Fremont, Calif.-based Arthur Ting, MD, was first introduced to robotic technology for knee surgery at an ambulatory surgery center.
As an experienced sports medicine physician who underwent a fellowship at Kerlan-Jobe Orthopaedic Clinic in Los Angles, Dr. Ting was interested in learning more about how robotic technology could help him perform more precise knee replacement procedures.
No other orthopedic device company allows real time virtual trialing and robotic tooling. The robotic technology was an easy fit for the surgery center because there was a total joint replacement program at the center already. "The robotic technology makes doing the knee replacements more reproducible and more precise," says Dr. Ting. "However, it was a process for me to incorporate the technology into my practice. There is a definite learning curve, but as a joint surgeon it allowed me to learn."
Jess Lonner, MD, an orthopedic surgeon at Rothman Institute and Jefferson Surgical Center at the Navy Yard, and his colleagues compared partial knee replacements with the Navio system to conventional surgical techniques and showed the use of robotics can improve bone preparation precision prosthesis alignment and soft tissue balance in partial knee replacements. Taken together, these factors improve outcomes and durability.
The initial cadaveric study included 25 knees to show the precision of bone preparation using the Navio system. A further clinical study including the initial 70 cases performed at the center with the Navio system found the alignment was within one degree of the preoperative plan in 92 percent of the cases. There were no instances of inadvertent soft tissue complications.
These procedures were performed in the surgery center — some days performing five partial knee replacements in addition to a few arthroscopic surgery cases at the ASC and the patients were discharged home after an average of three hours in the PACU. There were no hospital readmissions.
Learning the technology
Dr. Ting performed his first 35 robotically-assisted knee surgeries with an expert surgeon in the technology; then he felt confident doing the procedure on his own. He found the experienced surgeon's mentorship invaluable as he paved the way for bringing robotics into his surgery center and realized clinical advantages for his patients.
When he first began using the technology, Dr, Ting was amazed at how perfect the X-rays looked with regards to alignment and implant placement preciseness. Surgeons take images of the patient’s anatomy and plan the procedure based on those images. Then, the robotic system guides their procedure through the patient's anatomy.
"You've already committed to your cuts and you now trailing implants using standard instrumentation," he says. "The experience of watching the technology and being able to observe how accurately one was able to balance the knees introaoperatively prior to cutting was exciting. Being able to do the procedure virtually and make adjustments to the procedure experientially with computer technology makes the procedure more accurate when we perform in on the patient."
One of the huge drawbacks to acquiring new technology — even technology that shows clinical benefit — is cost. ASCs operate on a tight margin and new technologies, including the robot, come at an expense. However, more device companies now are developing platforms to meet the ASC's unique needs.
"The big advantage of the Navio system over other devices is the cost allows surgeons to introduce it introduce it into their ASCs," says Dr. Ting. "It's about one-fifth the cost of other robotic systems, so that's been a significant advantage for us.”
Dr. Ting can use the Navio system on all his patients — even Medicare patients — and finds the technology cost-effective. The machine is also mobile, so he can take it from one operating room to another — or one facility — without experiencing a huge financial burden.
“The mobility and overall cost of the Navio makes it much more practical in the outpatient setting," he says. "And there is no difference between Medicare of private insurance Navio system cost per case. We are able to use it with every patient whether the patient is contracted or non-contracted, Medicare or non-Medicare; that's been huge.”
It took about 30 cases for Dr. Ting's center to break even financially. The break even point is dependent on the profile of the ASC's payer mix, but generally after the first 30 cases the costs are comparative to cases with using the robot. Navio relieves the cost barrier for acquiring new technology and allows centers to cater toward physicians who want to use the new technology.
"The surgery center I work for has been physician-friendly and they usually accommodate physicians in any way they can, unlike most hospital settings," says Dr. Ting. "It was quite easy introducing the Navio into the ASC, especially since I had previous experience using the robotic system. The staff was in-serviced and we developed a comprehensive program."
Taking the robot outpatient
The center was already cutting-edge, hosting total joint replacements, and the robotic technology became another step in providing high-level care; however, if centers are not already performing at least partial knee replacements, incorporating the robot is more onerous.
"You would have to start from the beginning and get everything in place from the preoperative initiative, anesthesia and actual intraoperative procedure for the joint replacement," says Dr. Ting.
"You have to replace blood loss, monitor the patient intraoperatively and prepare the patient postoperatively with everything from anticoagulation to physical therapy. It would be a large undertaking but something more centers are moving toward in the future. I think that's going to become part of the standard of care for joint replacements are done at ASCs."
Robotic technology is revolutionizing surgical care; several specialties now routinely use robots during procedures for accuracy and guidance. Hospitals advertise the new technology as "revolutionary" and patients are becoming more educated about the possibility of better outcomes with the robot. In some cases, patients are even seeking out surgeons who use this technology.
"In the past, this technology has been somewhat less accessible to everyone because of the cost, but now we have a system that eliminates that barrier and people are learning more about robotics," says Dr. Ting. "I see more patients more requesting it."
Trailblazing in the future
There are many new technologies in orthopedics, from biologic solutions to implant design, but Dr. Ting sees robotic systems continuing to develop and becoming a larger part of the surgeon's armamentarium in the future. Current numbers show around 10 percent of knee replacements performed in the Unites States are partials, but some projections show the procedure exploding by more than 650 percent over the next 25 years.
"The robotic technology has allowed us to perform surgery more precisely, more accurately and have greater reproducibility; therefore, as physicians, we will want to use it," Dr. Ting says. "Because the Navio system has been successful, I think its use will rise exponentially. The demand for partial knee replacements is on the rise, and I think it will grow in the future."
The move toward ambulatory surgery centers is also gaining traction among orthopedic surgeons. ASC investment allows surgeons to remain independent while providing their patients a safe environment for surgery. ASCs typically have lower infection rates than hospitals and the personalized attention patients receive from staff make ASCs an ideal place for surgery. Advancement in pain management techniques allow patients to return home the same day of surgery and the quicker postoperative ambulation shortens recovery time.
"ASCs are built just for surgery whereas hospitals treat anyone from the terminally ill to the acutely ill patients, and then also surgery," says Dr. Ting. "For the surgeon, the ambulatory care center is set up specifically catering to their procedure and often they work with the same staff every day. I think there is a trend to bring all sorts of procedures into the ASC, and partial knee replacement is a perfect fit. Inevitably, I think all partial knees will be done in an ASC at some point in the future."
Robotic technology is now used in around 15 percent of partial knee replacements. A recent BCC Research report estimates the medical robotics and computer-assisted surgical technologies market will reach $4.6 billion in 2019, growing at a five-year compound annual growth rate of 7 percent. The United States is expected to account for 75 percent of the market by 2019.
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