04 Mar 2024

JTO - March 2024

Volume 12 Issue 1

From the Executive Editor

Perhaps fittingly, as 2024 springs into life, this issue is all about the future and most specifically the art and science of training our younger colleagues in the fields of trauma and orthopaedic surgery. There are rough seas for our colleagues to traverse as they train and many obstacles to overcome as depicted on our front cover by ST6 trainee Rebecca Mazel: it is important that we help them to look forward to the shores of a safe harbour and not to let them concentrate on the difficulties they have faced. As highlighted by Deepa Bose, the SAC Chair for T&O, to support our trainees, we need to understand the needs of the trainers and ensure that they too are well supported and prepared for the delivery of training and the core competencies (p44). The trainers need a tool kit (p46), a philosophy (p52) and an understanding of their direction of travel (p50).

There is much to learn if the articles featuring robotic surgery on pages 28 and 32 are correct – and they are! Change is with us and we must adapt and make it work for us and our patients. We may need to work differently and the Elective Hub Toolkit outlined on page 24 will help us do this. Along with improving the way we work, the National Consultant Information Programme (NCIP) on page 40 will give us a better understanding of the work we do by perhaps giving more depth and detail regarding our patients, their procedures and their outcomes. The data from NCIP will supplement that available from the NJR helping us all to improve our services and identify areas for development. Unbelievably (to me at least!) the NJR is soon to be 21: the third in our series of articles to celebrate its 20-year milestone is on page 20 and asks the pertinent question of who benefits?

Despite all these advances, it is sometimes important to remind ourselves of our beginnings. It is over 40 years since the British Casting Certificate became a nationally recognised qualification and nine years since the launch of the revised casting standards. The programmes have diversified and grown over time (p36) with a rewarding and ongoing collaboration between Mark Rees, the BOA National Casting Training Advisor and the BOA Casting Committee.

As the world around us continues to be troubled, Hiro Tanaka’s piece on page 16 reminds us that the world can change in the blink of an eye and asks us to ask this question of ourselves: what really matters?

There is good news too – four colleagues of the broader orthopaedic community were recognised in the New Year Honours list, we welcome Dominic Meek as a Trustee and our recent committee appointments represent the diversity of our membership.

On a personal note, I am delighted that the UKHSA/BOA study looking at the radiation exposure that our members receive has started with the results expected in the summer. This will give us the data we need to drive forward appropriate PPE and educational changes. On behalf of the BOA, I would like to thank all the centres that are taking part and Lynn Hutchings and Charlotte Lewis for all their hard work.

