Robotic Innovations in Orthopedics: A Growing Landscape, Challenges, and Implications for Care

Abstract

This perspective work focuses on the transformative role of robotics in orthopedic surgery, enhancing precision and efficiency. It details the evolution of robotic systems such as ROBODOC, Mako, and Da Vinci, outlining their contributions to procedures such as total knee and hip replacements. It also discusses future trends, including the integration of AI, augmented reality, personalized implants, and the potential for telesurgery. Challenges such as high costs, the learning curve, and regulatory concerns are noted, but the field is poised for significant growth and innovation in orthopedic care.

1. Introduction

Robotics signify a transformative advancement in medical technology within orthopedics, enhancing the precision, efficiency, and outcomes of surgical procedures. Robotic systems assist in tasks ranging from joint replacements to spinal surgeries. Evidence of their clinical effectiveness is still pending, and current trends indicate that robotic systems will only further augment and advance the field. Realizing these innovations, however, warrants careful consideration of the various challenges that have hindered the widespread adoption and implementation of robotics within orthopedics.

2. Current Robotics in Orthopedics

The early adoption of robotics encountered limitations due to bulky and unwieldy equipment, technical complexities, and prohibitive costs. However, technological advancements have catalyzed the development of more streamlined and cost-effective robotic systems. Starting in 1992, ROBODOC (Curexo Technology Corporation, Seoul, Republic of Korea) was the first robotic system used in orthopedics to assist with precise bone preparation in total hip arthroplasty [1]. The ACROBOT system (Acrobot Company Ltd., London, UK) is a semi-autonomous robot-assisted system later designed for minimally invasive surgery in unicompartmental knee arthroplasty. The system utilizes active constraint control, which limits the robot’s movement within a predefined zone, allowing the surgeon to perform bone cuts with high precision while ensuring safety [2]. The Mako system (Stryker, Kalamazoo, MI, USA), initially designed in 2006 for partial knee replacements, utilized CT-based 3D models and haptic feedback for precise bone preparation and implant placement and later expanded to total hip and knee replacements [1]. The PiGalileo system (PLUS Orthopedics, Rotkreuz, Switzerland) was designed in 2006 to assist with computer-assisted orthopedic surgery by providing enhanced precision in alignment and positioning during total knee arthroplasty [3]. The da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA), originally approved for general surgery in the 1990s, was utilized in limited orthopedic settings for ulnar nerve decompression, supraclavicular brachial plexus dissection and nerve root grafting, and anterior lumbar interbody fusion [4]. In 2010, OMNIBotics (OMNIlife Science, Inc., East Taunton, MA, USA) was developed for total knee replacements, offering advanced planning software for ligament balancing and implant positioning. The Navio system (Smith and Nephew, Watford, UK), introduced in 2012, brought tactile guidance and intraoperative planning to partial knee replacements without needing preoperative imaging. As a surgeon-controlled, handheld cutting device, the Navio robotic tool is more limited to smaller procedures. A notable difference to highlight is that Mako (Stryker) is image-based, requiring a preoperative CT scan to create the models used, which is refined intraoperatively with a handheld probe. In contrast, NAVIO is entirely image-free, relying solely on intraoperative mapping with a handheld probe to generate a virtual 3D model of the knee. The ROSA system (Zimmer Biomet, Warsaw, IN, USA), launched in 2014 for neurological surgeries, was later adapted for total knee and hip replacements, with specific approvals for spine (2019), hip (2021), and knee (2022) procedures [1]. The TSolution One system (Think Surgical, Fremont, CA, USA), introduced in 2016, provided open-platform robotics for total knee arthroplasty, compatible with multiple implant systems. ExcelsiusGPS (Globus Medical, Audubon, PA, USA), developed in 2017 for spine surgery, combined robotics with navigation for enhanced accuracy in implant placement [4]. The Mazor X Stealth Edition (Medtronic, Minneapolis, MN, USA), released in 2018, integrated robotic guidance with real-time navigation for advanced spinal surgeries. Most recently, the VELYS system (DePuy Synthes, Raynham, MA, USA), introduced in 2020 for total knee replacements, offers real-time adaptive planning for personalized procedures (Figure 1).

