Robotic Knee Replacements Ramping Up

Orthopedic surgery centers that purchase robotic platforms for knee replacement surgery are investing in the promise of positive outcomes and the potential to tap into a patient population that’s guaranteed to grow over the next decade. Surgeons love the precise cuts and more accurate implant placement afforded by robotic assistance, and savvy patients who research their treatment options are aware of the technology that can improve their recoveries and leave their new knee functioning better than it has in years — and perhaps even better than they expected.

Active robotic platforms feature a rotating burr that cuts the bone according to a preprogrammed surgical plan created by surgeons. During procedures, surgeons don’t move the robotic arm to make the cuts; they have the ability to start and stop the procedure, but the robot makes the cuts according to the pre-op plan. Haptic robotic platforms feature a cutting tool attached to a robotic arm, but the surgeon guides the cutting tool to control where the cuts are made.

Yair D. Kissin, MD, vice chair of the department of orthopedic surgery at Hackensack (N.J.) University Medical Center, says robotic systems provide several advantages over conventional knee replacement surgery, including less medial soft tissue release needed to balance the knee. Additionally, in some challenging cases involving bone deformity or severe bone loss, traditional cutting guides may not rest on the bone well or provide proper alignment and will therefore introduce error. With the robot arm cutting the bone, this error is essentially eliminated. Ultimately, robotic assistance lets surgeons make more precise cuts in the femur and tibia that lead to more accurate placement of the implant, a factor that improves the joint’s post-op function and extends the implant’s lifespan.

Dr. Kissin notes that many experts believe patients with significant joint deformity or bone loss might not be ideal candidates for robotic surgery, but he thinks otherwise: “I feel very strongly that these more challenging cases would benefit the most from robotic assistance, which provides more accurate cuts than traditional cutting guides to restore the patient’s anatomy.”

The functioning of the technology itself makes a difference in the robotic system’s accuracy, says Dr. Kissin. Because the steady arm of a robot employs a cutting burr, the joint is more stable than when a surgeon operates with a conventional saw, a factor Dr. Kissin says helps to boost the accuracy of cuts — and therefore post-op outcomes.

“Patient satisfaction rates for traditional total knee replacements are between 82% and 88%, but one of the drawbacks of traditional surgery is the potential for error introduced at each step,” says Dr. Kissin. “Although the error introduced in a single step may be negligible, it’s possible for errors to accumulate and lead to a less-than-optimal outcome.”

Eliminating or reducing the impact of human error means the technology has the potential to level the playing field among knee replacement surgeons and increase access to the procedure for the growing number of patients who will need to have their knees replaced in the coming years.

At Floyd Medical Center in Rome, Ga., surgical leadership and surgeons viewed robotic knee replacements as a way to enhance the facility’s orthopedic offerings in a competitive market and, more importantly, improve an already successful surgery. 

The robot could be a way to take our program to the next level.
  Gia Pyles, MSN, RN, CNOR

“We felt like our organization provides a fantastic patient experience,” says Gia Pyles, MSN, RN, CNOR, the medical center’s director of surgical services. “Our next step in our evolution of care was to look at what we can do to improve knee replacement outcomes. The robot could be a way to take our orthopedics program to the next level.”

The hospital recently purchased an active robotic system with the aim to start using it routinely during cases later this year. Part of the hospital’s reasoning for purchasing the robot was to improve the care of the patients who aren’t satisfied with the results of their knee replacements, according to Ms. Pyles. “After seeing the robot in action, one of the surgeons told me he thought the technology would eliminate cases after which he can’t figure out why the result was not perfect,’” she says. “In looking at the research, we expect the robot to solve malalignment issues that can’t be fixed with conventional instrumentation.”

For Floyd Medical Center, selecting a robot came down to surgeon preference and what the physicians found to be the most beneficial for their patients. After looking at several haptic robotic systems, Ms. Pyles says that seeing the active robot — developed by a vendor the hospital already works with extensively — in action got several of the surgeons on board with adding the technology. “Many of our total joint surgeons said that they thought they would use it, and most said they could see themselves using it for every primary total knee,” she says.

Finding the right surgical team is also key for the successful implementation of robotic knee replacements. Ms. Pyles notes that the medical center’s leadership interviewed staff and listened to their thoughts about the robotic system to see if they wanted to work with the technology. “Picking your team is so important,” she says. “They can make the transition smooth or very tough. I want the team working on these cases to not only support the use of the technology, but to believe in it.”

As with adding any new technique and technology, it takes time for surgeons and surgical teams to change their intraoperative routines. Therefore, at least initially, patients with significant comorbidities, such as obesity and cardiac issues, might not be ideal candidates for robotic knee replacements.

The additional time needed to complete a case will decrease and eventually be eliminated as robotics become more mainstream in orthopedic ORs, according to Dr. Kissin. “We’ve been performing traditional knee replacements the same way for years, so of course the procedures are more streamlined,” he says. “We’ll eventually get there with robotics.”

Time lost in the OR could be made up in the sterile processing department. Ms. Pyles says the several trays of cutting tools needed during conventional surgery are unnecessary thanks to the robotic arm. “That leaves facilities with less inventory to maintain, and less instrumentation to clean and process,” she adds.

At Hackensack Medical Center, COVID-19 put a damper on how quickly the facility could implement its robotic technology. The hospital first purchased its robot in January 2020, and began performing cases with the technology in February and March before the program was shut down due to the pandemic. Though COVID concerns linger, Dr. Kissin believes the promise of using the technology to provide even better care for knee replacement patients helped push providers through some trying times.

“The technology is helping us get to the other side of the pandemic,” he says. “We know we have the ability to perform the next level of orthopedic care, and the robot is a tool to help get us there.” OSM