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Surgical robots, navigation software and augmented reality (AR) generate a lot of buzz within conference exhibit halls and in orthopedic companies’ marketing campaigns. Still, surgeon adoption of enabling technology is far from widespread.
Mike Evers, Senior Market Analyst at ORTHOWORLD, estimates that sales of enabling technology account for about 2.3% of the $59 billion orthopedic market and noted that a relatively small number of companies have developed robotic and navigation systems. He expects enabling technology revenues to grow from an estimated $1.4 billion in 2024 to $1.7 billion by 2027. The growth is driven in large part by the segment’s top six companies — Stryker, Globus Medical, Medtronic, Smith+Nephew, Zimmer Biomet and DePuy Synthes — that account for 75% of the sales in the market.
“I believe the core innovation in enabling tech lies on the software side, particularly in surgical planning and navigation,” Evers added. “Ultimately, that’s where we’re likely to see the most progress with platforms that will drive further adoption.”
Customer-pleasing Benefits
Sharat Kusuma, M.D., Chief Strategy Officer and Medical Officer at Exactech and President of JointMedica, made a concerted effort to operate with various technologies during his career as a knee and hip replacement specialist.
Dr. Kusuma noted that many orthopedic surgeons have transitioned their cases from hospitals to ASCs for numerous reasons, including economic factors. He said surgeons who operate in ASCs, and especially those with ownership stakes in facilities, are focused on the bottom line and want to invest in cost-effective technology.
Marketing is a factor in the increased use of enabling technology — surgeons want to differentiate themselves from the competition by claiming that they operate with the latest high-tech tools — but Dr. Kusuma pointed to the importance of achieving quality outcomes in less time with streamlined platforms that don’t take up much space or in the operating room.
“Time is money in an ASC,” he said. “The more cases a surgeon completes, the better the facility does.”
According to Dr. Kusuma, the cognitive burden of performing numerous well-balanced knee replacement surgeries in a day is significant. “If a robotic or navigation system can help reduce that mental load, it would be a game-changer,” he said. “Some of these systems help surgeons make fewer decisions and more precise bone cuts, even when fatigue sets in.”
Dr. Kusuma said that surgeons who perform fewer than 100 knees a year account for almost 75% of the knee replacements performed in the U.S. He also noted that revision rates nearly double above the norm among surgeons who perform 50 or fewer knee replacements each year.
There’s potential for lower- and medium-volume surgeons and those who lack fellowship training to achieve more consistent outcomes, according to Dr. Kusuma. However, he noted that’s hard to prove because most clinical research comes from large academic centers with expert surgeons.
“We need studies conducted in community hospitals to truly understand the clinical impact of enabling technology on joint replacement outcomes,” he said. “Would it improve outcomes among surgeons who perform 20 knees a year?”
Navigation and robotic systems that help surgeons achieve better outcomes, regardless of case volume or skill, is a worthwhile clinical goal. “But here’s the irony: Many of the surgeons who could benefit the most from these technologies work at smaller hospitals and ASCs that may not have the budget to spend significant dollars on them,” Dr. Kusuma said.
Cost-effective technologies like AR navigation will play a significant role in driving the adoption of enabling technology as more cases move to ASCs, according to Dr. Kusuma. “AR can enhance procedures without adding excessive time or steep learning curves,” he said.
Dr. Kusuma believes the significant segmentation of the orthopedic market will drive enabling technology innovation. “I don’t think there will be a single standard of care,” he said. “The number of patients who need hip, knee, shoulder and ankle replacement is growing. There will be a variety of solutions to meet the diverse needs of this expanding market.”
He also believes it’s unreasonable to ask patients who are recovering as expected to revisit clinics for post-surgery follow-ups. “Monitoring and engagement software and apps, though perhaps less glamorous than robotics, will become the core drivers of technology adoption in orthopedics.”
Open Robotic Platforms
Evers said the traditional razor/razorblade sales model allows large orthopedic players to defend their implant market share by locking customers into a single robot vendor. However, he pointed out that players like THINK Surgical, eCential and Orthokey want to reshape the industry with implant-agnostic robots used in joint replacement and spine procedures.
In June, Zimmer Biomet entered into a limited distribution agreement to integrate its technology into a customized TMINI robotic solution from THINK Surgical, which has inked similar deals with Maxx Orthopedics, Signature Orthopaedics, b-ONE Ortho Corporation, Medacta and LINK Forge.
The TMINI handpiece automatically compensates for surgeon hand movement to locate bone pins along precisely defined planes and uses a CT-based three-dimensional surgical plan to enable accurate implant placement.
Zimmer Biomet saw an opportunity to explore the value of a CT-based handheld platform to accelerate the adoption of robotics in orthopedic surgery. On Sept. 5, the TMINI system received FDA 510(k) clearance for use with Zimmer Biomet’s Persona Knee System.
“Our strategic partnership with THINK Surgical allows us to address the needs of customers who require a robotic solution with a smaller O.R. footprint, but still want access to a comprehensive and clinically proven knee system,” said Nitin Goyal, M.D., Zimmer Biomet’s Chief Science, Technology and Innovation Officer. “We believe being one of the first to offer a wireless, handheld robot in their portfolio positions us as an innovator and promoter of customer-centric solutions.”
The ROSA robotic portfolio will continue to be the cornerstone of Zimmer Biomet’s enabling technology offerings, but the TMINI system addresses surgeon demand for a wireless handheld system for total knee replacement as more cases move to outpatient settings.
“Space is at a premium in the ASC, and TMINI offers a smaller footprint, which combined with Zimmer Biomet’s technology, allows us to offer the largest breadth of options for our surgeon customers,” Dr. Goyal said.
The joint replacement and spine landscape would change with the widespread adoption of implant-agnostic robotic platforms and the shift could result in long-term benefits. However, several factors are hindering the market adoption of implant-agnostic robots in orthopedic surgery.
Dr. Goyal said open platforms are attractive to many surgeons, but acknowledged that some physicians appreciate the design and trusted performance of a robotic system that’s optimized for specific implants. “These customers ultimately want a robot that perfectly pairs an implant and enabling technology,” he said.
Compatibility claims between surgical robots and implants are regulated. Enabling technology manufacturers are required to design, test, document and file for system compatibility, which requires cooperation among partner companies. “This is a significant undertaking,” Dr. Goyal said.
He also pointed out that customer economic value may be lessened if they’re unable to bundle robot, disposable and implant purchases.
Still, Zimmer Biomet is betting on the future of open robotic platforms.
“We’re proud to be the first company to offer two complementary robotic systems for surgeons looking to incorporate robotic assistance while performing a knee replacement,” Dr. Goyal said. “We believe the TMINI’s design is well-suited for knee procedures performed in ASCs and other outpatient settings.”
