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Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons
, Praharsha Mulpur, Tarun Jayakumar, A.B. Suhas Masilamani, Abhishek Ranjan, A.V. Gurava Reddy
∗Corresponding author: Tarun Jayakumar. tarunjaykumar@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Total joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes.
This cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons.
Most participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors.
Robotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.
Keywords
Surgeon perception
Robotics
Technology adoption
Robotic utilization
Robotic challenges
1 Introduction
Total joint replacement surgeries are established procedures in the management of end-stage hip or knee arthritis. Total hip or knee arthroplasty provide reliable and consistent reduction in pain and improvement in function and quality of life. However, despite advances in prosthetic design, peri-operative analgesia and rehabilitation protocols, dissatisfaction after TKA can vary from 10 to 20 %.1–3 The integration of technology and medicine has produced remarkable innovations in the field of arthroplasty over the past few generations.4 Artificial intelligence, machine learning and sensor based technology has made it possible to transform arthroplasty from an evidence based science to personalized medicine.5
In an effort to improve outcomes, computer-assisted surgery (CAS) technology was introduced in the 1990s with the aim of providing appropriate alignment. However, research showed no significant difference in long-term outcomes or revision rates despite reduction in alignment outliers.6
The ROBODOC system, a prototype robotic arm, made its debut in the field of arthroplasty in 1992.7 Subsequently, remarkable advancements in artificial intelligence, 3D imaging, and sensor technology8 have been achieved in the past two decades, resulting in a remarkable refinement of robotic technology capable of achieving a cut precision of up to a millimetre. Robotics in arthroplasty has been established in improving the accuracy of component positioning and limb alignment, with significant reductions in outliers.9–11 Robotic-arm technology with haptics have been shown to reduce the amount of soft-tissue trauma or injury during TKA, with lower levels of inflammatory markers.12,13 There are several reports of reduced pain, improved functional outcomes and superior long-term survival of robotic knee arthroplasty, compared to manual alternatives.14–18
Despite these benefits, factors such as the exorbitant cost of technology, a steep learning curve, excessive reliance on technology, and concerns of prolonged operative time have emerged as significant impediments to the widespread acceptance of robotic technology in arthroplasty.19
The burgeoning number of healthcare facilities and inquisitive nature of orthopaedic practitioners have fuelled a considerable demand for robotic-assisted joint replacement surgeries in India. Nevertheless, the market penetration of robotic surgery remains confined to a select few major urban cities within the country.20 Entrenched perceptions among operating surgeons, paucity of published literature on long-term outcomes, and elevated costs associated with the use of this technology are the root causes of resistance to the widespread adoption of robotic technology.
The aim of this study was to understand the perceptions of Indian arthroplasty surgeons towards robotic technology, its usage and factors limiting its adoption in their arthroplasty practice.
2 Material and methods
This study was a cross-sectional observational study. Data collection was done using a structured self-administered, online survey using a single mode questionnaire. This questionnaire was designed to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology in the field of arthroplasty.
The questionnaire, which had been validated by the American Association of Hip and Knee Surgeons (AAHKS) research committee,21 underwent appropriate modifications by a group of senior surgeons from the Indian Society of Hip and Knee Surgeons (ISHKS). The online questionnaire was subsequently distributed amongst the membership of the ISHKS, members during a three-month period spanning from October 2022 to January 2023. A consent letter, a covering letter outlining the study's objective, and a hyperlink to the questionnaire were disseminated among 950 potential respondents through multiple closed WhatsApp groups and personal emails. Only qualified orthopaedic surgeons in arthroplasty practice were eligible to participate in the study.
To expand the scope of participation, a snowball sampling technique was employed whereby existing participants were allowed to forward the survey link to their colleagues and fellow arthroplasty surgeons. Non-responders were sent a reminder email one month after the initial contact. The study was conducted in compliance with the Declaration of Helsinki and received an exemption from the Institutional Ethical Committee. The anonymity of all participants was strictly upheld during the process of data collection and analysis.
A 30-question survey was created on the Jotform platform (Jotform Inc.) and divided into four sections: 1-Baseline information, 2-Surgeon's arthroplasty experience, 3-Perceptions about robotic joint replacement, and 4-Limiting factors for robotic usage. Each section was carefully crafted to avoid any repetition or ambiguity, and a pilot survey was conducted in the study institute before dissemination.