 Deborah Eastwood, Immediate Past President 


Subspecialty Section


The development of new robotic MSK surgical services within the NHS

  1. Lawrie L, Gillies K, Davies L, et al. Current issues and future considerations for the wider implementation of robotic-assisted surgery: a qualitative study. BMJ Open. 2022;12:e067427.
  2. Lawrie L, Gillies K, Duncan E, Davies L, Beard D, Campbell MK. Barriers and enablers to the effective implementation of robotic assisted surgery. PLoS One. 2022;17(8):e0273696.
  3. Domb BG, El Bitar YF, Sadik AY, Stake CE, Botser IB. Comparison of Robotic-assisted and Conventional Acetabular Cup Placement in THA: A Matched-pair Controlled Study. Clin Orthop Relat Res. 2014;472(1):329-36.
  4. Illgen R, Bukowski B, Abiola R, et al. Robotic-assisted total hip arthroplasty: outcomes at minimum two-year follow-up. Surg Technol Int. 2017;30:365e72.
  5. Nodzo SR, Chang C, Carroll KM, et al. Intraoperative placement of total hip arthroplasty components with robotic-arm assisted technology correlates with postoperative implant position. Bone Joint J. 2018;100-B(10):1303-9.
  6. Kayani B, Konan S, Thakrar RR, Huq SS, Haddad FS. Assuring the long-term total joint arthroplasty. Bone Joint J. 2019;101-B(1_Supple_A):11-18.
  7. Tsai T-Y, Dimitriou D, Li J-S, Kwon Y-M. Does haptic robot-assisted total hip arthroplasty better restore native acetabular and femoral anatomy?. Int J Med Robotics Comput Assist Surg. 2016;12:288-95.
  8. Bell SW, Anthony I, Jones B, MacLean A, Rowe P, Blyth M. Improved Accuracy of Component Positioning with Robotic-Assisted Unicompartmental Knee Arthroplasty: Data from a Prospective, Randomized Controlled Study. J Bone Joint Surg Am. 2016;98(8):627-35.
  9. Thilak J, Thadi M, Mane PP, Sharma A, Mohan V, Babu BC. Accuracy of tibial component positioning in the robotic arm assisted versus conventional unicompartmental knee arthroplasty. J Orthop. 2020;22:367-71.
  10. Kayani B, Konan S, Pietrzak JRT, Huq SS, Tahmassebi J, Haddad FS. The learning curve associated with robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study. Bone Joint J. 2018;100-B(8):1033-42.
  11. Yang HY, Seon JK, Shin YJ, Lim HA, Song EK. Robotic total knee arthroplasty with a cruciate-retaining implant: a 10-year follow-up study. Clin Orthop Surg. 2017;9(2):169-76.
  12. Bellemans J, Vandenneucker H, Vanlauwe J. Robot-assisted total knee arthroplasty. Clin Orthop Relat Res. 2007;464:111-6.
  13. Hampp EL, Chughtai M, Scholl LY, et al. Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared with manual techniques. J Knee Surg. 2019;32:239-50.
  14. Kayani B, Konan S, Huq SS, Tahmassebi J, Haddad FS. Robotic-arm assisted total knee arthroplasty has a learning curve of seven cases for integration into the surgical workflow but no learning curve effect for accuracy of implant positioning. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1132-41.
  15. Moon YW, Ha CW, Do KH, et al. Comparison of robot-assisted and conventional total knee arthroplasty: a controlled cadaver study using multiparameter quantitative three-dimensional CT assessment of alignment. Comput Aided Surg. 2012;17:86-95.
  16. Caldora P, D'Urso A, Banchetti R, et al. Blood transfusion, hospital stay and learning curve in robotic assisted total hip arthroplasty. J Biol Regul Homeost Agents. 2020;34(4 Suppl. 3):37-49.
  17. Archer A, Salem HS, Coppolecchia A, Mont MA. Lengths of Stay and Discharge Dispositions after Total Knee Arthroplasty: A Comparison of Robotic-Assisted and Manual Techniques. J Knee Surg. 2023;36(4):404-10.
  18. Grosso MJ, Li WT, Hozack WJ, Sherman M, Parvizi J, Courtney PM. Short-Term Outcomes Are Comparable between Robotic-Arm Assisted and Traditional Total Knee Arthroplasty. J Knee Surg. 2022;35:798-803.
