The Future of Robotic-Assisted Total Joints

Orthopedics

By: John Berry

Published: 4/24/2020

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Improved precision, speedier recoveries and patient appeal are just a few of the reasons the robot is becoming a mainstay in orthopedics.


Forward-thinking facilities are embracing a high-tech approach to hip and knee replacements by outfitting their ORs with robotic platforms. Can you blame them? A growing body of evidence suggests robotic-assisted joint replacement results in more precise surgeries with fewer complications, allowing patients to ambulate sooner than they would after manual operations. There are also less proven, but very real, indirect benefits to adding ortho robots. Facilities that have already invested in the technology realize patients will come from near and far to have their joints replaced by surgeons who operate with the help of robotic assistance.

Unmatched accuracy

Precision is paramount during total hip or total knee replacements. Even the most skilled surgeons can't compete with the accuracy of bone cuts made during robotic-assisted surgery.

"It makes what we do more precise," says Cedric J. Ortiguera, MD, orthopedic surgeon at Mayo Clinic in Jacksonville, Fla. "All surgeons have outliers, a small percentage of procedures where we aim for certain targets that we end up missing. The use of robotics reduces the number of outliers and makes surgery a lot more exact."

Getting the cuts and implant placement just right can make or break the success of a procedure. Being mere millimeters off-target in the implant's alignment can reduce the overall lifespan of the hardware and could lead to the need for revision surgery. And if the implant winds up outside a certain range of ideal placement, the risk of implant failure is significantly increased.

Robotics takes surgery out of the realm of art and into the realm of science.
— Paul Miller, MD

Robotics has consistently shown to have a positive impact on both the success rate of procedures and recovery times of patients. "For a hip, the advantages are cuff position, leg length and offset, which is how much tension the muscles are under," says K. Seth Kuwik, MD, an orthopedic surgeon at the Orthopaedic Surgery Center in Youngstown, Ohio, who has performed approximately 500 robotic cases since 2015. "For a total knee replacement, it's about getting a balanced joint, having a knee with neutral alignment and flexion, and extension gaps that are equal."

By using CT scans to create a virtual 3D model of the patient's anatomy, robotic platforms allow surgeons to clearly visualize exactly what they'll be operating on before the first cut is made. The image-guidance component of robotic platforms helps surgeons plan their surgical routes with a greater degree of clarity and certainty. A simple scan of the joint gives the robot enough information to generate a model the surgical team can work with to minimize the invasiveness of procedures.

Pre-op scans of the joint also give surgeons the ability to more accurately assess anatomic landmarks in real time and adjust accordingly during surgery to obtain the most optimal joint alignment and function, says Dr. Kuwik. Robotics help surgeons replace hip joints in a way that ensures the leg on the operative side will match the length of the leg on the non-operative side. "Leg length is tough to assess," says Dr. Kuwik. "With the robot, you know exactly how long the leg will be after the implant is placed."

Mapping out a pre-operative plan allows the OR team to plan for complications that might occur during surgery. Instead of making key decisions after initial incisions are made, and possibly prolonging an operation and causing more soft tissue damage, the robotic platform lets the team focus on executing the ideal operation. Intraoperatively, the arm of the robot prevents the surgeon from straying from the preplanned route.

The question of cost

TRAINING TOOL Cedric J. Ortiguera, MD, orthopedic surgeon at Mayo Clinic in Jacksonville, Fla., explains the finer points of robotic-assisted total knee surgery.   |  Cedric J. Ortiguera, MD

Despite the increasingly well-documented advantages of using robotic-assisted platforms for total knee and total hip procedures, many facilities remain understandably hesitant to invest several million dollars into acquiring a platform. "You have to have enough volume to justify the cost," says Paul Miller, MD, an orthopedic surgeon at Monument Health Orthopedic & Specialty Hospital in Rapid City, S.D. "You need to amortize it over time, so you'll see a return on the investment."