Baseline information, including age, designation, and affiliation, was obtained through open-ended questions. Objective questions were used to evaluate the surgeon's arthroplasty experience and volume. To categorize the survey participants into either robotic users (RU) or robotic non-users (RNU), questions were posed about their formal training in arthroplasty, navigation, and robotics, as well as the availability and utilization of robotic technology in their institution of practice. The surgeon's perception of robotic-assisted arthroplasty was assessed using a 4-point forced-choice scale. Six yes/no type questions regarding limiting factors for robotic usage were also included in the survey questionnaire. Additionally, a descriptive question adapted from Roger's diffusion of innovation22 was used to allow study participants to self-categorize themselves into an adopter category.
2.1 Statistical analysis and questionnaire validity
Excel (Microsoft) and SPSS v25 were employed for statistical analysis. Open-ended questions primarily focused on baseline information such as age, designation, and affiliation. Descriptive statistics were used to analyse continuous variables like age, while categorical variables were presented as proportions. The proportions were tested using either a chi-square test or Fischer's exact test.
Prior to the dissemination of our questionnaire, an offline pilot survey was conducted within the authors' institution, involving 20 Consultant grade orthopaedic surgeons who perform arthroplasty in their routine practice and 18 arthroplasty fellowship surgeons. All questionnaires were returned without missing data or ambiguous responses. None of the questions in our survey have open ended questions, which have subjective interpretation. After data compilation and refining done in Microsoft excel, we were able to process responses in a uniform way. We did not perform a head-to-head comparison of responses between existing users or non-users of technology, as this is unlikely to be statistically robust. Due to our questionnaire's singular online administration, and in order to avoid duplication of entries, we were unable to undertake the customary test-retest reliability assessment during the data collection phase of our survey.
3 Results
3.1 Baseline information
Our survey achieved a response rate of 43.8 % (417/950) over a three-month period. Baseline demographic information of the participants is summarized in Table 1. The study participants had a mean age of 49.4 years (SD = 12.54) and were predominantly male (413–99.04 %). Most participants (52.7 %) were in their early arthroplasty practice (1–5 years), with 15.5 % having 6–10 years of experience. The majority of surgeons performed ≤25 primary total knee replacement surgeries annually and ≤10 primary total hip replacement surgeries annually (84.4 %). A total of 57.3 % of participants were affiliated with a large corporate hospital or a government hospital/medical college. Approximately half of the participants (59.4 %) had fellowship training in arthroplasty, with 31.4 % and 24.22 % obtaining formal training in the field of computer-navigation and robotics, respectively. Additionally, roughly one-fifth of the participants belonged to institutions where robotic technology for arthroplasty was already available.
| Sr. | Baseline demographic information | N (SD/%) |
| 1 | Mean age (SD, median, lower bound, upper bound) | 49.4 (12.54, 35, 26, 74) |
| 2 | Gender | |
| Female (%) | 413 (99.04 %) | |
| Male (%) | 4 (0.96 %) | |
| 3 | No. of years into arthroplasty practice | n (%) |
| 1–5 years | 220 (52.75 %) | |
| 6–10 years | 65 (15.59 %) | |
| 11–15 years | 48 (11.51 %) | |
| 16–20 years | 28 (6.71 %) | |
| More than 20 years | 56 (13.43 %) | |
| 4 | No. of primary total knee arthroplasties performed in a month | n (%) |
| a) 0-25 | 352 (84.41 %) | |
| b) 26-50 | 41 (9.83 %) | |
| c) 51-75 | 6 (1.43 %) | |
| d) 76-100 | 10 (2.39 %) | |
| e) More than 100 TKRs per month on average | 8 (1.91 %) | |
| 5 | No. of primary total hip arthroplasties performed in a month | n (%) |
| a) 0-10 | 352 (84.41 %) | |
| b) 11-20 | 53 (12.70 %) | |
| c) 21-30 | 5 (1.19 %) | |
| d) 31- 40 | 3 (0.71 %) | |
| e) More than 40 THRs per month on average | 4 (0.96 %) | |
| 6 | Institution of practice | |
| a) Government Teaching Institute/Medical College | 102 (24.46 %) | |
| b) Private Teaching Institute/Medical College | 86 (20.62 %) | |
| c) Small private practice (Own nursing home/freelance) | 92 (22.06 %) | |
| d) Large corporate hospital | 137 (32.85 %) | |
| 7 | Participants fellowship trained in arthroplasty (%) | 248 (59.47 %) |
| 8 | Participants fellowship trained in computer-assisted navigation (Hip/Knee) | 131 (31.41 %) |
| 9 | Participants fellowship trained in Robotic assisted arthroplasty (Hip/Knee) | 101 (24.22 %) |
| 10 | Participant's institutions having computer-navigation system | 73 (17.50 %) |
| 11 | Participant's institutions having robotics for arthroplasty | 101 (24.22 %) |
Among the robotic systems used, the Mako Robotic system was the most common (15.34 %), followed by the Navio/Cori System from Smith-Nephew (6.23 %). Out of the 101 robotic users, 29 (28.71 %) were high-volume robotic surgeons who performed >50 % of their surgical volume using robotic assistance (Table 2).