  19. Bhimani SJ, Bhimani R, Smith A, Eccles C, Smith L, Malkani A. Robotic-assisted total knee arthroplasty demonstrates decreased postoperative pain and opioid usage compared to conventional total knee arthroplasty. Bone Jt Open. 2020;1:8-12.
  20. Kayani B, Konan S, Pietrzak JRT, Tahmassebi J, Haddad FS. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study. Bone Joint J. 2018;100-B:930-7.
  21. Sephton BM, Bakhshayesh P, Edwards TC, Ali A, Kumar Singh V, Nathwani D. Predictors of extended length of stay after unicompartmental knee arthroplasty. J Clin Orthop Trauma. 2020;11:S239.
  22. Hamilton DA, Ononuju U, Nowak C, Chen C, Darwiche H. Differences in Immediate Postoperative Outcomes Between Robotic-Assisted TKA and Conventional TKA. Arthroplast Today. 2021;8:57.
  23. Anderson CG, Jang SJ, Brilliant ZR, et al. Complication Rate After Primary Total Hip Arthroplasty Using the Posterior Approach and Enabling Technology: A Consecutive Series of 2,888 Hips. J Arthroplasty 2023;38(7):S119-S123.e3.
  24. Shaw JH, Rahman TM, Wesemann LD, Z Jiang C, G Lindsay-Rivera K, Davis JJ. Comparison of Postoperative Instability and Acetabular Cup Positioning in Robotic-Assisted Versus Traditional Total Hip Arthroplasty. J Arthroplasty. 2022 Aug;37(8S):S881-S889.
  25. Bendich I, Vigdorchik JM, Sharma AK, et al. Robotic Assistance for Posterior Approach Total Hip Arthroplasty Is Associated With Lower Risk of Revision for Dislocation When Compared to Manual Techniques. J Arthroplasty. 2022;37(6):1124-9.
  26. Ng N, Gaston P, Simpson PM, et al. Robotic arm-assisted versus manual total hip arthroplasty a systematic review and meta-analysis. Bone Joint J. 2021;103-B(6):1009-20.
  27. Batailler C, White N, Ranaldi FM, Neyret P, Servien E, Lustig S. Improved implant position and lower revision rate with robotic-assisted unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1232-40.
  28. Robinson PG, Clement ND, Hamilton D, Blyth MJG, Haddad FS, Patton JT. A systematic review of robotic-assisted unicompartmental knee arthroplasty: prosthesis design and type should be reported. Bone Joint J. 2019;101-B(7):838-47.
  29. Kleeblad LJ, Borus TA, Coon TM, Dounchis J, Nguyen JT, Pearle AD. Midterm survivorship and patient satisfaction of robotic-arm-assisted medial unicompartmental knee arthroplasty: a multicenter study. J Arthroplast. 2018;33(6):1719-26.
  30. Fontalis A, Kayani B, Asokan A, Haddad IC, Tahmassebi J, Konan S, et al. Inflammatory Response in Robotic-Arm-Assisted Versus Conventional Jig-Based TKA and the Correlation with Early Functional Outcomes: Results of a Prospective Randomized Controlled Trial. J Bone Joint Surg Am. 2022;104(21):1905-14.
  31. Kayani B, Tahmassebi J, Ayuob A, Konan S, Oussedik S, Haddad FS. A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty. Bone Joint J. 2021;103-B(1):113-22.
  32. Khlopas A, Chughtai M, Hampp EL, et al. Robotic-arm assisted total knee arthroplasty demonstrated soft tissue protection. Surg Technol Int. 2017;30:441-6.
  33. MacDessi SJ, Griffiths-Jones W, Chen DB, et al. Restoring the constitutional alignment with a restrictive kinematic protocol improves quantitative soft-tissue balance in total knee arthroplasty: A randomized controlled trial. Bone Joint J. 2020;102(1):117-24.
  34. Choi BS, Kim SE, Yang M, et al. Functional alignment with robotic‑arm assisted total knee arthroplasty demonstrated better patient-reported outcomes than mechanical alignment with manual total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2023;31(3):1072-80.
  35. Chang JS, Kayani B, Wallace C, Haddad FS. Functional alignment achieves soft-tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology. Bone Joint J. 2021;103-B(3):507-14.