It's important to weigh the short-term investment challenges with the long-term marketing potential and new opportunities robotics can afford your facility. Patients are playing a much more active role in their care, and waves of these savvy shoppers are seeking out facilities that offer robotics.

"If you're in a large market, being able to advertise that you have a robot can help drive patients to you," says Dr. Miller.

This uptick in interest from patients — as well as the positive data from surgeons who have been using the platforms for almost a decade — have forced many facilities to reconsider incorporating robotics into their orthopedic repertoire.

Outpatient centers that have invested in robotic platforms for orthopedic work have noticed an increase in patients actively seeking out robotic assistance for their surgeries. "Patients come to us from literally all over the country," says Dr. Ortiguera. "They travel to us looking for centers that have experience with robotics. There's no question patients are attuned to this technology and are seeking it out."

The increasing use of robotics has led to concerns about whether tech may compensate for a lack of familiarity with traditional, manual techniques. "I think you have to have some basis on the overall performance of the total knee before operating with a robot," says Dr. Miller. "If you've been used to the robot, and it breaks, how do you complete the case? Hopefully surgeons [who use robotics] have had enough education and experience that they should be able to do that."

Questions like this show where robotic assistance is in terms of its growth and acceptance. The results over the past 10 years solidify the value of robots in joint replacements, but they are still new to the industry. Surgeons who adopted the technology at the outset have had time to appreciate the difference between manual techniques and robotic assistance. Moving forward, training younger surgeons to do the same during their education on and off robotic platforms will be essential. The benefits of augmenting surgical skill with robotic assistance can and has been changing the landscape of orthopedic surgery.

"Robotics takes surgery out of the realm of art and moves it into the realm of science," says Dr. Miller. "We can measure what we're doing during surgery, instead of relying on feel. And over time, as we gather more information from our results, we'll be able to fine- tune the use of robotics to a greater degree."

Game-changing evolution

PLANNING AHEAD Robotic platforms let surgeons map out preferred surgical pathways and guide them to make near-perfect bone cuts during surgery.   |  Cedric J. Ortiguera, MD

Robotics is directly impacting the demographics of the patients who undergo total joint replacement surgery. In fact, a significant element in the growth of robotic-assisted procedures is the rising number of younger patients deciding to have their joints replaced. With the success rate and reduced recovery time robotic platforms are providing, a surgery that was previously a last resort for older patients who had exhausted alternative treatments is now being made available for patients in their 40s and even 30s — particularly those who lead very active lifestyles.

"When we first started doing joint replacements in the 1970s, patients were just happy to go from a wheelchair to walking," says Dr. Ortiguera.

"Now, middle-aged and younger patients are looking to regain the activity levels they had before their joints wore down. Rightly or wrongly, they want to continue with high-demand activities."

Custom implants have been one way of improving joint replacement surgeries, but the ultimate success of any implant is based on how accurately the implantation is made and balanced. For younger patients —and even older patients — who expect to continue a more rigorous lifestyle, longevity of an implant and returning the joint to near normal function are major considerations that make them seek out the accuracy provided by robotic-assisted surgery.

"I think it's because of improved technology and better implants that we're seeing less wear rates that translate into a longer lifespan for the implant, which is important for younger patients," says Dr. Miller. "In highly active patients, the wear rate is about .04 millimeters a year, which means it would take them 25 years to wear through a millimeter of polyethylene."

The progress that robotic platforms will make in the next five to 10 years is an exciting prospect. "Robotics lets me develop a surgical plan for an individual patient that meets that patient's needs completely," says Dr. Miller.

A natural extension of this growth will be further improvements and innovations in current robotic technology. "I'm sure industry will improve the robotic platforms that are currently available," says Dr. Ortiguera. "Right now, robotics is being driven by industry and by patient demand. Our hope is that in the coming years it will be driven by proven outcomes, but it will take time to get those results."

Between the increased interest among patients and the promise of improved outcomes, it's clear robotic-assisted surgery will play a pivotal role in the future of total joints and remain a major part of orthopedics' progression into the future. OSM

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