Cost of robotic surgery boom questioned by UK evidence

The NHS aims to increase robotic surgery sevenfold by 2035, but early UK big-data studies show no clear advantage over traditional methods in implant survival, revision risk, or complication rates. The research is published in the BMJ.
Given the significant expense of robotic surgery (around £1 million in upfront costs, plus an additional £1,000-2,500 per patient), the results call into question the NHS’s 10-year plan to widely adopt robotics for hip and knee replacements.
Studies have shown that robotic-assisted hip and knee replacement surgery improves implant placement – potentially reducing the need for further revision surgery – but it’s still unclear whether this leads to better clinical outcomes and a lower revision risk.
NICE has therefore called for urgent research into the effect of robotic surgery on revision risk after joint replacement.
Researchers analysed data from the National Joint Registry for 666,283 total hip replacements (656,080 conventional and 10,203 robotic) and 697,145 total or partial knee replacements (675,034 conventional and 22,111 robotic) performed between 2018 and 2024 in public and private hospitals across the UK.
They used a statistical technique called propensity score matching to balance underlying differences between patients who had conventional or robotic surgery, allowing them to draw more reliable conclusions.
They also considered other potentially influential factors, such as age, sex, body mass index, diagnosis, physical fitness, implant type, and surgeon volume.
They then compared a range of outcomes, including implant survival, patient survival, reasons for revision, and complications during surgery, for an average of 2.5 years after surgery.
The results show no differences in implant survival, overall or cause-specific revision risk, or complications during surgery between conventional and robotic hip and knee replacement groups. Patient survival also did not differ between the conventional and robotic hip replacement groups.
Robotic surgery was, however, associated with a lower risk of hip revisions that may be related to implant mal-positioning than conventional surgery.
Because these are observational studies, no firm conclusions can be drawn about cause and effect. The authors also acknowledge that other unmeasured factors could have affected their findings and note that the limited follow-up period may mask longer-term outcomes.
Additional research is needed to compare patient functional outcomes across groups, which the ongoing RACER clinical trials will address in due course.
However, they point out that target trial emulation is one of the most robust methods for analysing observational data, providing vital insights to help commissioners plan care.
As such, they conclude: ‘These results highlight the importance of careful evaluation of robotic technology in publicly funded healthcare systems, given the substantially higher capital and procedural costs involved.’