Research and best practice development can help training programs integrate robotic joint arthroplasty

The prevalence of robotic-assisted total hip arthroplasty (THA) and knee arthroplasty (TKA) has rapidly expanded. Recent studies show robotic TKA procedures increasing more than 600% from 2015 to 2020 and project they will make up 50% of all TKAs in the United States by 2030. As adoption accelerates, training programs face the challenge of effectively integrating these systems into resident and fellow education.

Technical skill acquisition and development
Robotic technology enhances learning by providing real-time feedback on alignment, resection angles, and soft-tissue balance. Shapira et al found that without robotic guidance, many fellows placed acetabular cups outside the safe zone. Robotics allows for immediate correction, reinforcing accuracy and improving learning. Likewise, a recent randomized trial from Saad et al demonstrated that dedicated training with robotic TKA software significantly improved trainees’ knowledge of alignment and gap-balancing concepts compared with the use of traditional didactics.

The planning workflows and haptic boundaries of modern systems enable residents to perform procedures with reduced risk. Duensing et al found that 45% of senior residents believed robotic TKA improved their understanding of procedural steps and anatomy. Real-time metrics can demonstrate how subtle adjustments affect biomechanical outcomes, strengthening technical decision-making.

However, concerns exist that overreliance on robots may impair development of fundamental manual skills among the next generation of orthopaedic surgeons. In the same survey, 25% of residents with robotic experience believed it compromised their training with traditional instrumentation, and high robotic case exposure was correlated with reduced comfort performing standard knee replacements without robotic assistance. Thus, a balanced training approach that includes both robotic and traditional techniques is essential.

Case volume and surgical exposure
Surgical volume and case diversity are crucial for training. However, access to robotic technology varies significantly among training programs, which presents another barrier to integration.

LeRoy et al reported that although 68% of U.S. orthopaedic trainees had some exposure to robotic surgical technology, only 43% received formal training. Additionally, fewer than half of respondents were given increasing autonomy with the systems. Consequently, 67% of trainees reported that they did not feel comfortable independently using robotic technology. Therefore, many residents may finish their orthopaedic training without hands-on robotic surgexperience, leading to disparities in proficiency among graduates.

Robotics may also influence the types of cases that trainees encounter. Kolessar et al noted a 28% rise in overall knee arthroplasty volume after robotic introduction, primarily from increased robotic unicompartmental knee arthroplasty (UKA) procedures. According to several studies, this might expand exposure to UKAs and complex cases that were previously less common for trainees.

Operative autonomy and decision-making
Robotic surgery affects the progression of operative autonomy in unique ways. Despite exposure, trainees’ autonomy to operate robots during surgery may vary based on staff experience. This cautious approach may stem from the required learning curve and the desire to avoid technical errors.

However, as trainees become more adept, autonomy can expand. Studies show no difference in outcomes when residents versus attendings perform robotic TKA, suggesting that robotics can enhance autonomy when properly integrated. The robot’s haptic feedback and safety features can prevent major errors, potentially enhancing autonomy by allowing residents to perform delicate steps of procedures with technology ensuring accuracy.

Robotic arthroplasty also shifts decision-making partially into the digital realm. Preoperative planning requires decisions on implant sizing and alignment targets before any bone is cut. In ideal scenarios, attendings involve residents in this process, allowing them to gain experience with inputting desired component positions and observing predicted effects.

This interactive experience teaches critical thinking about alignment goals and personalized positioning. According to LeRoy et al, more than 71% of trainees reported that robotics improved their understanding of procedural planning and biomechanics.

How can residency programs adapt to innovation?
As robotic arthroplasty grows, training programs must adapt. Most trainees believe robotics will significantly impact their field yet feel inadequately trained. Future adaptations may include several key components:

1. Formal robotic surgery curriculum: structured modules on robot basics, computer-based preoperative planning, and supervised progression from assisting to performing robotic procedures
2. Simulation and skills labs: no-risk settings to build familiarity with interfaces and instrumentation before live cases
3. Balanced case mix and dual training: ensures competence in both robotic and traditional techniques by alternating between approaches

Future implications
Looking ahead, robotic technology will likely continue to evolve with the integration of augmented reality, artificial intelligence, and improved automation. Standardized credentialing in robotic arthroplasty may emerge, similar to current certifications for other advanced surgical tools.

Residency programs must remain agile, continuously updating their curricula to equip future surgeons with the necessary skills for both robotic and traditional techniques.

Robotic arthroplasty is reshaping orthopaedic training by enhancing skill acquisition through precision and feedback while raising important considerations about maintaining operative volume, preserving trainee autonomy, and ensuring comprehensive skill acquisition and development.

Training programs that balance technological integration with traditional skills will produce versatile surgeons capable of leveraging cutting-edge tools while retaining the judgment and dexterity necessary for any surgical environment.

Shujaa T. Khan, MD, is a clinical research fellow for adult reconstruction in the Department of Orthopaedic Surgery at Cleveland Clinic.

Ahmed K. Emara, MD, is an orthopaedic surgery resident at Cleveland Clinic. Dr. Emara is the Education Committee chair of the AAOS Resident Delegate Executive Committee and a member of the AAOS Now Editorial Board.

Ignacio Pasqualini, MD, is an orthopaedic surgery resident at Cleveland Clinic.

Matthew Deren, MD, is an orthopaedic surgeon and director of the Adult Reconstruction Fellowship at Cleveland Clinic.

Nicolas S. Piuzzi, MD, is vice chair of research and associate professor in the Department of Orthopaedic Surgery at Cleveland Clinic. Dr. Piuzzi is also codirector of the Musculoskeletal Research Center, director of the Cleveland Clinic Adult Reconstruction Research Program, and executive editor of The Journal of Bone & Joint Surgery.

References

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