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Is Computer-Assisted Surgery the Future of Orthopedics?

With the digital medicine revolution in full swing, just about every specialty will experience some form of healthcare technology impact. AI algorithms, deep learning systems, and neural networks are already being used to detect lung cancer, screen skin lesions, and predict acute kidney injury. In the surgical realm, technological advancements previously involved the use of computer-assisted surgery (CAS) to improve precision and facilitate minimally invasive approaches. In orthopedics, CAS was introduced in the 1990s with perhaps joint replacement surgery as its most popular and widespread application. Despite the promise and potential of CAS to improve component positioning, few studies have demonstrated clinical benefit and the technology was largely abandoned. Due to improvements in technology and a focus on patient-specific surgery, there has been renewed interest in the use of CAS in orthopedics, this time in the form of robotics.

The rise of robotics in orthopedics can largely be traced back to MAKO Surgical Corporation, a medical device company founded in Florida in 2004. The system was initially used to perform partial knee replacements with total hip arthroplasty added a few years later. In 2013, Stryker acquired MAKO Surgical Corp. for $1.65 billion (and added the ability to perform knee replacements), thus taking robotic-assisted joint replacement surgery mainstream and kicking off a new round of competition in the already highly competitive world of orthopedic implant device manufacturing. Just recently, Zimmer Biomet introduced the ROSA Knee System, a robotic-assisted platform specializing in knee replacement innovation. Not to be outdone, Depuy Synthes is expected to introduce its robotic platform, currently named Orthotaxy, in 2020, also with a focus on knee replacement surgery. The company also announced a collaboration with Google to develop an advanced surgical robotics program. Other implant companies have also entered the robotics arena with Smith and Nephew leveraging Blue Belt Technologies platform to create its Navio System and UK-based Corin acquiring OMNI Orthopaedics Inc., a robotic-assisted knee replacement company. 

The lure of robotics in orthopedics includes the ability to more precisely prepare bone and place implants with the goals of improving recovery, reducing complications, and obviating the need for expensive revision procedures. Robotic-assisted surgery represents an evolution of CAS and can be viewed as an adjunctive tool to improve a physician’s ability to perform the procedure.

Robotic-assisted surgery is not without its critics. Much like CAS, the data showing the superiority of robotic procedures is sparse. Some critics argue that the use of robotic assistance can give a false sense of security and, much the way an airline pilot should not blindly trust his or her instruments, a surgeon who lacks the ability to critically evaluate the information being provided can get into trouble. In addition, installing and maintaining robotic equipment can be expensive. Hospitals justify the capital cost of acquiring robotic systems by assuming an increase in the volume of patients attracted by newer technology. However, as robotics becomes more commonplace, competitive advantage may disappear and the costs will eventually be passed on to the system as a whole, perhaps leading to more expensive care.

It remains to be seen if robotic-assisted orthopedic surgery can succeed and display more staying power than the CAS that came before it. As technology improves and more data is collected, robotics may eventually show true improvement in outcomes and allow for a personalized approach to orthopedic surgery that justifies their cost. The future evolution of robotics may include the ability to 3D print custom hip and knee replacement implants, use AI algorithms to further improve component positioning, and even remote joint replacement surgery. While current criticisms are valid, there is merit in exploring what these platforms have to offer and allowing applications of robotics to evolve over time. For the foreseeable future, the Orthopedic Robot Wars will continue to heat up. Time will tell if there is room for all of these robotic solutions and whether or not they justify their cost with demonstrable improvement in outcomes.

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