Robotic-assisted surgery in sports medicine: Where is it?

In 2002, the late Freddie Fu and colleagues released an editorial in which they summarized and commented on the future of computer-assisted surgery (CAS) within sports medicine surgery [22]. The authors surmised that the ‘…integration of arthroscopic and 3D images as well as virtual kinematics thereby enables the surgeon to better and more consistently assess graft placement.’ They did note, however, that limitations in the form of cost, accessibility, learning curve and precision still needed to be overcome [22]. The same was said about computer-assisted arthroplasty surgery at the turn of the 21^st century, but despite a tempered enthusiasm [25], adult reconstruction orthopaedists continued to drive innovation in a way that sports medicine surgeons and arthroscopists have not. Since the year 2000, over 1700 publications can be found on PubMed® (National Library of Medicine; Bethesda, MD) when using the Boolean terms ‘(robotic) AND (arthroplasty)’. During the same time frame, less than 700 publications can be found when searching ‘(robotic) AND ((sports medicine) OR (arthroscopy) OR (ACL) OR (osteotomy))’ while excluding the terms ‘arthroplasty’ and ‘dental’.

Arthroplasty surgeons have demonstrated that robotic-assisted surgery leads to less resection error [31], better placement of components [1, 38] and yields better final alignment [23, 30] without an increased risk of complication [15]. Every major arthroplasty manufacturer now has a navigation system or robot commonly found in hospitals and ambulatory surgery centres. Why are these robots not programmed to assist with sports medicine cases? Sports medicine and arthroscopy seem to have lagged in this trend. Is it because the subspecialty of sports medicine is more accurate or precise than adult reconstruction? Data would suggest surgeons from neither subspecialty are as accurate as they think they are with manual techniques [12, 27, 39]. Is it because current technologies map bony landmarks but not the chondral surfaces or soft tissues? This is partly true, but burgeoning technology does exist to integrate magnetic resonance images (MRIs) with intraoperative registration in a manner analogous to computed tomography (CT)-based mapping [3]. Lack of industry interest due to lower revenue capability may be the primary driver [4, 18], but the onus is on surgeons to push innovation in the direction we see fit.

Many sports medicine orthopaedists have interests beyond the arthroscope [5]. Even joint preservationists recognize the time and place for arthroplasty. The concept of lower extremity alignment principles is how many intellectually marry interests in both sports medicine and arthroplasty. A well-performed, functionally aligned (i.e., kinematic, restricted kinematic, etc.) total knee arthroplasty (TKA) should be considered the end-stage option in the joint preservationist's practice. The sports practice patient, who often has higher functional demands, may achieve lower patient-reported outcome measures with the classic, neutrally-aligned TKA [24]. Robotic systems' three-dimensional (3D) perioperative navigation could allow surgeons to tailor a patient's alignment to their specific needs in a manner analogous to osteotomy surgery templating.

The power of this technology has not yet been realized by sports medicine orthopaedists. The technology now exists to create uniplanar and biplanar osteotomy cuts within 1 mm of accuracy [33]. Live alignment axes could be visualized as alignment corrections are made. Drill tunnels could be created in the exact anterior cruciate ligament (ACL) footprint (based on bony and/or soft tissue registration). Devastating intraoperative complications such as multiligamentous knee reconstruction tunnel convergence could be eliminated. The ability to combine CT, MRI and intraoperative registration all into one 3D templating, navigation and robotic-assisted surgery system should exist. Collaboration is needed to modify the robotic systems already in place or ensure future iterations have sports medicine applications.

Opponents of CAS have touted the lack of clinical benefit in both the arthroplasty [19, 21, 29, 32, 37] and sports medicine fields [9, 11]. Admittedly, both the objective and subjective data suggesting clinical superiority of navigation or robotic-assisted surgical systems in the field of sports medicine is limited, but it does now exist within the arthroplasty literature [16, 17, 20, 34, 36, 40]. Accuracy and precision are shown to be improved in computer-assisted ACL reconstruction [9-11, 39, 41], but clinical outcome superiority has yet to be demonstrated. An easy counter, however, is that superiority will never be found if the procedures are not being performed nor technology offered with the most up-to-date iteration of robotic systems available. More research is needed to flesh out the value of what sports medicine surgeons generally accept as simple truths; accuracy matters in both tunnel positioning and realignment osteotomy. As for now, the argument against robotics within sports medicine surgery is reminiscent of how Drs. Stephen Burkhart and Lanny Johnson described the early days of arthroscopy [2].

American orthopaedists are demonstrating an increased interest in alignment and osteotomy surgery, as evidenced by a rise in US-based publications [13]. Surgeons now recognize the lasting benefit of osteotomies, both in younger patients whose chondral lesions, menisci or ligament reconstructions get offloaded [8, 14, 28, 35] and also in middle-aged to elderly patients with single-compartment osteoarthritis [6, 7, 18, 26]. Clinical and academic interest in osteotomy surgery is increasing [13]. I would encourage more seasoned sports medicine orthopaedists, particularly those with an interest in alignment, to recognize how their arthroplasty colleagues have outpaced them in embracing technological advancements. There is a whole host of young sports medicine surgeons whose training underscored the value of computer-assisted surgery and who saw this field as an opportunity for growth within the subspecialty.

The authors declare no conflict of interest.

The authors have nothing to report.