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aries may not be the best candidate," says Dr. Flanagan. "I'd say, though, that one out of every 100 isn't a good candidate. It doesn't mean the person can't get a knee replacement, but on some people, the robot won't be able to account for the deformity." While that's the case in some complex cases, Dr. Kissin notes that he's found the robot useful in tra- ditionally hard-to-perform surgeries. In his facility's study on the active robot, he notes there was one patient who presented with a lot of bone loss in the knee. They were able to use the robot to perform the replacement, and he's now a patient Dr. Kissin cites when touting the robot's advantages. "What was interesting in that case is that robot- ic surgery might have been better because the bone loss would not allow usual tools to sit how they're supposed to and could have introduced error," says Dr. Kissin. "Some of the worst knees might make for better candidates as this technolo- gy continues to grow." Overcoming obstacles While the benefits of robotic surgery are plenty, there are a few things to consider before you add the technology. First, make sure you understand which implants work with what system. Dr. Kissin notes that his robot is able to use a variety of implants from different companies, which made it an attractive investment because surgeons don't have to change their preferred brand of implant. Speaking of investment, be prepared for a high price tag with this technology. Northwestern Medicine says its robot cost $1.2 million, and Dr. Flanagan notes that there's also a slight increase in the cost of disposables for each case. "Part of the handle and saws are changed out every case, so that's an added cost per case," he says. "However, having some cases completed more quickly and lowering the chance of revision surgery helps to make up for some of that cost difference." There's also a learning curve to using robotic technology. "You have to get certified to use a new system, so even if surgeons have already performed a lot of knee replacements, they don't automatically know how to use it," says Dr. Flanagan. Depending on the case, robotic assistance also can add some time to the procedure — Dr. Flanagan says it can tack on about five to 10 minutes to get the platform set up — but during more challenging cases, the robot actually helps to shorten case times. "We're able to cut some of our complex procedures from two hours to one hour," he says. Dr. Kissin notes that his active technology robot typically adds about a half-hour per case, plus some additional time as the surgeon first gets comfortable with using the system. "When you perform robotic surgery, it looks and feels differently, so there's defi- nitely a learning curve," he says. "But after about five cases, and certainly after the first 10, there is an improvement in the surgeon's time and comfort level in using the technology. The ultimate goal for us is to get it to time-neutral." Despite these challenges, the surgeons say the robot adds a level of reassurance that both their facility and patients appreciate. "I'm a believer," says Dr. Kissin. "Hopefully, we will be seeing research soon that shows that robotic assistance is truly a benefit to patients. A lot of technology has come and gone, but I think this is going to be a part of the future of knee replacements." OSM 1 8 • S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 2 0 ARM FOR A LEG Robots give surgeons the confidence to attempt complex knee replacement techniques, which could improve outcomes. Stefan Kreuzer, MD