| 1 | Utilization of Robotic system in institutions of survey participants | (n = 101) |
| Stryker MAKO Robotics | 64 (15.34 %) | |
| Smith-Nephew Navio/Cori | 26 (6.23 %) | |
| Meril Cuvis Joint System | 7 (1.67 %) | |
| Zimmer Rosa | 4 (0.95 %) | |
| 2 | % cases performed using robotic technology | (n=101) |
| 0–25 % | 35 (34.65 %) | |
| 25–50 % | 37 (36.63 %) | |
| 50–75 % | 21 (20.79 %) | |
| 75–100 % | 8 (7.92 %) |
| 1 | If the cost of robotics comes down, would you be interested in adopting it in your arthroplasty practice? | n = 417 | |||
| Yes | 326 (78.17 %) | ||||
| No | 23 (5.51 %) | ||||
| Undecided | 68 (16.30 %) | ||||
| Total (n=417) | Robotic Users/Robotic trained fellows (n=101) | Non users (n=316) | p-value chi-square | ||
| 2 | Robotic-assisted TKA/THA may be associated with better survival/implant longevity | ||||
| Agree | 189 (45.32 %) | 69 (68.31 %) | 120 (37.97 %) | P < 0.00001 | |
| Disagree | 53 (12.70 %) | 11 (10.89 %) | 42 (13.29 %) | ||
| Neutral (Undecided) | 175 (41.96 %) | 21 (20.79 %) | 154 (48.73 %) | ||
| 3 | Robotic technology leads to less complications after total joint arthroplasty | ||||
| Agree | 170 (40.76 %) | 53 (52.47 %) | 117 (37.02 %) | P = 0.0060 | |
| Disagree | 92 (22.06 %) | 26 (25.74 %) | 66 (20.88 %) | ||
| Neutral (Undecided) | 155 (37.17 %) | 22 (21.78 %) | 133 (42.08 %) | ||
| 4 | Robotics improves only implant positioning and alignment | ||||
| Agree | 276 (66.18 %) | 66 (65.34 %) | 210 (66.45 %) | 0.8376 | |
| Disagree | 64 (15.34 %) | 31 (30.69 %) | 33 (10.44 %) | ||
| Neutral (Undecided) | 77 (18.46 %) | 4 (3.96 %) | 73 (23.10 %) | ||
| 5 | Robotic-arm assisted surgery takes away surgeon autonomy. | ||||
| Agree | 101 (24.22 %) | 22 (21.78 %) | 79 (25 %) | P = 0.5113 | |
| Disagree | 251 (60.19 %) | 75 (74.25 %) | 176 (55.69 %) | ||
| Neutral (Undecided) | 65 (15.58 %) | 4 (3.96 %) | 61 (19.30 %) | ||
| 6 | Robotics is associated with reduced pain and faster rehabilitation after surgery | ||||
| Agree | 169 (40.52 %) | 59 (58.41 %) | 110 (34.81 %) | P < 0.0001 | |
| Disagree | 127 (30.45 %) | 27 (26.73 %) | 100 (31.64 %) | ||
| Neutral (Undecided) | 121 (29.01 %) | 15 (14.85 %) | 106 (33.54 %) | ||
| 7 | Robotics improves patient reported outcomes | ||||
| Agree | 184 (44.12 %) | 65 (64.35 %) | 119 (37.65 %) | P < 0.0001 | |
| Disagree | 76 (18.22 %) | 17 (16.83 %) | 59 (18.67 %) | ||
| Neutral (Undecided) | 157 (37.64 %) | 19 (18.81 %) | 138 (43.67 %) | ||
| 8 | Robotics will reduce the burden of revisions in the future | ||||
| Agree | 169 (40.52 %) | 57 (56.43 %) | 112 (35.44 %) | P = 0.0002 | |
| Disagree | 91 (21.82 %) | 18 (17.82 %) | 73 (23.10 %) | ||
| Neutral (Undecided) | 157 (37.64 %) | 26 (25.74 %) | 131 (41.45 %) | ||
3.2 Perception regarding the usefulness of robotic technology in arthroplasty (Table 3)
