study
Burgio Carmelo 1
http://orcid.org/0000-0001-8306-1869
Bosco Francesco francescobosco@icloud.com
francesco.bosco03@unipa.it

12
Rovere Giuseppe 34
Giustra Fortunato 5
Lo Bue Giorgia 1
Petillo Antonio 1
Lucenti Ludovico 1
Palumbo Gaetano 6
Camarda Lawrence 1
1 https://ror.org/044k9ta02 grid.10776.37 0000 0004 1762 5517 Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
2 grid.415266.2 Department of Orthopaedics and Traumatology, G.F. Ingrassia Hospital Unit, ASP 6, Palermo, Italy
3 https://ror.org/03h7r5v07 grid.8142.f 0000 0001 0941 3192 Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
4 https://ror.org/02p77k626 grid.6530.0 0000 0001 2300 0941 Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome “Tor Vergata”, Rome, Italy
5 grid.415044.0 0000 0004 1760 7116 Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco di Torino-ASL Città di Torino, Turin, Italy
6 Department of Orthopedic and Traumatology, Casa Di Cura Musumeci-GECAS, Catania, Italy
18 7 2024
18 7 2024
2024
34 6 31553162
22 4 2024
11 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Background

Robot-assisted total knee arthroplasty (RA-TKA) has significantly improved knee surgery outcomes in the last few years. However, its association with the periprosthetic joint infection (PJI) rate remains debatable. This study investigates the incidence of early and delayed PJI in a multicentric cohort of patients who underwent RA-TKA, aiming to elucidate the risk associated with this procedure.

Methods

This retrospective study analyzed data from a consecutive series of patients who underwent RA-TKA using the NAVIO Surgical System (Smith & Nephew, Memphis, USA) between 2020 and 2023. The inclusion criteria encompassed individuals over 18 years of age with a minimum follow-up period of three months. The primary outcome was the incidence of early and delayed PJI, defined according to the European Bone and Joint Infection Society (EBJIS) diagnostic criteria. Secondary outcomes included the evaluation of postoperative complications.

Results

The study included patients who underwent RA-TKA with the NAVIO system, achieving an average follow-up of 9.1 ± 3.9 months. None of the patients met the EBJIS criteria for a likely or confirmed infection, indicating an absence of both early and delayed PJI cases. Two patients required subsequent surgical interventions due to patellar maltracking and prosthetic loosening, respectively. Additionally, three patients underwent passive manipulation under anesthesia (MUA).

Conclusion

The findings indicate no evidence of early or delayed PJI in patients undergoing RA-TKA within the study period. The low complication rate further supports the reliability and safety of this surgical technique in short-term follow-up.

Level of evidence

IV.

Keywords

Robot
RA-TKA
Total knee arthroplasty
PJI
Periprosthetic joint infection
Università degli Studi di PalermoOpen access funding provided by Università degli Studi di Palermo within the CRUI-CARE Agreement.

issue-copyright-statement© Springer-Verlag France SAS, part of Springer Nature 2024
==== Body
pmcIntroduction

Total knee arthroplasty (TKA) has evolved significantly in recent years, becoming a prevalent procedure in orthopedic surgery [1–3]. Despite reports of substantial clinical success, dissatisfaction persists in approximately 20% of patients undergoing conventional TKA (C-TKA) [4, 5]. This has led to the development of Robot-Assisted (RA) TKA, a technique growing in popularity due to its precision in implant placement [6, 7]. RA-TKA utilizes preoperative X-ray or CT-scan images to tailor planning and implant selection to individual patient anatomy, potentially enhancing joint function, balance, and longevity [6]. The technique may also allow for more precise, minimally invasive approaches, resulting in less tissue damage and quicker recovery [7]. Early follow-up studies hint at improved outcomes [6], although RA-TKA is associated with longer surgical times, potentially increasing infection risk [6, 8–12].

Periprosthetic joint infection (PJI) remains a severe complication in TKA [8], leading to revisions, extended hospital stays, and increased costs, despite advancements in aseptic techniques and antibiotic management [13, 14]. Traditional TKA reports PJI incidences between 0.5% and 2.5%, making it a leading complication [13, 14]. In the U.S., infection is the primary cause of TKA revision failure, with an incidence of 44.1% [14]. However, the incidence of PJI in RA-TKA is not well-documented in the literature [12–14].

Diagnosing PJI is complex, with multiple criteria developed over time [15, 16]. The ICM 2013 criteria have been historically prevalent [17], and in 2018, more sensitive criteria were introduced, though not universally accepted [18]. Both criteria have limitations in confirming or excluding infection [17, 18]. In response, the European Bone and Joint Infection Society (EBJIS) introduced new PJI criteria in 2021 [19], featuring a middle category for patients with a higher likelihood of infection and proposing a staged diagnostic approach, using less invasive tests initially, followed by more specific tests if needed. This approach has shown promise in improving diagnostic accuracy [19–22].

