Patient Perceptions and Interest in Robotic-Assisted Total Joint Arthroplasty

Abstract

Background

Robotic-assisted total joint arthroplasty (rTJA) has growing interest among patients and surgeons. However, patient interest in and perceptions of rTJA have not been well explored. We sought to investigate the influence of patient demographics on interest in rTJA and patient perceptions regarding rTJA.

Methods

Patients presenting for their initial adult reconstruction consultation received an optional anonymous survey prior to seeing the provider. Patient sociodemographic parameters were recorded. Additional questions assessed interest in and perceptions surrounding rTJA. Results were analyzed to determine whether patient factors correlated with survey responses.

Results

A total of 360 patients participated. Analysis of responses revealed 77.8% of patients were interested in rTJA. Interest level positively correlated with patient age (R_s = 0.139, P = .010), education level (R_s = 0.168, P = .002), household income (R_s = 0.274, P < .001), and White race (F = 4.157, P = .016). At least 100 patients believed rTJA was easier and more accurate, but more expensive and had a significant learning curve for the surgeon. Over 100 patients believed robots were capable of independently performing most or all of the rTJA operation.

Conclusions

Patient interest in rTJA varies between patients. Many patients have an incomplete understanding of rTJA, and orthopaedic surgeons should address patient perceptions during surgical consultation.

Level of Evidence

IV, Cross-sectional study.

Introduction

Robotic-assisted total joint arthroplasty (rTJA) was introduced to improve surgical accuracy, patient satisfaction, and reduce complications. Many studies have shown a higher consistency of implant position and mechanical alignment with the use of robotics in arthroplasty [[1], [2], [3], [4], [5]]. Furthermore, an increasing number of studies support the clinical benefit and cost effectiveness of rTJA, reporting equivalent or improved patient satisfaction, functional outcomes, and value of rTJA compared to traditional total joint arthroplasty (TJA) [[6], [7], [8], [9], [10], [11]]. As a result, hospitals and orthopaedic surgeons across the United States and globally are increasingly utilizing robotic technology in TJA [12,13].

Industry marketing campaigns have successfully increased patient interest in rTJA, and Google search analysis has shown an exponential growth in rTJA interest from patients over the past decade [14]. However, some patients may be more hesitant to adopt new technologies. Additionally, some reports have highlighted public misconceptions regarding robotic-assisted orthopaedic surgery, and there is debate surrounding whether patients hold accurate and informed perceptions surrounding rTJA [15,16]. These patient perceptions have not been well explored and would be especially relevant toward understanding patient preferences on rTJA and the effect of direct-to-patient marketing campaigns.

Thus, the purpose of this study was twofold: 1) to investigate how patient demographics affect interest in rTJA, and 2) to explore patient perceptions regarding rTJA.

Material and methods

This study was determined exempt by the institutional review board prior to initiation. A survey was distributed by registration staff members to all new patients of age 18 years or older presenting for initial hip or knee reconstruction consultation prior to seeing the provider. Surveys were conducted at an urban/suburban outpatient university-affiliated orthopaedic clinic between February 3rd and March 16th, 2020, and April 2nd and October 7th, 2021. The survey is shown in Appendix A. Due to the onset of the COVID-19 pandemic, survey collection was halted in spring 2020 and restarted for a second survey period in 2021 after in-person clinic visits returned to pre-COVID-19 levels and loosening of restrictions following a large-scale COVID-19 vaccination. Survey participation was anonymous, optional, and for research purposes only, and patients were asked to deposit completed surveys in drop boxes prior to the patient’s exiting the office.

Survey responses were coded into a database by research team members, and paper copies were shredded. Demographics were collected including age, gender, race, household income in US dollars, and highest level of education. Additional investigator-derived questions assessed interest levels in robotic-assisted surgery and perceptions of robotics and navigation in orthopaedic surgery. No supplemental information on robotics was given.

Descriptive statistics were conducted with RStudio version 4.2.2 (Posit Software, Boston, MA). Subgroup analysis was performed to investigate whether patient age, gender, race, household income level, or education level were associated with interest in robotic assisted surgery. Spearman’s correlation with Rs correlation coefficient, Mann-Whitney U, and one-way ANOVA tests with F-value representing the ratio of intergroup variance to intragroup variance were used to evaluate these relationships. A P-value of <.05 indicates statistical significance.