The majority of the study participants (66.18 %) believed that robotics only improved implant positioning and alignment. However, a large number of robotic users (30.6 %) disagreed with this statement. Even among the high-volume robotic surgeons who operated on more than 75 % of their cases with robotic assistance, 62.5 % believed that robotics contributed to improvements beyond implant positioning and alignment. Robotic users were highly convinced about the role of robotics in reducing pain and enabling faster rehabilitation (67.02 %). However, approximately one-third of the overall study participants remained unconvinced about these potential benefits (30.4 %) (Fig. 1). Similarly, approximately 44.12 % of surgeons agreed about the positive influence of robotics in enhancing patient-reported outcomes, although a substantial proportion of surgeons (37.6 %) remained undecided about this issue.
A considerable number of study participants (40.7 %) believed that the usage of robotics resulted in a lower incidence of complications. Although a large number of robotic non-users expressed a neutral stance towards this proposition (23.52 %), 57.44 % of the robotic users were convinced about the same. Among the high-volume robotic surgeons who operated on more than 50 % of their cases with robotic assistance, 68.9 % agreed that the usage of robotics resulted in a lower incidence of complications (Table 4). There was a significant difference in opinion among surgeons with <10 years and >20 years of arthroplasty experience (p ≤ 0.002), where the senior and higher experience group did not agree to the role of robotics in reduction of complications (Table 5). When enquired about the influence over surgeon's autonomy, majority of the surgeons agreed on the preservation of the surgeon's autonomy and decision making throughout the operative procedure (60.19 %), although a quarter of the non-users (19.30 %) remained undecided about this issue. The disagreement was even stronger in users who used robotic assistance in >25 % cases.
| Total | None (Non robotic surgeons) N = 323 | 1–25 % N = 28 | 25–50 % N = 37 | 50–75 % N = 21 | 75–100 % N = 8 | ||
| 1 | Robotic-assisted TKA/THA may be associated with better survival/implant longevity | ||||||
| Agree | 189 | 121 (37.46 %) | 14 (50 %) | 29 (78.37 %) | 17 (80.95 %) | 8 (100 %) | |
| Disagree | 53 | 48 (14.86 %) | 3 (10.71 %) | 2 (5.405 %) | 0 (0 %) | 0 (0 %) | |
| Undecided | 175 | 154 (47.67 %) | 11 (39.28 %) | 6 (16.21 %) | 4 (19.04 %) | 0 (0 %) | |
| 2 | Robotic technology leads to less complications after total joint arthroplasty | ||||||
| Agree | 170 | 116 (35.91 %) | 8 (28.57 %) | 26 (70.27 %) | 13 (61.90 %) | 7 (87.5 %) | |
| Disagree | 92 | 76 (23.52 %) | 11 (39.28 %) | 1 (2.702 %) | 4 (19.04 %) | 0 (0 %) | |
| Undecided | 155 | 131 (40.55 %) | 9 (32.14 %) | 10 (27.02 %) | 4 (19.04 %) | 1 (12.5 %) | |
| 3 | Robotics improves only implant positioning and alignment | ||||||
| Agree | 276 | 211 (65.32 %) | 21 (75 %) | 24 (64.86 %) | 17 (80.95 %) | 3 (37.5 %) | |
| Disagree | 64 | 39 (12.07 %) | 5 (17.85 %) | 11 (29.72 %) | 4 (19.04 %) | 5 (62.5 %) | |
| Undecided | 77 | 73 (22.60 %) | 2 (7.14 %) | 2 (5.405 %) | 0 (0 %) | 0 (0 %) | |
| 4 | Robotic-arm assisted surgery takes away surgeon autonomy. | ||||||
| Agree | 101 | 80 (24.76 %) | 7 (25 %) | 9 (24.32 %) | 4 (19.04 %) | 1 (12.5 %) | |
