Orthopaedics is one of the primary areas of surgery where robotic applications have been developed. Though robotic surgery is already in use, it continues to raise questions in terms of safety, cost effectiveness of the technology, practicality, and whether it is the best option for surgeons.
The spanner in the works
In terms of enhancing patient care and offering the best technology for medical professionals to perform robotic surgeries, there are many obstacles and limitations to conquer before robotic surgery technique can be incorporated fully into the medical domain.
Despite having advantages such as better accuracy levels and precision in the preparation of bone surfaces, more consistent and reproducible results and better spatial accuracy over conventional orthopaedic procedures, the successful use of robotic surgery in the field of orthopaedics continues to be questioned.
While several short-term studies have substantiated the feasibility of using robotic applications in orthopaedic surgeries, factors such as low ROI, the need for special training and limited applicability have contributed to the restricted use of robotics in orthopaedics. Also, because there are no published long-term data describing the efficiency of robot-supported orthopaedic surgery, the technology remains underused.
Advancing technology moves robotics ahead
The medical industry has seen dramatic changes in terms of technological advances and developments associated with computer and robot-assisted surgical procedures. These changes have been made possible not only by advances in engineering technology and computing, but also by the need to improve clinical outcomes, reduce cost and improve the efficiency of health delivery.
Robotics technology has been developed since 1983 for a variety of surgical speciality areas such as orthopaedics surgery, cardiac surgery, abdominal surgery, neurosurgery and thoracic surgery, among others.
The introduction of robotic technology in orthopaedics surgery in the late 1980s has shown the path to lead to the first robot-assisted hip replacement performed on a human in the year 1992. This technology was subsequently commercialised in 1994 following approval by the EU.
Though the majority of the preliminary research and development was carried out by schools and centres in Germany, the interest has spread not only over its European counterparts but also to North America and the rest of the world.
Orthopaedic applications that are of maximum interest to surgeons, scientists and hospitals are knee and hip replacement and spinal fusion. Bones are relatively simple to manipulate and deform little during the process of cutting when compared to operating on soft tissues, so image-driven techniques are quite straightforward for the implementation purpose of surgeries.
The outcome is that robotic applications can result in better agreement with a predefined plan than with similar manual procedures. Additional work is being carried out in the other areas such as fracture treatment and craniofacial reconstruction.
Commercially available robotic devices can be classified as active or passive devices or can be classified as positioning or cutting/milling devices. Some of the well-known specific path techniques used in orthopaedic surgeries include ROBODOC, ACROBOT, CASPAR (Computer Assisted Surgery, Planning and Robotics) and Minerva (neurosurgical robot).
Where robotics really help
The major advantages of robot-supported orthopaedic surgery over conventional orthopaedic procedures are better accuracy level and precision in the preparation of bone surfaces, more consistent and reproducible results, and better spatial accuracy. The orthopaedics field is ideally suitable for robotic system application since the ability to separate and rigidly fix bones in known positions that allows robotic systems to be securely fixed to the bone.
In robot-supported orthopaedic surgeries the utilisation of semi-active systems is the area with the most potential for future research and applications. The robot system acts as an advanced tool, merging the experience of the surgeon along with the system's advantages. The main reasons why robot-supported orthopaedic surgery has gained importance over computer-assisted surgery are better levels of accuracy, precision and safety.
Existing robotic applications in surgery consist of positioning devices such as AESOP/Sydne (Intuitive Surgical, Inc), telesurgical manipulators such as Robodoc (Integrated Surgical Systems), NeuroMate (Integrated Surgical Systems), Acrobot (Acrobot Company Ltd), image-driven radio surgical systems like CyberKnife (Accuray, Inc) and Da Vinci (see figure 2) and Zeus (Intuitive Surgical, Inc).
The clinical areas where robotic technology is being used include advanced cardiac surgery, gastrointestinal surgery, neurosurgery, gynaecology, orthopaedics, paediatrics, radio surgery and urology.
Where robotics goes wrong
Robotic surgery is relatively new technology and its utilities and efficiency have not yet been fully established. To date, only studies pertaining to feasibility have been conducted and no long-term trial studies have been executed. Several procedures need to be redesigned in order to optimise robotic arms use and enhance efficiency level.
Another drawback of robotic systems is their cost. With a price tag of nearly a million dollars, cost effectiveness has always been a concern.
Whether the cost of robotic systems will rise or fall in the near future will completely depend upon the improvements in technology such as haptics, increased processor speed and gaining of experience with robotic systems.
The cost factor will also depend on how much hospitals and health organisations have to spend to upgrade their existing systems. Furthermore, the success of robotic systems will depend on the recognition based on their widespread multidisciplinary use.
Another disadvantage of robotic systems is the relatively big footprints and cumbersome robotic arms that these systems come with. Considering the fact that most hospitals are already struggling with crowded operating rooms, it becomes very difficult for the robot and the surgical team to fit into the operating room.
In this case, miniaturisation of the robotic arms and tools or the installation of larger operating rooms with wall mountings and multiple booms will have to be addressed for the robotic systems. This will in turn increase the cost of building rooms for these robots. Furthermore, a lack of well-suited compatible equipment and instruments increases dependence on tableside assistants to do part of the surgery.
In addition to the aforementioned factors, many top companies are of the opinion that the use of robotic surgery is not very relevant in the field of orthopaedics. The need for robotic surgery is where the demand for accuracy is very high and in surgeries where there are chances that surgeons' hand tremors could create complications.
While performing procedures like nerve resection or procedures within the brain, the use of surgeons' hands are supposed to be avoided. In conditions like this, robotic surgery is highly recommended as it can be finely controlled by the surgeon to achieve the highest accuracy levels.
However, in orthopaedics, a surgeon can achieve the same level of accuracy without using the robot system. Also, unlike in other surgeries, orthopaedics surgery is a skilful surgery which requires the complete involvement of a surgeon. It requires in-depth evaluation, precision and implantation techniques to be carried out by a surgeon.
For closed surgeries (without opening the fracture), robotics surgery can play a significant role. The future of robotic surgery technology depends completely on the improvement of existing surgical methods and techniques. At this time however, robotic surgery still remains as a novel concept and the accessibility of long-term results regarding the success of effective procedures is quite limited.