A total of 410 patients returned surveys. Of these, 360 completed questions regarding patient demographics and rTJA. Other incomplete surveys were excluded from the analysis. There was no record for unreturned or incomplete surveys, although an estimate of new patient volume at the clinic would suggest at least 650 new patients during the study period. Median age of survey participants was 63 years (lower quartile 51, upper quartile 71). Of these, 213 (59.2%) patients were identified as female. Of those who reported race, 70 (19.4%) patients identified as Black, 260 (72.2%) as White, 30 (8.3%) as other. Of those who reported the highest level of education completed, 4 (1.1%) reported middle school, 4 (1.1%) reported some high school, 38 (10.6%) reported high school, 72 (20%) reported some college, 44 (12.2%) reported associate’s (2-year college), 113 (31.4%) reported bachelor’s (4-year college), and 85 (23.6%) reported master’s or doctorate. Of those who reported household income, 43 (11.9%) reported <$30K, 68 (18.9%) reported $30K-$60K, 110 (30.6%) reported $60K-$100K, 120 (33.3%) reported $100K-$250K, and 19 (5.3%) reported >$250K. Distribution of demographics for the United States, the state of North Carolina, and survey respondents are presented in Figure 1 [17,18].

Figure 1.

Demographics of the United States, North Carolina, and survey populations. Source of NC and US data: 2017-2021 5-year estimates, American Community Survey, U.S. Census Bureau. HS: high school; Associate’s: 2-year college degree; Bachelor’s: 4-year college degree; Grad/Prof: Graduate/Professional degree; $, US dollars.

Results

Technology and surgeon preferences

Overall, 280 (77.8%) patients were interested in rTJA to some degree (Fig. 2). Interest level was positively correlated with patient age (R_s = 0.139, P = .010), education level (R_s = 0.168, P = .002), household income (R_s = 0.274, P < .001), and White race (F = 4.157, P = .016). There was no significant correlation between patient gender and interest in rTJA (P = .111). Only 41 (11.4%) patients had a first-degree relative or personal experience with rTJA. Patients on average believed 30%-50% of academic institutions used robotics and navigation in orthopaedic surgery, and patients believed this utilization rate to be about the same as in private practice. Additionally, 111 (30.8%) patients believed robots could independently perform “most” or “all” of rTJA operations. Overall, 115 (31.9%) patients perceived rTJA to have improved surgical accuracy, and 102 (28.3%) perceived rTJA to have improved surgical ease. Additionally, 111 (30.8%) patients perceived rTJA to be more expensive and pose a significant learning curve for surgeons. Additional perceived benefits and drawbacks of rTJA are shown in Figure 3.

Figure 2.

Patient interest in robotic-assisted surgery.

Figure 3.

Patient perceptions regarding rTJA compared to conventional TJA.

Discussion

Current literature supports equivalent or improved implant positioning, patient outcomes, and cost associated with rTJA [1,2,4,[6], [7], [8], [9], [10], [11]]. A recent GlobalData analysis [19] reported that 11% of knee arthroplasties in 2020 used robotic assistance, with robotic volume expected to double by 2030. As usage and interest in rTJA increase, it is important to understand patient preferences and factors affecting patient choice in rTJA [12]. There is considerable interest among the arthroplasty community on whether patient interest and perception of rTJA parallels with scientific evidence and industry marketing. Prior research has demonstrated lower health literacy in the elderly, those with lower income, and those with lower education levels (C. Wu et al, unpublished data, 2023). These patients are possibly more hesitant to adopt newer advancements in orthopaedic surgery, such as rTJA. The present study demonstrated that most patients expressed some interest in rTJA, with higher income and education levels associated with increased interest in rTJA. Surprisingly, increasing age was associated with interest in rTJA in our study population. These correlations were weak but statistically significant. Education, income, and age could be speculated to correlate with more advanced understanding and interest in technological innovations, especially as a result of marketing campaigns, leading to preference toward rTJA, but neither this study nor prior research can definitively support or refute this claim without more detailed surveying of patient perceptions.

