Robotics and Enabling Technologies in Musculoskeletal Surgery

The word robot is thought to have been the brainchild of Czech playwright and writer Karel Čapek, who introduced the term in a 1920 play, Rossum’s Universal Robots. It is derived from the Czech word robota, meaning “servitude” or “forced labor” [7]. His play originated the cliché of the “not-to-be-trusted” robot, by concluding with the roboti staging a rebellion that ultimately led to the extinction of the human race.

Later, in the early 1940s, science fiction writer Isaac Asimov first used the word robotics in a short story in which he painted a more benevolent picture of the robot in human society. Asimov characterized robots as supportive servants that out of deference to their human creators must obey 3 laws: (1) avoid harm to humans, (2) obey orders of humans, and (3) self-preservation as long as laws (1) and (2) are followed [2].

In recent years, a fourth industrial revolution or “Industry 4.0” has been described as involving principles of “interconnection,” or the ability of machines, devices, sensors, and people to connect, and “technical assistance,” or systems that help humans in decision-making and advanced tasks. The possibilities evoked by this revolution in robotic science capture the imagination. Many applications exist in a field as spatial and technical as musculoskeletal surgery. Haptic feedback, in which a surgical instrument communicates tactile information to the surgeon; 3-dimensional image-guided placement of surgical instruments and implants; surgical instruments with embedded smart sensors; and augmented or mixed-reality overlays onto the surgical field-of-view are just a few of the possibilities.

Collaborative robots, or “cobots,” as they are commonly abbreviated, are built to interact physically with humans in a shared workspace. While robotic assistance and cobots may be new additions to our health care lexicon, the first examples of implementation of this concept date back to industrial applications developed in the mid-1990s. At that time, university researchers developed cobots with General Motors (GM) that provided controlled placement of objects with precision [8]. “Hand guiding” was one collaborative feature developed that allowed the robot to use end-effector technology to sense its position in 3-dimensional space to read forces applied to the robot [6]. As this history demonstrates, many of the technologies with the potential to enhance surgical practice already exist and are used in other industries.

Now that robots have been conceptualized for over a century and implemented in industrial and some surgical applications for decades, have we finally reached the time when robotic technologies will take hold and fulfill the promise to drive health care into the future? Current market trends provide some insight. During the first pandemic year, robotics companies garnered $6.3 billion in venture funding, which was up 50% from the year before [5]. The global health care robotics market is expected to grow at a compound annual growth rate (CAGR) of 21.3% from 2020 to 2027 and reach a market value of over $32.5 billion dollars by 2027 [1]. Indeed, the surge of funding into robotics seems to herald a tipping point for its widespread adoption in health care.

If we accept the notion that a boom in “health-tech” is under way, can we forecast the future of health care by extrapolating the technological advances of other industries? Of the many examples of rapid incorporation of tech into our lives, the evolution of the telephone (rotary phone, handheld phone, flip phone, and now indispensable smart phone) is one of the most relatable. Similarly, might advanced surgical planning software and robotic navigation systems threaten to make open surgery (exposure and direct visualization of anatomical landmarks), followed by intraoperative 2-dimensional projection radiography (biplanar fluoroscopy or X-ray) go the way of the rotary phone?

The skill and craftsmanship of an experienced surgeon are by no means replaceable by technology and are unlikely to become obsolete, now or in the near future. However, the eldest of the Generation Z physicians are now entering surgical training programs in which they will likely be exposed to robotic-assisted surgery and surgical navigation. Is it realistic to think that future surgeons won’t find a significant place for advanced technology and robotics in their operating rooms? The more difficult stretch of the imagination is that they would not.

In this context, we orthopedic educators and mentors are faced with new questions about our responsibilities to future surgeons and patients. Any technology has the potential to fail. Will it be best to preserve surgical training as a craft focused on individual technical excellence and mastery of spatial anatomic relationships while eschewing overreliance on technology? Perhaps this poses a false dilemma, and virtual training and surgical simulators have the potential to enhance a surgeon’s understanding of anatomy rather than to replace or weaken it.

As regular users in recent years of surgical navigation and robotics technologies, we understand that a significant learning curve exists for their integration in the operating room. Many currently practicing surgeons may well never find the time or patience to create a meaningful role for surgical robots. Undoubtedly, there will be skepticism as to the value of these technologies in a field as deeply rooted in tradition and apprenticeship as surgery.

The famed quantum physicist Max Planck once said, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it” [4]. In support of this aphorism, a 2019 study by researchers at Massachusetts Institute of Technology (MIT) found that the passing of one “thought leader” was followed by a large influx of unique ideas and highly cited publications [3]. “Together, these results paint a picture of scientific fields as scholarly guilds to which elite scientists can regulate access, providing them with outsized opportunities to shape the direction of scientific advance in that space,” write the researchers. Possibly this can be viewed as a warning; if established scientists are not open to new and potentially paradigm-shifting ideas, perhaps the criticism that we are no better than scholarly guilds has merit?

In assembling articles for this special issue of HSS Journal from early adopters of robotic, navigation, and other enabling technologies in musculoskeletal surgery, we have enjoyed seeing the levels of innovation involved—not necessarily from the companies that manufacture them but rather from the skilled surgeons that have put them to use in exciting ways to improve care. While the technologies discussed in this issue may be transformed and even obsolete in a few short years, it is our hope that this issue will spark fruitful dialogue on the role of technology in the operating room.

Good research stimulates conversation and debate. In this spirit, we hope that through this special issue, we will stimulate conversation by providing readers with thought-provoking content on innovative technologies in musculoskeletal surgery.