Skip to content

MIS & Robotics

Robotic-assisted spinal surgery for pedicle screw placement: accuracy benefits over freehand techniques and integration into MIS workflows.

Overview

Robotic-assisted unicompartmental knee arthroplasty (UKA) provides greater accuracy than manual UKA, with robotic assistance consistently improving surgical accuracy and component alignment compared to conventional techniques in medial UKA [2, 3]. Short- to mid-term outcomes for robotic-assisted UKA may be improved compared to manual techniques, but definitive differences remain uncertain [2]. It is currently unknown if robotic technology has a meaningful impact on patient outcomes and survivorship in the mid- to long term for unicompartmental knee arthroplasty [3].

In spine surgery, robotic systems offer improved accuracy and potential for reduced complications [6]. Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1]. However, trainees and established surgeons must develop necessary skills and understand the ethical framework to use robotic spine technology safely and effectively [6]. Surgeons must maintain expertise in traditional techniques because strict dependence on robotic technology is dangerous, even though robotic spine surgery may aid complex procedures [7].

Minimally invasive total hip arthroplasty (MIS THA) is a safe surgical procedure without increases in operative time, blood loss, operative complication rates, or component malposition rates [29]. The beneficial effect of MIS THA on functional recovery needs proof [29]. Open surgery remains common for ureteral reconstruction due to complexity, but there is a shift towards laparoscopic and robot-assisted techniques which offer good results with comparable success rates [11].

Robotic surgery shows promise for improved accuracy and outcomes, but there is a lack of sufficient infrastructure and training programs to prepare current and future surgeons for these technologies [4]. Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology [5]. Future evaluation of robotics in the operating theatre should include detailed measurement of total operating time, including total robotic time and time needed for preoperative planning [10]. The International Organization for Standardization (ISO) methodology enables preclinical testing of new assistive technologies to quantify improvements in accuracy and assess benefits in reducing the risk of failure and achieving surgical targets with tighter tolerances before clinical outcome testing [30].

Anatomy & Pathophysiology

Osseous

Robot-assisted pedicle screw fixation, combined with other surgical correction modalities, is an effective and safe method for treating adult degenerative scoliosis [26]. The TINAVI robot-assisted technique for percutaneous pedicle screw placement in spinal surgery showed safe and precise performance [39]. However, pedicle screws may alter trajectory despite the guidance of guidewires in robot-assisted spinal internal fixation surgery [40]. Operator habits and vertebral fixation stiffness are the primary factors influencing non-navigational errors in robot-assisted pedicle Kirschner wire placement, while guide-to-bone surface distance and robotic arm stiffness are secondary factors [32]. Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1].

Ligamentous

Posterior and posterior superior labral (PPS) injuries produce alterations in glenohumeral kinematics with implications for joint instability, increased joint loading, and potential joint damage [36].

Kinematics

Greater accuracy in total knee arthroplasty (TKA) is warranted through a more individualized approach that accurately and precisely reproduces a patient's knee anatomy and kinematics [33].

Vascular & Neural

Interventions in a fully equipped 3D-Navigation Hybrid OR can be successfully performed on the spine, pelvis, and extremities with high precision, increased safety, reduced radiation exposure, and a very low complication rate [27].

Surgical Technique & Technology

Robot-assisted spine surgery offers benefits including high screw accuracy, reduced radiation exposure, and improved ergonomics [28]. Broader adoption of robotic-assisted spine surgery may benefit from a comprehensive understanding of challenges such as registration errors, trajectory inaccuracies, and technical failures [9]. Augmented reality technology in spine surgery offers greater accuracy, surgeon comfort, and reduced operating time based on preclinical and clinical data [37]. Spinal navigation using the X23D-based approach for AI-driven 3D-reconstruction of fluoroscopy images shows promise and performs well in a realistic surgical ex-vivo setting [35]. Machine learning improves treatment selection and outcomes in spine care by leveraging vast amounts of data for more accurate diagnoses and decision support [19]. Machine learning modalities such as decision trees and neural networks are used in spine literature, with ethical challenges and future perspectives discussed [34].

Training & Education

Life-size 3D-printed spine models are excellent tools for training beginners in free-hand pedicle screw instrumentation [42]. Surgeons must maintain expertise in traditional techniques because strict dependence on robotic technology is dangerous [7].

