Original Article

Proc IMechE Part H:

J Engineering in Medicine
2022, Vol. 236(5) 697–710
Human-robot-robot cooperative Ó IMechE 2022
Article reuse guidelines:
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DOI: 10.1177/09544119221083140

1-DOF traction device for robot- journals.sagepub.com/home/pih

assisted fracture reduction system

Woo Young Kim1, Sanghyun Joung2, Il Hyung Park3,

Jong-Oh Park1 and Seong Young Ko1

Abstract
While performing musculoskeletal long bone fracture reduction surgery, assistant surgeons can often suffer from physical fati-
gue as they provide resistance against the tension from surrounding muscles pulling on the patient’s broken bones. These days,
robotic systems are being actively developed to mitigate this physical workload by realigning and holding these fractured bones
for surgeons. This has led to one consortium proposing the development of a robot-assisted fracture reduction system consist-
ing of a 6-DOF positioning robot along with a 1-DOF traction device. With the introduction of the 1-DOF traction device, the
positioning robot does not have to fight these contraction forces so can be compact improving its maneuverability and overall
convenience; however, considering surgeon-robot interactions, this approach adds the requirement of controlling two different
types of robots simultaneously. As such, an advanced cooperative control methodology is required to control the proposed
bone fracture reduction robot system. In this paper, a human-robot-robot cooperative control (HRRCC) scheme is proposed
for collaboration between the surgeon, the positioning robot, and the traction device. First, the mathematical background of
this HRRCC scheme is provided. Next, we describe a series of experiments that show how the proposed scheme facilitates a
reduction in the load placed on the positioning robot from strong muscular contraction forces making it possible to conduct
fracture reduction procedures more safely despite the muscular forces.

Keywords
Admittance control, robot-assisted fracture reduction, human-robot-robot cooperative control, positioning robot, trac-
tion device

