In the first of a season of posts exploring the tension between emerging technology and traditional clinical judgement, Yorkshire Knee Clinic’s Prof. Nick London explores the current state of play – and starts by busting a few myths.
It’s easy to get carried away with technology. Certainly, for many of the patients I talk to, there’s something very persuasive and appealing about a robot having an (artificial) hand in your knee surgery. The precision. The risks and judgement calls reduced to simple 1s and 0s. How can that not be better?
Given our natural inclination to put our faith in new technology that seems just one step removed from magic, robot knee surgery has become fertile ground for companies to make big claims. They don’t have to make untrue claims – they simply have to dangle the carrot and let our minds fill in the blanks. And if the insurance company will pay for it, what does it matter that the surgery is more expensive than traditional methods?
People don’t even contemplate the idea that knee surgery involving robots could be worse.
In defence of technology
This isn’t a rant against technology. The knee consultants at Yorkshire Knee Clinic are regularly involved in the development of new implants, processes and technologies. We welcome anything that reduces risk and/or improves patient outcomes. You can read more about the technologies that are (or are about to) make a real difference to the work of knee surgeons here.
At some point in the fairly near future, artificial intelligence may reach a point at which knee surgeons can oversee procedures whilst a robot does all the physical work. When that work delivers better results, reduces risk and cuts costs we’ll be all for it. That day (or something fairly close to it) is coming, but we are not there yet.
The fact is we’ve been here before. Patient specific instrumentation, for example, was pitched as a technological solution for improving the accuracy of total knee replacements, but whilst studies identified some limited benefits to the system, they were outweighed by just as many (if not more) negative effects – not least of which was cost.
Robotics appears, at present (with the emphasis very much on ‘at present’) to be following a similar path. No robot currently performs any part of the soft tissue surgery – that’s still entirely the domain of the knee surgeon. But a robot may be used as a cutting tool. Without the correct data fed to it the robot cannot make the correct cut – so the experience of the knee surgeon remains vital in spotting when the robot is wrong.
There is some (fairly weak) evidence to suggest that the accuracy of the cut is improved using the robot but most of the time we’re talking here about the robot following measurements given to it by the surgeon.
Where the position is reversed and the robot guides the surgeon, the picture is considerably muddier. Computer navigated surgery involves the knee surgeon inserting a series of pins into the bone above and below the knee which the computer can use as reference points to understand the full topography of the knee. It may sound impressive, but the process swallows up time, may increase the risk of infection (because more or larger incisions increase risk) and simply doesn’t deliver the required ‘bang for your buck’.
Cost / benefit
Ultimately, that has been the deciding factor for technological development in knee surgery to date. It costs considerably more. It may increase risk. And there’s no compelling evidence to suggest it improves outcomes.
There is, however, compelling evidence that experience does lead to better outcomes. Generally speaking, a knee surgeon who has performed many procedures in a facility that has also seen many successful operations is more likely to deliver better results than either a robot or a less experienced surgeon. And using a robot does not remove that need for experience.
The position regarding robotics will change. As technology gets better it gets cheaper, and there will be a point at which the clinical and cost benefits align. For now, the knee specialists at Yorkshire Knee Clinic continue to seek and evaluate new implants, technologies and procedures.
But if you need a knee replacement in the near future and your choice is between a robotically ‘enhanced’ procedure or a knee surgeon who has performed thousands of successful operations, well… it doesn’t take a computer to work out the answer.
Prof. Nick London
Specialist Knee Surgeon & Visiting Professor to Leeds Beckett University
“An excellent knee surgeon. He probably does as many partial knee replacements as anyone in the country.”
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