  36. Winnock de Grave P, Kellens J, Tampere T, Vermue H, Luyckx T, Claeys K. Clinical outcomes in TKA are enhanced by both robotic assistance and patient specific alignment: a comparative trial in 120 patients. Arch Orthop Trauma Surg. 2023;143(6):3391-9.
  37. Karasavvidis T, Pagan Moldenhauer CA, Haddad FS, et al. Current Concepts in Alignment in Total Knee Arthroplasty. J Arthroplasty. 2023;38(7 Suppl 2):S29-S37.
  38. Marchand KB, Moody R, Scholl LY, Bhowmik-Stoker M, Taylor KB, Mont MA, Marchand RC. Results of Robotic-Assisted Versus Manual Total Knee Arthroplasty at 2-Year Follow-up. J Knee Surg. 2023;36(2):159-66.
  39. Gustke KA. Two-year results with robotic arm-assisted total knee arthroplasty: comparison with a non robotic-assisted group. Orthop Procs. 2020;102-B(SUPP_9):26.
  40. Blyth MJG, Anthony I, Rowe P, Banger MS, MacLean A, Jones B. Robotic arm-assisted versus conventional unicompartmental knee arthroplasty: exploratory secondary analysis of a randomised controlled trial. Bone Joint Res. 2017;6(11):631-9.
  41. Gilmour A, MacLean AD, Rowe PJ, Banger MS, Donnelly I, Jones BG, Blyth MJG. Robotic-arm-assisted vs conventional unicompartmental knee arthroplasty. The 2-year clinical outcomes of a randomized controlled trial. J Arthroplast. 2018;33(7S):S109-S115.
  42. Canetti R, Batailler C, Bankhead C, Neyret P, Servien E, Lustig S. Faster return to sport after robotic-assisted lateral unicompartmental knee arthroplasty: a comparative study. Arch Orthop Trauma Surg. 2018;138(12):1765-71.
  43. Clement ND, Gaston P, Bell A, et al. Robotic arm-assisted versus manual total hip arthroplasty. Bone Joint Res. 2021;10(1):22-30.
  44. Domb BG, Chen JW, Lall AC, Perets I, Maldonado DR. Minimum 5-Year Outcomes of Robotic-assisted Primary Total Hip Arthroplasty With a Nested Comparison Against Manual Primary Total Hip Arthroplasty: A Propensity Score–Matched Study. J Am Acad Orthop Surg. 2020;28(20):847-56.
  45. Han PF, Chen CL, Zhang ZL, Han YC, Wei L, Li PC, Wei XC. Robotics-assisted versus conventional manual approaches for total hip arthroplasty: A systematic review and meta-analysis of comparative studies. Int J Med Robot. 2019;15(3):e1990.
  46. Samuel LT, Acuña AJ, Mahmood B, Emara AK, Kamath AF. Comparing early and mid-term outcomes between robotic-arm assisted and manual total hip arthroplasty: a systematic review. J Robot Surg. 2022;16(4):735-48.
  47. Shaw JH, Rahman TM, Wesemann LD, Z Jiang C, G Lindsay-Rivera K, Davis JJ. Comparison of Postoperative Instability and Acetabular Cup Positioning in Robotic-Assisted Versus Traditional Total Hip Arthroplasty. J Arthroplasty. 2022;37(8S):S881-S889.
  48. Karunaratne S, Duan M, Pappas E, Fritsch B, Boyle R, Gupta S, et al. The effectiveness of robotic hip and knee arthroplasty on patient-reported outcomes: A systematic review and meta-analysis. Int Orthop. 2019;43(6):1283-95.
  49. Fontalis A, Kayani B, Haddad IC, Donovan C, Tahmassebi J, Haddad FS. Patient-Reported Outcome Measures in Conventional Total Hip Arthroplasty Versus Robotic-Arm Assisted Arthroplasty: A Prospective Cohort Study With Minimum 3 Years' Follow-Up. J Arthroplasty. 2023;38(7S2):S324-S329.
  50. Schopper C, Proier P, Luger M, Gotterbarm T, Klasan A. The learning curve in robotic assisted knee arthroplasty is flattened by the presence of a surgeon experienced with robotic assisted surgery. Knee Surg Sports Traumatol Arthrosc. 2023;31(3):760-7.
  51. Robertson C, Shaikh S, Hudson J, Roberts PG, Beard D, Mackie T, et al. The RoboCOS Study: Development of an international core outcome set for the comprehensive evaluation of patient, surgeon, organisational and population level impacts of robotic assisted surgery. PLoS ONE. 2003;18(3):e0283000.
  52. McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC, et al. No surgical innovation without evaluation: the IDEAL recommendations. Lancet. 2009;26;374(9695):1105-12.

