ICJR DEBATES: A Role for Robotics in Joint Replacement Procedures

    The use of robotics in joint replacement surgery is a controversial topic, with proponents claiming increased accuracy of bone cuts and implant positioning and opponents countering that the technology does not lead to improvements in clinical outcomes.

    At ICJR’s Pan Pacific Orthopaedic Congress, Stefan W. Kreuzer, MD, MS, from Houston, Texas, and Rajesh N. Maniar, MD, from Mumbai, India, addressed the issue in a debate over the pros and cons of robotic-assisted joint replacement surgery.

    Stefan W. Kreuzer, MD, MS
    INOV8 Orthopedics, Houston, Texas

    Although joint arthroplasty is generally a successful procedure, Dr. Kreuzer noted that there is room for improvement. About 19% of total knee arthroplasty patients, for example, are known to be dissatisfied with the outcome of their procedure. Surgeons have been focused on changing that trend, making refinements to implants and technique to help improve outcomes and reduce the number of dissatisfied patients.

    Satisfaction rates are much higher in total hip arthroplasty patients, so surgeons were surprised to learn that in 1 study, the acetabular cup was found to be placed outside the Lewinnek safe zone in about 50% of cases. [1] Not only that, but another study also found that cup position alone does not predict the risk of dislocation. [2] Taken together, Dr. Kreuzer said, these studies seem to indicate a need for more research to confirm the correct component position in total hip arthroplasty.

    The use of robotic technology can help solve these issues, and, in fact, Dr. Kreuzer sees robotics as the future of joint arthroplasty. But, he said, it’s not quite ready for “prime time” yet. Robotic systems are expensive and still too complex for the community surgeon; even for high-volume surgeons, the use of robotics increases operating room time.

    So what does Dr. Kreuzer think it will take to make robotic technology successful?

    • The target – the correct component position – must be defined. Otherwise robotics will just be “accurately incorrect.”
    • The impact of implant position on outcomes must be studied with something other than plain radiographs, as they are not accurate enough to draw conclusions about clinical benefits.
    • The use of robotics must provide return on investment to the healthcare system through reduced component inventory and minimizing the need for manual instruments.

    Watch Dr. Kreuzer’s presentation here.

    Rajesh N. Maniar, MD
    Lilavati Hospital, Breach Candy Hospital, Mumbai, India

    The first robotic total knee arthroplasty was described in 1993. So why is it, Dr. Maniar asked, that after more than 2 decades, robotics is still not widely used used for knee replacement procedures?

    He noted that although proponents of robotic surgery claim improved accuracy of bone cuts and more precise component placement, no clinical studies correlate improvements in surgical technique with better clinical outcomes or increased implant longevity.

    Most published studies reporting on robotic-assisted joint replacement surgery have found improved accuracy in component placement, and some have found a short-term trend toward clinical improvement when compared with conventional technique. [3-6] However, no studies found these improvements to be statistically significant, and all studies found an increase in operative times when using robotic-assisted technique; some found an increase in complication rates following robotic-assisted surgery.

    Dr. Maniar concluded that the few benefits of robotic-assisted surgery are increased accuracy of component placement and a decrease in the number of outliers. The disadvantages, however, are many, including an exponential increase in cost, a steep learning curve, and cumbersome and time-consuming technology. Due to the use of pins and trackers needed for the navigation, the procedure is more invasive, with more extensive surgical exposures. Yet, Dr. Maniar said, clinical outcomes are comparable to those of conventional techniques.

    Watch Dr. Maniar’s presentation here.


    Dr. Kreuzer has disclosed that he receives royalties from Stryker/Mako Hip & Knee, that he is a consultant for and receives royalties from Corin, that he receives royalties from Zimmer Biomet, that he is a consultant for Medtronic, and that he is the owner of Innovative Orthopedic Technology. Dr. Maniar has disclosed that he is a consultant for DePuy Synthes.


    1. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone for Acetabular Component Position. Clin Orthop Relat Res (2016) 474:386–391.
    2. Esposito CI, Gladnick BP, Lee y, Lyman S, Wright TM, Mayman DJ, Padgett DE. Cup Position Alone Does Not Predict Risk of Dislocation After Hip Arthroplasty. J Arthroplasty. 2015 Jan; 30(1): 109–113.
    3. 1 Decking J, Theis C, Achenbach T, Roth E, Nafe B, Eckardt A. Robotic total knee arthroplasty: The accuracy of CT-based component placement. Acta Orthopaedica Scandinavica,2004, 75:5, 573-579.
    4. 2 Park SE, Lee CT. Comparison of robotic-assisted and conventional manual implantation of a primary total knee arthroplasty. J Arthroplasty.2007 Oct;22(7):1054-9.
    5. Liow MH, Xia Z, Wong MK, Tay KJ, Yeo SJ, Chin PL. Robot-assisted total knee arthroplasty accurately restores the joint line and mechanical axis. A prospective randomized J Arthroplasty. 2014 Dec;29(12):2373-7.
    6. Liow MHL, Goh GS, Wong MK, Chin PL, Tay DK, Yeo SJ. Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc. 2017 Sep;25(9):2942-2951.