The trouble with robotic joint replacements

Orthopedic

Seven orthopedic surgeons connected with Becker's to discuss the biggest drawbacks of robotic joint replacement technology. 

Ask Orthopedic Surgeons is a weekly series of questions posed to surgeons around the country about clinical, business and policy issues affecting orthopedic care. We invite all orthopedic surgeon and specialist responses.

Next question: If current economic trends continue, what will have to change for orthopedic surgeons to remain successful? 

Please send responses to Riz Hatton at rhatton@beckershealthcare.com by 5 p.m. CDT Thursday, April 20.

Note: Responses have been lightly edited for length and clarity.

Thomas DeBerardino, MD. Sports Medicine Orthopaedic Surgeon at UT Health San Antonio: Many of the robotic joint replacement platforms are dependent upon preoperatively obtained advanced imaging via CT scan or MRI. The translation to the treatment algorithm is decidedly dependent upon high-quality scans. When suboptimal scans are submitted, suboptimal robotic algorithms are produced. That can lead to a false sense of surgeon security when trusting the robot to be a value-added and costly addition to joint replacement surgery.

David Kalainov, MD. Medical Director of Musculoskeletal at Northwestern Memorial Hospital (Chicago): Expensive (fixed and variable costs) in the setting of relatively declining CMS payments; in general, no clear-cut benefit for patient outcomes in comparison to hip/knee replacements performed without robotic assistance; evolving and potentially less expensive technologies (augmented reality) that may soon replace robots. As currently designed, robots for joint arthroplasty may adversely impact value in healthcare (value equals quality/cost where quality can be defined by outcome). 

Matthew Levine, MD. Orthopedic Physician at the Centers for Advanced Orthopaedics (Bethesda, Md.): There are several drawbacks to the current robots performing joint replacements. The first drawback is usually the most obvious: technology is expensive. There is not currently a mechanism to pay for the increased cost for hospitals or surgery centers. Medicine is shifting to value-based care, so it is hard to justify higher costs without evidence of improved outcomes.

That leads us to the second drawback. There is no consistent, evidence-based study to verify improved outcomes for joint replacement patients. 

Third, there is no consistency among manufacturers or across platforms. Some robots use CT scans, some use X-rays and others use MRIs to plan surgeries. While there are benefits to preoperative planning, having inconsistent processes makes it hard to utilize the robots effectively or compare different systems.

The fourth drawback is that robots do things differently. Some robots only plan, some plan with guidance on how to make cuts, and some perform the cuts and help insert implants. The variability between different systems creates challenges in trying to develop a universal platform that can be validated and demonstrate value. 

Lastly, it has become a highly competitive market. Both doctors and facilities try to demonstrate to patients the newest technology. By marketing technology, patients may switch doctors to benefit from a system that may not improve outcomes. This has the potential to undermine the doctor-patient relationship and also erode trust between physicians and hospitals. 

Vivek Mohan, MD. Orthopedic Surgeon at Southern California Permanente Medical Group (Pasadena): Time, cost, tendency towards blind faith, eventual complete reliance on technology, lack of haptics (the art versus the science), the list goes on.

Joseph Nessler, MD. Orthopedic Surgeon at St. Cloud Orthopedics (Sartell and St. Cloud, Minn.): Without a doubt robotic technology in hip and knee replacement surgery has been very disruptive to the status quo. There are many advantages I have seen with robotic technology, including improved accuracy and consistent surgical results and also the ability to plan and streamline surgical workflow as we have in our ASC. The biggest drawback is initial start-up costs, but most manufacturers are becoming very creative in financing, rebates and incentives, so this once major hurdle is slowly becoming less of a barrier. The other concern is inconsistency in robotic platforms. Some so-called robotic platforms today are just glorified navigation systems, and surgeons and administrators need to do their homework when evaluating different manufacturers' offerings.

Arjun Saxena, MD. Adult Hip and Knee Reconstruction Surgeon at Rothman Orthopaedic Institute (Philadelphia): AAHKS surveys demonstrate that robotic utilization in hip and knee replacement has increased each year in the recent past. As more surgeons adopt advanced technology, more trainees are exposed to them as well. The biggest drawback to this is the fact that trainees have less exposure to manual instrumentation. I do have concerns that these surgeons will leave training programs and only seek positions where robotic programs are present. Alternatively, they may perform poorly in situations in which only manual instrumentation is available. As robotic systems are not widely available in the revision settings, I wonder how these surgeons will fare in complex revision arthroplasty. Ultimately, I predict technology will prevail, but these are the concerns I have as an "older" surgeon.  

Daniel Yanicko Jr., MD. Lake Cumberland Regional Hospital (Somerset, Ky.): I feel they add cost and in the long run no patient benefit, but they may have use in very complex knee cases. 

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