Date received: 25 October 2018; accepted: 24 January 2022

Introduction operating surgeon align the fractured bones. Since the

Minimally invasive osteosynthesis, especially closed
intramedullary nailing, has recently become the preferred
method for long bone fracture reduction surgery due to
the successful surgical outcomes it produces; however, sig-
nificant disadvantages to this approach have been
reported, including the physically difficult tasks that sur-
geons must perform, potential misalignment of fracture
segments, and the large amounts of radiation exposure
experienced by patients as well as operating staff.
Necessity for robot-assisted fracture reduction
systems
During femur fracture reduction surgery, several assis-
tant surgeons pull and hold a patient’s leg to help the
muscles surrounding the bones will strongly contract in
these situations, considerable force is required to posi-
tion then hold the bones in place. It has been reported
that the maximum force and torque exerted by thigh
muscle tension in adult males can measure up to 411 N
1
School of Mechanical Engineering, Chonnam National University,
Gwangju, South Korea
2
Medical Device and Robot Institute of Park, Kyungpook National
University, Daegu, South Korea
3
School of Medicine, Department of Orthopedic Surgery, Kyungpook
National University, Daegu, South Korea
Corresponding author:
Seong Young Ko, School of Mechanical Engineering, Chonnam National
University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, South Korea.
Email: sko@jnu.ac.kr
698
and 74 Nm, respectively.1 Recently, in order to mitigate
the physical burden of assistant surgeons during these
procedures, and to reduce X-ray radiation exposure for
patients and operating staff, robot-assisted fracture
reduction (RAFR) systems equipped with 3-dimen-
sional (3D) medical navigation systems have been
developed by several research groups.2–9
Literature review
Several research groups have developed RAFR systems
using powerful robots to mitigate surgeons’ physical
fatigue. Westpal et al.5 proposed a robot-assisted long
bone fracture reduction system that employs a six-axis
articulated industrial robot (Stäubli TX-90) and a 3D
image navigation system, which is telemanipulated
using a joystick. Tokyo University in Japan6 proposed
a RAFR system (FRAC-Robo) equipped with a six-
axis serial robot and a 3D image navigation system.
This robot can be connected to a patient’s foot to move
the distal bone fragment while being interactively con-
trolled using one force/torque (F/T) sensor. Palmerston
North Hospital in New Zealand7 proposed a RAFR
system that consisted of a 6-degree-of-freedom (DOF)
parallel robot and a manual reduction table. The
University of Hong Kong utilized a specially designed
parallel robot in their long bone RAFR system.8
Dagnino et al.9 developed a RAFR system that consists
of a 6-DOF parallel robot and a 4-DOF carrier plat-
form. The above-mentioned RAFR systems are mainly
manipulated by surgeons using teleoperation to con-
duct fracture reduction tasks.5–9 For some systems,
experimental results from situations where the muscu-
lar contraction forces or soft tissues are considered
explicitly have not been reported.5,8,9 Some systems are
bulky,6 and some require use of additional structures,
such as a carriage platform.7,9 In this study, teleopera-
tion along with manual interactive manipulation was
adopted as the intended control method so that sur-
geons can intervene in the robotic surgery procedure
and manipulate the robot directly while checking a
patient’s status.10
Moreover, during conventional fracture reduction
surgery, a manual traction device is often used. These
manual traction devices may use weights to pull the
bone and pulleys to change the direction of that force,
or they may use a manual winch system to pull and
hold a broken bone in place. Generally, these devices
are fixed to the frame of a patient’s bed. In a similar
way, fracture tables have also seen widespread use for
assisting fracture reduction surgery.
For control, most surgical robot systems have a
surgeon-robot cooperative control scheme so the sur-
geon can manage surgical processes. Most systems
include a sensor-based virtual guide11 and/or a force
feedback control to aid the user’s force-torque com-
mands and environmental reaction forces.10,12 This
Proc IMechE Part H: J Engineering in Medicine 236(5)
research group has previously developed a RAFR sys-
tem in which one serial type positioning robot is used
solely to provide force feedback and force scale func-
tionality this system operates based on the assumptions
that the positioning robot has a sufficient load capacity
and that two F/T sensors are available.10 Recently,
Park et al.13,14 proposed a new approach where a
single-axis motorized traction device is used to assist
with the strong muscular contraction force exerted
along the bone’s axial axis alongside a serial robot.
This combination is promising because the largest
forces are required along the axial axis of the bone,
while the forces in the other directions are lower.1,15,16
Thus, for that system, the traction device manages the
strong muscular forces acting along the bone’s axial
axis, while the serial robot manages the remaining
forces along other axes. The small serial robot has been
named the ‘‘positioning robot.’’ Employing the separate
traction device helps reduce the maximum payload on
the positioning robot and improves the surgeon’s man-
euverability. However, since two different types of
robots are used together, a cooperative control scheme
is required. If a positioning robot and a traction device
move independently, the traction force produced by the
traction device may create additional loads for the posi-
tioning robot to deal with. To conduct fracture reduc-
tion surgery based on a surgeon’s commands like one
integrated system, an efficient control structure must
be developed.
Thus, for the cooperative control of both the posi-
tioning robot and the traction device, where the two
robot systems are connected to the fractured bone phy-
sically, a human-robot-robot cooperative control
(HRRCC) scheme is proposed. In detail, as the surgeon
controls the positioning robot, the traction device
moves to minimize the load placed on the positioning
robot. It is expected that this scheme will help surgeons
conduct RAFR surgery while experiencing lower physi-
cal loads and stresses than before, in addition, the sys-
tem will protect bone fragments from damage, such as
a secondary fracture caused by excessive forces from
the robots’ operations.
In the field of industrial robots, initially coordina-
tion of multiple robotic arms was developed using
coordinated control17 or by expanding hybrid position/
force control methods.18 Since then, adaptive con-
trol19,20 and neural network control21 techniques have
been developed and applied for control of multiple
robots. Motion synchronization techniques for multi-
axis robots have also been developed using cross-
coupling approaches.22–24 It should be noted that the
existing synchronization methods found in previous lit-
erature, like those mentioned above, are all related to
motion control. Motion synchronization using force
tracking control for human-robot collaboration has
