Periprosthetic fractures associated with pin placement in robot- or navigation-assisted total knee arthroplasty: a systematic review and meta-analysis.

The adoption of robotic and computer navigation technologies in total knee arthroplasty (TKA) has expanded rapidly, introducing new device-related complications. Among these, fractures occurring at tracker pin insertion sites have raised increasing clinical concern. This systematic review and meta-analysis evaluated the incidence, observed associations, and clinical outcomes of periprosthetic fractures associated with pin placement in robotic- and navigation-assisted TKA. Methods: A systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420261325067). Studies involving adult patients undergoing primary robotic- or navigation-assisted TKA that reported periprosthetic fractures attributable to tracker pin sites were included. Extracted data encompassed study design, navigation or robotic platform, pin configuration, fracture characteristics, and clinical outcomes. A random-effects meta-analysis was performed to estimate the pooled fracture incidence and its 95% confidence interval (CI). Prespecified subgroup analyses examined the influence of pin diameter, cortical engagement, and anatomical pin location. Results: Seventeen studies encompassing 13,217 robotic- or navigation-assisted TKA procedures met the inclusion criteria. The pooled incidence of pin-related periprosthetic fracture was 0.11% (95% CI, 0.06–0.21%), with moderate heterogeneity (I² = 48%). Increased fracture risk was consistently observed with diaphyseal pin positioning and bicortical fixation compared with metaphyseal or unicortical placement. Additional observed associations included larger pin diameters (≥ 4 mm) and multiple drilling attempts. No evidence of significant publication bias was identified. In reported cases, fracture management led to successful union and satisfactory functional recovery. Conclusions: Tracker pin–associated periprosthetic fractures are uncommon but clinically meaningful complications of robotic and navigation-assisted TKA. Risk mitigation strategies may include placing metaphyseal unicortical pins, minimizing drilling attempts, and selecting smaller-diameter pins. Heightened caution is warranted in patients with compromised bone quality or elevated body mass index.