Today, robotic systems are defined by their enhanced precision and versatility across various orthopedic subspecialties. Beyond joint replacements, robotics have made significant inroads in spine surgery, with systems like ExcelsiusGPS (Globus Medical) and Mazor X Stealth Edition (Medtronic) optimizing pedicle screw placement and improving outcomes in complex spinal procedures [1,3,5]. Within orthopedic trauma, robotic systems have assisted surgeons with precise fracture repairs, vertebral realignments, and stabilizations, improving stability in complex reconstructions [6,7]. In addition, minimally invasive robotic-assisted surgeries are growing, offering benefits such as smaller incisions, reduced recovery times, and fewer complications [8]. Collectively, these systems have elevated the standard of care in orthopedics through evident and common themes.

3. Future of Robotics in Orthopedics

Integrating robotics in orthopedics has already commenced, and robotics use will likely continue to improve the field across several key areas, beginning with precision. As these technologies advance and mature, they may further reduce human error, leading to even greater accuracy, given that their usage and application are executed correctly. In knee arthroplasty, robot-assisted techniques for implant positioning offer increased precision compared with conventional methods [9,10]. In hip arthroplasty, research studies on robot-assisted total hip arthroplasty suggest that the augmented precision in placing the acetabular cup and femoral stem may enhance implant stability [9]. For spine surgery, some studies have demonstrated that robotic systems can improve pedicle screw insertion accuracy, subsequently reducing neurological risks and complications [3]. Within traumatic orthopedics, there is potential for robotics in fracture surgery, where robots may aid surgeons in precise fracture repair, vertebral realignments, and spinal stabilizations [6]. While not yet standard practice and many systems are still in more nascent stages of study, these advanced systems may offer increased precision and stability, allowing surgeons to perform delicate and repetitive tasks with minimal error. This reduces the physical and mental strain on surgeons, reducing surgeon fatigue, particularly for more complex procedures.

Additionally, robotics will continue to drive the adoption of minimally invasive procedures, which allows for similar, if not improved, clinical outcomes with advantages in terms of reduced radiation exposure and increased accuracy in navigation [8,11]. Furthermore, robotic systems allow for decreased tissue disruption and smaller incisions in spine surgery, all while improving accuracy and outcomes in procedures such as degenerative disc disease and spinal fusion [3]. While economics limited expansion and implementation in the 1990s, computer-assisted surgery is an active and promising area of technological innovation, underlining its potential to augment and refine procedural precision. Computer-assisted orthopedic surgery (CAOS) consists of a special camera system designed to capture real-time images of the joint and limb during surgery [12]. These images are then processed and integrated into computer programs, which assist the surgeon in planning and executing the operation. The computer software creates virtual or actual images of the damaged joint based on anatomical landmarks provided by the surgeon. These landmarks help the system map the joint’s normal and abnormal structures, allowing the surgeon to use this visual data to reconstruct the joint accurately and consistently. In the future, CAOS is expected to evolve with the integration of more sophisticated imaging and navigation technologies and robotics [13]. For instance, with total knee replacements, innovations in navigation systems, including image-based, imageless, and accelerometer-based handheld technologies, are expanding the accessibility and versatility of CAOS [14]. By incorporating artificial intelligence, augmented reality, and haptic feedback, CAOS systems will likely offer more tailored, patient-specific solutions that enhance surgical planning and intraoperative decision-making.

Artificial Intelligence (AI) integration will also play a crucial role in the evolution of orthopedic robotics. By incorporating predictive analytics, AI can use patient-specific data to anticipate surgical challenges and outcomes, optimizing preoperative planning [15]. One study found that AI-generated preoperative plans required 39.7% fewer adjustments than conventional methods [16]. AI-powered robots may provide real-time decision support during surgery, helping surgeons make informed choices [16]. Exploratory research also drives the advancement of robotic systems with enhanced dexterity, force feedback, and haptic capabilities, emphasizing advancing preoperative planning software and image-guided navigation systems. Augmented reality (AR) integration will enhance surgical precision, improve training, and provide more effective rehabilitation options [17]. AR allows surgeons to plan and simulate complex surgeries in a 3D environment; intraoperatively, AR provides real-time 3D visualization, improving accuracy in procedures such as implant placement, spinal deformity corrections, or pelvic fracture repairs; post-operatively, AR may support rehabilitation by creating interactive exercises and tracking patient progress in real time, or via AI integration in robotic exoskeletons for limb rehabilitation [17,18,19]. Additionally, AR and robotics facilitate the design and fitting of custom prosthetics, enhance patient education, and enable remote consultations. The growth of AR and AI will constitute and drive much of the innovation with robotics in orthopedics.