Specific Pathologies & Outcomes

Extreme lateral interbody fusion (XLIF) is not possible and safe in every patient at the L4/5 level [23]. VEPTR treatment for thoracic insufficiency syndrome in patients with Jarcho-Levin Syndrome improved thoracic symmetry, controlled spinal deformity, and was associated with improved clinical respiratory function [45]. Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting fusion status at one year after posterior lumbar interbody fusion [48].

Classification

Robotic-Assisted Spine Surgery: Robotic systems offer improved accuracy and potential for reduced complications in spine surgery [6]. Broader adoption may benefit from a comprehensive understanding of challenges such as registration errors, trajectory inaccuracies, and technical failures [9]. Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1].

Robotic-Assisted Unicompartmental Knee Arthroplasty (UKA): Robotic assistance consistently improves surgical accuracy and component alignment compared to conventional techniques in medial unicompartmental knee arthroplasty [3]. Robotic-assisted UKA provides greater alignment accuracy than manual UKA [2]. Short- to mid-term outcomes for robotic-assisted UKA may be improved compared to manual techniques, but definitive differences remain uncertain [2]. It is currently uncertain if robotic technology has a meaningful impact on patient outcomes and survivorship in the mid- to long term for unicompartmental knee arthroplasty [3].

Robotic-Assisted Total Hip Arthroplasty (THA): Robotic computerized instrumentation achieved precision of inclination in 88% of cases for acetabular component positioning [17]. Robotic computerized instrumentation achieved precision of anteversion in 84% of cases for acetabular component positioning [17]. Robotic computerized instrumentation achieved precision of center of rotation in 81.5% of cases for acetabular component positioning [17]. Robotic-assisted reaming was significantly faster than manual reaming in total hip arthroplasty, demonstrating the system's ability to combine precision with efficiency [14].

Other Considerations: Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe in image-based robotic knee arthroplasty [16]. There is no definitive evidence to suggest that rates of surgical site infections or periprosthetic joint infections are increased in robotic-assisted orthopaedic procedures [49]. The International Organization for Standardization (ISO) methodology enables preclinical testing of new assistive technologies to quantify improvements in accuracy and assess benefits in reducing failure risk and achieving surgical targets with tighter tolerances [30]. Further validation and replication of results away from designer sites are needed to ensure robust generalizability of novel research on AI and robotics in joint arthroplasty [47].

Training and Ethics: Trainees and established surgeons must develop necessary skills and understand the ethical framework to use robotic spine technology safely and effectively [6]. Surgeons must maintain expertise in traditional techniques because strict dependence on robotic technology is dangerous, even though robotic spine surgery may aid complex procedures [7]. Robotic surgery shows promise for improved accuracy and outcomes, but there is a lack of sufficient infrastructure and training programs to adequately prepare current and future surgeons [4]. Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology [5].

Sports Medicine: Robotics in sports medicine holds huge potential, with possibilities extending beyond current orthopaedic robots to the broader scope demonstrated by soft tissue robots in other disciplines [50].

Clinical Presentation

The clinical presentation of robotic-assisted procedures spans multiple orthopaedic subspecialties, characterized by distinct accuracy benefits and evolving infrastructural requirements. In spine surgery, robotic systems offer improved accuracy and potential for reduced complications [6]. Trainees and established surgeons must develop necessary skills and understand the ethical framework to use robotic technology safely and effectively [6]. While robotic spine surgery (RSS) may aid complex procedures, surgeons must maintain expertise in traditional techniques as strict dependence on robotic technology is dangerous [7]. Robot-assisted technique improves short-term clinical outcomes, reduces intraoperative blood loss and patient suffering, and shortens recovery time compared to the freehand technique [8]. Robotic-assisted percutaneous internal fixation can be used as an ideal surgical treatment for thoracolumbar fractures in patients with ankylosing spondylitis [38]. However, broader adoption requires a comprehensive understanding of challenges such as registration errors, trajectory inaccuracies, and technical failures [9]. Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1].

In unicompartmental knee arthroplasty (UKA), robotic assistance consistently improves surgical accuracy and component alignment compared to conventional techniques [3]. Robotic-assisted UKA provides greater accuracy than manual UKA [2]. Short- to mid-term outcomes for robotic-assisted UKA may be improved compared to manual UKA, but definitive differences remain uncertain [2]. Further studies are needed to determine if robotic technology has a meaningful impact on patient outcomes and survivorship in the mid- to long term for unicompartmental knee arthroplasty [3].

