HSS’ Use of Robotics in Surgery

Todd Albert, M.D. is surgeon-in-chief and medical director and Korein-Wilson Professor of Orthopaedic Surgery at Hospital for Special Surgery (HSS) in New York. Dr. Albert, president-elect of the Scoliosis Research Society (SRS), knows that as a surgeon, it’s good to control what you can control. One way of doing this that incorporates the value of listening to patients is by using a technology they are asking for—robotics.

“A full 1% of all joint replacements in the entire country are performed at HSS,” says Dr. Albert to OTW. “People seek out what is new and if we can give them that in a safe manner, then we are being responsive to our patients. In addition, we have a responsibility to orthopedic surgeons to define what is best. And while I am not saying robotics are necessarily the best option, we have an obligation to invest in them given their proven track record in some procedures.”

“HSS invests in robotics research because our surgeons—who drive innovation—are interested in it and want to take the lead in stellar patient care. Many total joint surgeons do not use robotics, however, if the data show improved results then they will end up adopting robotics.”

At present, HSS has three Stryker Mako machines, which are primarily being utilized in knee and hip surgery. One lucky HSS physician who pioneered the use of these sophisticated machines is Andrew Pearle, M.D. He told OTW, “We do approximately 500 partial knee replacements a year, 85% of which are done using a robot; we perform over 100 total knee surgeries a year using a robot. In all, we do more robotic cases worldwide of any facility.”

“Although we are beginning to show a clinical impact with partial knee replacement, it is not clear that this will be the case with total knees and hips. There was an early high failure rate with partial knees so it was easy to see a clinical impact. The robots control a lot of crucial surgical variables that have a direct bearing on clinical impact (long leg alignment, implant congruence, soft tissue balance). The robot controls all those simultaneously so the doctor can understand the tradeoffs of different implant positions.”

“And while the clinical outcomes are excellent with robotics in total hip and total knee surgery, it is not clear which set of variables will have an impact on clinical outcome. Robotics are definitely refining our surgical technique so the X-rays look perfect every time. And that is what you want…utmost control of your surgical technique.”

“We are part of a six-center study for robotics in partial knee replacement. This involves nearly 1,000 knees, 2.5-year follow-up, and 98.9% survivorship. There is a 60-70% drop in early failures in other cohort and registry studies so thus far our study has the best survival in the short term.”

Only a facility such as HSS could undertake such grand plans. “Robotics are an expensive undertaking,” says Dr. Pearle. “The capital cost is high ($1 million per machine), you need more personnel, and an OR that is a reasonable size. The set up takes more time and there is a 5-20 case learning curve. The biggest issue is getting the initial workflow settled (how to position the machine and orienting your team to a heavy piece of equipment).”

“In the past, robotic technologies have often been sold on marketing as opposed to clinical outcomes—something which has resulted in a great deal of skepticism. We are quite serious about doing research with them, however, and we do not market our use of robots.”