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  • Brian Cole

Robotics, ASCs combined show promise in orthopedics

Robotic surgery in orthopedics has increased in the past 2 decades, with a 2021 study in the Journal of the American Academy of Orthopaedic Surgeons citing the estimated global market for medical robotics to surpass $20 billion by 2023.

Despite the increased use of robotic systems in orthopedics and other surgical specialties, previously published research has shown the use of robotic systems is still relatively uncommon in ASCs among procedures which otherwise commonly use robotic techniques. In orthopedic surgery, this could be due to several factors, including mixed outcomes and the learning curve associated with the use of robotics, as well as cost and space constraints associated with the ASC setting, sources told Orthopedics Today.

“I think robots are like any other new tool. New tools can improve surgical procedures but also come with risk and potential negatives,” James A. Browne, MD, professor of orthopedic surgery at the University of Virginia, told Orthopedics Today.

Promising results

In terms of surgical outcomes with the use of robotics, the published literature has shown promising results with improved functional outcomes and implant durability, as well as high accuracy among both total joint and spine procedures, according to sources who spoke with Orthopedics Today.

“There is about an 8% or 9% risk of misplacement of pedicle screws that drops down to 1% or 2% when we start utilizing image guidance or robotics,” Nicholas Theodore, MD, professor of neurosurgery at Johns Hopkins University, said.

Carlos J. Lavernia, MD, adjunct professor of biomedical engineering at the University of Miami and adjunct professor of mechanical engineering at Florida International University, said robotic systems with 3D planning allow surgeons to take the hip-spine connection into account, which can help reduce the revision rate in total hip replacements. Robotic technology may also allow surgeons to reduce soft tissue damage in total knee replacement, he said.

“When you do not have to expose the knee as widely as you do when you are doing an open case, the haptic portion of the robot keeps that blade that you use to cut the bone from going into the soft tissue,” Lavernia said. “So, the confidence that you are not going to cut it is there and you do not have to expose all around like most of the primary cases without the robot have to do.”

Jan A. Koenig, MD, vice chair of the department of orthopedics and director of computer assisted and robotic orthopaedic surgery at NYU Langone Long Island Hospital, said robotics can provide a more precise fit and better soft tissue balance in TKR.

“When you do conventional total knee replacement without the use of robotics, it is hard to measure the intraoperative balance and make the corrections you need to do,” Koenig, who is also associate professor at NYU Long Island School of Medicine, told Orthopedics Today. “Before robotics and computers, we had no way of measuring it and now we can measure it to the millimeter and degree and that is why we are so accurate with it.”

Synergy between robotics, ASC

Jess H. Lonner, MD, attending orthopedic surgeon at Rothman Orthopaedic Institute, said use of robotic systems may improve early recovery and patient satisfaction, and some robotic tools may improve ergonomics and the physiologic strain that surgeons experience on a case-by-case basis compared with conventional techniques.

“We have performed studies that show that with some robots we can improve the surgical experience for the surgeons, and maybe those improved ergonomics will result in less musculoskeletal pain and lower rates of musculoskeletal injury, which is a huge problem among joint replacement surgeons,” Lonner, professor of orthopedic surgery at Thomas Jefferson University, said.

Similarly, Lonner said patient and surgeon satisfaction is typically higher when surgery is performed in an ASC compared with a general hospital. When the use of robotics is combined with an ASC setting, the possibility of a synergistic relationship exists, he said.

“When you combine the two, when you do a procedure that has innately higher patient satisfaction in a facility where there is innately higher patient and surgeon satisfaction, technology and the setting complement each other,” Lonner told Orthopedics Today.

Despite this, Browne said much of the evidence surrounding improved outcomes after robotic surgery has not been strong or conclusive.

“We know that they can be precise tools and there are some advantages to robots, but being able to say that it clearly benefits a patient and their outcome with surgery is not something that we have been able to prove yet,” Browne said. “A lot of robotics and the adoption of robotics is market-driven and certainly it can drive volumes into the ASCs, but when you start to go down the path of improved outcomes, I think you are on shaky ground.”

