<p>Objective: This study was designed to evaluate and contrast the clinical outcomes between TiRobot-assisted (TA) and conventional fluoroscopy-guided (FG) Harms surgery in the management of upper cervical fractures with atlantoaxial instability. Methods: A retrospective analysis was conducted on patients with upper cervical fractures accompanied by atlantoaxial instability who underwent Harms surgery in the First People’s Hospital of Yulin between January 2017 and December 2024. The patients were stratified into two groups based on the preoperative shared decision-making. The TA group comprised 23 patients who consented to TiRobot-assisted Harms surgery, while the FG group comprised 21 patients who consented to C-arm-guided Harms surgery. The assessed parameters encompassed baseline characteristics, perioperative metrics, radiological findings, and follow-up outcomes. Results: All patients successfully underwent Harms surgery. The two groups were comparable in the baseline characteristics (<i>P &gt;</i> 0.05). Compared with the FG group, the TA group showed a significantly superior first-pass screw placement success (<i>P &lt;</i> 0.001) and significantly reduced intraoperative hemorrhage (<i>P &lt;</i> 0.001), but operative time (<i>P &gt;</i> 0.05) and length of stay (<i>P &gt;</i> 0.05) did not differ significantly. No significant intergroup differences were observed in the Visual Analogue Scale (VAS) scores, Japanese Orthopaedic Association (JOA) scores, and American Spinal Injury Association (ASIA) grades before surgery, at 3 months and 6 months after surgery, and at the last follow-up (<i>P &gt;</i> 0.05). As time passed, the VAS scores significantly decreased in both groups (<i>P &lt;</i> 0.001), and the JOA scores&#xa0;(<i>P</i> &lt; 0.01) and ASIA grades (<i>P</i>&#xa0;&lt; 0.05)&#xa0;significantly improved in both groups. The two groups exhibited no significant differences in fracture healing rate and osseous fusion rate at 6 months after surgery (<i>P &gt;</i> 0.05). The screw placement accuracy in the TA group was significantly higher than that in the FG group for all patients and for patients excluding those with Gehweiler type 3 fractures (<i>P &lt;</i> 0.01). Conclusion: Compared to the conventional fluoroscopy-guided Harms surgery, TiRobot-assisted Harms surgery achieved significantly higher first-pass screw placement success and screw placement accuracy, coupled with reduced intraoperative hemorrhage. With its higher safety and efficacy, it is a beneficial surgical approach for upper cervical fractures with atlantoaxial instability.</p>