Enhanced Mid-Resection Workflow Technique for Severe Varus Deformity Correction Using Robotic-Arm Assisted Total Knee Arthroplasty

Introduction: Robotic technology in total knee arthroplasty has been proven to improve accuracy of component positioning, achieve alignment targets, and balance the knee objectively. However, the utility of robotics in correction of severe varus deformities of the knee has not been investigated in detail. The aim of this paper was to establish the utility and describe the technique of robotic-arm assisted total knee arthroplasty (RA-TKA) in achieving pre-balance in severe varus deformities of the knee. Materials and Methods: Among the existing Mako (Stryker, Kalamazoo, Michigan) RA-TKA workflows, pre-resection workflow is limited to knees which can be pre-balanced by component positioning according to functional alignment. Mid-resection workflow (distal femur/tibia first) is reserved for complex cases, whereby the extension gap is balanced first. In our experience, both workflows could not achieve pre-balance in severe varus deformities, necessitating the need to develop a novel technique. The ability of the robot to execute precise bone cuts allows for a provisional postero-medial femoral bone cut in flexion, giving access to remove large inaccessible posterior osteophytes and the tight posterior capsule, thus balancing the knee in extension. The flexion gap is subsequently matched to the extension gap by alterations in axial component positioning. Conclusion: This novel “enhanced mid-resection workflow” technique establishes the utility of the RA-TKA in balancing severe varus deformities of the knee. We also propose an algorithm which simplifies and helps surgeons choose between the three workflows to pre-balance knees irrespective of the severity of the varus deformity.