Joint replacement of the knee, hip, and shoulder has witnessed substantial improvement in implant design over the past 4 decades. Modern materials, fixation methods, manufacturing, and sterilization techniques now allow patients to engage in a high level of physical activity and still enjoy 20+ years of pain relief and improved function from their implant. Surgical techniques have also advanced to reduce tissue trauma and disrupt less muscle around the joint. This can speed recovery and result in less pain and better ultimate outcomes. As implant design has reached maturity and most companies offer similar options to one another, implant companies are now focusing their strategy on technology to capture market share and drive implant sales.
Such technology may include robotic-assisted surgery, non-robotic surgical navigation systems, augmented reality holographic overlays of patient anatomy, and other software-based tools that surgeons can use to provide information about implant placement and optimal soft tissue tension during surgery. The idea behind most of these technologies is to improve the precision of implant placement during surgery with the theory that optimized sizing and placement will yield better short and long-term outcomes and lower implant-related complications such as loosening, wear, and functional issues related to malalignment.
While the benefit of precision on outcomes seems logical, in fact, the picture is more nuanced when one considers what this precision is measured against. Arthritic joints suffer from anatomic derangement in the forms of bone wear, soft tissue contracture, and mechanical malalignment compared to anatomic norms. Determining what an anatomic implant position should be in the setting of boney deformity and soft tissue contracture can be difficult especially when one considers that most implants are off-the-shelf and not custom fit to a patient’s specific boney geometry. Thus a robot can precisely replicate a CT-based virtual preoperative plan of an individual patient’s surgery, but that plan is just an estimation or guess as to what implant position “should” result in improved function and implant longevity.
To date, for many joint replacement procedures, there are no gold standard consensus guidelines for optimal implant placement and there is also very limited evidence that advanced technology such as robotic-assisted surgery leads to any significant improvement in the long-term outcomes. A potential danger of such technology is that surgeons who rely on technology to perform joint reconstruction are unable to do the operation well without said technology. Reliance on these solutions may train a generation of surgeons that never really learn to navigate the nuances of joint replacement using the precision of their experience-based tactile feel and vision.
An apt analogy is when the pilot Chesley Sullenberger successfully landed his plane in the Hudson River after a bird strike took out both engines and he lost all thrust. This was a scenario where autopilot and simulation were unable to account for all of the variables that necessitated his emergency landing in the river. The overarching message from this story is that you have to know how to fly the plane when difficult situations occur and you need the experience and intuition that sometimes technology cannot provide.
Experience is our hallmark at the Knee Hip and Shoulder Center. We have performed thousands of knee, hip, and shoulder replacements and based on this extensive experience have chosen the implants the technology that provides true value to patient outcomes and is not just a marketing ruse to attract patients on the promise of better outcomes. As implant companies focus more of their strategic growth on technology that results in implant sales, direct-to-consumer marketing will deliver messaging to prospective patients that is not evidence-based nor free from bias. Our commitment is on real outcomes, not promises that are built on hype. We know how to fly the plane and our AVATAR approach is a testament to this expertise.