The primary aim of this study was to assess the incidence of early PJI following RA-TKA using the EBJIS criteria. Additionally, the study evaluated the occurrence of delayed PJI in a select group of patients. A comprehensive analysis of postoperative complications was also conducted to provide a thorough evaluation of this patient population. The hypothesis posits that RA-TKA is not associated with an elevated risk of early or delayed PJI.

Material and methods

Study design

This retrospective study examines a consecutive series of patients diagnosed with grade III-IV knee osteoarthritis, classified according to the Ahlbäck classification, who underwent RA-TKA at the Orthopedic and Traumatology Unit of AOUP 'P. Giaccone', Palermo, Italy, and at Casa Di Cura Musumeci-GECAS, Catania, Italy, between January 1, 2020, and September 1, 2023. Surgical procedures were conducted by two experienced surgeons (L.C. and G.P.), and all patients received a cemented prosthesis. Antibiotic prophylaxis followed standard protocols, with cefazolin administered unless contraindicated by beta-lactam allergy, MRSA history, or current MRSA colonization, in which case vancomycin or a broad-spectrum antibiotic was used [23].

All patients received standard postoperative care at their respective institutions, including early mobilization, active and passive range of motion (ROM), and weight-bearing as tolerated, immediately postoperatively. Patients were discharged after an average of 5 days, ranging from four to seven days. Discharge criteria included effective pain control, knee flexion of at least 90°, and independent mobilization with crutches.

The follow-up protocol consisted of a thorough evaluation during the first year after surgery, involving both clinical and radiological assessments. Clinical evaluations were conducted on the fifteenth day, first month, second month, third month, sixth month, and first year post-surgery. Postoperative X-rays were obtained at one month, three months, and one-year postoperatively.

Clinical evaluation

Two researchers (C.B. and F.B.) conducted the follow-up clinical assessments. This evaluation included a thorough review of each patient's recent pharmacological and medical history, focusing on wound healing issues, fever, purulence around the prosthesis, and the presence of any sinus tract. The assessment also encompassed a detailed observation of symptoms such as erythema at the surgical site, swelling, warmth, pain around the surgical wound, and a comprehensive recording of all postoperative complications.

Radiographic analysis

Anteroposterior (AP), lateral, and AP long-leg weight-bearing radiographs of the knee were conducted to evaluate potential radiological signs of implant loosening. The radiographs were carefully evaluated by an expert orthopedic surgeon (L.L.) for the presence of any radiolucent lines at the bone-implant interface, osteolysis, or changes in implant position that could indicate loosening of the prosthetic components. In case of any uncertainties, a third author (L.C.) was involved to resolve any disagreements.

Inclusion and exclusion criteria

Inclusion criteria for the study included utilizing the NAVIO Surgical System (Smith & Nephew, Memphis, USA) for knee replacement surgery, age greater than 18 years and a minimum follow-up period of at least three months. Exclusion criteria were history of ipsilateral UKA or revision TKA, contralateral TKA, knee osteotomy, ligamentous reconstruction, or extensive trauma-related surgery.

PJI diagnostic criteria

The occurrence of PJI is typically classified into three postoperative phases: early, delayed, and late [17, 18]. The early phase is defined as the period within three months following surgery, the delayed phase extends from just over three months to within 12 months, and the late phase occurs more than 12 months after the surgical procedure [18]. Our study primarily focuses on the immediate postoperative period, a critical timeframe for evaluating postoperative risks and complications associated with RA-TKA. This accurate evaluation is vital for assessing the initial response to the surgical procedure, the effectiveness of infection control measures, and the overall immediate safety profile of the RA technique [18].

The EBJIS has established diagnostic criteria to standardize the diagnosis of joint infections, specifically focusing on PJIs. Based on these guidelines, three diagnostic categories are identified: 'Infection Unlikely', 'Infection Likely', and 'Infection Confirmed' [19–21] (Fig. 1).Fig. 1 EBJIS criteria for the diagnosis of periprosthetic joint infection (PJI). *—Infection is only likely if there is a positive clinical feature or raised serum C-reactive protein (CRP), together with another positive test (synovial fluid, microbiology, histology, or nuclear imaging). PMN—Polymorphonuclear; %—percentage; CFU—Colony Forming Unit; WBC—White blood cells

In this study, the suspicion of PJI was raised based on the EBJIS clinical criteria, specifically under the classifications of "Infection Likely" or "Infection Confirmed," within three months and one-year postoperatively, for early and delayed PJI, respectively [19, 20]. Patients who responded positively to the “Infection Likely” and “Infection Confirmed” clinical criteria were requested to return to the hospital for further evaluation. This evaluation encompassed the examination of serum C-reactive protein (CRP), synovial fluid analysis, microbiology, histology, and nuclear imaging. According to EBJIS diagnostic criteria [19], the research team ensured that these patients had no other inflammatory causes, immunosuppressive conditions, or antibiotics and immunosuppressant intake within two weeks before the examination that could affect the sensitivity and specificity of these inflammatory markers.