| Disagree | 251 | 181 (56.03 %) | 20 (71.42 %) | 28 (75.67 %) | 15 (71.42 %) | 7 (87.5 %) | |
| Undecided | 65 | 62 (19.19 %) | 1 (3.57 %) | 0 (0 %) | 2 (9.523 %) | 0 (0 %) | |
| 5 | Robotics is associated with reduced pain and faster rehabilitation after surgery | ||||||
| Agree | 169 | 106 (32.81 %) | 13 (46.42 %) | 28 (75.67 %) | 16 (76.19 %) | 6 (75 %) | |
| Disagree | 127 | 110 (34.05 %) | 8 (28.57 %) | 4 (10.81 %) | 5 (23.80 %) | 0 (0 %) | |
| Undecided | 121 | 107 (33.12 %) | 7 (25 %) | 5 (13.51 %) | 0 (0 %) | 2 (25 %) | |
| 6 | Robotics improves patient reported outcomes | ||||||
| Agree | 184 | 114 (35.29 %) | 12 (42.85 %) | 31 (83.78 %) | 19 (90.47 %) | 8 (100 %) | |
| Disagree | 76 | 68 (21.05 %) | 6 (21.42 %) | 1 (2.702 %) | 1 (4.761 %) | 0 (0 %) | |
| Undecided | 157 | 141 (43.65 %) | 10 (35.71 %) | 5 (13.51 %) | 1 (4.761 %) | 0 (0 %) | |
| 7 | Robotics will reduce the burden of revisions in the future | ||||||
| Agree | 169 | 116 (35.91 %) | 8 (28.57 %) | 28 (75.67 %) | 12 (57.14 %) | 5 (62.5 %) | |
| Disagree | 91 | 83 (25.69 %) | 4 (14.28 %) | 2 (5.405 %) | 2 (9.523 %) | 0 (0 %) | |
| Undecided | 157 | 124 (38.39 %) | 16 (57.14 %) | 7 (18.91 %) | 7 (33.33 %) | 3 (37.5 %) | |
| Total | <10 years n = 285 | 10–20 years n = 76 | >20 years n = 56 | P value* Chi-square test | ||
| 1 | Robotic-assisted TKA/THA may be associated with better survival/implant longevity | |||||
| Agree | 189 | 147 (51.57 %) | 25 (32.89 %) | 17 (30.35 %) | p < 0.0038ap = 0.0037b | |
| Disagree | 53 | 28 (9.824 %) | 16 (21.05 %) | 9 (16.07 %) | ||
| Undecided | 175 | 110 (38.59 %) | 35 (46.05 %) | 30 (53.57 %) | ||
| 2 | Robotic technology leads to less complications after total joint arthroplasty | |||||
| Agree | 170 | 133 (46.66 %) | 23 (30.26 %) | 14 (25 %) | P = 0.0104aP = 0.0028b | |
| Disagree | 92 | 53 (18.59 %) | 24 (31.57 %) | 15 (26.78 %) | ||
| Undecided | 155 | 99 (34.73 %) | 29 (38.15 %) | 27 (48.21 %) | ||
| 3 | Robotics improves only implant positioning and alignment | |||||
| Agree | 276 | 188 (65.96 %) | 50 (65.78 %) | 38 (67.85 %) | P = 0.9766aP = 0.7848b | |
| Disagree | 64 | 44 (15.43 %) | 12 (15.78 %) | 8 (14.28 %) | ||
| Undecided | 77 | 53 (18.59 %) | 14 (18.42 %) | 10 (17.85 %) | ||
| 4 | Robotic-arm assisted surgery takes away surgeon autonomy. | |||||
| Agree | 101 | 73 (25.61 %) | 19 (25 %) | 9 (16.07 %) | P = 0.9138aP = 0.1273b | |
| Disagree | 251 | 170 (59.64 %) | 43 (56.57 %) | 38 (67.85 %) | ||
| Undecided | 65 | 42 (14.73 %) | 14 (18.42 %) | 9 (16.07 %) | ||
| 5 | Robotics is associated with reduced pain and faster rehabilitation after surgery | |||||
| Agree | 169 | 127 (44.56 %) | 22 (28.94 %) | 20 (35.71 %) | P = 0.0141aP = 0.2222b | |
| Disagree | 127 | 77 (27.01 %) | 27 (35.52 %) | 23 (41.07 %) | ||
| Undecided | 121 | 81 (28.42 %) | 27 (35.52 %) | 13 (23.21 %) | ||
| 6 | Robotics improves patient reported outcomes | |||||
| Agree | 184 | 144 (50.52 %) | 23 (30.26 %) | 17 (30.35 %) | P = 0.0017aP = 0.0058b | |
| Disagree | 76 | 40 (14.03 %) | 20 (26.31 %) | 16 (28.57 %) | ||
| Undecided | 157 | 101 (35.43 %) | 33 (43.42 %) | 23 (41.07 %) | ||