also been studied.25 In recent years, multiple robot
arms have been studied for force control
Kim et al.
Figure 1. Conceptual setup of a 6-DOF positioning robot and
a 1-DOF traction device for procedure on a fractured femur
model with phantom muscles: (1) 6-DOF positioning robot,
(2) 1-DOF traction device, (3) Interaction F/T sensor,
(4) Operational F/T sensor, (5) Pin holder, (6) Distal bone
fixation jig, (7) Fractured femur with phantom muscle,
(8) Proximal bone fixation jig.
synchronization so that a specific robot arm can be
applied to a workpiece with the desired force.26 This
work has proceeded to simulated experiments.
Contributions of this work
The first major contribution of this work is the pro-
posed HRRCC scheme to control two different types
of robots based on singular commands from the sur-
geon. To the best of the authors’ knowledge, this is the
first such approach for medical robots. Second, a
RAFR system was implemented in which a 1-DOF
traction device manages most of the muscular contrac-
tion force while a bone fragment is being positioned
while a 6-DOF positioning robot manages the remain-
ing forces on other axes. Third, it was experimentally
verified that our single control structure can provide
Figure 2. A simplified dynamics model including the positioning robot, traction device, human operator, and fractured bones with
muscles.
699
both assistance against contraction force and the reduc-
tion of contact forces. When bone fragments are placed
into contact with each other, the contact forces between
them can be reduced significantly, the force feedback
function of the proposed HRRCC then limits the dis-
placements of the positioning robot.
Human-robot-robot cooperative control
Dynamics modeling using simplified one-DOF
systems
In this section, the control structure and mathematical
background of the HRRCC scheme are described. A
conceptual layout of the two robot systems involved, a
positioning robot and a traction device, are shown in
Figure 1. The fractured distal bone is firmly connected
to the end of the 6-DOF positioning robot through a
round fixation jig, the positioning robot can then be
moved to adjust the position and orientation of the dis-
tal bone according to the surgeon’s maneuvering
motion to align it with the proximal bone. In order to
reduce the axial load on the positioning robot during
the alignment process caused by the strong contractile
forces from the muscles around the bone, a 1-DOF
traction device is connected in parallel with the posi-
tioning robot for traction of the distal bone. The proxi-
mal fractured bone is firmly fixed to a round bone
fixation jig, and the fixation jig is fixed to the frame of
the surgical bed.
In practice, it is expected that the HRRCC will be
applied to multiple-DOF systems; however, for simpli-
city, a one-DOF positioning robot and a one-DOF
traction device are considered and modeled in this
work. The overall system is represented as mass/spring/
damper systems, as shown in Figure 2. This assumes
that the muscles are passive leading to the choice of a
spring-damper model. The positioning robot and the
traction device are both represented as linear mass-
damper systems. Although the proximal bone is fixed
700
(a) (b)
(c)
Figure 3. Block diagrams of (a) positioning robot and distal bone
fixation jig derived from (4), (b) traction device and traction cable
derived from (5), and (c) fractured bone with muscle, distal bone
fixation jig, and traction cable derived from (6).
to the frame of the surgical bed through the proximal
fixation jig, for simplicity, the proximal bone is
assumed to be fixed directly to the ground. For each
distal bone fixation jig, the cable/pin holder and the
muscles are modeled as spring-damper systems.
Finally, as an operator (the surgeon) manipulates the
positioning robot directly, he/she is considered to be
connected to the positioning robot in series.
For this model, the dynamics of the positioning
robot and the distal bone fixation jig can be described
as follows:
mr x€r +(br + bf )x_ r + kf xr  bf x_ e kf xe = t r + fm
where tr and fm denote the torque of a robot actuator
and the force exerted by a human operator, respec-
tively. xr and xe denote the displacement of the posi-
tioning robot and the displacement of the distal bone,
respectively. mr and br denote the mass and viscosity
coefficients of the robot, respectively. bf and kf denote
the viscosity coefficient and the spring constant of the
distal bone fixation jig, respectively.
Secondly, the dynamics of the traction device and
the traction cable can be described as follows:
mtr x€tr + (btr + bc )x_ tr + kc xtr  bc x_ e  kc xe = t tr
where t tr denotes the torque of a traction device actua-
tor. xtr denotes the displacement of the traction device.
mtr and btr denote the mass and viscosity coefficients of
the traction device, respectively. bc and kc denote the
viscosity coefficient and the spring constant of the trac-
tion cable, respectively.
Proc IMechE Part H: J Engineering in Medicine 236(5)
The dynamics of the distal fractured bone, which
interacts with the positioning robot, the traction device
and the muscles, are modeled as follows:
me x€e + (bf + bc + be )x_ e + (kf + kc + ke )xe
ð3Þ
 bf x_ r  kf xr  bc x_ tr  kc xtr = 0
where me, be, and ke denote the mass coefficient of
the distal bone, the viscous coefficient and stiffness
coefficient of the muscles between the bones,
respectively.
(1) to (3) can be transformed into s-domains using a
Laplace transform and can be rewritten as shown in (4)
to (6). Their block diagrams can be represented as
shown in Figure 3:
Gr (s) Gr (s)
x_ r = (t r + fm )+ x_ e
1 + Zf (s)Gr (s) 1 + Zf (s)Gr (s)
ð4Þ
where Gr (s) denotes the transfer function of the posi-
tioning robot, that is, Gr (s) = 1=(mr s + br ), and Zf (s)
denotes the impedance of the distal fixation jig, that is,
Zf (s) = bf + kf =s.
Gtr (s) Z~c (s)Gtr (s)
x_ tr = t tr + x_ e ð5Þ
1 + Zc (s)Gtr (s) 1 + Zc (s)Gtr (s)
where Gtr (s) denotes the transfer function of the trac-
tion device, that is, Gtr (s) = 1=(mtr s + btr ), and Z~c (s)
denotes the impedance of the traction cable, that is,
Z~c (s) = bc + kc =s.
Zf (s)Ge (s)
x_ e = x_ r
1 + Zf (s)Ge (s) + Z~c (s)Ge (s)
ð6Þ
ð1Þ Z~c (s)Ge (s)
+ x_ tr
1 + Zf (s)Ge (s) + Z~c (s)Ge (s)
where Ge (s) denotes the transfer function of the
distal fractured bone with the muscle, that is,
Ge (s) = 1=(me s + be + ke =s).
Figure 4 illustrates the proposed HRRCC scheme,
this includes the block diagrams described in Figure 3
and additional blocks for the robot controllers and the
dynamics of an operator. The basic concept of the
HRRCC is as follows: x_ m is calculated by multiplying
an admittance gain from Am to fm that is measured by
an operational F/T sensor. Similarly, x_ s is calculated by
ð2Þ
multiplying an admittance gain from As to fs, which is
measured by an interaction F/T sensor. The desired
velocity of the E–E x_ r_d is defined by the subtraction of
x_ s from x_ m, that is, x_ r_d = x_ m – x_ s. The robot’s E–E is
adjusted to follow x_ r_d at each sampling time. This con-
trol architecture allows the scale of fm to fs to be adjus-
table in proportion to the ratio of As to Am.10 These
blocks are marked by a red dashed line in Figure 4 and
Kim et al. 701