Data collection

Patients were stratified according to their minimum follow-up: early, for patients with a minimum follow-up of three months, and delayed, for patients with a minimum follow-up of one-year. Data analysis was managed by an independent author (C.B.). In cases, where data discrepancies or uncertainties arose, an experienced knee surgeon (L.C.) was consulted to ensure resolution and accuracy. Any cases of disagreement were resolved by a third author (F.B.).

Data extraction

This study enrolled 137 patients who underwent RA-TKA: 66 patients received treatment at the Orthopedic and Traumatology Unit, AOUP 'P. Giaccone', Palermo, Italy, and 71 at Casa Di Cura Musumeci-GECAS, Catania, Italy. Participants were selected based on a uniform assessment process, evaluating demographic information, medical history, and follow-up duration to align with predefined inclusion criteria. Out of the initial cohort, 19 patients were excluded because considered lost to follow-up. This categorization was based on their discontinuation of participation in scheduled outpatient check-ups and subsequent nonresponsiveness to multiple contact attempts via telephone and email. Consequently, 118 patients met all the inclusion criteria and were declared eligible for the early PJI evaluation.

At the final follow-up, 68 patients were found to have a minimum follow-up of one-year. Therefore, a delayed PJI investigation was carried out for these patients. The detailed patient enrolment process is shown in the flow chart (Fig. 2).Fig. 2 Flowchart of patient enrollment in the study: a comprehensive overview. n—number of evaluation cases; n tot—total number of evaluation cases; EBJIS—European bone and joint infection society; PJI—periprosthetic joint infection

Ethical approval

This retrospective study, examining an established surgical procedure, strictly adhered to the ethical guidelines set forth in the 1964 Helsinki Declaration and its subsequent amendments. All participating patients were fully informed about the nature and purpose of the study and provided their informed consent before than the surgical procedure. Research Protocol: Robotic Knee Prosthesis. Approval by Local Ethics Committee Palermo 1: Minutes No. 03/2024.

Statistical analysis

The statistical analysis of the data involved expressing categorical variables as counts and percentages and continuous variables as means with standard deviations (SDs). The statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA), allowing for a comprehensive and accurate interpretation of the study's findings.

Results

Demographic and clinical data

After applying inclusion and exclusion criteria, a total of 118 patients were recruited and analyzed. The cohort comprised 74 women (62.7%) and 44 men (37.3%). The median follow-up period was 9.1 ± 3.9 months. The average age at follow-up was 68.9 ± 8.1 years, and the average body mass index (BMI) was 29.7 ± 5.6 kg/m2. The average surgical time was 121 ± 20.5 min. Prostheses were more commonly placed on the right side in 61 patients (51.7%), while 57 patients (48.3%) had left-sided prostheses. Detailed demographics are shown in Table 1.Table 1 Demographic and clinical data of patients enrolled in the study cohort

Demographic characteristics	Values	
Patients, Total N°	118	
Gender	
Male, N° (%)	44 (37.3)	
Female, N° (%)	74 (62.7)	
Age, (years old), Mean ± SD	68.9 (8.1)	
BMI (kg/m2)	
Male, Mean ± SD	29.3 (4.0)	
Female, Mean ± SD	29.9 (6.4)	
Total, Mean ± SD	29.7 (5.6)	
Follow-up time (months), Mean ± SD	9.1 (3.9)	
Surgical timing (minutes), Mean ± SD	121 (20.5)	
Side of prosthesis	
Right, N° (%)	61 (51.7)	
Left, N° (%)	57 (48.3)	
Comorbidities	
Diabetes, N° (%)	20 (16.9)	
Hypertension, N° (%)	16 (13.6)	
Vascular disease, N° (%)	11 (9.3)	
Peripheral neuropathy, N° (%)	7 (5.9)	
Rheumatic disorders, N° (%)	9 (7.6)	
Fracture, N° (%)	4 (3.9)	
N°—number of evaluation cases; SD—standard deviation; %—percentage, Kg—kilogram; m—meter