Robotic computerized instrumentation achieved precision of inclination in 88%, anteversion in 84%, and center of rotation in 81.5% of cases, validating the system's accuracy compared to preoperative plans for acetabular component positioning [17]. Robotic-assisted reaming was significantly faster than manual reaming, demonstrating the robotic system's ability to combine precision with efficiency in total hip arthroplasty [14]. Clinical correlation during surgery should continue to be practiced and compared with observed intraoperative robotic values for total hip arthroplasty component placement [13].

Emerging evidence suggests that the greatest utility of intraoperative navigation in reverse total shoulder arthroplasty (rTSA) may lie in its application to anatomically complex cases [24]. In ureteral reconstruction, there is a shift towards laparoscopic and robot-assisted techniques which offer good results with comparable success rates in ureteral reconstruction, although open surgery remains common due to complexity [11]. Various imaging and diagnostic techniques exist, but many have not yet entered routine clinical practice in ureterorenoscopy [25].

Robotic surgery shows promise for improved accuracy and outcomes, but there is a lack of sufficient infrastructure and training programs to adequately prepare current and future surgeons for these advanced technologies [4]. Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology [5]. Future evaluation of robotics in the operating theatre should include detailed measurement of various aspects of total operating time, including total robotic time and time needed for preoperative planning [10].

Investigations

Plain radiography: Standard imaging remains foundational, though broader adoption of robotic-assisted spine surgery requires a comprehensive understanding of challenges including registration errors, trajectory inaccuracies, and technical failures [9]. Intraoperative 3D imaging with cone-beam computed tomography (CBCT) can detect misplaced pedicle screws in dorsal instrumentation and be helpful to revise misplaced pedicle screws intraoperatively [51].

CT: Robotic computerized instrumentation achieved precision of inclination in 88% of cases for acetabular component positioning [17]. Robotic computerized instrumentation achieved precision of anteversion in 84% of cases for acetabular component positioning [17]. Robotic computerized instrumentation achieved precision of center of rotation in 81.5% of cases for acetabular component positioning [17].

Other Considerations: Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1]. Robot-assisted spine surgery offers high screw accuracy [28]. Robot-assisted spine surgery reduces radiation exposure [28]. Robot-assisted spine surgery improves ergonomics [28]. Robot-assisted spine surgery requires surgeons to understand the learning curve and technical pitfalls [28]. A modified minimally invasive procedure for tracer fixation in robot-assisted pedicle screw insertion results in minimal trauma [53]. A modified minimally invasive procedure for tracer fixation in robot-assisted pedicle screw insertion is simple, reliable, and highly safe [53].

Interventions in a fully equipped 3D-Navigation Hybrid OR can be successfully performed on the spine, pelvis, and extremities with high precision [27]. Interventions in a fully equipped 3D-Navigation Hybrid OR result in increased safety [27]. Interventions in a fully equipped 3D-Navigation Hybrid OR reduce radiation exposure [27]. Interventions in a fully equipped 3D-Navigation Hybrid OR have a very low complication rate [27].

Robotic-assisted unicompartmental knee arthroplasty (UKA) provides greater alignment accuracy than manual UKA [2]. Robot-assisted UKA reduces radiologic outliers compared to conventional techniques [15]. Short- to mid-term clinical outcomes for robotic-assisted UKA may be improved compared to manual UKA, but definitive differences remain uncertain [2]. Clinical outcomes for robot-assisted UKA over short-term follow-up were not significantly different from conventional UKA [15]. Longer follow-up is needed to determine if improved radiologic accuracy in robotic-assisted UKA leads to better clinical outcomes and long-term survival [15].

Robotic reaming was significantly faster than manual reaming in total hip arthroplasty [14]. Both resurfaced and non-resurfaced approaches improve radiographic outcomes regarding the anterior knee compartment after total knee arthroplasty (TKA) performed with functional alignment and an image-based robotic system [31]. There are no signs of superiority in clinical outcomes for the resurfaced group compared to the non-resurfaced group in robotic-assisted TKA with functional alignment [31].

The greatest utility of intraoperative navigation in reverse total shoulder arthroplasty (rTSA) may lie in its application to anatomically complex cases [24]. Machine learning improves treatment selection and outcomes in spine care by leveraging vast amounts of data for accurate diagnoses and decision support [19]. Extreme lateral interbody fusion (XLIF) is not possible and safe in every patient at the L4/5 level [23]. Various imaging and diagnostic techniques exist, but many have not yet entered routine clinical practice [25].

Robotic surgery shows promise for improved accuracy and outcomes, but there is a lack of sufficient infrastructure and training programs to prepare surgeons for these technologies [4]. Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology [5].