Figure 4. Block diagram of a proposed human-robot-robot cooperative control scheme: (a) blocks for positioning robot and distal
bone fixation jig, (b) blocks for traction device and traction cable, and (c) blocks for fractured bone with muscles, distal bone fixation
jig, and traction cable.

are identical to those described in the group’s former positioning robot’s E–E x_ r can be represented as a
work.10 In addition, by using fs as the input of the trac- function of the operational force fm and the interaction
tion device, local feedback control can be implemented. force fs as follows:
By multiplying the admittance gain Atr to fs, the desired
velocity of the traction device’s E–E x_ tr_d is generated, Cr (s)Gr (s)ðAm (s)fm  As (s)fs Þ
x_ r =
this becomes the input of the traction device controller. 1 + Cr (s)Gr (s)
ð7Þ
Herein, lm and ls denote the degree of direct influence lm Gr (s)fm  ls Gr (s)fs
+
from human forces and environmental forces on the 1 + Cr (s)Gr (s)
actual force applied by the robot actuator, respectively,
these range from 0 to 1. If the robot is non-back-
drivable (e.g. with an industrial robot), lm and ls tend In addition, x_ tr can be represented as follows:
to be closer to 0. Otherwise (e.g. with an impedance-
Ctr (s)Gtr (s) ltr Z~c (s)Gtr (s)
type haptic device), lm and ls tend to be closer to 1 .27 x_ tr = Atr (s)fs  x_ e ð8Þ
In Figure 2, as it is assumed here that the robots are 1 + Ctr (s)Gtr (s) 1 + Ctr (s)Gtr (s)
purely back-drivable, there are no direct influence ratio
blocks like those from Figure 3, that is, lm and ls are Herein, fs can be defined as:
considered to be unity; however, for practicality, the
blocks for lm and ls were added, as the robots are not fs = Zf (s)ðx_ e  x_ r Þ ð9Þ
purely back-drivable. Instead, the positioning robot and
the traction device are modeled with large gear ratios,
from the blocks in group (a) in Figure 4.
so they can be considered to have direct influence ratios
Substituting fs = Zf (s)ðx_ e  x_ r Þ into (8) yields:
close to zero. Following this reasoning, the direct influ-
ence ratio lm was adopted as shown in Figure 4. Ctr (s)Gtr (s)
x_ tr = Atr (s)Zf (s)ðx_ r  x_ e Þ
1 + Ctr (s)Gtr (s)
ð10Þ
Characteristics analysis using simplified model ltr Z~c (s)Gtr (s)
 x_ e
In this subsection, some of the characteristics of the 1 + Ctr (s)Gtr (s)
proposed HRRCC are analyzed.
This is because, for simplicity, the robots are
Ability to minimize load on a positioning robot. First, con- assumed to have large gear ratios and the direct influ-
sider the situation in which the robot and traction ence ratio can then be considered to be zero, that is,
device pull on the distal bone. According to the  = Ctr (s)Gtr (s) ,
ltr = 0. In addition, we represent G(s) 1 + Ctr (s)Gtr (s)
whole block diagram in Figure 4, the velocity of the and then (10) can be represented as:
702
x_ tr = Gtr Atr (s)Zf (s)ðx_ r  x_ e Þ
From the blocks in group (c) in Figure 4, x_ e can be rep-
resented as:

x_ e = Ge (s)Zf (s)ðx_ r  x_ e Þ
x_ e = Ge (s) Zf (s)ðx_ r  x_ e Þ + Z~c (s)ðx_ tr  x_ e Þ
By substituting (11) into (12), (12) can be represented
as:
x_ e = Ge (s)Zf (s)ðx_ r  x_ e Þ + Ge (s)Z~c (s)

ð13Þ
Gtr Atr (s)Zf (s)ðx_ r  x_ e Þ  x_ e
(13) can then be derived as:
Zf (s)Ge (s) + Zf (s)Atr (s)Gtr (s)Z~c (s)Ge (s)
x_ e =
1 + Zf (s)Ge (s) + Z~c (s)Ge (s) + Zf (s)Atr (s)Gtr (s)Z~c (s)Ge (s)
By substituting x_ e from (14) into (9), fs can be repre-
sented as:
Zf (s) + Zf (s)Z~c (s)Ge (s)
fs =
1 + Zf (s)Ge (s) + Z~c (s)Ge (s) + Zf (s)Atr (s)Gtr (s)Z~c (s)Ge (s)
If the control gains of the traction device, Ctr(s), are
chosen properly, and at least at a low frequency, the
fs
=
fm 1 + Cr (s)Gr (s) + Zf (s)Ge (s) + Cr (s)Gr (s)Zf (s)Ge (s) + Cr (s)Gr (s)Zf (s)As (s)
traction device follows the input signal sufficiently well,
then we can say Gtr (s)’1 to achieve further simplifica-
tion. Then, we find that the transfer functions from x_ r
to fs and xr to fs become, respectively, a type 0 system
where no integrator exits and a type 1 system where
one integrator is included.28 This means that, when
there is motion of the robot’s E–E, an interaction force
will exist. However, the positioning robot’s E–E will
move slowly, then fs becomes small, that is, its steady
state is zero.
Based on this result, it is expected that the load on
the positioning robot is reduced to zero and that all of
the muscle forces are managed by the traction device,
this means that ftr becomes equivalent to fe.
Ability to scale up/down the force feedback. Next, consider a
situation in which the robot and traction device release
the distal bone, resulting in the muscle becoming
relaxed (muscular contraction release). When the mus-
cle is relaxed and the two fractured bones are aligned
well, the fractured bones come into contact. In this situ-
ation, the cable tension becomes zero, and then the
Proc IMechE Part H: J Engineering in Medicine 236(5)
ð11Þ cable dynamics no longer affect the system’s dynamics,
this means we can assume that the spring and damping
coefficients of the cable are zero, that is, Z~c (s)’0. In
this case, (12) can be rewritten as:
ð16Þ
ð12Þ
Assuming the robots are not backdrivable, (7) can be
represented as follows:
ðAm (s)fm  As (s)fs ÞCr (s)Gr (s)
x_ r = ð17Þ
1 + Cr (s)Gr (s)
By substituting (17) into (16), (16) can be rewritten as:
ðAm (s)fm  As (s)fs ÞCr (s)Gr (s)Zf (s)Ge (s)
x_ e =
1 + Cr (s)Gr (s) + Zf (s)Ge (s) + Cr (s)Gr (s)Zf (s)Ge (s)
x_ r
ð18Þ
ð14Þ
By substituting (9) into (16), (19) can be obtained:
x_ e = Ge (s)fs ð19Þ
x_ r By substituting (19) into (18), (18) can be rewritten as:
ð15Þ ðAm (s)fm  As (s)fs ÞCr (s)Gr (s)Zf (s)
fs =
1 + Cr (s)Gr (s) + Zf (s)Ge (s) + Cr (s)Gr (s)Zf (s)Ge (s)
ð20Þ
By rewriting (20) for fs/fm, (21) can be obtained as:
Cr (s)Gr (s)Zf (s)Am (s)
ð21Þ
If the control gains of the positioning robot Cr(s)
are chosen properly, at least at low frequencies,
the robot will follow the input signal well, resulting
in 1 \ \ Cr(s)Gr(s), this in turn means that
Cr (s)Gr (s) 
1 + Cr (s)Gr (s) = Gr (s)’1. The feedback block consisting
of Cr (s) and Gr (s) can be replaced by Gr (s) in Figure 4
and Gr (s) can be considered as a position-controlled
robot transfer function in the general case. When two
fractured bones make contact, the stiffness and viscous
coefficients of Ge(s) increase to those of the proximal
bone. Therefore, at a low frequency, we can assume
that |Ge(s)| \ \ 1. Finally, if a fixation jig with high
impedance is used, that is, Zf(s) .. 1, we obtain (22),
which is similar to the result described in Ye and
Chen10:
fs Am (s)
ffi ð22Þ
fm As (s)
Therefore, for a RAFR system with the proposed
HRRCC, while pulling a distal fractured bone
Kim et al.
Figure 5. Overview of the experimental setup. A robot-
assisted long bone fracture reduction system consisting of a
6-DOF positioning robot, a 1-DOF traction device, a fractured
bone with muscles, and a 3-D image navigation system:
(1) Fractured femur bone with phantom muscles, (2) 6-DOF
positioning robot, (3) 1-DOF traction device, (4) Traction cable,
(5) 3-D image navigation s/w, (6) Optical tracking system,
(7) Operational F/T sensor, (8) Interaction F/T sensor,
(9) Reference maker for distal bone, (10) Reference marker for
proximal bone, (11) Proximal bone fixation jig, (12) Distal bone
fixation jig, (13) Distal medical pins, (14) Proximal medical pins,
and (15) Bespoken Steinman pin holder and Steinmann pins.
surrounded by muscles, the traction device is controlled
with a view to minimizing the axial load on the posi-
tioning robot. On the other hand, if two fractured
bones collide, the cable’s tension becomes zero, this
results in the positioning robot providing feedback on
the contact force with adjustable scaling fs/fm = Am(s)/
As(s).
Experimental setup
In this section, we describe an experimental setup to
verify the performance of the proposed HRRCC
scheme. For these experiments, the RAFR system cur-
rently being developed by the research consortium
mentioned above, was utilized.3,14
Overview of the experimental setup
Figure 5 shows an overview of the experimental setup.
The femur model (Pacific Research Laboratories, Inc.,
composite femur, left, medium size) was prepared by
creating a simple fracture in the middle of the femur.
The phantom muscles between the fractured bones are
made of a silicon material. The silicon-based phantom
muscles were bonded at various locations around the
fractured bones. By changing the lengths and thick-
nesses of the phantom muscles, the contraction force
was set to roughly 15 kN/m. Although both muscles
703
and silicone display some of the same elastic physical
characteristics, it is difficult to accurately mimic
the behavior of real muscles around the femur using
silicone materials because their physical behavior is dif-
ferent. However, the purpose of this experiment is not
to accurately simulate the contractile force of the
muscles on the femur, it is instead to observe whether
the traction robot assists by minimizing the axial load
on the bones by providing appropriate traction in real-
time to cancel the axial load on the positioning robot.
Therefore, the external contractile force necessary for
this experiment was generated using silicone material.
The RAFR system consisted of a six-axis serial
type positioning robot developed by Hyundai Heavy
Industries Co., Ltd. (HHI), a single-axis motorized
traction device developed by Taekyung Automation
System Co. and Chonnam National University, and a
3-D image medical navigation system developed by
Corelinesoft Co., Ltd.
1-DOF traction device
The 1-DOF traction device was attached to a support-
ing fixture on the side of the positioning robot. The
position of the traction device was adjusted to align the
axial axis of the proximal bone and the traction direc-
tion following the procedure described in Mukherjee
et al.9 As explained, the traction device was attached to
the distal fractured bone in parallel to the positioning
robot. The connection procedure was as follows. First,
a Steinmann pin was used to pierce through the most
distal part of the distal fractured bone, both sides of the
pin were inserted into a bespoke pin holder. The pin
holder was connected to the E-E of the traction device
through a cable. As the OA Foundation suggested in,29
the proximal fractured bone’s axial axis was aligned
with the tractional direction. The tractional direction
was set in the opposite direction of the muscular con-
traction to oppose those forces. As shown in Figure 6,
the 1-DOF traction device consists of four parts: an
actuator, a traction part, a controller, and a supporting
fixture. The traction part was made of a single-axis lin-
ear motion guide with a ball screw platform (Misumi
Co., pitch: 10 mm, length: 350 mm, maximum traction
force: 300 N). A servo motor (Maxon Motor Co., Ltd,
RE 60W DC motor, gear ratio 21:1) was selected as the
actuator. As shown in Figure 6(a), an EPOS2 from
Maxon Motor Co. was used as the motor controller, it
was connected to the main controller PC by a USB
cable. A load cell was mounted at the end of the trac-
tion rod to monitor the traction force exerted. An eye
bolt attached at the load cell was connected to the pin
holder on the distal fractured bone using a cable. The
maximum speed of the traction device was set to
419.52 rpm (corresponding to 69.92 mm/s), the accel-
eration and deceleration were both set to 100,000 rpm/s.
The supporting fixture was designed to be fixed to the
704
(a)
(b)
Figure 6. Hardware configuration of 1-DOF traction device; (a) mechanical structure: 1. Actuator, 2. Traction part, 3. Controller,
4. Supporting fixture (b) communication channel setup between the HRRCC and traction device’s controller.
supporting post on the side of the positioning robot’s
base.
Fixation of fractured bones
To fix the fractured bones to fixation jigs, several medi-
cal pins were used. First, the pins were fixed to each
part of the fractured bone’s shaft, and then the other
sides of the pins were fixed to C-shaped bone fixation
jigs. The jigs were fixed onto the frame of the patient
bed or onto the E-E of the positioning robot.13 The
pins used were conventional Shantz pins that had been
modified to increase their rigidity. The pins were
designed and manufactured by Solco Medical Co.,
Ltd., who are part of our consortium.30–32 As described
in Kyungpook National University Industry-Academic
Cooperation Foundation,32 the fixation pin is designed
to be fixed on the one side of the bone in order not to
interfere a guide wire or an intramedullary rod inside
the medullary cavity. To attach the proximal bone fixa-
tion jig to the patient bed, a serial linked holder (Noga
Engineering Ltd., MA-61003) was utilized.
Utilization of two F/T sensors
For the force feedback and force scaling of the pro-
posed cooperative control, two F/T sensors were
installed on the last link of the positioning robot, as
described in.10 In this implementation, an operational
F/T sensor (Gamma SI-130-10) from ATI Co., Ltd.
Proc IMechE Part H: J Engineering in Medicine 236(5)
was used to measure the force exerted on the position-
ing robot by the human operator. An interaction F/T
sensor (Delta SI-660-60) from ATI Co., Ltd was also
used to measure the force exerted on the positioning
robot by the environment.
Setup of dynamic reference markers
To utilize the 3-D image navigation system, dynamic
reference markers were attached to the proximal and
distal fractured bones, as shown in Figure 5. During the
reduction procedure, the positions of the reference mar-
kers were measured by a Polaris Spectra optical tracker
system (OTS) from NDI Co., and then the positions
and orientations of the fractured bones were estimated
using the registration results. This locational informa-
tion on the bones was then shown in real-time by the
3-D image navigation system developed by Corelinesoft
Co., Ltd.
Registration setup
As a registration algorithm that finds the relationship
between the OTS coordinate system and the CT coordi-
nate system, a point-to-point matching algorithm based
on feature points was temporarily used. Three K-wires
with diameters of 1.0 mm were inserted before taking
the CT image. The real positions of the inserted points
were measured using a probe from the OTS system, the
positions in the CT were then identified using the 3-D
Kim et al. 705

