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Robotic orthopaedic surgery requires a step-wise introduction
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When one of the world’s largest orthopaedic companies purchases a company that produces robotic arms used in orthopaedic surgery for $1.65 billion, it is clear robotic surgery will be a trending topic at orthopaedic and trauma congresses in the future.
Early attempts at the application of robotic technology began 3 decades ago, but failed to improve the results of procedures that involved implanting prostheses. Now the technology has advanced, but it is uncertain whether this will lead to better results or if there will be any clinical and functional benefits from the intraoperative use of a robotic arm.
The re-introduction of robotic technology in orthopaedics follows the introduction of other technology designed to improve implant surgery: computer-assisted surgery (CAS) and patient-specific instrumentation (PSI). Initially, the expectations for both of those approaches were also high, but as time passed, the expectations were tempered once the results of more high-quality studies were published.
Similar results reported
Computer-assisted surgery has provided orthopaedic surgeons with a high level of precision and accuracy, but it has not consistently resulted in improved patient-reported outcome measures (PROMs) or a reduced risk of revision. Furthermore, PSI has not been better than standard instrumentation for total knee replacement (TKR). For example, PSI has not significantly reduced the number of outliers or improved the accuracy in these cases.
On the other hand, PSI and CAS are both beneficial when conventional instrumentation cannot be used in a patient undergoing TKR because he or she has an intramedullary nail, a long-stemmed implant or a malunited femoral fracture.
We may assume the use of robotics or robotic-assistance devices will improve surgical accuracy and positioning of implants, and achieving consistent component placement is an important goal in implant-related procedures. However, there is still some debate about the optimal position of a prosthesis and the ultimate position of an implant can have consequences for the stability of the joint. In TKR, stability is also influenced by femoral component design, the use of a cruciate-retaining or cruciate-sacrificing design, tibial rotation and soft tissue contractures. Robotic surgery will not influence these factors much, if at all.
Cost of new technology
Although optimal positioning of an implant remains important, it does not solve all the possible problems that can occur in total joint replacement (TJR). Currently, we still do not know if robotic assistance in TJR will result in improved outcomes, longer survival of the implants or greater patient satisfaction. What is known, however, is it will increase the cost of the procedure significantly.
In the past, there were several surgical complications related to robotic surgery, including a high rate of infection. In theory, this technology has the potential to improve surgery. In particular, a robotic arm that the surgeon controls seems to be a good way to accumulate initial experience with these systems. However, surgeons must maintain control of the procedure. Therefore, although this new technology may seem like it will enhance the surgeons’ techniques and outcomes, it will not and cannot replace the surgeon.
Our aim is to improve the results of surgery, but we should not risk a worldwide disaster in doing so. Initially, only a few centers should perform high-level, prospective randomized studies in robotic surgery. After they are successful, the next step is to perform careful registry studies that involve evaluation of PROMs.
An online search reveals there are centers in some countries that advertise their use of robotic surgery to attract more patients. I contend the orthopaedic community should not expose large numbers of patients to a technology that has not yet been proven. Thus, a stepwise introduction of robotic surgery is the only safe way to go forward.
- Reference:
- Victor J, et al. Clin Orthop Relat Res. 2014;doi:10:1007/s11999-013-2997-4.
- For more information:
- Jan A.N. Verhaar, MD, PhD, is a member of the Orthopaedics Today Europe Editorial Board and is the president of EFORT. He can be reached at Erasmus University Medical Center, Room HS-101, 3000CA Rotterdam ZH, The Netherlands; email: j.verhaar@erasmusmc.nl.
Disclosure: Verhaar reports no relevant financial disclosures.