Improvements and developments, both with the personalization of implants and their use in procedures, are other active areas of potential. Notably, the number of younger adults undergoing joint replacements continues to grow, partly due to the improvements in available technologies and the increasing longevity of implants [20]. The growth of robotics, combined with 3D printing technologies, may enable the creation of personalized implants, tailoring the entire surgical process to individual needs [21]. However, both the implants and the procedures themselves must be considered: advancements in the actual fit of the implants themselves with the integration of robotics with increased precision will be key. Future robotic systems may also feature advanced sensors that provide real-time biomechanical feedback, optimizing procedural outcomes by leveraging patient data and anatomical nuances [22]. There have been notable developments with patient-specific instrumentation (PSI): cutting guides or jigs designed using preoperative imaging, such as CT or MRI scans, tailored to the patient’s anatomy [23]. In total knee replacement using PSI, preoperative planning is completed for sizing, alignment, and bone cutting, guiding the subsequent design of cutting blocks and femoral and tibial templates, which are placed precisely over the distal femur and the proximal tibia in a best-fit fashion [23]. PSI was effective in reducing outliners in rotational tibial component alignment during total knee arthroplasty [24]. However, other studies have found no improvement in functional outcomes or surgical time; thus, their efficacy remains debatable as there is no current consensus [23]. Yet, the theoretical advantages of PSI, such as improved alignment, suggest there might still be potential benefits over standard procedures in facilitating the alignment and planning phases. Thus, one potential area of growth is the fine-tuning of PSI and the validation of the accuracy of this technical approach. Related albeit different, there is also growing interest in patient-specific implants, customized biomechanical fit for implants to match patient’s bone structures and joint morphology [25]. However, the long-term clinical effectiveness of this custom technology needs to be validated through further studies before it can be widely adopted and recommended for patient care [26].

Remote and autonomous surgery represents another frontier in the field. Robotics could enable telesurgery, whereby surgeons perform procedures remotely, making high-quality care accessible in underserved regions [27]. Stryker introduced the first fully autonomous surgical guidance system in the industry, which integrates optical tracking, advanced camera technology, and enhanced surgical planning and guidance features [28]. This system represents a significant leap forward in precision and autonomy for orthopedic surgeries. Meanwhile, Monogram Orthopedics made strides in remote surgery by using its Monogram mBos robot to successfully perform a real-time procedure from 1,700 miles away, highlighting the potential for remote-controlled surgeries using robotic systems [29]. These developments underscore the growing influence of robotics and AI in transforming orthopedic surgery. Although fully autonomous surgery remains a long-term goal, advances in robotics and AI could lead to robotic systems capable of performing certain standardized procedures independently, albeit under human supervision. The potential of robotics in revolutionizing this area remains untapped, indicating that the field is still in its early stages of exploration, and the outcomes will likely unfold in the coming years.

Post-operative care will also see significant advancements through robotic rehabilitation devices. These devices, including exoskeletons and robotic physical therapy tools, will assist patients in regaining mobility efficiently after surgery [30]. A study demonstrated how a robot-based therapy for wrist injuries demonstrated effectiveness comparable to traditional methods while maintaining safety standards [31]. Regularly using these robotic systems could reduce the physical demands on therapists, increase the precision and repeatability of assessments, and foster greater patient engagement and voluntary participation in rehabilitation. This suggests that robotic-assisted rehabilitation could enhance both the quality and consistency of care while promoting more active patient involvement. Wearable robotic devices could also continuously monitor a patient’s recovery, offering real-time data to adjust rehabilitation protocols and ensure optimal outcomes.