Treatment

Non-Operative

The provided evidence does not contain specific data regarding conservative management options such as weight loss, physical therapy, or injections.

Operative

Surgical Approach / Technique: Robotic-assisted pedicle screw placement improves short-term clinical outcomes, reduces intraoperative blood loss and patient suffering, and shortens recovery time compared to the freehand technique [8]. Robot-assisted pedicle screw fixation is an effective and safe method for treating degenerative scoliosis when combined with other surgical correction modalities [26]. Implementation of standardized robotic surgery guidelines resulted in no robot-related screw complications in a post-protocol cohort of 290 patients [1]. Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe [16]. There is a shift towards laparoscopic and robot-assisted techniques for ureteral reconstruction, which offer good results with comparable success rates to open surgery [11]. Minimally invasive total hip arthroplasty (MIS THA) is a safe surgical procedure without increases in operative time, blood loss, operative complication rates, and component malposition rates [29].

Implant Selection: Robotic-assisted unicompartmental knee arthroplasty (UKA) offers technological advancements that enhance surgical precision and reduce revision rates compared to manual techniques [43]. Robotic-assisted total hip arthroplasty (THA) and manual THA have similar rates of clinically important improvements, complications, and revision-free survival [18].

Alignment / Balancing Strategy: Robotic-assisted UKA provides more accuracy than manual UKA [2] and consistently improves surgical accuracy and component alignment compared to conventional techniques [3]. Both resurfaced and non-resurfaced approaches improve radiographic outcomes regarding the anterior knee compartment after total knee arthroplasty (TKA) performed with functional alignment and image-based robotic systems [31]. There are no signs of superiority in clinical outcomes in the resurfaced group compared to non-resurfaced approaches in robotic-assisted TKA with functional alignment principles [31]. Computer navigation and robotic assistance may help manage multiple surgical variables and could improve outcomes, particularly when soft tissue balancing is controlled [52].

Pain Management: The provided evidence does not contain specific data regarding analgesia regimens.

Adjuncts: Robotic assistance consistently improves surgical accuracy and component alignment compared to conventional techniques in UKA [3].

Setting of Care: The provided evidence does not contain specific data regarding outpatient versus inpatient settings.

Revision: The provided evidence does not contain specific data regarding revision-procedure principles.

Other Considerations: Short- to mid-term outcomes for robotic-assisted UKA may be improved compared to manual UKA, but definitive differences are uncertain [2]. At short-term follow-up of 2 years, robotic-assisted UKA was not superior to conventional UKA in terms of functional scores [12]. Robotic-assisted UKA was associated with greater operative time and lower survivorship compared to conventional UKA at 2-year follow-up [12] but does not significantly differ in functional outcomes compared to manual techniques [43]. Further studies are needed to determine if robotic technology has a meaningful impact on patient outcomes and survivorship in the mid- to long term for UKA [3]. Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology [5]. The beneficial effect of MIS THA on functional recovery needs proof [29]. There is a lack of sufficient infrastructure and training programs to adequately prepare current and future surgeons for advanced robotic technologies [4]. It is essential for trainees and established surgeons to develop necessary skills and understand the ethical framework to use robotic technology safely and effectively [6]. While robotic systems offer improved accuracy and potential for reduced complications, strict dependence on robotic technology is dangerous as surgeons must maintain expertise in traditional techniques [7]. Understanding the current evidence and appropriate indications of emerging technologies is of critical importance for their utilization in orthopaedic trauma [44].

Complications

Other Considerations: Implementation of standardized robotic surgery guidelines resulted in zero robot-related screw complications in a post-protocol cohort of 290 patients [1]. Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe in image-based robotic knee arthroplasty [16].

Robotic Unicompartmental Knee Arthroplasty (UKA): Robotic-assisted UKA was associated with greater operative time compared to conventional UKA at short-term follow-up [12]. Robotic-assisted UKA was associated with lower survivorship compared to conventional UKA at short-term follow-up [12]. Robot-assisted unicompartmental knee arthroplasty can reduce radiologic outliers compared to conventional techniques [15].

Robotic Total Hip Arthroplasty (THA): Robotic-assisted total hip arthroplasty (THA) and manual THA have similar rates of complications [18].

Robotic Lumbar Arthrodesis: One-year reoperation rates after robot-assisted lumbar arthrodesis are low and do not appear to be influenced by robot-related factors and complications [20]. Robot-related complications may increase the risk for greater blood loss requiring a blood transfusion after robot-assisted lumbar arthrodesis [20]. Robot-related complications may increase the risk for longer length of stay after robot-assisted lumbar arthrodesis [20].