Early PJI evaluation

A significant observation was that none of the patients fulfilled the EBJIS criteria for “Infection Likely” or “Infection Confirmed” in the early PJI evaluation. This is noteworthy, especially considering that the average C-reactive protein (CRP) levels in the five suspected cases of infection were 1.5 ± 0.5 mg/dL, which falls within normal limits and does not suggest an infection-related inflammatory response. The synovial fluid cytological analysis revealed a leucocyte count of less than 1,500 cells/µl and a percentage of polymorphonuclear neutrophils (PMN) below 65% in all five patients examined. The average surgical timing of patients suspected of early PJI was 119.4 ± 2.9 min, slightly lower than the population’s average. The most common EBJIS clinical sign for the suspicion of early PJI was wound healing problems, observed in five patients (4.2%). Specifically, three patients showed prolonged diastasis of the margin, and two patients presented bleeding in the upper and middle-lower part of the wound. All wound healing problems were adequately addressed with dressing, and no surgical wound revision was needed. Furthermore, radiological assessments revealed no indications of prosthetic loosening, a common sign of PJI.

Delayed PJI evaluation

Radiological signs of loosening were detected at the one-year follow-up for one patient. Subsequently, suspicion of delayed PJI was raised, and the patient underwent further examinations to fulfill diagnostic criteria. Serum C-reactive protein levels were within the normal range, indicating an absence of an inflammatory response. Synovial fluid analysis appeared clear with no bacterial growth detected. Histological examination, as well as nuclear imaging, did not present any significant inflammatory response. As a result, the diagnosis of delayed PJI, according to EBJIS diagnostic criteria of “Infection Likely” or “Infection Confirmed”, was excluded. Furthermore, no particular differences were seen in the surgical timing compared to the study cohort.

As shown in Table 2, these findings emphasize the non-occurrence of delayed PJI among the patients who underwent RA-TKA within one-year of follow-up. This outcome highlights the potential effectiveness of RA-TKA in mitigating short-term postoperative joint infection risks.Table 2 Postoperative characteristics of patients with PJI suspicion

Patients	Age (years)	Timing of clinical PJI suspicious	Surgical timing (minutes)	E	S	W	P	Recent fever	Wound healing problem	Purulence around the prosthesis	Sinus tract	Radiological sign of loosening	CRP (mg/dL)	
1	79	30 days	117	Y	Y	Y	Y	N	Y	N	N	N	1,5	
2	71	15 days	120	N	Y	Y	Y	N	Y	N	N	N	1,3	
3	71	30 days	116	N	Y	N	Y	N	Y	N	N	N	0,8	
4	52	90 days	121	N	Y	Y	Y	N	Y	N	N	N	2,2	
5	70	60 days	123	Y	Y	Y	Y	N	Y	N	N	N	1,7	
6	62	1 year	115	Y	Y	Y	Y	N	N	N	N	Y	1.1	
E—Erythema of the surgical site; S—Swelling; W—Warmth; P—Pain in or around the surgical site; CRP—C-reactive protein; Y—yes; N—no; mg—milligram; dL—deciliter

Postoperative complications and clinical outcome

The study found few significant complications, with only two cases necessitating additional surgical procedures. One patient experienced patellar maltracking and underwent revision five months after the primary procedure. The second patient underwent revision one-year postoperatively due to prosthetic loosening attributed to the malposition of the tibial component, following the exclusion of infectious causes based on EBJIS criteria. Additionally, three individuals underwent passive manipulation under anesthesia (MUA) to address knee stiffness and limited ROM, occurring at four, seven, and eight months postoperatively, respectively. Notably, there were no reported instances of wound infection.

Discussion

The study's main finding was that RA-TKA performed using the NAVIO surgical system did not result in any cases of PJI, as defined by the EBJIS criteria [19]. Specifically, no cases were classified as “Infection Likely” or “Infection Confirmed” for early or delayed PJI. Two patients required secondary surgical procedures related to different aseptic complications, at five months and one-year postoperatively. This suggests that, while certain complications were noted, short-term postoperative joint infection risks do not seem to be increased by RA-TKA.

While, traditional TKA has been reported to yield generally good clinical results, dissatisfaction rates as high as 20% have been documented [4, 5]. RA-TKA was developed to address this issue, offering enhanced precision and accuracy in implant placement. Smith et al. [9] observed a higher patient satisfaction rate of 94% in RA-TKA compared to 82% in manual TKA. Gao et al. [10] conducted a meta-analysis revealing that kinematic alignment in RA-TKA could lead to better clinical outcomes than mechanical alignment in the short-term. Similarly, Zhang et al. [11] demonstrated improved accuracy in component positioning and better patient-reported outcomes in RA-TKA versus manual TKA.

Our study contributes to the limited assessment of PJI risk in RA-TKA. We observed no increased risk of PJI in RA-TKA, and this evidence aligns with other research comparing PJI rates between RA-TKA and C-TKA [24–28].