| 7 | Robotics will reduce the burden of revisions in the future | |||||
| Agree | 169 | 130 (45.61 %) | 24 (31.57 %) | 15 (26.78 %) | P = 0.0281aP = 0.0093b | |
| Disagree | 91 | 55 (19.29 %) | 21 (27.63 %) | 15 (26.78 %) | ||
| Undecided | 157 | 100 (35.08 %) | 31 (40.78 %) | 26 (46.42 %) | ||
| Sr. | Limitation for robotic usage | Total | Users | Non users |
| 1 | Cost of robot/Installation cost | 390 (93.52 %) | 91 (90.09 %) | 299 (94.62) |
| 2 | Lack of complete insurance cover for robotic-assisted arthroplasty procedures | 345 (82.73 %) | 83 (82.17 %) | 262 (82.91 %) |
| 3 | Limited availability and a lack of formal training or certification programs | 306 (73.38 %) | 52 (51.48 %) | 254 (80.38 %) |
| 4 | Resistance from corporate management based on cost-effectiveness | 288 (69.06 %) | 59(58.41 %) | 229 (72.47 %) |
| 5 | Issues with patient acceptance and/or affordability | 284 (68.10 %) | 61 (60.39 %) | 223 (70.57 %) |
| 6 | Published literature does not show distinct advantage of robotics over manual surgery | 271 (64.98 %) | 53 (52.47 %) | 218 (68.99 %) |
45.32 % of the surgeons were convinced about the potential of robotics to enhance survival and longevity in total knee arthroplasty. This perception was twice as prevalent among robotic users than non-users. Among the high-volume robotic surgeons who performed more than 50 % of their cases with robotic assistance, 86.2 % believed that robotics played a key role in improving the survival and longevity of their operated knees. Although the majority of the surgeon participants agreed that robotics would reduce the burden of revisions in the future, almost one-third of the study participants remained uncertain about this proposition (37.64 %). This consensus did not differ between high- and low-volume robotic surgeons.
Overall, a significant proportion of the participating surgeons (78.1 %) expressed a willingness to integrate robotics into their arthroplasty practice, provided that the cost of this technology is lowered. The inclination towards adoption was higher in robotic trained surgeons (88.11 %), whereas a significantly higher number of non-robotic trained surgeons were undecided regarding the same (18.98 %).
A significant difference in opinion was noted between robotic users and non-users for questions linked to the role of robotics in improving longevity (p < 0.00001), reduction in complications (p = 0.006), better rehabilitation (p = 0.0001), improved outcomes (p < 0.0001) and reduced burden of revisions (p = 0.0002). Both groups exhibited agreement on the matters pertaining to the surgeon's autonomy (p = 0.8376) and positioning of the implant (0.5113). Further a subgroup analysis was done based upon the % volume operated with robotic assistance. As the operated volume using robotic assistance increased, the perception in favour of robotics increased. Higher volume robotic surgeons (volume 50 % and above) were almost fully convinced about the role of robotics in improvement of outcomes (93.1 %), reduction in pain and faster rehabilitation (75.86 %), and better longevity (86.20 %).