Solution to high cost

Although sources who spoke with Orthopedics Today said the use of robotics systems may increase revenue for ASCs, the initial expense of the robotic system may be an issue, as the smaller overhead of ASCs may not allow these facilities to afford large capital equipment.

However, Theodore said the initial cost of a robotic system should not deter orthopedic surgeons and administrators from considering adopting one in their ASCs.

“The reality is that if you are going to be doing 100 outpatient surgeries a year, I can promise that technology will probably be paid off fairly quickly and most of the vendors are willing to work with surgery centers in coming up with creative ways to finance technology,” Theodore told Orthopedics Today.

Lonner said one way that ASCs may be able to pay for a robotic system is through volume-based payment methods, in which the cost per case is modulated based on volume commitments by the surgeons.

“In other words, if a hospital or surgery center can increase the use of a certain product, a knee replacement or a hip replacement, by a negotiated amount, then there is an incentive in pricing that can go toward paying down the cost of the system,” Lonner said. “There typically is no longer this big, upfront capital cost that, in the past, would keep the robotic systems out of the surgery centers.”

Change in reimbursement

Transportable robotic systems may be another workaround for ASCs that are attached to a hospital by allowing surgeons to wheel or transport the system, potentially bought under the hospital’s capital equipment budget, from the hospital to the surgery center, Theodore said.

“Now, a lot of, and I would probably say most, ambulatory surgery centers are not, unfortunately, attached to a hospital,” Theodore said. “They are freestanding for a reason, but as we further think about how things go in the future, that is one solution.”

From a reimbursement standpoint, Lavernia said research has shown use of a robotic system can be cost-effective in a 90-day episode of care, with a decrease in cost between $1,000 to $4,000 per case. Because ASCs receive reimbursement on a fee-for-service basis and not for 90-day episodes of care, he said a robotic system in an ASC may not be cost-effective. Lavernia added that access to these new technologies may be limited to the pioneers developing them and to the first ASC in a particular region to adopt these unless reimbursement for the use of robotic technology is changed.

“I think radical change needs to occur in the way that technology is reimbursed by the federal government, as well as private payers,” Lavernia told Orthopedics Today. “I think until that happens, there is going to be a significant impediment in getting new things to an ASC environment because the cost is too high.”

Learning curve

With one of the goals of migrating some orthopedic surgical procedures out of the OR and into an ASC being to save costs, Theodore said procedure time must be reduced for a procedure to be successful in an ASC.

“From a patient perspective, the least amount of time under general anesthesia the better and that increases your chance of getting the patient home the same day,” Theodore said.

Although previously published results have shown the use of robotic technology may decrease the time it takes to perform a surgery, sources told Orthopedics Today surgeons need to keep the learning curve associated with adopting new technologies in mind.

Because the learning curve varies from system to system and surgeon to surgeon, it is not ideal to use a robot in an ASC until the surgeon has surpassed the learning curve to reduce complications, Browne said.

“To be able to do joint replacement safely and efficiently at an ambulatory surgery center, you have to have already established a technique that leads to reliable and predictable outcomes,” he said. “Adopting new technologies and new techniques in the ASC setting can be suboptimal and potentially lead to patient harm.”

Be familiar with the robotic system

Even surgeons who have experience with use of an orthopedic robotic surgery system may experience an increase in procedure time anywhere from 15 to 30 minutes depending on the system they use, according to Lonner.

Nicholas Theodore, MD, performs a robotic-assisted minimally invasive lumbar fusion in the inpatient setting

Nicholas Theodore, MD, professor of neurosurgery at Johns Hopkins University, performs a robotic-assisted minimally invasive lumbar fusion in the inpatient setting, where he said surgeons should familiarize themselves with robotic technology prior to its use in the ASC.

“Surgical times vary by surgeon and, depending on the robotic system, in certain cases there is a considerable increase in surgical time and expense when using an advanced technology, like a robotic system, whereas other surgeons, with some robots, have found that the surgical times and perioperative costs are less because of use of the robot,” Lonner said.

