As many experts believe , one must be a good conventional surgeon and then he may be a good CAOS surgeon. Technology is adjunct and not replacement of core skills. As long as technological advances do not affect basic patient assessment, choosing right treatment option, good clinical history and examination etc..there is scope for utilising these as additional advantage.

Each have pros and cons and limitations. And the avenue is newer and time will tell about its utility, validity and superiority as well as reveal its complications, technical glitches and lacunae.

I concur with Prof Ganesh Dharmshaktu.

Technology assists in the areas of operative precision and techniques.

Good clinical skills are necessary to discern the right operation for the appropriate patient.

In answer to your specific questions-

1. Robotics would be a useful and important addition to the future of the operative aspect of orthopaedics, in terms of operative precision & techniques, as stated above.

2. Artificial intelligence would need to be a long way ahead of its current development for an automated machine to do an operation independently, but it would be possible. (I imagine when we have a majority of driverless cars in every city in the world with almost no accidents= a long way off).

3. The risks are the increased costs involved in this technology- both as a social cost, as well as a personal cost to the patient, certainly in the early stages of its adoption. (compare current so-called 'robotic' surgery costs, which are not sustainable except in limited indications).

4. The complication rate would I think be related to the skill and training of the surgeon.

I agree with both of the comments above. I have worked in this field all my career (18+ years) and I have seen things come and go. The difference between what sticks and what fades out is very obviously the difference it makes to the outcome and also the simplicity of use. There are many surgical innovations which have great outcomes but are too complex, or possibly too user specific, to become common despite their benefits. One example of this is Impaction Bone Grafting, which has some amazing results in the right patient and the right surgeon, however this is not common place outside of certain pockets (SW UK, Scandinavia) due to its complexity. Conversely many things which make only a small difference to outcome (when looked at objectively) have been adopted because they make the procedure simpler (cementless hips for example).

The mass adoption of CAOS, and Robotics in particular, will come when robotic surgery facilitates procedures which cannot otherwise be done. One near-term example of this is bi-compartmental knee arthroplasty. This is currently considered very specialist, but most specialist knee surgeons know that using individual components and balancing the knee in this way based on morphotype, whilst leaving ligaments in place that are removed for total knee arthroplasty, makes sense. The reason they do not do it is because it is extremely technically demanding and would likely lead to failure in their hands.

We should also look to mass adoption of 3D imaging (which is a surprisingly recent phenomenon given the age of the technology!). Believe it or not when I started in this industry most implants and procedures where developed using a handful of specimens and 2d Imaging and patients almost never had CT scans routinely. With low-dose 3D imaging use (such as EOS) increasingly standard of care, some of the cost and time is already part of the procedure making the step to CAOS a smaller one.

The third part here is the influence of manufacturing techniques - a lot of surgery is carried out in a specific way because the implants have to be made a certain way, and because the instruments to implant them also have this constraint. For example all drill holes are straight and round and all saw cuts are flat, this means that implants have these features too. The introduction of mass scale 3D printing in different metals removes this relationship, meaning that design complexity can increase to better reflect loading and purpose. Robotic arm assisted surgery facilitates this by not being reliant on saws and drills and therefore facilitating the implantation of novel shapes.

Finally we should look to areas where Navigation has hit and has stayed put - one great example here is Orthopaedic Oncology, specifically for the pelvis. There is now an irrefutable body of evidence published showing the benefits of navigation for pelvic tumours as Navigation makes a huge difference: one study shifted the error rate in this type of surgery from 25% to 6%; this saves lives! If robotics are applied into these very complex areas with open platform non-procedure specific software and hardware, we can expect to see wide adoption (albeit in a very small area). This is the effect of a strongly emotive need.

In summary I have heard it said many times that "robotics has never entered an industry and then left"... There is some truth in this. One thing that robotics will never replace is patient selection which I think remains in the hands of surgeons, and is probably the key to a successful outcome in most cases!

Surgery of the future?

1/ set procedures such as joint replacements, will be done entirely by technicians doing the same procedure so often they become quick and precise

2/implants will be inserted by robots based on patient specific computerized preplanning and manufacture.

3/the robots will be controlled by technicians off site at a center specializing in the procedures.

4/a certified surgeon will be assigned to monitor a number of procedures being concurrently carried out at a surgery center, but like an anesthesiologist supervising CRNAs, he will mostly be sipping coffee and analyzing his stock portfolio!

I agree with the comments above made by the esteemed faculty. My personal view is that there is no alternative of a skilled and well trained surgeron. Core skills are required to use ribots and computer aided procedures. COAS is being used and is most helpful in complicated cases where patient specific implants are required so one can have 3D reconstruction of comlex anatomy that will help in manufacturing pre operatively and positioning of the implant during surgery.Robots are useful and are thought to be the future but in my view as an adjunct however but a lot of more work is being done for precision, easy to use and cost effectiveness.