Table 1. Nomenclature for human-robot-robot cooperative Table 2. Experimental parameters.

control.
Item Specification (Unit)
Symbol Descriptions
Stiffness of phantom muscle 15 (kN/m)
fop Force exerted by human muscles Stiffness of bone fixation Jig 72.9 (kN/m)
fm Force measured by operational force sensor Stiffness of traction cable 129.2 (kN/m)
(master force sensor) Compressive strength of 157 (Mpa)
fs Force measured by interaction force sensor composite bone
(slave force sensor) Compressive modulus of 16.7 (Gpa)
ftr Force exerted by traction device composite bone
Gr Dynamics of positioning robot
Gtr Dynamics of traction device
Ge Dynamics of distal fractured bone with muscles
tr Actuating torque exerted by positioning robot’s stiffness of the bone fixture jig was measured at
controller
72.9 3 103 (N/m),10 while the stiffness of the traction
t tr Actuating torque exerted by traction device’s
controller cable (f 4 mm, steel wire rope) was measured to be
Cr Controller of positioning robot 129.2 3 103 (N/m). All the above-mentioned para-
Ctr Controller of traction device meters, including the stiffness of the silicon muscle, are
Am Admittance gain corresponding to fm in listed in Tables 1 and 2.
positioning robot system
As Admittance gain corresponding to fs in
positioning robot system
Atr Admittance gain corresponding to fs in traction
Experimental results
device system In this chapter, the results from the experimental
xr Displacement of robot’s end-effector
xtr Displacement of traction device’s end-effector evaluation of the proposed HRRCC scheme are
xe Displacement of distal bone presented.
x_ r Velocity of robot’s end-effector
x_ tr Velocity of traction device’s end-effector
x_ e Velocity of distal bone Decrease in axial load on robot
x_ m Velocity converted by multiplying an admittance
gain Am to fm The purpose of this experiment was to show that the
x_ s Velocity converted by multiplying an admittance proposed HRRCC scheme can decrease the axial load
gain As to fs on the positioning robot while a surgeon manipulates
Zh Impedance of human arm (surgeon’s arm) the positioning robot along with the traction device.
Zf Impedance of distal bone fixation jig
Zc Impedance of traction cable
Four subjects participated and were asked to conduct
lm Direct influence ratio of fm to Gr the fracture reduction procedure in two different ways:
ls Direct influence ratio of fs to Gr (Case A) used the positioning robot only and (Case B)
ltr Direct influence ratio of ftr to Gtr used both the positioning robot and the traction device.
In this experiment, the subjects used the 3-D medical
navigation system views but did not observe the bones
directly. In each case, the initial values and final values
image navigation system. The registration errors of the
of the loads on all six axes of the positioning robot were
proximal and distal fractured bones were measured to
measured and used to compare the changes in load.
be less than 0.5 mm.
The force and torque values from the operational F/T
sensor and interaction force F/T sensor as well as the
Selection of experimental parameters force values from the load cell mounted on the traction
device were also recorded for the analysis.
To evaluate the performance of the HRRCC, two frac-
tured bones were placed with certain initial offsets. In
the axial direction, the proximal and distal fracture Comparison of the increase in each axis’ actuator
bones overlapped by about 50 mm, the distal bone was load. Figure 7 shows comparisons of the average
rotated by about 15° along with the AP, lateral, and increase in individual actuator loads on the positioning
axial axes with respect to the proximal fractured bone. robot from before to after performing the fracture
The fracture reduction procedure was carried out until reduction process over the two cases. Please note that
the translation and rotation errors reached less than the positioning robot in its current setup provides per-
2.0mm and 2.0°, respectively. Force feedback was acti- centage values of the actuator loads with respect to its
vated along three translational axes, but torque feed- maximum allowed power. In addition, the controller
back was not utilized in this experiment. The force system of the positioning robot automatically ceases
scale of the force feedback was set as one-to-one by set- providing actuation power when the actuator load
ting both the translational admittance gains of Am and reaches 100%. As such, in this analysis, comparison
As to 0.45 3 1023 m/Ns and setting both the rotational using percentage values is useful to understand when
admittance gains of Am and As to 0.35 rad/Nms. The critical situations occur. In Case A(using the
706 Proc IMechE Part H: J Engineering in Medicine 236(5)

axis’ load increased by only 2.68%, a reduction of 97%

compared to Case A.

