# Robotic Systems and Navigation Techniques in Orthopedics: A Historical Review
## 2 Robotic Systems (RSs)
### Hands-On RS
#### 2.2.10. Rosa  
ROSA (robotic surgical assistant) (Zimmer Biomet Robotics, formerly MedTech SA, Montpellier, France) is a robotic system for TKA and THA [17]. The FDA approved its ROSA hip system (ROSA Hip System FDA 2021 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K210998](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K210998)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K210998](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K210998))) in 2021, and the ROSA knee system (ROSA Knee System FDA 2022 file (accessed on 28 June 2023): [[https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K213708](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K213708)]([https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K213708](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K213708))) in 2022. According to the FDA documents, the ROSA hip system (ROSA Hip System website (accessed on 28 June 2023): [[https://www.zimmerbiomet.com/en/products-and-solutions/zb-edge/robotics/rosa-hip-system.html](https://www.zimmerbiomet.com/en/products-and-solutions/zb-edge/robotics/rosa-hip-system.html)]([https://www.zimmerbiomet.com/en/products-and-solutions/zb-edge/robotics/rosa-hip-system.html](https://www.zimmerbiomet.com/en/products-and-solutions/zb-edge/robotics/rosa-hip-system.html))) (as shown in Figure 8a) is a CT-free, fluoroscopic-guided system that can be used to assist surgeons in accurately positioning and implanting hip components, while the robotic arm is used to assist in the guidance of the surgical tools. Fluoroscopic images, intraoperatively acquired by a C-arm, will be used to determine the surgical tools' orientation in relation to the patient's anatomy and as a guide for bone component orientation. The system provides pre-, intra-, and post-operative measurements relative to the patient's anatomy. The robotic arm is kept stationary to keep the instruments in a fixed orientation during bone component implanting. The ROSA knee system (ROSA Knee System website (accessed on 28 June 2023): [[https://www.zimmerbiomet.com/en/products-and-solutions/specialities/knee/rosa-knee-system.html](https://www.zimmerbiomet.com/en/products-and-solutions/specialities/knee/rosa-knee-system.html)]([https://www.zimmerbiomet.com/en/products-and-solutions/specialities/knee/rosa-knee-system.html](https://www.zimmerbiomet.com/en/products-and-solutions/specialities/knee/rosa-knee-system.html))) (as shown in Figure 8b) can assist surgeons with bone resections and  
Figure 7: PiGalileo System and ligament balancer. The ligament balancer with force and distance scale is used to measure the ligament tension and gap size. (Reproduced with permission from _[PERSON] et al., Modern Navigated Ligament Balancing in Total Knee Arthroplasty with the PiGalileo System, 2007, Springer Nature_). assessing the state of soft tissues to facilitate implant positioning intraoperatively. This system can be either image based or imageless. For the image-based option, a preoperative 3D virtual bone model needs to be generated preoperatively, which can be used by the surgeon to make a preoperative surgical plan. For the imageless option, the landmarks data on the patient's bony anatomy are collected intraoperatively and used to create an intraoperative surgical plan. The accuracy of the resections, knee state evaluation, and soft tissue assessment are the same between the two options since both of them are always based on intraoperative landmarks. The robotic arm can assist in precisely positioning the component relative to the implantation plan.