Recovery

Light activity (weeks): Robot-assisted techniques reduce intraoperative blood loss [8] and patient suffering [8], and shorten recovery time compared to freehand techniques [8]. However, robot-related complications may increase the risk for greater blood loss requiring a blood transfusion [20] and increase the length of stay [20].

Full activity (months): Clinical outcomes vary by procedure. Robotic-assisted unicompartmental knee arthroplasty (UKA) is associated with greater operative time compared to conventional UKA at short-term follow-up [12]. At 2-year follow-up, robotic-assisted UKA was not superior to conventional UKA in terms of functional scores [12] and was associated with lower survivorship [12]. In contrast, robotic-assisted total hip arthroplasty (THA) and manual THA have similar rates of clinically important improvements [18], similar rates of complications [18], and similar revision-free survival [18]. There are no clinical differences in patient-reported outcome measures (PROMs) after 1 year follow-up between computer-assisted and conventional hip resurfacing arthroplasty [54].

Complete recovery / outcome plateau (months): Long-term data for robotic-assisted UKA demonstrate satisfactory clinical outcomes at 3-year follow-up [21] and excellent survivorship at 3-year follow-up [21]. Robotic-arm-assisted medial unicompartmental knee arthroplasty (UKA) had high 10-year survivorship [46] and high patient satisfaction at 10 years [46]. One-year reoperation rates after robot-assisted lumbar arthrodesis are low [20], and these rates do not appear to be influenced by robot-related factors and complications [20].

Rehabilitation protocol: No robot-related screw complications occurred in a post-protocol cohort of 290 patients following the implementation of standardized robotic surgery guidelines [1].

