Response to the Editorial “Robotic-assisted surgery in sports medicine—A broader vision for the future”

Abstract

We extend our great appreciation to Richards et al. [6] for advancing the critical discussion on the application of robotic-assisted surgery in sports medicine. Their editorial is both timely and highly relevant, focussing on the rapidly expanding potential for robotic systems to address key challenges in the world of sports medicine. However, whilst the analysis remains insightful and expands the discussion, we feel it is limited to extrapolating current arthroplasty-oriented robotic systems to soft tissue or arthroscopy applications [1].

To advance the conversation, we believe orthopaedic surgeons must look more broadly, gaining insights from not only the current generation of orthopaedic robots, but also the decades of experience gained with soft tissue robots in other disciplines (such as general surgery, urology, obstetrics/gynaecologist, cardiothoracic surgery, and neurosurgery). With this vision, we can prepare our practice and patients for a future where robotics may be a transformative force.

Robotic systems in other fields of soft tissue surgery offer interesting sources of inspiration. Platforms such as the Da Vinci Surgical System (Intuitive) have set new benchmarks in precision, dexterity, and ergonomics for laparoscopic procedures [5, 8]. These systems have reliably demonstrated that robotics has the potential not only to enhance dexterity and execution, but also enhance visibility and exposure, safety, training, and competence, as well as surgeon ergonomics. Aptly translating these capabilities to sports medicine has the potential to revolutionise arthroscopic practice on multiple levels.

Examples of these potential advances and applications are numerous. Presently, we typically use a large rigid fixed 30-degree scope due to the manual demands of current arthroscopy. With robotics, much smaller, highly flexible, thin scopes that are robotically controlled will enable much easier and expanded access and clear visualisation in the tight joint spaces we work with [4]. Robotics would also allow easy use of a second scope for further visual enhancement—for example, viewing both sides of a rotator cuff tear during repair. Even more so, one can imagine that in the future, a variable angle arthroscope may be best when controlled by an automatic machine to provide the best view.

With robotic control of the scope, the surgeon's hand is then freed to return them to the natural advantages of two-handed surgery. Robotic control of the accuracy and precision of the instruments can assist with the avoidance of surface cartilage damage seen too frequently in hip and knee arthroscopy, and elsewhere [3]. As seen in other soft tissue robots, the capability and advantages of 3D visualisation can be introduced to arthroscopy. Beyond visual enhancement, robotic control with AI enhancement can provide joint mapping capabilities via simultaneous localisation and mapping (SLAM), allowing navigation and precise measurement of multiple parameters, without the need for pre-loaded data or anatomic reference markers.

Robotic control of fluid management, with the ability to input data from any instruments within the joint, could allow far more precise pressure and flow control providing enhanced and more consistent clarity while operating, all the while minimising the risk of extravasation. In addition, robotic surgical arms can easily measure forces and tensions they are subjected to. Measurement of the tension of repaired structures has the potential to better inform their viability and suitability for repair.

Finally, there is vast potential in robotic training and competence. Options such as dual workstations, surgical simulators, VR and AR training tools will be available to the robotic sports surgeon [2]. Remote and multi-surgeon procedures will be additional capabilities.

While discussion of the potential future of our craft is invigorating, due consideration to the significant barriers to adopting robotics in sports medicine, including cost, accessibility, and learning curves is critical for ultimate success. Simulation-based training programs, already widely used in laparoscopic surgery, will inevitably play a crucial role in equipping surgeons with the skills needed for robotic arthroscopy [7]. Investment in continuous education to ensure that surgeons remain proficient as technologies evolve is key, and should not overly rely on industry support.

In conclusion, we look forward to an exciting future with a huge potential for integration of robotics in sports medicine, and thank Richards et al. [6] for bringing further attention to this important topic. We hope that we have been able to highlight that these are not limited to adaptation of current orthopaedic robots, and to the much broader scope and possibilities well demonstrated by soft tissue robots in other spheres.

The authors declare no conflict of interest.