In order to note the difference in perception based upon years of surgical experience, the surgeons were divided into 3 groups, <10 years, 10–20 years, >20 years. Overall, surgeons with <10 years of arthroplasty experience were in favour of robotics, in contrast to those >20 years of arthroplasty experience who were majorly non decisive with respect to its effect over longevity (53.56 %), complication rates (48.21 %), outcomes (41.07 %) and reduction in burden of revisions (46.52 %).
3.3 Limitations for robotic usage in arthroplasty (Table 6)
Installation cost (93.52 %) and lack of complete insurance cover for robotic assisted arthroplasty procedure (82.73 %) were the two biggest hurdles against adoption of robotic technology in arthroplasty. This was followed by lack of formal robotic training opportunities (73.3 %), resistance from corporate management (69.1 %), and issues with patient's acceptance (68.1 %). Furthermore, the lack of published literature demonstrating clear benefits of robotic-assisted arthroplasty over traditional manual surgery led to some surgeons refraining from adopting the technology.
4 Discussion
Robotic arm assistance is currently at the forefront of technological innovations in the field of orthopaedics.23,24 Computer navigation, which was introduced in the field of orthopaedics three decades ago, assisted surgeons in managing complicated deformities with precision. Although computer-navigation empowered the surgeons with better component positioning, they were accompanied with inherent problems of cost, accessibility, increased surgical time, and longer learning curve.25 Besides, although the jig-placement was guided, the cuts were performed manually using the standard saw system. Ever since robotic technology was introduced in the market, it underwent several generations of improvement until, Mako robotic arm, manufactured by Stryker Corporation was approved for use by FDA.26 Several semi-automatic to fully automatic arthroplasty robots are presently available for use in Indian market, however, it has still not achieved a significant market share of arthroplasty due to several reasons. The present study was unique in identifying the reasons for and against the use of existing robotic technology in the field of arthroplasty in India. The study was unique as it considered inputs from only practising arthroplasty surgeons with a relatively high response rate (43.8 %).
The study included a significant proportion of participants practising in institutes having computer navigation (17.50 %) or robotic assistance for arthroplasty (14.22 %) or both, thus avoiding a selection bias. Most of the study participants were fellowship trained in arthroplasty (59.47 %), thus ensuring the quality of the responses. Although, majority of the participants were young surgeons with <10 years of arthroplasty experience (68.34 %), all of them regularly performed hip and knee arthroplasties every month. MAKO (Stryker corporation) was the most use robotic system (15.34 %) followed by Smith-Nephew Navio/Cori (6.23 %).
Among the ISHKS members, 78.17 % of the study participants were willing to adopt robotics into their arthroplasty practice provided the cost of installation would come down, with few being undecided and only a fraction (5.15 %) not willing to accept robotic technology. A significant volume of surgeons were convinced regarding the role of robotics in improving alignment, reduction of pain and reduction of complications, however, the non-clinical motivators like marketing, administrative and peer pressure and patient demand for technology were not studied in our survey. A study conducted among AAHKS members revealed that the aforementioned non-clinical factors served as motivators for robotic adoption in 19.7 % of robotic users and 40.1 % of non-users.21
When queried about implant positioning and alignment, a substantial majority of surgeons (66.18 %) were convinced of the significant role played by robotics in enhancing overall implant alignment. This conviction was bolstered by comparative studies conducted in the past, which compared alignment goals and results between robotics and conventional techniques. Notably, high-volume robotic surgeons, who performed 80–100 % of their cases using robotics, believed that robotics encompassed a broader scope beyond merely improving implant positioning and achieving alignment goals. This belief was supported by the work of Masse et al., who successfully employed the ROSA robotic system to perform TJA with personalized alignment techniques, thereby restoring knee alignments specific to each patient's pre-osteoarthritic phenotype.27 Multiple studies have demonstrated outstanding outcomes where individualized functional alignment was achieved through the utilization of robotic technology.27–29
Among the participants of the study, the primary obstacle to widespread adoption of robotics in the Indian context was the substantial cost associated with installation (93.52 %). The price tag for acquiring an arthroplasty robot in India ranged from $0.9 to 2 million. Furthermore, a significant hindrance to the utilization of robotics among surgeons stemmed from incomplete insurance coverage (82.73 %). As per the guidelines set forth by the Insurance Regulatory & Development Authority of India (IRDAI) in 2019, insurance companies were mandated to include coverage for robotic-assisted procedures within the scope of modern treatment.30 However, most insurance providers only offer limited coverage for such procedures. A substantial majority of surgeons experienced a notable lack of access to formal training programs in robotic surgery, which consequently acted as a significant obstacle preventing their adoption of robotics in arthroplasty practice. Fixed package rates, coupled with a competitive market environment and pressure from corporate management to contain costs, emerged as another significant hindrance to the widespread adoption of robotics. Patient acceptance and lack of literature supporting distinct advantage of robotics over conventional techniques were yet other limiting factors.