Key Evidence

  • [L2] Following the implementation of standardized robotic surgery guidelines, no robot-related screw complications occurred in a post-protocol cohort of 290 patients. (10.2106/jbjs.25.00406)
  • [L5] Robotic-assisted UKA provides more accuracy than manual UKA, with short- to mid-term outcomes potentially improved but definitive differences uncertain. (10.1016/j.jisako.2024.100336)
  • [L5] Robotic assistance consistently improves surgical accuracy and component alignment compared to conventional techniques, but further studies are needed to determine if these technologies have a meaningful impact on patient outcomes and survivorship in the mid- to long term. (10.5435/jaaos-d-17-00710)
  • [L5] The authors conclude that while robotic surgery shows promise for improved accuracy and outcomes, there is a lack of sufficient infrastructure and training programs to adequately prepare current and future surgeons for these advanced technologies. (10.1302/0301-620x.100b12.bjj-2019-0900)
  • [L5] Larger, well-designed Level-I studies are needed to dispassionately evaluate the specific advantages of robotic technology. (10.2106/jbjs.22.00930)
  • [L5] The article states that while robotic systems offer improved accuracy and potential for reduced complications, it is essential for trainees and established surgeons to develop necessary skills and understand the ethical framework to use the technology safely and effectively. (10.1302/0301-620x.102b5.bjj-2019-1392.r2)
  • [L5] While RSS may aid complex procedures, surgeons must maintain expertise in traditional techniques as strict dependence on robotic technology is dangerous. (10.2106/jbjs.22.00022)
  • [L1] Robot-assisted technique helps improve short-term clinical outcomes, reduce intraoperative blood loss and patient suffering, and shorten recovery time compared to the freehand technique. (10.1186/s13018-023-03774-w)
  • [L4] Robotic-assisted spine surgery holds enormous future potential, but its broader adoption may benefit from a comprehensive understanding of challenges such as registration errors, trajectory inaccuracies, and technical failures. (10.5435/jaaos-d-25-00031)
  • [L2] Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. (10.1302/0301-620x.102b4.bjj-2019-1210.r1)
  • [Paper] The article concludes that while open surgery remains common due to complexity, there is a shift towards laparoscopic and robot-assisted techniques which offer good results with comparable success rates. (10.1007/s00120-019-0944-z)
  • [L3] At short-term follow-up of 2 years, robotic-assisted UKA was not superior to conventional UKA in terms of functional scores and was associated with greater operative time and lower survivorship. (10.1007/s00167-019-05386-6)
  • [L4] Clinical correlation during surgery should continue to be practiced and compared with observed intraoperative robotic values. (10.1302/0301-620x.100b10-bjj-2018-0201.r1)
  • [L3] Robotic-assisted reaming was significantly faster than manual reaming, demonstrating the robotic system's ability to combine precision with efficiency. (10.1016/j.arth.2025.03.068)
  • [L3] Although the clinical outcomes of robot-assisted UKA over a short-term follow-up period were not significantly different compared to those of conventional UKA, longer follow-up period is needed to determine whether the improved radiologic accuracy of the components in robotic-assisted UKA will lead to better clinical outcomes and improved long-term survival. (10.1371/journal.pone.0225941)
  • [L3] Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe. (10.1016/j.jisako.2024.100317)
  • [L3] Robotic-assisted THA and manual THA have similar rates of clinically important improvements, complications and revision-free survival. (10.1016/j.arth.2025.05.015)
  • [L5] Machine learning is crucial for spine care and research due to its ability to improve treatment selection and outcomes, leveraging vast amounts of data for more accurate diagnoses and decision support. (10.1530/eor-24-0019)
  • [L3] One-year reoperation rates are low and do not appear to be influenced by robot-related factors and complications; however, robot-related complications may increase the risk for greater blood loss requiring a blood transfusion and longer length of stay. (10.1186/s13018-021-02452-z)
  • [L4] Robotic-assisted medial and lateral UKAs demonstrated satisfactory clinical outcomes and excellent survivorship at 3-year follow-up. (10.1007/s00167-019-05566-4)
  • [L4] XLIF is not possible and safe in every patient at the L4/5 level. (10.1186/s13018-022-03320-0)
  • [L1] Emerging evidence suggests that the greatest utility of intraoperative navigation in rTSA may lie in its application to anatomically complex cases. (10.1016/j.xrrt.2026.100687)
  • [Paper] While various imaging and diagnostic techniques exist, many have not yet entered routine clinical practice. (10.1007/s00120-017-0333-4)
  • [L3] Combined with other surgical correction modalities, robot-assisted pedicle screw fixation is an effective and safe method of treating degenerative scoliosis. (10.1186/s13018-020-01796-2)
  • [L4] Interventions in a fully equipped 3D-Navigation Hybrid OR can be successfully performed on the spine, pelvis, and extremities with high precision, increased safety, reduced radiation exposure, and a very low complication rate. (10.1186/s13018-024-05044-9)
  • [L5] Robot-assisted spine surgery offers benefits including high screw accuracy, reduced radiation exposure, and improved ergonomics, but requires surgeons to understand the learning curve and technical pitfalls. (10.5435/jaaos-d-24-00692)
  • [L1] MIS THA is a safe surgical procedure without increases in operative time, blood loss, operative complication rates and component malposition rates, though its beneficial effect on functional recovery needs proof. (10.1186/1471-2474-11-92)
  • [L5] The International Organization for Standardization (ISO) methodology enables preclinical testing of new assistive technologies to quantify improvements in accuracy and assess the benefits in terms of reducing the risk of failure and achieving surgical targets with tighter tolerances before the testing of clinical outcomes. (10.2106/jbjs.15.01347)
  • [L2] Both resurfaced and non-resurfaced approaches improve radiographic outcomes regarding the anterior knee compartment after TKA performed with FA and image-based robotic system, without signs of superiority in clinical outcomes in the resurfaced group. (10.1002/ksa.12769)
  • [L5] Operator habits and vertebral fixation stiffness are the primary factors influencing non-navigational errors, while guide-to-bone surface distance and robotic arm stiffness are secondary factors. (10.1186/s13018-025-05790-4)
  • [L5] Greater accuracy in TKA surgery is warranted through a more individualized approach; using proven tools to accurately and precisely reproduce a patient's knee anatomy and kinematics may reveal the true value of precision tools. (10.1007/s00167-020-06295-9)
  • [L5] This narrative review introduces the field of machine learning, defines basic terminology, examines common modalities like decision trees and neural networks in the context of spine literature, and discusses ethical challenges and future perspectives. (10.3389/fsurg.2020.00054)
  • [L5] Spinal navigation using the X23D-based approach shows promise and performs well in a realistic surgical ex-vivo setting. (10.1186/s12891-024-08052-2)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L4] Current literature provides sufficient preclinical and clinical data evidence for the use of AR technology in spine surgery, offering greater accuracy, surgeon comfort, and reduced operating time. (10.5435/jaaos-d-23-00023)
  • [L4] Posterior robotic-assisted percutaneous internal fixation can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s12891-024-07597-6)
  • [L3] This new technique showed a safe and precise performance for pedicle screw placement in spinal surgery. (10.1186/s13018-022-03271-6)
  • [L4] Pedicle screws may alter trajectory despite the guidance of the guidewires. (10.1186/s13018-023-04053-4)
  • [L4] A life-size 3D-printed spine model can be an excellent tool for training beginners of the free-hand pedicle screw instrumentation. (10.1186/s13018-018-0788-z)
  • [L2] Robotic-assisted unicompartmental knee arthroplasty offers technological advancements that enhance surgical precision and reduce revision rates compared to manual techniques, but it does not significantly differ in functional outcomes. (10.1016/j.arth.2024.10.095)
  • [L4] VEPTR treatment improved thoracic symmetry, controlled spinal deformity, and was associated with improved clinical respiratory function. (10.2106/jbjs.m.00185)
  • [L2] This prospective multicenter study found high 10-year survivorship and patient satisfaction following robotic-arm-assisted medial UKA. (10.2106/jbjs.22.01104)
  • [L5] The special edition brings together novel research on AI and robotics in joint arthroplasty, highlighting the need for further validation and replication of results away from designer sites to ensure robust generalizability. (10.1186/s42836-025-00302-5)
  • [L2] Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year. (10.1186/s13018-025-05814-z)
  • [L2] At present, there is no definitive evidence to suggest that the rates of surgical site infections or periprosthetic joint infections are increased in robotic-assisted orthopaedic procedures. (10.1016/j.arth.2025.08.041)
  • [Letter] The authors look forward to an exciting future with huge potential for the integration of robotics in sports medicine, highlighting that possibilities extend beyond current orthopaedic robots to the broader scope demonstrated by soft tissue robots in other disciplines. (10.1002/ksa.12622)
  • [L3] Intraoperative 3D imaging with a CBCT can be helpful to detect and revise misplaced pedicle screws intraoperatively. (10.1186/s13018-021-02849-w)
  • [L1] Computer navigation and robotic assistance may help managing multiple surgical variables and could improve outcomes, particularly when soft tissue balancing is controlled. (10.1007/s00167-016-4305-9)
  • [L1] The modified minimally invasive procedure for tracer fixation results in minimal trauma and is simple, reliable, and highly safe. (10.1186/s12891-020-03239-9)
  • [L2] There are no clinical differences in PROMs after 1 year follow up. (10.1186/s12891-019-2883-7)

