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    ICJR DEBATES: Robotics and Joint Replacement Surgery

    Should orthopaedic surgeons seriously consider the adoption of robotics in their practice? What evidence is there that robotics improves outcomes in joint replacement patients? Is robotics a tool for the future, or has the future already arrived?

    We asked 2 orthopaedic surgeons with experience in using advanced technologies – Douglas E. Padgett, MD, and Michael P. Bolognesi, MD – to consider these issues as they debated whether robotics has a role in joint replacement during a session at the 6th Annual ICJR South Hip & Knee Course.

    RELATED: Register for the 7th Annual ICJR South Hip & Knee Course

    Here’s what they had to say.

    Douglas E. Padgett, MD, from Hospital for Special Surgery in New York, noted that there are 3 big issues in joint replacement surgery:

    • Bearing wear and failure
    • Instability (primarily an issue for total hip arthroplasty)
    • Patient satisfaction (primarily an issue for total knee arthroplasty)

    Is there a way for surgeons to gain control over these issues, particularly with patients who need replacement surgery to treat knee osteoarthritis?

    The answer is yes, according to Dr. Padgett: the use of robotic-assisted unicompartmental arthroplasty (UKA).

    This is a controversial position to take, Dr. Padgett acknowledged, but he takes it because research has shown that UKA allows for conservation of the anterior and posterior cruciate ligaments and is associated with a low complication rate, [1] rapid return to work, and cost savings. Research has also shown 96% return to preoperative level of sports participation [2] and 90% maintenance or improvement in sports activity. [3]

    Durability of UKA can be an issue, but failures are often associated with technical errors such as over- or under-correction, [4] varus angulation of the tibial slope, [5] and too much or too little posterior slope. [6] Robotics, Dr. Padgett argued, can help to improve outcomes by enhancing control of these surgical variables.

    The future of robotics, Dr. Padgett said, is here and now.

    Click the image above to watch Dr. Padgett’s presentation.

    Michael P. Bolognesi, MD, from Duke University Medical Center in Durham, North Carolina, is not against the use of technology such as robotics in joint replacement surgery – he was, after all, an early and enthusiastic adopter of computer navigation. He also believes development of robotic technology for joint replacement has been moving in the right direction.

    But the issue that surgeons should not lose sight of, he said, is the cost of adding robotic technology to their institution’s operating rooms. The technology currently has a significant price tag, which some institutions simply are unable to bear, regardless of how much their surgeons may want to use it with their patients.

    The other issue, Dr. Bolognesi said, is that the evidence for robotic technology is primarily in the abdominal surgery and thoracic surgery literature, where robotics has a good track record. In orthopaedics, robotics had a rough start: The idea was appealing, but the execution did not go as well as expected, he said.

    Dr. Bolognesi acknowledged that both objections – cost and evidence – are likely to disappear in the future. Progress is being made, the technology has evolved, and more studies are being done. Like personal computers, the robot will get smaller and easier to use, but will also need to be less expensive.

    Robotic technology for joint replacement surgery should be pursued, Dr. Bolognesi said, but right now, he believes it is not ready for prime time.

    Click the image above to watch Dr. Bolognesi’s presentation.

    Disclosures

    Dr. Padgett and Dr. Bolognesi have no disclosures relevant to their presentations.

    References

    1. Brown NM, Sheth NP, Davis K, et al. Total knee arthroplasty has higher postoperative morbidity than unicompartmental knee arthroplasty: a multicenter analysis. J Arthroplasty. 2012 Sep;27(8 Suppl):86-90. doi: 10.1016/j.arth.2012.03.022. Epub 2012 May 4.
    2. Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surg Sports Traumatol Arthrosc. 2008 Oct;16(10):973-9. doi: 10.1007/s00167-008-0596-9. Epub 2008 Aug 12.
    3. Naal FD, Fischer M, Preuss A. Return to sports and recreational activity after unicompartmental knee arthroplasty. Am J Sports Med. 2007 Oct;35(10):1688-95. Epub 2007 Jun 8.
    4. Hernigou P, Deschamps G. Alignment influences wear in the knee after medial unicompartmental arthroplasty. Clin Orthop Relat Res. 2004 Jun;(423):161-5.
    5. Collier MB, Eickmann TH, Sukezaki F, McAuley JP, Engh GA. Patient, implant, and alignment factors associated with revision of medial compartment unicondylar arthroplasty. J Arthroplasty. 2006 Sep;21(6 Suppl 2):108-15.
    6. Hernigou P, Deschamps G. Posterior slope of the tibial implant and the outcome of unicompartmental knee arthroplasty. J Bone Joint Surg Am. 2004 Mar;86-A(3):506-11.