Following the framework of Roger's diffusion of innovation,22 the surgeon participants in our study were classified according to their inclination to embrace new technological innovations. The majority of surgeons fell under the category of enthusiasts, accounting for 43.40 % of the participants, displaying a strong willingness to experiment with novel technological advancements. Subsequently, 25.89 % of the participants exhibited visionary characteristics, indicating their readiness to adopt after observing positive outcomes in a few notable case series. Only a small fraction, comprising 2.63 % of the individuals, adhered to a traditionist mindset, reluctant to explore and adopt new innovations (Table 7).
| Under which category of technology adoption would you classify yourself under? (n = 417) | N(%) |
| Early majority- I'll use it if enough people I trust use it | 57 (13.66 %) |
| Enthusiast- I'll try anything new if it has a possibility of being better | 181 (43.40 %) |
| Sceptic- Give me well-designed prospective randomized controlled trials before I consider it | 60 (14.38 %) |
| Traditionalist- It's a fad | 11 (2.63 %) |
| Visionary- I'm willing to test it out if there are a couple of good case series | 108 (25.89) |
| Arthroplasty experience | Early majority | Enthusiast | Sceptic | Traditionalist | Visionary | Total |
| <10 years | 44 | 127 | 33 | 7 | 74 | 285 |
| 11–20 years | 6 | 30 | 17 | 2 | 21 | 76 |
| >20 years | 7 | 24 | 10 | 2 | 13 | 56 |
| Total | 57 (13.66 %) | 181 (43.40 %) | 60 (14.38 %) | 11 (2.63 %) | 108 (25.89 %) | 417 |
One of the notable strengths of our study was the ability to capture a wide range of opinions and perceptions from arthroplasty surgeons who varied in terms of age, experience, and exposure to robotic technology. This allowed us to present a comprehensive understanding of the subject matter. In addition, our study effectively showcased the receptiveness and openness of the surveyed group towards embracing and adopting new technological advancements.
There are some limitations of this study. Firstly, as with most online questionnaire-based surveys, the response rate is limited and provides a relatively narrow view of the whole demographic. However, this is the easiest and most efficient way to disseminate survey material. Secondly, it was difficult to evaluate non-clinical factors such as marketing, monetary, or financial liabilities or incentives associated with robotic usage or adoption. Thirdly, the AAHKS questionnaire was modified to reflect the general usage of technology in the Indian environment, and the amended questionnaire was distributed to senior surgeons who were designated Key Opinion Leaders within the national faculty. The questionnaire was finalized based on their suggestions and was not subjected to validity assessment. Finally, all participants in the study were practicing arthroplasty surgeons with various levels of expertise. We did not distinguish and stratify surgeons based on their membership status with national arthroplasty bodies or based on their practice setup (For example, Rural versus urban centres, Solo versus team or group practice).
5 Conclusion
There is an increasing adoption of robotic technology in India for total joint arthroplasty. This survey showed cost remains the major impediment against the adoption of robotics in arthroplasty. As the cost of the robotic systems reduces, we may see a significant rise in the number of installations across the country. Insurance reimbursement remains a challenge for both surgeons and patients, which may require advocacy from the national orthopaedic organizations to change.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Ethical committee approval
Taken.
Author contribution
All authors contributed equally to this manuscript.
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