For instance, Vandenberk et al. [27] published clinical results of a single-center retrospective cohort study of 230 NAVIO RA-TKA patients and 489 C-TKA patients, with a mean follow-up of 31 months and 29.7 months, respectively, that resulted in a PJI rate of 0% for RA-TKA compared to 1% for C-TKA. Joo et al. [26] reported a PJI rate of 0.2% in 851 patients who underwent RA-TKA, with a follow-up ranging from 4 to 15 months. Mitchell et al. [28] performed a comparative study between RA-TKA and C-TKA, describing no statistically significant difference in complication rates at one-year follow-up.

The detailed planning and multiple steps involved in RA-TKA with robotic systems contribute to increased surgical time. Studies have consistently shown prolonged surgical durations in RA-TKA compared to C-TKA [12, 26–28]. In their research, Nogalo et al. [12] concluded that RA-TKA is associated with longer operative times. Given the extended surgical duration, there has been a growing focus on related complications, particularly the risk of developing PJI. Pugely et al. [29] identified an increased risk of infection after 120 min of surgery, while Peersman et al. [30] and Ravi et al. [31] also reported increased infection risks associated with longer TKA surgeries. However, these findings are not universally consistent. Our study's average surgical time was 121 ± 20.5 min, similar to other studies [32–34], which did not report an increased PJI rate despite extended surgical durations. Specifically, Singh et al. [32], Held et al. [33], and Scigliano et al. [34] found no significant difference in postoperative complications or revision surgery rates due to prolonged surgical times.

The main strengths of this study include its considerable cohort size, which enhances the level of evidence. The multicentric approach broadens patient diversity, ensuring more robust and generalizable data. Additionally, the meticulous application of exclusion criteria, particularly for patients with alternate sources of inflammation or immunodepression, significantly bolsters the validity of CRP measurements in the context of assessing surgical outcomes.

However, this study is not without limitations. Firstly, its retrospective design inherently carries biases typical of such methodologies, which might affect the interpretation of the results. Secondly, despite the implementation of uniform peri-operative protocols across different centers, subtle variations in surgical techniques could potentially impact clinical outcomes. The third limitation of the study lies in the absence of a control group, which is crucial for a comprehensive evaluation of the impact of independent variables. A control group enables the isolation of specific effects, necessitating caution in interpreting the obtained results. Lastly, the follow-up duration constraints limited our ability to assess late PJIs. The study also did not fully encompass the evaluation of delayed PJIs due to the inability to achieve a complete one-year follow-up for all participants. To mitigate this limitation, a rigorous and ongoing follow-up protocol has been instituted for the included patients. These continued assessments are essential for the prospective monitoring and detection of delayed and late PJIs, providing a more comprehensive understanding of the long-term infection risks associated with the surgical procedure.

Conclusion

This study demonstrates the absence of early and delayed PJI in RA-TKA cases, using the EBJIS criteria, within the study period, thereby contributing additional evidence to this technique’s short-term efficacy and safety. However, further research is necessary to corroborate these findings and to confirm the long-term reliability of RA-TKA, particularly in the context of late PJI.

Acknowledgements

None.

Author contributions

CB, FB, GR, GLB, and AP have contributed substantially to conception and design, data acquisition, analysis, and interpretation. They have been involved in drafting the manuscript and revising it critically for important intellectual content, given final approval of the version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. LL, FB, and FG have contributed substantially to the data analysis, interpretation, and manuscript drafting. GP, and LC have made substantial contributions to concept and design the manuscript and revising it critically for important intellectual content.

Funding

Open access funding provided by Università degli Studi di Palermo within the CRUI-CARE Agreement.

Availability of data and materials (data transparency)

Dataset analyzed in this study is available from the corresponding author on reasonable request.

Code availability (software application or custom code)

Not applicable.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Consent for publication

All patients were informed about the study and consented to participate.

