Do the outcomes of orthopedic surgery performed with robotics outweigh the costs?
Click Here to Manage Email Alerts
Click here to read the Cover Story "Surgeons, administrators should consider business aspects of the decision."
More evidence needed
There are two areas in orthopedic surgery where robotics has been employed successfully: joint arthroplasty and pedicle screw instrumentation in spine surgery. In joint arthroplasty, robotics is used to aid the accuracy of bone cuts in total knee arthroplasty and the accurate placement of the acetabular component in total hip arthroplasty. Many cadaveric and retrospective clinical studies have demonstrated high accuracy with bone cuts in arthroplasty leading to improved overall implant alignment and increased accuracy of screw placement in pedicle instrumentation. Despite these advantages, however, it is unclear whether robotic assistance results in improved outcomes that justify its added costs. For example, the advantages gained from robotics must outweigh the added costs of the robotic system itself, the annual service and maintenance fees of the system, as well as the cost of disposables. One also has to factor in the possible increased anesthesia and operative time in the beginning of the learning curve for the surgeon, as well as the cost of preoperative advanced imaging or the use of intraoperative CT/fluoroscopy to register the patient to be tracked by the navigational system. One area where robotic surgery may improve cost-effectiveness is by decreasing the revision rates of joint arthroplasty and spine surgery. Some studies suggest a decreased need for revision surgery with robotic assistance; however, these studies, at present, are generally retrospective studies with implicit bias. Robotics in orthopedic surgery is here to stay and will help surgeons in particularly complex cases; however, more evidence is needed to determine whether outcomes truly outweigh the costs in more routine surgical procedures.
Alexander R. Vaccaro, MD, PhD, MBA, is president of Rothman Orthopaedic Institute, Richard H. Rothman Professor and chair of the department of orthopedics, and professor of neurosurgery at Thomas Jefferson University and Hospitals in Philadelphia.
Disclosure: Vaccaro reports he has stock ownership with Globus Medical.
No long-term evidence
U.S. health care is rapidly moving from a fee-for-service payment model to a value-based reimbursement model. Value is defined as outcomes divided by the costs required to achieve them. To be successful at value-based care, we must examine all of our interventions in terms of the patient value these provide. This is especially true of interventions which claim to improve outcomes, but are more costly. The increased cost of these interventions is easy to quantify, but the improved outcomes are usually more difficult to ascertain. Robotic-assisted joint replacements certainly fit the previous description. There is no doubt that these add cost to the procedure; what is less certain is quantifying the improved outcomes, if any, these provide. There is some evidence (level 4) that short-term outcomes may be improved with robotic knee replacements. There is no evidence that long-term outcomes are improved by robotic hip or knee replacements. Perhaps these will be, but perhaps these will not be; at this time, nobody knows.
Joseph A. Bosco III, MD, is a professor and vice chair for clinical affairs in the department of orthopedic surgery at NYU Langone Health in New York.
Disclosure: Bosco reports no relevant financial disclosures.