from AAOS Now – February 1, 2020
by John Cherf, MD, MPH, MBA, Chief Medical Officer, Lumere; and Simon Kerr, Category Advisor, Lumere
There is a long history of innovation in supplemental technology for joint arthroplasty procedures, from the early intramedullary cutting jig decades ago to today’s digital soft-tissue balancers, computer navigation, and robotics. Currently, several robotic systems are approved for joint replacement procedures, and more are expected to come to market over the next two years. All of the four major orthopaedic vendors offer a robotic system or will soon: Stryker’s MAKO, Smith & Nephew’s NAVIO, Zimmer Biomet’s ROSA, and DePuy Synthes’ yet-to-be-named system, in addition to smaller vendors such as OMNI (OMNIBot) and Think Surgical (TSolution One).
These robotic systems can be classified as active (TSolution One), haptic (MAKO, NAVIO), or passive (ROSA, OMNIBot). Additional differences in these systems include their footprint in the operating room (OR), portability, preoperative imaging requirements, interoperability, and approved indications, ranging from total knee only (ROSA, OMNIBot) to total knee, partial knee, and total hip (MAKO). Shoulder and ankle arthroplasty indications are likely to be approved.
As the market continues to expand, healthcare facilities need to consider whether the investment is justifiable and sustainable. In order to answer this, four factors should be further evaluated: (1) clinical implications, (2) financial/operational implications, (3) marketing considerations, and (4) physician recruitment and retention.
This article evaluates those four areas as they relate to robotic technology for total joint arthroplasty.
Although robotic technology is associated with incredibly accurate placement of knee and hip arthroplasty implants, the published literature has not yet substantiated that robotic surgeries have led to improved clinical outcomes compared to manual or computer-assisted surgeries. Some studies have found marginal, short-term improvements in pain or joint scores associated with robotics compared to manual surgery; however, there is a lack of high-quality, long-term (10 to 20 years) clinical data to objectively evaluate the impact of this new technology. Further studies are required to elucidate the outcomes of robotic technology compared to manual or computer-assisted surgery. The ultimate question that needs to be asked is, “Does this technology increase the value we provide our patients?”
Finances and operations
The most popular robotic system for joint replacement requires an upfront capital investment of high six figures to low seven figures (approximately $1,000,000), with six-figure annual service agreements and disposables that can add $1,000 or more to every case. It’s crucial to remember that in our current healthcare environment, robotic and manual procedures have similar reimbursement, and there is tremendous downward pressure on future reimbursement. At the same time, joint replacement is shifting toward hospital outpatient and ambulatory surgery center (ASC) settings, where reimbursement is even lower. In fact, the Centers for Medicare & Medicaid Services recently announced the removal of total hip replacement from the inpatient-only list, which joined total knee replacement as eligible for hospital-based outpatient surgery. We expect to see opportunities for reconstructive joint procedures to further shift to the ASC space as well. This trend will only continue to make the economics of using robotic technology less attractive in the future. Operationally, current literature suggests that cases employing robotics have similar or longer operative times than manual surgery, primarily due to the setup required. However, longer operative times may diminish as physicians and OR staffs become more familiar with using robotic systems.
Robotic systems for reconstructive joint surgery were initially marketed primarily for their potential to improve clinical outcomes. With the lack of compelling data to support that claim, vendors shifted to promoting increased procedure volume based on patient demand and physician satisfaction. Vendors have begun offering marketing resources to healthcare facilities to deploy sophisticated advertising campaigns targeting patients and referral networks to attempt to boost volumes. However, the question of whether patients gravitate toward healthcare professionals who use robotic technology is not well understood. As price transparency becomes the norm, high-cost healthcare centers may not be as attractive to patients. It is prudent for those considering investing in robotic technology to perform market research to determine whether patient volume is likely to increase. If not, it may cause an unnecessary “technology arms race.”
Physician recruitment and retention
Robotic system vendors have strategically targeted teaching hospitals and academic medical centers to promote familiarity with new generations of surgeons during their training. The hope is that surgeons will become dependent on robotic technology and either join health systems that have invested in robotics or become passionate advocates for their purchase. However, the systems are expensive recruiting tools, and there is limited evidence quantifying increased physician satisfaction with the technology. Although there may be anecdotal evidence that a procedure using robotic technology may be slightly less burdensome mentally and physically, there are concerns about over-reliance or dependence. There must be a balance where robotics is viewed as an extension of a surgeon’s skill set, not a necessity.
At present, robotic technology is fairly limited in its functionality, primarily assisting surgeons in making precise resections for accurate implant placement. Future innovation may bring autonomous robotic technology that could lead to the surgeon being more of a “monitor” than an “operator.” Although this may be a long way from today’s reality, we must promote an honest, evidence-based dialogue about the impact of robotic technology on the profession and the value of care provided to our patients. It is imperative that members of the orthopaedic surgeon community be good stewards of technology and critically consider these factors when evaluating the adoption of robotics.
John Cherf, MD, MPH, MBA, FAAOS, is the chief medical officer at Lumere, the practice and payment section leader of the AAOS Health Care Systems Committee, a member of the AAOS Council on Education, and a member of the AAOS Now Editorial Board.
Simon Kerr is a category advisor specializing in medical device research and market dynamics related to orthopaedics, spine, and neuromodulation at Lumere.