Prior research has shown patient preoperative expectations to be predictive of postoperative outcomes and satisfaction, more so than absolute functional level [[20], [21], [22]]. Understanding patients’ varying perceptions toward rTJA may shed light on their expectations for the operation. A study by Pagani et al. (2021) reported several misconceptions about rTJA, with only half of the surveyed patients understanding the role of the robot in rTJA [15]. Additionally, they identified several concerns with rTJA shared across surveyed patients. Other studies on public perceptions of nonorthopaedic robotic-assisted surgery also reported significant knowledge gaps, which could lead to misinformed decisions [23]. In our study, many patients reported accurate perceptions of rTJA, particularly regarding improved surgical accuracy and learning curve for the surgeon [24,25]. However, many patients incorrectly perceived rTJA to be more expensive or that a robot could be capable of independently performing most or all of the surgery. Additionally, current data suggests rTJA to have similar operative times compared to traditional TJA after the initial learning curve associated with rTJA [25]. Our findings support a recent study by Abdelaal et al. [16] reporting limited patient knowledge regarding rTJA and a wide range of perceived benefits and drawbacks of rTJA. Ultimately, appropriate preoperative counseling addressing each patient’s perceptions and concerns can improve shared decision-making and selection for patients who would benefit most from rTJA. Additional research is needed to further explore specific misperceptions, patient factors, and marketing campaigns affecting patient concerns and decision-making.

There are several limitations to this study. First, our study population was quite small. Additionally, our survey was an optional part of the intake process prior to an adult reconstruction specialty clinic visit, and this method at best represents a nonstructured convenience sampling method. Our results may be significantly impacted by responder bias, especially given our low rate of survey completion. Many respondents chose not to disclose some demographic information or answer questions regarding preference on rTJA. As a result, our subgroup analyses were limited, and our reported patient population may not accurately represent those in our community. Furthermore, this survey was distributed at a large academic institution, and our findings may not be applicable to other institutions or specialties outside of adult reconstruction and orthopaedic surgery. The racial, gender, and educational level distributions of our survey respondents differed from those of the state and national populations. Future studies at other locations may inform the generalizability of this study’s findings. Many of our survey questions on patient perceptions of rTJA included subjective measures such as surgical ease and surgical learning curve, which can vary between surgeons. Additionally, the answer choices for patient interest in rTJA may have biased patients toward a positive response. Future studies with larger patient populations and more objective comparable measures of patient rTJA perception are needed to allow for detection and stronger analysis of any existing trends between patient demographics and their interest in and perceptions of rTJA. Alternatively, focus group-based studies targeting patients with more detailed narrative data on patient expectations and opinions on rTJA, including perceptions gleaned from marketing campaigns, may inform best practices for patient counseling.

Conclusions

Interest and utilization of rTJA is rising in the United States and globally, and most patients report some interest in rTJA. Patient age, household income, and educational levels are associated with increased interest. However, many patients have inaccurate perceptions of rTJA, which could possibly affect patient expectations and postoperative outcomes. Ultimately, orthopaedic surgeons should consider and address patient perceptions when selecting patients to undergo rTJA procedures to optimize surgical outcomes.

Conflicts of interest

M. Bolognesi receives royalties from Smith & Nephew, TJO, and Zimmer; is a speaker bureau of Zimmer and TJO; is an unpaid consultant for Amedica; has stock options in Amedica and TJO; receives research support from Zimmer, KCI, Exactech, Inc., DePuy, A Johnson & Johnson Company, and Biomet; receives material support from Acelity, AOA Omega, Smith & Nephew; is an editorial/governing board member of Journal of Arthroplasty and Arthroplasty Today; and is a board/committee member of Orthopaedic Research and Education Foundation, Eastern Orthopaedic Association, and AAHKS. W. Jiranek receives royalties from DePuy and A Johnson & Johnson Company; is a paid consultant for Moximed; has stock options in Biomech Holdings LLC, Parvizi Surgical Innovation; and is a board/committee member of American Association of Hip and Knee Surgeons and the Hip Society. S. Ryan is a paid consultant for ROMTech. T. Seyler receives royalties from Restor3d and Pattern Health; is a paid consultant for Heraeus, Peptilogics, and Smith & Nephew; receives research support from Zimmer; receives financial or material support from Lippincott Williams & Wilkins; and is a board/committee member of AAHKS. All other authors declare no potential conflicts of interest.

For full disclosure statements refer to 10.1016/j.artd.2024.101342.

CRediT authorship contribution statement

Jerry Chang: Formal analysis, Writing – original draft, Writing – review & editing. Christine Wu: Conceptualization, Data curation, Writing – review & editing. Zoe Hinton: Conceptualization, Data curation. Sean Ryan: Conceptualization, Data curation. William Jiranek: Data curation, Resources, Supervision. Michael Bolognesi: Data curation, Resources, Supervision. Thorsten Seyler: Conceptualization, Data curation, Resources, Supervision, Writing – review & editing.