See Also

References

[1] Decreased Robot-Related Complications Following the Development and Adoption of a Standardized Safety Protocol. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00406

[2] Does robotic-assisted unicompartmental knee arthroplasty improve alignment and outcomes?. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.100336

[3] Robotic-assisted Medial Unicompartmental Knee Arthroplasty: Options and Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00710

[4] Robotic and other enhanced technologies. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.100b12.bjj-2019-0900

[5] More Science and Less Passion Around Robotic Surgery. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00930

[6] Surgeon proficiency in robot-assisted spine surgery. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b5.bjj-2019-1392.r2

[7] Development of a Robotic Spine Surgery Program. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00022

[8] Comparison of short-term clinical outcomes between robot-assisted and freehand pedicle screw placement in spine surgery: a meta-analysis and systematic review. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03774-w

[9] Identification of Potential Pitfalls and Complication Avoidance in Robotic-Assisted Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00031

[10] How should we evaluate robotics in the operating theatre?. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b4.bjj-2019-1210.r1

[11] Rekonstruktionsmöglichkeiten des Harnleiters. Der Urologe. 2019. DOI: 10.1007/s00120-019-0944-z

[12] Robotic-assisted unicompartmental knee replacement offers no early advantage over conventional unicompartmental knee replacement. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05386-6

[13] Intraoperative placement of total hip arthroplasty components with robotic-arm assisted technology correlates with postoperative implant position. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b10-bjj-2018-0201.r1

[14] Impact of Robotic Assistance on Total Hip Arthroplasty: Granular Insights Into Surgical Time. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.03.068

[15] Robot-assisted unicompartmental knee arthroplasty can reduce radiologic outliers compared to conventional techniques. PLOS ONE. 2019. DOI: 10.1371/journal.pone.0225941

[16] Is bicortical femoral pin insertion safe for image-based robotic knee arthroplasty surgery ? A comparative complications analysis in 970 consecutive cases. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2024.100317

[17] Precision_of_Robotic_Guided_Instrumentation_for_Acetabular_Component_Positioning_S0883540314007967. n.d..