Due to the robotic system learning curve, Theodore recommends surgeons use the robotic system in an inpatient setting, which provides a better support system for managing complications, before making the move to outpatient robotic surgery.

“If you want to make yourself successful, you are going to have to use this technology in an inpatient setting so that you are familiar with the nuances of robotic integration and doing these procedures,” he said.

Size may matter

Browne said the size of the robotic system may also pose a challenge for ASCs, which tend to have smaller ORs compared with hospitals.

“The bulkiness and the large footprint of the equipment is going to be a challenge for many ASCs and may limit widespread adoption of current technology,” Browne said.

However, not all ASCs may have an issue with space, Koenig said, because some ASCs built more recently have larger ORs compared with those built 20 years ago. Similarly, some of the newer generation robotic systems have a lower profile than previous generations, he said.

“There are some mini-robotic systems, such as Omnibotics (Corin), that are low profile,” Koenig said. “It only takes maybe a 2-foot by 4-foot space in an OR environment. You can park the nanostation in a simple closet and the system can be folded into a suitcase that carries the monitor and computer laptop and a camera we use during the procedure. It makes it more portable than some of the larger systems out there.”

The use of robotic systems in an ASC can also help save space by facilitating preoperative planning which can significantly decrease the inventory of trials needed in the OR, as well as the inventory of what is needed on the back table and in storage, according to Lavernia.

As ASCs are developed in the future, Lonner said larger ORs that can accommodate total joint arthroplasty or spine cases that use robotic technology need to be considered.

“Different robots come in a variety of shapes and sizes so the room requirements in the ORs may differ from one system to another, but in general, there is more of a space requirement than for some other cases, like hand surgery cases or simple knee arthroscopy cases,” Lonner said.

Considerations for adoption

When considering whether to adopt a robotic system in an ASC setting, surgeons in the ASC need to be interested in using the system regularly, Theodore said.

“You cannot just put [the robot] there and think that it is just going to be using itself,” Theodore said. “There has to be individuals who are interested and committed to utilizing the technology," he said.

Browne said surgeons and administrators need to consider the possible drawbacks associated with robotic technology, including the cost, learning curve and possibility of complications.

“Surgeons and ASCs do need to consider potential scenarios where it may actually be counter-productive and not in the patient’s best interest to employ a robot,” Browne said.

In addition, surgeons need a backup plan for instances when the system fails to work, according to Theodore.

“Understand what the limitations of the technology are and have a backup plan because there always could be a potential situation where there is a software glitch, there is a reason that the technology does not work,” he said.

Lonner said, prior to adoption, surgeons also must be sure they are comfortable using the technology and have protocols in place for performing joint replacement surgeries in an ASC without a robot.

“Make sure that you first develop a joint replacement experience with the ASC without a robot and that your protocols work to get patients home safely and without a high rate of complications or readmissions to a hospital,” he said.

Learn to use robotics

Once those protocols are in place, Koenig said surgeons and staff of the ASC should be trained on the robotic system and develop their competencies.

“First, use it for your simplest cases so you learn and have a good feel for it and that your team is able to use it as well, because that is important,” Koenig said. “It is not just a surgeon performing surgery. The whole team has to be on board. Once everybody’s competent with it, then you can transfer the care for the right patients to the outpatient facility.”

In addition to knowing how to use the robotic system, Lonner said it is important for surgeons to help negotiate reasonable contracts and rates with the robot manufacturer so that use of a robotic system is profitable or cost neutral for the ASC.

“You obviously do not want to make an investment in a technology that is going to end up costing the surgery center for each case that is done,” Lonner said. “Even though it might drive patient volume, if it is costing money on a case-by-case basis, it is probably not a great investment.”

Lavernia said it is helpful for surgeons to be familiar with the layout of their city or town in terms of which facilities use a robotic system for orthopedic surgery and whether the surgery is being done in an inpatient or outpatient setting.

“Definitely, every orthopedic surgeon needs to learn how to use these robots because in 5 years, maybe 10 [years], there is not going to be a joint replacement that is going to be done without a robot,” Lavernia said.

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