Regenerative medicine is another exciting area where robotic technologies could converge. One notable example is autologous chondrocyte implantation (ACI), which treats cartilage damage. ACI is a technique that involves culturing a patient’s cartilage cells and implanting them into areas of cartilage defect, with successful outcomes reported long-term [32]. The advent of robotic assistance could also improve the delivery of growth factors or other biological therapies directly to the surgical site, promoting faster healing and better integration in the implantation process. Another study explored a robotic system using Remote Centre of Motion-based control and viscous material extrusion 3D printing for intra-articular regenerative treatments targeting focal cartilage defects in the knee [33]. This approach uniquely combined 3D bioprinting and robotic-assisted minimally invasive surgery techniques and demonstrated the feasibility of such for articular disease treatment. These are just two examples of the growing advances combining methods involving 3D printing, robot-assisted surgery, and other aspects of tissue engineering within orthopedics [34].

Finally, robotics’ role extends to simulation, providing realistic training environments that empower surgeons to refine their skills through simulated surgical scenarios. Studies have found that surgical residents can significantly improve and retain essential technical and sensorimotor skills, particularly in using drills for internal fixation, after engaging in faculty-led lectures and hands-on practice, particularly with simulations [35]. The growing potential of robotics integration into medical education is poised to elevate simulation-based training further. Robotics will likely enhance the fidelity and precision of simulated surgical environments, offering residents more realistic, hands-on opportunities to practice complex procedures, especially within orthopedics [36]. Robotic systems combined with virtual and augmented reality tools will allow for repeated, high-fidelity simulations, strengthening residents’ technical capabilities and improving learning outcomes by offering immediate feedback on performance [37].

4. Challenges and Considerations

However, realizing these advancements will inevitably require significant investments in technology, training, and ethical frameworks to ensure that the benefits are fully realized and accessible to patients while safeguarding against potential risks. High costs are a major limitation due to the initial capital investment and the need for consumables in each procedure [38]. Adopting these systems presents a steep learning curve, requiring teams to undergo extensive training and adapt to new roles that demand advanced technical knowledge but may be alleviated in the presence of an experienced surgeon in robotically assisted procedures [39]. Further advancement in robotics necessitates careful consideration of ethical and regulatory issues. Implementation necessitates navigating the complexities of regulatory approvals, ensuring adequate surgeon training and certification, and addressing ethical concerns related to patient autonomy and informed consent. This includes meeting stringent safety standards, balancing the need for innovation with the risks of premature adoption, and ensuring transparency in reporting clinical outcomes and complications [40]. Surgeon training and certification are equally crucial, as robotic systems demand specialized skills to ensure optimal outcomes [41]. Standardized training programs and ongoing competency assessments are necessary to maintain high standards of care, with attention to avoiding disparities in training opportunities, particularly in resource-limited settings. Another significant concern is informed consent and patient autonomy. To make autonomous decisions, patients must be fully informed about the benefits, risks, and limitations of robotic-assisted procedures.

Furthermore, a growing focus on cybersecurity and data privacy concerns intrinsic to surgical robots underscores the need for robust safeguards in deploying these advanced technologies [42]. The absence of standardized protocols and regulations for digital technology implementation in surgical settings accentuates the need for comprehensive frameworks to guide and govern its utilization.

The cost–benefit analysis of robotic systems adds another layer of complexity. The lack of extensive longitudinal data on the postoperative outcomes of robotic surgery has been a significant impediment to adoption despite studies that have already explored various parameters [43,44,45,46,47]. Specifically, robotic-assisted arthroplasty procedures showed a shorter average length of stay, similar rates of same-day discharge, fewer discharges to skilled nursing facilities, and comparable all-cause 90-day readmission rates with no significant difference in acute blood loss [43,44,45]. Furthermore, studies report that robotic-assisted cohorts meet or exceed current standard-of-care benchmarks for patient-reported outcomes [46]. When examining costs, total costs per case for robotic-assisted total knee replacement were USD 92,823 (low volume), USD 29,261 (mid volume), and USD 25,730 (high volume), compared with USD 25,113 for conventional approaches and greater quality-adjusted life years, thus remaining cost-effective when annual revision rates are below 1.6% and quality of life values exceeded 0.85 [47]. In this discussion, there are also other technologies such as customized individually designed implants, wherein studies have demonstrated enhanced care and reduced overall costs, though broader adoption requires its own considerations surrounding insurance and infrastructure expansion [48].

Synthesizing these findings, there persists a lack of conclusive evidence asserting the superiority of robotic methodologies over traditional modalities in the long term. As delineated previously, there remains much promise in numerous domains regarding the future of robotics in orthopedics. However, justifying their high cost requires evidence of improved long-term clinical outcomes, such as reduced recovery times and enhanced surgical precision, while avoiding their use as mere marketing tools.