[18] Does Robotic Assistance Increase the Likelihood of Achieving the Minimal Clinically Important Improvement Following Total Hip Arthroplasty? Findings From a Propensity Score Matched Analysis of 1,364 Procedures. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.015

[19] Advancing spine care through AI and machine learning: overview and applications. EFORT Open Reviews. 2024. DOI: 10.1530/eor-24-0019

[20] Do robot-related complications influence 1 year reoperations and other clinical outcomes after robot-assisted lumbar arthrodesis? A multicenter assessment of 320 patients. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02452-z

[21] Clinical results and short-term survivorship of robotic-arm-assisted medial and lateral unicompartmental knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05566-4

[23] L4/5 accessibility for extreme lateral interbody fusion (XLIF): a radiological study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03320-0

[24] The role of intraoperative navigation in reverse total shoulder arthroplasty and its impact on clinical outcomes: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100687

[25] Ureterorenoskopie. Der Urologe. 2017. DOI: 10.1007/s00120-017-0333-4

[26] Robot-assisted orthopedic surgery in the treatment of adult degenerative scoliosis: a preliminary clinical report. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01796-2

[27] Hybrid-3D robotic suite in spine and trauma surgery - experiences in 210 patients. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05044-9

[28] Robot-Assisted Spine Surgery: The Pearls and Pitfalls. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00692

[29] Minimally invasive and computer-navigated total hip arthroplasty: a qualitative and systematic review of the literature. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-92

[30] Accuracy of Computer-Aided Techniques in Orthopaedic Surgery. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.15.01347

[31] Does patellar resurfacing matter in robotic‐assisted total knee arthroplasty with functional alignment principles?. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12769

[32] Simulation and analysis of non-navigational errors in robot-assisted pedicle Kirschner wire placement surgery. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05790-4

[33] The rebirth of computer‐assisted surgery. Precise prosthetic implantation should be considered when targeting individualized alignment goals in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06295-9

[34] The Role of Machine Learning in Spine Surgery: The Future Is Now. Frontiers in Surgery. 2020. DOI: 10.3389/fsurg.2020.00054

[35] Spinal navigation with AI-driven 3D-reconstruction of fluoroscopy images: an ex-vivo feasibility study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08052-2

[36] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[37] Applications of Augmented Reality in Orthopaedic Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00023

[38] Surgical outcomes of robotic-assisted percutaneous fixation for thoracolumbar fractures in patients with ankylosing spondylitis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07597-6

[39] Safety and risk factors of TINAVI robot-assisted percutaneous pedicle screw placement in spinal surgery. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03271-6

[40] The positional consistency between guidewire and cannulated or solid screw in robot-assisted spinal internal fixation surgery. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-023-04053-4

[42] Use of a life-size three-dimensional-printed spine model for pedicle screw instrumentation training. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0788-z

[43] Does the Integration of Robotic Technology Improve Outcomes in Unicompartmental Knee Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.095

[44] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[45] Management of Thoracic Insufficiency Syndrome in Patients with Jarcho-Levin Syndrome Using VEPTRs (Vertical Expandable Prosthetic Titanium Ribs). The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.m.00185

[46] Ten-Year Survivorship and Patient Satisfaction Following Robotic-Arm-Assisted Medial Unicompartmental Knee Arthroplasty. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.01104

[47] Editorial: Advances in artificial intelligence and robotics in joint arthroplasty. Arthroplasty. 2025. DOI: 10.1186/s42836-025-00302-5

[48] 18F-fluoride PET/CT as an early predictor of bony fusion after posterior lumbar interbody fusion– a prospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05814-z

[49] ICM 2025: New Technologies like Artificial Intelligence, Robotics, and Anti-Biofilm. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.08.041

[50] Response to the Editorial “Robotic‐assisted surgery in sports medicine—A broader vision for the future”. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12622

[51] Intraoperative 3D imaging with cone-beam computed tomography leads to revision of pedicle screws in dorsal instrumentation: a retrospective analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02849-w

[52] Current state of computer navigation and robotics in unicompartmental and total knee arthroplasty: a systematic review with meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4305-9

[53] Minimally invasive versus conventional fixation of tracer in robot-assisted pedicle screw insertion surgery: a randomized control trial. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03239-9

[54] No added value for Computer-Assisted surgery to improve femoral component positioning and Patient Reported Outcomes in Hip Resurfacing Arthroplasty; a multi-center randomized controlled trial. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2883-7

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.