Informed consent

All patients were informed about the study and consented to participate.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Canovas F Dagneaux L Quality of life after total knee arthroplasty Orthop Traumatol Surg Res 2018 104 1S S41 S46 10.1016/j.otsr.2017.04.017 29183821
Canovas F, Dagneaux L (2018) Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res 104(1S):S41–S4629183821 10.1016/j.otsr.2017.04.017
2. Giustra F Bistolfi A Bosco F Highly cross-linked polyethylene versus conventional polyethylene in primary total knee arthroplasty: comparable clinical and radiological results at a 10-year follow-up Knee Surg Sports Traumatol Arthrosc 2023 31 3 1082 1088 10.1007/s00167-022-07226-6 36409325
Giustra F, Bistolfi A, Bosco F et al (2023) Highly cross-linked polyethylene versus conventional polyethylene in primary total knee arthroplasty: comparable clinical and radiological results at a 10-year follow-up. Knee Surg Sports Traumatol Arthrosc 31(3):1082–108836409325 10.1007/s00167-022-07226-6
3. Dietz MJ Chaharbakhshi EO Roberts AJ Gilligan PH Kasicky KR Pincavitch JD Maintenance of surgical optimization in total joint arthroplasty patients J Arthroplasty 2024 11 1650 1655 10.1016/j.arth.2024.01.013
Dietz MJ, Chaharbakhshi EO, Roberts AJ, Gilligan PH, Kasicky KR, Pincavitch JD (2024) Maintenance of surgical optimization in total joint arthroplasty patients. J Arthroplasty 11:1650–165510.1016/j.arth.2024.01.013
4. Bourne RB Chesworth BM Davis AM Mahomed NN Charron KD Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010 468 1 57 63 10.1007/s11999-009-1119-9 19844772
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD (2010) Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 468(1):57–6319844772 10.1007/s11999-009-1119-9
5. Gunaratne R Pratt DN Banda J Fick DP Khan RJK Robertson BW Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature J Arthroplasty 2017 32 12 3854 3860 10.1016/j.arth.2017.07.021 28844632
Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW (2017) Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature. J Arthroplasty 32(12):3854–386028844632 10.1016/j.arth.2017.07.021
6. Mancino F Cacciola G Malahias MA What are the benefits of robotic-assisted total knee arthroplasty over conventional manual total knee arthroplasty? A systematic review of comparative studies Orthop Rev (Pavia) 2020 12 Suppl 1 8657 32913593
Mancino F, Cacciola G, Malahias MA et al (2020) What are the benefits of robotic-assisted total knee arthroplasty over conventional manual total knee arthroplasty? A systematic review of comparative studies. Orthop Rev (Pavia) 12(Suppl 1):865732913593
7. Cacciola G Bosco F Giustra F Learning curve in robotic-assisted total knee arthroplasty: a systematic review of the literature Appl Sci 2022 12 21 11085 10.3390/app122111085
Cacciola G, Bosco F, Giustra F et al (2022) Learning curve in robotic-assisted total knee arthroplasty: a systematic review of the literature. Appl Sci 12(21):1108510.3390/app122111085
8. Bosco F Cacciola G Giustra F Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature Eur J Orthop Surg Traumatol 2023 33 7 2703 2715 10.1007/s00590-023-03480-7 36867259
Bosco F, Cacciola G, Giustra F et al (2023) Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature. Eur J Orthop Surg Traumatol 33(7):2703–271536867259 10.1007/s00590-023-03480-7
9. Smith AF Eccles CJ Bhimani SJ Improved patient satisfaction following robotic-assisted total knee arthroplasty J Knee Surg 2021 34 7 730 738 10.1055/s-0039-1700837 31731324
Smith AF, Eccles CJ, Bhimani SJ et al (2021) Improved patient satisfaction following robotic-assisted total knee arthroplasty. J Knee Surg 34(7):730–73831731324 10.1055/s-0039-1700837
10. Gao ZX Long NJ Zhang SY Yu W Dai YX Xiao C Comparison of kinematic alignment and mechanical alignment in total knee arthroplasty: a meta-analysis of randomized controlled clinical trials Orthop Surg 2020 12 6 1567 1578 10.1111/os.12826 33099892
Gao ZX, Long NJ, Zhang SY, Yu W, Dai YX, Xiao C (2020) Comparison of kinematic alignment and mechanical alignment in total knee arthroplasty: a meta-analysis of randomized controlled clinical trials. Orthop Surg 12(6):1567–157833099892 10.1111/os.12826
11. Zhang J Ndou WS Ng N Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis Knee Surg Sports Traumatol Arthrosc 2022 30 8 2677 2695 10.1007/s00167-021-06464-4 33547914
Zhang J, Ndou WS, Ng N et al (2022) Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30(8):2677–269533547914 10.1007/s00167-021-06464-4
12. Nogalo C Meena A Abermann E Fink C Complications and downsides of the robotic total knee arthroplasty: a systematic review Knee Surg Sports Traumatol Arthrosc 2023 31 3 736 750 10.1007/s00167-022-07031-1 35716186