Comparison of measured forces from the Two F/T sensors and

Figure 7. Comparisons of the increases in the six axes’
actuation loads on positioning robot after fracture reduction in
two cases: (Case A) using positioning robot only and (Case B)
using both the positioning robot and traction device. In Case A,
the average increase of all six axes’ actuation loads measured
38.1%. The fifth actuation load increased by 91.14% from the
initial value to after the reduction procedure was complete. In
Case B (using both the positioning robot and traction device),
the average increase measured only 1.4%. The fifth axis’s load
increased by only 2.68%, a 97% reduction compared to Case A.
positioning robot only), the average increase for all six
axes’ actuation loads was measured to be 38.1%. The
fifth actuation load increased by 91.14% from the ini-
tial value after the reduction procedure. In Case B
(using both the positioning robot and traction device),
the average increase measured was only 1.4%. The fifth
load cell. In this subsection, the loads experienced by
each robot will be discussed. Figure 8(a) and (b) show
the measured forces during the traction task of the frac-
ture reduction procedure in Case A and Case B, respec-
tively. The operational force Fm is represented as a red
dashed line, the interaction force Fs as a blue solid line,
and the traction force Ftr as a green dotted line. While
the distal fractured bone was pulled by the positioning
robot (during the traction task), Fm and Fs were mea-
sured, the results are plotted in Figure 8(a). During
human operation of the positioning robot, when the
distal fractured bone was being pulled, the Fs signal is
positive due to the contraction force of the surrounding
muscles. Conversely, if the positioning robot moves the
bone in the opposite direction bringing the bones into
contact, the signal becomes negative. The maximum
force measured was 158.8 N. In Case B, as shown by
Figure 8(b), Fs maintained an average of 0.6 N, whereas
Ftr was measured up to a maximum of 172.6 N. As the
1-DOF traction device opposes most of the muscular
contraction force along the longitudinal axis of the
bone, the load on the positioning robot is reduced sig-
nificantly. The maximum interaction forces experienced
in the individual experiments are listed in Table 3 for
comparison.
Figure 9 shows the trajectory profile of the position-
ing robot and the traction device as the fracture reduc-
tion operation progresses from the initial positioning of
the fractured bone to completion of fracture alignment
according to the human’s operational force-torque

Figure 8. Comparisons of forces during the traction task part of the fracture reduction procedure: the operational force Fm, the
interaction force Fs, and the traction force Ftr are shown in (a) Case A – using only the positioning robot and (b) Case B – using both
the positioning robot and traction device: Fs measured up to a maximum of 158.8 N while conducting the reduction task in (a). Fs
averaged 0.6 N, whereas Ftr measured up to a maximum of 172.6 N in (b). As the 1-DOF traction device manages most of the
muscular contraction force along the longitudinal axis of the bone, the load on the positioning robot is reduced significantly
eliminating the chance of it becoming overloaded.
Kim et al.
Table 3. Comparison of the Measured Maximum Interaction Forces (Fs) during the Traction Task in Fracture Reduction Procedure
for Case A and Case B.
Subject 1 2
Max. Inter. Forces Fs (N)
Case A (Positioning Robot Only) 154.7
Case B (Positioning Robot + Traction Device) 14.32
Figure 9. Reduction trajectory profile: (a)–(c) the translational
positions (x, y, z) of the broken end of the distal fractured bone
with respect to the positioning robot’s base frame (d) the
position of the end of the traction device with respect to the
traction device’s base frame, (e) the x-axis direction’s interaction
force Fs. (f) the traction force Ftr.
commands. (a) to (c) Show the translational positions
(x, y, z) of the distal fractured bone’s broken side with
respect to the position of the robot base frame. It
is mapped as the positioning robot’s tool position.
(d) Shows the position of the end-effector of the trac-
tion device with respect to the traction base frame, and
(e) shows the x-axis direction’s interaction force Fs, and
(f) shows the traction force Ftr. This graph also shows
that the axis’ actuator load on the position robot’s end-
effector is reduced thanks to the traction force assis-
tance. The maximum traction force was measured to be
146.7 N. From the time when the maximum traction
force was measured to the completion of fractured
bone alignment, the total displacement of the bone held
by the positioning device was measured to be 10.1 mm
and the displacement of the traction device was mea-
sured to be 10.3 mm.
Force feedback function of HRRCC
The purpose of this experiment was to verify whether
the force feedback function of the proposed HRRCC
scheme reduces the excessive force required of the posi-
tioning robot during the fracture reduction procedure
707
3 4 Average 6 STDEV
158.8 180.0 161.0 163.63 6 9.7
11.39 15.94 15.19 14.21 6 2.0
and also to determine the level of transparency of the
force feedback. To demonstrate the force reduction
effectiveness, experiments were performed for two
cases: Case A, using the positioning robot only without
a force feedback function, and Case B, using both the
positioning robot and the traction device while the pro-
posed HRRCC scheme was active. In the experiment,
for simplicity, the motion of the positioning robot was
constrained to 1-DOF motion along the longitudinal
axis of the bone, the 1-DOF interaction force was mea-
sured in both cases. For each case, the operational
force Fm, the interaction force Fs, and the displacement
of the positioning robot were measured. Figure 10
shows the force and displacement variations after the
two fractured bones made contact. Please note that the
data in Figure 10 were recorded in the situation where
no visual feedback was provided, this was done to
clearly demonstrate the effect of HRRCC. Fm is repre-
sented by a red dashed line, and Fs is represented by a
blue solid line. Figure 10(a) shows the forces in Case A
(without force feedback). Since the fractured bones
were separated initially, Fm could be recorded from
t = 1 s while Fs remained zero. Note that since admit-
tance control without a force feedback function was
utilized, the sign of Fm is related to the velocity of the
robot’s E–E, and thus it is roughly proportional to the
variation of the interaction force fs. When contact with
the bone was released, Fs became zero again, and only
Fm could be measured. In this experiment, an Fs of up
to 2220 N could be recorded because no feedback
information was provided, including by the 3-D image
navigation system. The value of 2220N is almost the
maximum force against which the temporary bone fixa-
tion jig that was used can resist. If a stronger fixation
jig is used, it is expected that this maximum value could
be higher. Due to the considerable power of the robot,
the bones and mechanical structure cannot maintain
their positions or orientations. Thus, there was a large
displacement of the robot’s position, as shown in graph
Figure 10(c).
Figure 10(b) shows the results from Case B (with
force feedback using the proposed HRRCC). Even
after the bones are placed in contact, the positioning
robot continued to exert force on the broken bone. The
interaction force Fs caused the robot to move back-
ward, which reduced the excess force acting on it.
Thus, the interaction force Fs maintained a similar
value to the operational force input Fm. Since Fs acts as
a resistive force against the robot’s motion, it was also
708 Proc IMechE Part H: J Engineering in Medicine 236(5)