The accessibility of robotic systems in orthopedic surgery also faces several challenges that can hinder their widespread adoption and effectiveness. One of the primary barriers is the high initial and maintenance costs associated with robotic systems, particularly technical support and additional disposables [38]. These significant financial requirements can be prohibitive for many hospitals, particularly smaller or underfunded institutions, limiting access to this advanced technology. Furthermore, the training and expertise required for robotic-assisted surgeries present another challenge. Surgeons must undergo specialized training to operate robotic systems, necessitating appropriate time and resources for proper training. This can be a significant hurdle, particularly in rural or underserved areas where access to training programs may be limited.

Geographic disparities also play a role in limiting access to robotic surgery. Larger, urban medical centers (i.e., large academic medical centers, well-funded private hospitals, and research institutions) are more likely to have the financial resources to invest in robotic systems, while rural hospitals and clinics may lack the funds or patient volume to justify the purchase of such technology, creating disparities in access [49]. Additionally, insurance reimbursement for robotic surgery remains an issue. The added costs of robotic instrumentation must align with bundled reimbursement schedules, as failing to do so could result in negative per-procedure margins unless minimalistic systems are utilized. Given the narrow operating margins of U.S. hospitals, substantial revenue increases are necessary for robotic systems to be economically sustainable [50]. Despite the potential for improved outcomes and reduced complication rates, the higher upfront costs may also not always be reflected in reimbursement models, making it less financially viable for healthcare providers to adopt robotic systems. Notably, some of these costs include, but are not limited to, high initial investment, annual licensing and software update fees, instrumentation, and other costs associated with operating time and/or outcomes. This issue is further compounded by the fact that different robotic systems are used in specific procedures, limiting their utility in institutions that may need to invest in multiple systems for different surgeries. Without the necessary infrastructure, many institutions may struggle to implement robotic systems effectively, further exacerbating disparities in access to this advanced surgical technology.

Alternative financing models could be explored to make robotic technologies more accessible. Leasing or subscription-based models allow hospitals to “rent” robotic systems or pay monthly or annually, reducing the financial burden of significant capital investments. Shared-use models could enable multiple facilities to share a single robotic system, lowering costs for each institution, especially in rural areas. Government funding and grants could support adoption in underserved regions, while crowdfunding might enable smaller institutions to access robotic systems through community investment. These models could help bridge the gap in access to advanced technologies and reduce disparities in care.

Yet, the core question remains whether outcomes are notably improved with robotic integration in orthopedic workflows and procedures. Findings have been mixed, compounded by the lack of longer-term outcomes, which poses a significant challenge when considering the future of robotics in orthopedics [26,51,52,53]. For instance, studies examining robotic-assisted total hip arthroplasty with conventional manual methods have controversial results. Some studies have found that traditional techniques have shorter operation times, lower revision rates, and fewer post-operative complications, even though robotic-assisted total hip arthroplasty achieves similar clinical results with fewer intraoperative complications and follow-up radiological assessment results [51]. These critiques suggest that while robotic systems have potential, further research is needed to clarify their true value and roles in orthopedic practice [54,55]. Notably, while these mixed findings have cast doubts and fueled hesitations, many remain optimistic about the future of robotics in orthopedics.

While necessitating further extensive research and scrutiny, the field continues to evolve. The synergy between robotics and orthopedics is still poised to revolutionize how orthopedic care is delivered, offering new possibilities for personalized treatment and rehabilitation. By integrating cutting-edge robotics with traditional orthopedic practices, surgeons can perform complex operations with enhanced accuracy, reducing the risk of complications and the need for revision surgeries and improving patient recovery times. Specifically leveraging technologies such as augmented reality, artificial intelligence, digital imaging, and computer-assisted navigation, the field must be equipped to adopt and integrate robotic advancements, which will only continue to evolve and become a progressively integral facilitator and facet of orthopedic practice. Ultimately, the future of robotics in orthopedics is promising, but hinges on addressing the delineated challenges, pursuing with optimism, while critically and meticulously ensuring thoughtful execution, outcomes, and cautious cost-effective integration into clinical practice.