Nogalo C, Meena A, Abermann E, Fink C (2023) Complications and downsides of the robotic total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 31(3):736–75035716186 10.1007/s00167-022-07031-1
13. Walter N Rupp M Hierl K Long-term patient-related quality of life after knee periprosthetic joint infection J Clin Med 2021 10 5 907 10.3390/jcm10050907 33668957
Walter N, Rupp M, Hierl K et al (2021) Long-term patient-related quality of life after knee periprosthetic joint infection. J Clin Med 10(5):90733668957 10.3390/jcm10050907
14. Mortazavi SM Molligan J Austin MS Purtill JJ Hozack WJ Parvizi J Failure following revision total knee arthroplasty: infection is the major cause Int Orthop 2011 35 8 1157 1164 10.1007/s00264-010-1134-1 20959981
Mortazavi SM, Molligan J, Austin MS, Purtill JJ, Hozack WJ, Parvizi J (2011) Failure following revision total knee arthroplasty: infection is the major cause. Int Orthop 35(8):1157–116420959981 10.1007/s00264-010-1134-1
15. Parvizi J Zmistowski B Berbari EF New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society Clin Orthop Relat Res 2011 469 11 2992 2994 10.1007/s11999-011-2102-9 21938532
Parvizi J, Zmistowski B, Berbari EF et al (2011) New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469(11):2992–299421938532 10.1007/s11999-011-2102-9
16. Osmon DR Berbari EF Berendt AR Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America Clin Infect Dis 2013 56 1 1 10 10.1093/cid/cis966 23230301
Osmon DR, Berbari EF, Berendt AR et al (2013) Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56(1):1–1023230301 10.1093/cid/cis966
17. Parvizi J Gehrke T International consensus group on periprosthetic joint infection definition of periprosthetic joint infection J Arthroplasty 2014 29 7 1331 10.1016/j.arth.2014.03.009 24768547
Parvizi J, Gehrke T (2014) International consensus group on periprosthetic joint infection definition of periprosthetic joint infection. J Arthroplasty 29(7):133124768547 10.1016/j.arth.2014.03.009
18. Parvizi J Tan TL Goswami K The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria J Arthroplasty 2018 33 5 1309 1314.e2 10.1016/j.arth.2018.02.078 29551303
Parvizi J, Tan TL, Goswami K et al (2018) The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 33(5):1309-1314.e229551303 10.1016/j.arth.2018.02.078
19 McNally M Sousa R Wouthuyzen-Bakker M The EBJIS definition of periprosthetic joint infection Bone Joint J 2021 103B 1 18 25 10.1302/0301-620X.103B1.BJJ-2020-1381.R1
McNally M, Sousa R, Wouthuyzen-Bakker M et al (2021) The EBJIS definition of periprosthetic joint infection. Bone Joint J 103B(1):18–2510.1302/0301-620X.103B1.BJJ-2020-1381.R1
20. McNally M Sigmund I Hotchen A Sousa R Making the diagnosis in prosthetic joint infection: a European view EFORT Open Rev 2023 8 5 253 263 10.1530/EOR-23-0044 37158373
McNally M, Sigmund I, Hotchen A, Sousa R (2023) Making the diagnosis in prosthetic joint infection: a European view. EFORT Open Rev 8(5):253–26337158373 10.1530/EOR-23-0044
21. Sigmund IK Luger M Windhager R McNally MA Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013 Bone Joint Res 2022 11 9 608 618 10.1302/2046-3758.119.BJR-2022-0078.R1 36047011
Sigmund IK, Luger M, Windhager R, McNally MA (2022) Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013. Bone Joint Res 11(9):608–61836047011 10.1302/2046-3758.119.BJR-2022-0078.R1
22. Boelch SP Rüeckl K Streck LE Diagnosis of chronic infection at total hip arthroplasty revision is a question of definition Biomed Res Int 2021 2021 8442435 10.1155/2021/8442435 34840982
Boelch SP, Rüeckl K, Streck LE et al (2021) Diagnosis of chronic infection at total hip arthroplasty revision is a question of definition. Biomed Res Int 2021:844243534840982 10.1155/2021/8442435
23. Norvell MR Porter M Ricco MH Cefazolin vs second-line antibiotics for surgical site infection prevention after total joint arthroplasty among patients with a beta-lactam allergy Open Forum Infect Dis 2023 10 6 ofad224 10.1093/ofid/ofad224 37363051
Norvell MR, Porter M, Ricco MH et al (2023) Cefazolin vs second-line antibiotics for surgical site infection prevention after total joint arthroplasty among patients with a beta-lactam allergy. Open Forum Infect Dis 10(6):ofad22437363051 10.1093/ofid/ofad224
24 Hossain FS Konan S Patel S Rodriguez-Merchan EC Haddad FS The assessment of outcome after total knee arthroplasty: are we there yet? Bone Joint J 2015 97B 1 3 9 10.1302/0301-620X.97B1.34434
Hossain FS, Konan S, Patel S, Rodriguez-Merchan EC, Haddad FS (2015) The assessment of outcome after total knee arthroplasty: are we there yet? Bone Joint J 97B(1):3–910.1302/0301-620X.97B1.34434
