Study: Robotic TKA costs more, takes longer than manual procedure
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For experienced high-volume surgeons, robotic total knee arthroplasty was a longer and more costly procedure than manual total knee arthroplasty, with similar lengths of stay and complications, a comparison of cost and quality showed.
Researchers retrospectively reviewed data from 2,392 manual TKA (MTKA) procedures performed by six high-volume MTKA surgeons matched 1:1 with robotic TKA (RTKA) procedures using the Mako system by Stryker that were performed by six high-volume RTKA surgeons. Outcome measures included operative time, length of stay (LOS), total direct cost, 90-day complications, utilization of post-acute services and 30-day readmissions.
Overall, median LOS was 33 hours for both groups. There were no significant differences in 90-day complication rates (0.9% for the MTKA group vs. 0.7% for the RTKA group) and wound complications, such as surgical site bleeding and wound infection, between the groups. Moreover, no deaths or mechanical failures were found in either group.
Median operative time was 78 minutes for the RTKA group and 70 minutes for the MTKA group. Additionally, median total direct cost per case was significantly greater for RTKA than for MTKA, $11,615 vs. $8,674.
Fewer 30-day readmissions occurred in the RTKA group (1.2%) compared with the MTKA group (4.9%). Discharge directly home was 95% in both groups; however, 38% of patients in the RTKA group were discharged home with home health care (HHC) compared with 29% of patients in the MTKA group. In addition, discharge to a skilled nursing facility was 5% in both groups.
“In this series of propensity-score matched patients, RTKA was observed to be a longer and costlier procedure than MTKA, without clinically significant differences in LOS or complications. HHC was more frequently utilized after RTKA than MTKA, but readmissions occurred more frequently after MTKA,” the researchers wrote in the study.
“In the era of value-based health care, any additional costs are of concern to both providers and health care systems. As margins continue to decrease, additional expenditures must add value to the delivery of care,” they added. “Longer-term follow-up and functional outcome studies are required to determine if the greater cost of RTKA is offset by lower revision rates and/or improved functional results.”
Editor’s Note: This article was updated on Jan. 24, 2022, with more detailed results from the study.
Perspective
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Tompkins and colleagues provided science to a critical issue in total knee arthroplasty, namely that robotics is associated with greater cost and increased procedure time. As physician reimbursement for TKA continues to decline and powerful external forces accelerate the migration into the outpatient setting, scrutiny must be applied when assessing the value of technology.
In a recent article of time-driven activity-based costing, robotic-assisted TKA was found to have higher total hospital costs due to longer operating room times with higher supply and personnel costs. Further, there are potential deleterious consequences resulting from increased operative time.
In a recent article investigating robotic-assisted vs. manual unicompartmental knee arthroplasty (UKA), a higher early revision rate was observed in the robotic-assisted UKAs for periprosthetic infection. Despite robotics being promoted by implant manufacturers, there is little data to support its value in TKA.
In a well-conducted large cohort study, multivariate analysis revealed that robotic-assisted and manual TKA demonstrated similar minimal clinically important difference at 4 weeks and 6 months in all outcomes. Further, the few select studies demonstrating a clinical benefit of robotics in total joint arthroplasty are authored by surgeons with associated conflicts of interest.
In 2022, there is insufficient unbiased peer-reviewed evidence to support the clinical value of robotic-assisted TKA. Therefore, by providing unbiased peer-reviewed scientific evidence, the article by Tompkins puts a “nail in the coffin” of a costly and inefficient technology that in its current form provides no clinical value in the modern health care environment.
References:
DeFrance MJ, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2020.10.033.
Fang CJ, et al. Arthroplast Today. 2021;doi:10.1016/j.artd.2021.11.008.
Shaw JH, et sl. J Arthroplasty. 2021;doi:10.1016/j.arth.2021.02.038.
St Mart JP, et al. Bone Joint J. 2020;doi:10.1302/0301-620X.102B3.BJJ-2019-0713.R1.
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