Robotic surgery in orthopaedics: What does the future hold?

  1. Vermue H, Batailler C, Monk P, Haddad F, Luyckx T, Lustig S. The evolution of robotic systems for total knee arthroplasty, each system must be assessed for its own value: a systematic review of clinical evidence and meta-analysis. Arch Orthop Trauma Surg. 2023;143(6):3369-81.
  2. Riantho A, Butarbutar JCP, Fidiasrianto K, Elson E, Irvan I, Haryono H, Prasetio JN. Radiographic Outcomes of Robot-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. JBJS Open Access. 2023;8(2):e23.00010.
  3. Ma M, Song P, Zhang S, Kong X, Chai W. Does robot-assisted surgery reduce leg length discrepancy in total hip replacement? Robot-assisted posterior approach versus direct anterior approach and manual posterior approach: a propensity score-matching study. J Orthop Surg Res. 2023;18(1):445.
  4. Lopez IB, Benzakour A, Mavrogenis A, Benzakour T, Ahmad A, Lemée JM. Robotics in spine surgery: systematic review of literature. Int Orthop. 2023;47(2):447-56.
  5. Perfetti DC, Kisinde S, Rogers-LaVanne MP, Satin AM, Lieberman IH. Robotic Spine Surgery: Past, Present, and Future. Spine (Phila Pa 1976). 2022;47(13):909-21.
  6. ISO 8373:2021 - Robotics Vocabulary. Available at: www.iso.org/standard/75539.html.
  7. U.S. Food and Drug Administration (FDA). Computer-Assisted Surgical Systems. Available at: www.fda.gov/medical-devices/surgery-devices/computer-assisted-surgical-systems.
  8. Simsek C, Kaan HL, Aihara H. Future Directions for Robotic Endoscopy–Artificial Intelligence (AI), Three-Dimensional (3D) Imaging, and Natural Orifice Transluminal Endoscopic Surgery (NOTES). Tech Innov Gastrointest Endosc. 2023;25(1):95-101.
  9. Zhang Y, Wang C, Zhou S, Jiang W, Liu Z, Xu L. A Comparison Review on Orthopedic Surgery Using Piezosurgery and Conventional Tools. Procedia CIRP. 2017;65:99-104.
  10. Holzinger D, Ureel M, Wilken T, Müller AA, Schicho K, Millesi G, Juergens P. First-in-man application of a cold ablation robot guided laser osteotome in midface osteotomies. J Craniomaxillofac Surg. 2021;49(7):531-7.
  11. Bollars P, Meshram P, Al Thani S, Schotanus MGM, Albelooshi A. Achieving functional alignment in total knee arthroplasty: early experience using a second-generation imageless semi-autonomous handheld robotic sculpting system. Int Orthop. 2023;47(2):585-93.
  12. Christen B, Tanner L, Ettinger M, Bonnin MP, Koch PP, Calliess T. Comparative Cost Analysis of Four Different Computer-Assisted Technologies to Implant a Total Knee Arthroplasty over Conventional Instrumentation. J Pers Med. 2022;12(2):184.
  13. Wu XD, Zhou Y, Shao H, Yang D, Guo SJ, Huang W. Robotic-assisted revision total joint arthroplasty: a state-of-the-art scoping review. EFORT Open Rev. 2023;8(1):18-25.
  14. Kayani B, Tahmassebi J, Ayuob A, Konan S, Oussedik S, Haddad FS. A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty. Bone Joint J. 2021;103-B(1):113-22. 
  15. Sharma AK, Plaskos C, Shalhoub S, Lawrence D, Vigdorchik JM, Lawrence JM. Ligament Tension and Balance before and after Robotic-Assisted Total Knee Arthroplasty - Dynamic Changes with Increasing Applied Force. J Knee Surg. 2024;37(2):128-34. 
  16. Chang JS, Kayani B, Wallace C, Haddad FS. Functional alignment achieves soft-tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology. Bone Joint J. 2021;103-B(3):507-14.
  17. Thomas TL, Goh GS, Nguyen MK, Lonner JH. Pin-Related Complications in Computer Navigated and Robotic-Assisted Knee Arthroplasty: A Systematic Review. J Arthroplasty. 2022;37(11):2291-2307.e2.
  18. Félix I, Raposo C, Antunes M, Rodrigues P, Barreto JP  Towards markerless computer-aided surgery combining deep segmentation and geometric pose estimation: application in total knee arthroplasty. Comput Methods Biomech Biomed Eng Imaging Vis. 2021;9:271-8.
  19. Hu X, Baena FRY, Cutolo F. Head-Mounted Augmented Reality Platform for Markerless Orthopaedic Navigation. IEEE J Biomed Health Inform. 2022;26(2):910-21
  20. Lex JR, Koucheki R, Toor J, Backstein DJ. Clinical applications of augmented reality in orthopaedic surgery: a comprehensive narrative review. Int Orthop. 2023;47(2):375-91.