25. Richards JA Williams MD Gupta NA No difference in PROMs between robotic-assisted CR versus PS total knee arthroplasty: a preliminary study J Robot Surg 2022 16 5 1209 1217 10.1007/s11701-021-01352-y 34997477
Richards JA, Williams MD, Gupta NA et al (2022) No difference in PROMs between robotic-assisted CR versus PS total knee arthroplasty: a preliminary study. J Robot Surg 16(5):1209–121734997477 10.1007/s11701-021-01352-y
26. Joo PY Chen AF Richards J Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study Bone Jt Open 2022 3 8 589 595 10.1302/2633-1462.37.BJO-2022-0076.R1 35848995
Joo PY, Chen AF, Richards J et al (2022) Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study. Bone Jt Open 3(8):589–59535848995 10.1302/2633-1462.37.BJO-2022-0076.R1
27. Vandenberk J Mievis J Deferm J Janssen D Bollars P Vandenneucker H NAVIO RATKA shows similar rates of hemoglobin-drop, adverse events, readmission and early revision vs conventional TKA: a single centre retrospective cohort study Knee Surg Sports Traumatol Arthrosc 2023 31 11 4798 4808 10.1007/s00167-023-07524-7 37555860
Vandenberk J, Mievis J, Deferm J, Janssen D, Bollars P, Vandenneucker H (2023) NAVIO RATKA shows similar rates of hemoglobin-drop, adverse events, readmission and early revision vs conventional TKA: a single centre retrospective cohort study. Knee Surg Sports Traumatol Arthrosc 31(11):4798–480837555860 10.1007/s00167-023-07524-7
28. Mitchell J Wang J Bukowski B Relative clinical outcomes comparing manual and robotic-assisted total knee arthroplasty at minimum 1-year follow-up HSS J 2021 17 3 267 273 10.1177/15563316211028568 34539266
Mitchell J, Wang J, Bukowski B et al (2021) Relative clinical outcomes comparing manual and robotic-assisted total knee arthroplasty at minimum 1-year follow-up. HSS J 17(3):267–27334539266 10.1177/15563316211028568
29. Pugely AJ Martin CT Gao Y Schweizer ML Callaghan JJ The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty J Arthroplasty 2015 30 9 Suppl 47 50 10.1016/j.arth.2015.01.063 26071247
Pugely AJ, Martin CT, Gao Y, Schweizer ML, Callaghan JJ (2015) The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty 30(9 Suppl):47–5026071247 10.1016/j.arth.2015.01.063
30. Peersman G Laskin R Davis J Peterson MG Richart T Prolonged operative time correlates with increased infection rate after total knee arthroplasty HSS J 2006 2 1 70 72 10.1007/s11420-005-0130-2 18751850
Peersman G, Laskin R, Davis J, Peterson MG, Richart T (2006) Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2(1):70–7218751850 10.1007/s11420-005-0130-2
31. Ravi B Jenkinson R O'Heireamhoin S Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: a population-based retrospective cohort study EClinicalMedicine 2019 16 74 80 10.1016/j.eclinm.2019.09.015 31832622
Ravi B, Jenkinson R, O’Heireamhoin S et al (2019) Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: a population-based retrospective cohort study. EClinicalMedicine 16:74–8031832622 10.1016/j.eclinm.2019.09.015
32. Singh V Fiedler B Simcox T Aggarwal VK Schwarzkopf R Meftah M Does the use of intraoperative technology yield superior patient outcomes following total knee arthroplasty? J Arthroplasty 2021 36 7S S227 S232 10.1016/j.arth.2020.11.001 33277145
Singh V, Fiedler B, Simcox T, Aggarwal VK, Schwarzkopf R, Meftah M (2021) Does the use of intraoperative technology yield superior patient outcomes following total knee arthroplasty? J Arthroplasty 36(7S):S227–S23233277145 10.1016/j.arth.2020.11.001
33. Held MB Gazgalis A Neuwirth AL Shah RP Cooper HJ Geller JA Imageless robotic-assisted total knee arthroplasty leads to similar 24-month WOMAC scores as compared to conventional total knee arthroplasty: a retrospective cohort study Knee Surg Sports Traumatol Arthrosc 2022 30 8 2631 2638 10.1007/s00167-021-06599-4 33961067
Held MB, Gazgalis A, Neuwirth AL, Shah RP, Cooper HJ, Geller JA (2022) Imageless robotic-assisted total knee arthroplasty leads to similar 24-month WOMAC scores as compared to conventional total knee arthroplasty: a retrospective cohort study. Knee Surg Sports Traumatol Arthrosc 30(8):2631–263833961067 10.1007/s00167-021-06599-4
34. Scigliano NM Carender CN Glass NA Deberg J Bedard NA Operative time and risk of surgical site infection and periprosthetic joint infection: a systematic review and meta-analysis Iowa Orthop J 2022 42 1 155 161 35821941
Scigliano NM, Carender CN, Glass NA, Deberg J, Bedard NA (2022) Operative time and risk of surgical site infection and periprosthetic joint infection: a systematic review and meta-analysis. Iowa Orthop J 42(1):155–16135821941
