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Robotic surgery: Does it still have a place in orthopaedics?
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Computer-assisted surgery is intended to improve the quality of the surgical procedure in a reproducible, standardized fashion. It focuses on the precision of the surgical process itself by using surgical robots as the active systems. In orthopaedic surgery they are designed to prepare bony surfaces with extraordinarily high precision, far exceeding the manual capacities of a human surgeon.
Robots were first introduced for femoral preparation in total hip replacement, but later were used for knee arthroplasty. It has been shown that robotic assistance may provide an optimal contact at the bone/prosthesis interface in cementless implants, resulting in improved primary stability (Prymka et al 2004, Thomsen et al 2001) and perfect secondary bony integration.
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In contrast, computer navigation of instruments and implants are passive procedures, which do nothing but provide exact positioning of the prostheses relative to bone and joints from high-precision measurements of leg axes and joint positions.
In the mid-1990s, robotic surgery gained good footing in Germany with a high input of finance and scientific intelligence supporting individual and system-based learning curves. The introduction of the new technology was aggressively driven by the marketing activity of the manufacturers and by raising public awareness in the popular press.
Apart from the attraction of an innovative procedure, proponents of the technology advocated for the widespread application of the systems in order to get an early return on the high investments. Nonscientific public discussions and competitive marketing often dominated the debate on its clinical value.
The potential advantages of robotic surgery could not be realized during this process because scientific evaluation of the procedures was rarely done and was often of a very low professional standard. In addition, the precision of the robotic system was greater — within a tenth of a millimeter, in some cases — than the ability to know where to place the implant for perfect positioning. A lack of basic clinical knowledge became obvious in that respect — for example, whether or not to correct a pathological anteversion of the proximal femur and to what extent should cortical or cancellous bone contact be provided for each part of the implant. The consequences of altering the geometry of the head/socket relationship were also just beginning to be recognized.
Choosing sides
As a result, strong conflicts of opinion among orthopaedic surgeons began to emerge. Surgeons were either enthusiastically in favor of the new technology or deeply opposed to its introduction, questioning the need for such a technique. With time, more and more failures became obvious, with nerve lesions, persistent pain and limping observed, but it took a long time for these to be reported in the literature (Niethard 1999, Prymka u Hassenpflug 2003).
Public opinion on the value of robotic surgery then turned around, and the systems quickly lost their popularity. In particular, their widespread application without prospective scientific evaluation did not give an objective picture of the collateral damage to muscle caused by the robotic drill bits and retractors, or the neurological deficits resulting from the long-term rigid immobilization during the procedure, which resulted in limping and functional deficits. The result was that, at present, robotic surgery has been almost totally withdrawn from the orthopaedic market in Germany.
This is not because the system has only produced bad results. In difficult cases, especially after fractures or previous osteotomies with complex deformities, robotics has produced perfect results (Hassenpflug et al 2004).
It is not the system that is at fault, but its implementation as a marketing tool of clinics and suppliers that led to a downturn in its popularity. In addition, the high costs of the system makes the application of robotics in orthopaedic surgery more difficult to justify until perfect results are documented. This will prove extremely difficult because of the high success rate of conventional hip replacement.
Perhaps the high-volume hip arthroplasty market is not the ideal target for robotic surgery. In the future, we may discover other applications where a high precision of bone surface preparation is needed. Perhaps further innovations in cutting devices, laser beams or water power instruments instead of the current milling tools could support a revival of robotic surgery for special applications. However, the introduction of these new technologies must be accompanied by a more thorough scientific evaluation and better communication of the clinical results.
Orthopaedics Today International Editor David L. Hamblen, PhD, FRCS, contributed to this commentary.
Editor’s note: Stay tuned for more coverage on robotics in orthopaedic surgery in the July/August issue of Orthopaedics Today International.
Joachim Hassenpflug, MD, PhD, is director of the department of orthopaedic surgery at the University Hospital of Schleswig-Holstein in Kiel, Germany. He also serves on the Orthopaedics Today International Editorial Advisory Board.
For more information:
- Hassenpflug J, Prymka M. Navigation and robotics in joint and spine surgery. Computer-assisted orthopaedic surgery; difficulties and prospects. In: Stiehl JB, Konermann W, Haaker R: Navigation and robotic in total joint and spine surgery. Springer, Berlin, Heidelberg, New York 2004: 169-172.
- Niethard FU (1999) Computer assisted orthopaedic surgery (CAOS) in der Hüftendoprothetik. Z Orthop 137:1.
- Prymka M, Hassenpflug J. (2003): Abbruch des Trochanter minor und Einsinken des Prothesenschaftes nach roboterunterstützter Hüftprothesenimplantation. Ein Fallbericht und Aufarbeitung des Schrifttums. Unfallchirurg 106:671-675.
- Prymka M, Vogiatzis M, Hassenpflug J. (2004): Primäre Rotationsstabilität von manuell und roboterunterstützt implantierten Hüftvollprothesen. Unfallchirurg 107:285-293.
- Thomsen M, Aldinger P, Görtz W, Lukoschek M, Lahmer A, Honl M, Birke A, Nägerl H, Ewerbeck V. (2001): Die Bedeutung der Fräsbahngenerierung für die roboterassistierte Implantation von Hüftprothesenschäften. Unfallchirurg 104:692-699.