  21. Iqbal, H., Tatti, F. & Rodriguez y Baena, F. Augmented reality in robotic assisted orthopaedic surgery: A pilot study. J Biomed Inform 120, 103841 (2021).
  22. Dias, R. D. et al. Intelligent interruption management system to enhance safety and performance in complex surgical and robotic procedures. Lecture Notes in Computer Science (including subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics) 11041 LNCS, 62–68 (2018).
  23. Hasan, L. K. et al. Virtual Reality in Orthopedic Surgery Training. (2021) doi:10.2147/AMEP.S321885.
  24. Cragg, J. et al. Surgical cognitive simulation improves real-world surgical performance: randomized study. BJS Open 5, (2021).
  25. Manuguerra, A. et al. Non-technical skills in robotic surgery and impact on near-miss events: a multi-center study Non-technical skills in robotic surgery and impact on near-miss events: a multi-center study Non-technical skills in robotic surgery and impact on near-miss events: a multi-center study. Surg Endosc 2021,.
  26. Hung, A. J. et al. A deep‐learning model using automated performance metrics and clinical features to predict urinary continence recovery after robot‐assisted radical prostatectomy. BJU Int 124, 487–495 (2019).
  27. Goltz, D. E. et al. A Novel Risk Calculator Predicts 90-Day Readmission Following Total Joint Arthroplasty. J Bone Joint Surg Am 101, 547–556 (2019).
  28. Farooq, H., Deckard, E. R., Ziemba-Davis, M., Madsen, A. & Meneghini, R. M. Predictors of Patient Satisfaction Following Primary Total Knee Arthroplasty: Results from a Traditional Statistical Model and a Machine Learning Algorithm. J Arthroplasty 35, 3123–3130 (2020).
  29. Pua, Y. H. et al. Machine learning methods are comparable to logistic regression techniques in predicting severe walking limitation following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 28, 3207–3216 (2019).
  30. Aggarwal, R., Farag, S., Martin, G., Ashrafian, H. & Darzi, A. Patient Perceptions on Data Sharing and Applying Artificial Intelligence to Health Care Data: Cross-sectional Survey. J Med Internet Res 23, (2021).
  31. Haddad, F. S. & Horriat, S. Robotic and other enhanced technologies: Are we prepared for such innovation? Bone and Joint Journal 101-B, 1469–1471 (2019).
  32. Fleming, C. A. et al. Surgical trainee experience and opinion of robotic surgery in surgical training and vision for the future: a snapshot study of pan-specialty surgical trainees. J Robot Surg 16, 1073–1082 (2021).
  33. Cobb, J. P., Kannan, V., Brust, K. & Thevendran, G. Navigation Reduces the Learning Curve in Resurfacing Total Hip Arthroplasty. Clin Orthop Relat Res 463, 90–97 (2007).
  34. Hung, A. J. et al. Experts vs super-experts: differences in automated performance metrics and clinical outcomes for robot-assisted radical prostatectomy. BJU Int 123, 861–868 (2019).
  35. Naik, N. et al. Legal and Ethical Consideration in Artificial Intelligence in Healthcare: Who Takes Responsibility? Front Surg 9, 862322–862322 (2022).
  36. Griffin, J. et al. Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial (RACER-knee): a study protocol. BMJ Open 13, e068255 (2023).
  37. Kayani, B., Konan, S., Tahmassebi, J., Ayuob, A. & Haddad, F. S. Computerised tomography-based planning with conventional total hip arthroplasty versus robotic-arm assisted total hip arthroplasty: Study protocol for a prospective randomised controlled trial. Trials 21, 1–10 (2020).
  38. Kayani, B. et al. Robotic-arm assisted medial unicondylar knee arthroplasty versus jig-based unicompartmental knee arthroplasty with navigation control: Study protocol for a prospective randomised controlled trial. Trials 21, 1–11 (2020).

Training philosophy – the why

1. George Bernard Shaw, Man and superman, 1903

2. Tertullian, Apologeticus, 33

3. Epictetus, Discourses, 2.17.1

4. Oscar Wilde, De Profundis, 1897

5. Emerson, The complete works of Ralph Waldo Emerson: Letters and social aims

6. Diogenes Laertius, Lives of eminent philosophers, 7.1.23

7. Ryan Holiday, The Daily Stoic. 2016

8. Epictetus, Enchiridion