Robotic knee surgery uses a mechanical arm or guidance system to assist the orthopedic surgeon during a total or partial knee arthroplasty. While the technology offers potential benefits like enhanced precision in bone cutting and implant placement, it introduces drawbacks related to cost, logistical complexity, distinct clinical risks, and limitations in access. The decision to use this technology involves weighing these disadvantages against the perceived benefits.
Higher Costs and Operating Room Logistics
The implementation of a robotic system represents a substantial financial burden for healthcare facilities, which often translates into higher costs for the patient. The initial investment for a surgical robot is significant, typically ranging from $1 million to $2.5 million. Hospitals also face ongoing annual maintenance contracts that can exceed $100,000. Furthermore, each procedure requires specialized, disposable instruments unique to the robotic platform, adding an estimated $1,000 to $3,500 to the cost of a single surgery.
The complexity of the equipment introduces challenges to the operating room’s logistical flow. Robotic procedures often require a longer operative time compared to conventional surgery, primarily due to setting up the bulky equipment, calibrating the system, and registering the patient’s anatomy. Studies show that robotic-assisted total knee arthroplasty may take an average of seven to ten minutes longer than a manual procedure, especially during a surgeon’s initial learning phase. This longer time under anesthesia slightly increases generalized surgical risks for the patient, in addition to raising overall hospital operational costs.
Specific Clinical Risks Associated with Robotic Guidance
The use of a robotic guidance system introduces specific physical complications not typically associated with traditional knee replacement surgery. A unique risk is the potential for pin site complications, which arise because the system requires rigid fixation pins to be drilled into the patient’s femur and tibia to act as trackers for the robot. These pin sites can be a source of problems, including superficial pin-site infections or persistent drainage.
A more serious complication is a stress fracture at the pin insertion site, with reported incidence rates ranging from 0.06% to 4.8%. These fractures typically occur postoperatively and may require further surgical intervention like open reduction and internal fixation. The risk of these complications depends on factors such as the pin’s diameter and its placement. Pins inserted into the weaker central shaft (diaphysis) are more prone to causing an issue than those placed in the stronger ends of the bone (metaphysis).
The robotic workflow can also increase the patient’s exposure to radiation. Many robotic platforms rely on a preoperative computed tomography (CT) scan to generate a three-dimensional model of the patient’s joint for surgical planning. The radiation dose from this necessary CT scan is higher than that of standard X-rays, adding to the patient’s lifetime exposure. Finally, there is a risk of technical malfunction, such as a software glitch or mechanical failure of the robotic arm, which may necessitate an intraoperative conversion to a traditional manual procedure.
Limitations in Access and Surgeon Training
The high barrier to entry for hospitals and surgeons creates significant limitations in the availability of robotic knee surgery. Due to the multimillion-dollar acquisition cost and the need for specialized support staff, robotic systems are disproportionately concentrated in large, urban medical centers. This financial and logistical concentration results in a disparity of access, particularly for patients in rural or smaller hospital settings who must travel farther to receive the procedure.
Surgeons face a steep learning curve when adopting robotic technology, requiring significant training and a consistent volume of cases to achieve proficiency and reduce operative time. While some studies suggest a surgeon can integrate the technology into their workflow after as few as seven to 11 cases, achieving true proficiency, where surgical times stabilize, may require between 20 to 80 procedures. Furthermore, an over-reliance on the robotic system could potentially diminish a surgeon’s fundamental manual and tactile skills. If a robotic system fails mid-procedure, the surgeon must be able to seamlessly convert to a manual technique, a capability that could be compromised by relying too heavily on the technology.