By Dr. Thomas King
Medical innovation is intriguing, as people often assume that anything “new” is automatically “better,” especially when it is endorsed by trusted authorities like doctors. Unfortunately, this assumption is misguided. In the field of orthopedics, we have witnessed numerous innovations in the past few decades that have proven to be either harmful at worst or ineffective at best. Examples of such failed innovations include metal-on-metal total hips, computer-assisted total knees, and thermal capsulorrhaphy.
One of the challenges lies in demonstrating significant advancements or improvements in a procedure as exceptional as total joint replacement (TJR). Over the course of 50 years, TJR has undergone extensive refinement through the collaboration of countless investigators, resulting in a long-term success rate of over 90% after more than 20 years. While TJR is not flawless, any technical variation introduces a greater risk of harm than benefit. Therefore, any proposed innovation must answer the question: “Which problem are you attempting to solve?”
It is important to clarify that true “robots” for total joint procedures do not currently exist. Highly sophisticated robots, such as the Da Vinci system, are being employed in other surgical fields for procedures like prostate surgery, where the surgeon operates remotely. In orthopedics, the so-called “robots” that have been promoted for the past 15 years are essentially basic cutting arms controlled by the surgeon’s hand. They are not remote-controlled or fully autonomous but claim to assist the surgeon in making precise bone cuts and in avoiding inadvertent injury to ligaments and other soft tissues for these reasons that I don’t use a robot.
This analogy can be compared to a hair stylist using a bowl as a guide while cutting hair—it ensures precision but lacks individual style. Similarly, robot cutting arms in orthopedics can help the surgeon stay within predefined boundaries, but this level of skill is considered rudimentary. Experienced surgeons already possess the skills necessary to avoid inadvertent injury to surrounding ligaments and soft tissues without relying on such assistance. These are fundamental skills expected of a surgeon.
Claims that the robotic arm leads to smaller incisions, less tissue trauma, less pain, or faster recovery are often exaggerated and misleading. The notion that these robots inherently provide these benefits is false hype. While advancements in surgical technology can contribute to improved outcomes, the benefits associated with robotic systems in orthopedics are still a matter of debate and ongoing research. Perhaps one day, true robots, AI, and augmented reality will assist in executing intricate surgeries, but we have not reached that stage yet.
The promotion of “robotics” for total joint procedures has persisted for over 15 years under the guise of improving short and long-term outcomes. However, there is no evidence to support these claims of patient improvement. So why is there such fervent promotion? The public’s misconception of the technology allows its application as a powerful marketing tool for surgeons and a lucrative profit center for manufacturers, given the multimillion-dollar cost of these machines. The marketing hype makes unsubstantiated claims.
In my opinion, precise and customized surgery performed in real-time, considering the unique dimensions of each joint and the constraints of surrounding soft tissues, leads to more functional and durable outcomes and this is why I don’t use a robot. The ability to make precise bone cuts is the simpler aspect. The challenge lies in understanding how and when to modify the procedure to accommodate the individual anatomy of each joint. Cutting arms, in this case, only serve as obstructions, blocking the surgeon’s line of sight. As of now, the “robot” remains idle in the corner of my operating room. I have no quarrel with surgeons who prefer it but it adds no value for my patients. This type of surgery relies as much on art as it does on science.
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