(a) (b)

(c) (d)

Figure 10. Force feedback evaluation while fractured bones have been placed in contact during the fracture reduction procedure:
(a) force comparison of Fm and Fs and (c) position profile of positioning robot in Case A, (b) force comparison and (d) position profile
of the positioning robot in Case B (with 1-DOF force feedback). Without force feedback, an operational force of about 22.6 N could
move the bone up to 33 mm, resulting in the largest interaction force reaching 2227 N. With force feedback, an operational force of
about 234.02 N could move the bone up to 3.99 mm, resulting in the largest interaction force reaching –34.13 N. The force feedback
control prevented the robot from applying the strong forces to the proximal bone seen in (c). Note that this data was recorded in a
situation where no visual feedback was provided to more clearly understand the effects of force feedback.

Table 4. Comparison of the measured maximum interaction forces (Fs) while fractured bones placed into contact during fracture
reduction procedure for Case A and Case B. Note that 3-D Image navigation views were provided in these experiments.

Subjects 1 2 3 4 Average 6 STDEV

Case A
Max. Fs (N) 225.03 219.57 230.7 217.88 223.3 6 5.8
Max. position profile (mm) 3.32 2.54 4.1 2.34 3.8 6 0.8
Case B
Max. Fs (N) 217.45 27.24 212.71 216.31 213.4 6 4.6
Max. position profile (mm) 2.13 1.17 1.66 2.71 1.92 6 0.7

observed that the operators tended to naturally reduce
the forces they applied.
Based on this preliminary test, four participating
subjects were then asked to conduct the task of placing
the bones in contact from the fracture reduction proce-
dure by directly manipulating the positioning robot.
Table 4 lists the maximum interaction forces Fs as well
as the maximum X-axis’ displacement of the position-
ing robot for two cases: Case A, without 1-DOF force
feedback from the HRRCC scheme but with visual
feedback, and Case B, with both force feedback and
visual feedback. The interaction forces in Case A mea-
sured 223.3 6 5.8 N, while those in Case B measured
13.4 6 4.6 N. As visual feedback was provided, the
subject carefully moved the robot; thus, the maximum
force was decreased compared to earlier experiments.
Although the interaction force was reduced after pro-
viding visual feedback, the maximum interaction force
decreased substantially when force feedback was also
provided. The X-axis displacement of the proximal
fractured bone in Case A measured 3.8 6 0.8 mm, while
in Case B it measured 1.92 6 0.7 mm, a 49% decrease
in force.
Conclusion
Our research consortium has developed a robot-assisted
long bone reduction system, which consists of a serial
Kim et al.
type manipulator in the form of a positioning robot to
accurately position the fractured bones during the
reduction procedure while a traction device is used
simultaneously to combat the considerable contraction
forces from the surrounding muscles that would other-
wise make such procedures much more difficult. To
effectively control a 6-DOF serial type positioning
robot and a 1-DOF traction device through a surgeon’s
operational command inputs, a human-robot-robot
cooperative control (HRRCC) scheme is proposed. In
the proposed HRRCC scheme, the robots are physi-
cally connected, and they share force information
recorded by sensors for feedback control. To measure
the operational and interaction forces separately, two
F/T sensors were installed on the end-effector of the
positioning robot. By applying admittance control to
the two forces, the positioning robot can be manipu-
lated directly, while a force feedback function is imple-
mented for bone contact situations. Furthermore, a
1-DOF motorized traction device is actuated by apply-
ing another manner of admittance control as feedback
from the interaction forces. The use of the developed
robot-assisted fracture reduction system showed that
the 1-DOF traction device is able to manage most of
the muscular contraction forces experienced while posi-
tioning a fractured bone, this allows the positioning
robot to conduct the reduction task without fighting
large axial loads. When the fracture bones are placed in
contact, the positioning robot acts as though is no trac-
tion device, allowing it to provide scaled force feedback
in consideration of the operational and interaction forces.
Performance in these tasks was verified using 1-DOF
mathematical modeling and a working prototype.
In future work, we need to expand our theoretical
modeling to formulate a general case describing an n-
DOF positioning robot and traction device. Theoretical
analyses regarding the range of the admittance gains
and the stability and transparency of the proposed
HRRCC system should also be carried out. In addition,
animal tests are expected to be conducted using a work-
ing prototype.
Acknowledgements
The authors thank the research consortium, especially
Hyundai Heavy Industry Co., Solco Biomedical Co.,
Ltd., Taekyung Automation System Co., and
Corelinesoft Co., Ltd., for their support of this work.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship, and/or
709
publication of this article: This work was supported by
the National Strategic R&D Program for Industrial
Technology (No. 10041605) funded by the Ministry of
Trade, Industry and Energy (MOTIE), South Korea
and also by the Korea Medical Device Development
Fund grant funded by the Korean government (the
Ministry of Science and ICT, the Ministry of Trade,
Industry and Energy, the Ministry of Health and
Welfare, the Ministry of Food and Drug Safety) (proj-
ect number: KMDF_PR_2020901_0122, 1711138226).
ORCID iDs
Woo Young Kim https://orcid.org/0000-0001-8355-
5113
Seong Young Ko https://orcid.org/0000-0003-4316-
0074
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