First robotic knee surgery done in Hamilton

HAMILTON, Ont. – Canada’s first knee replacements by a doctor-controlled robot have taken place at St. Joseph’s Healthcare. The robot has been used in four knee operations since Jan. 18 in a pilot study funded by hospital donors.

“It’s very fledgling,” said Dr. Anthony Adili (pictured), who did the surgeries. “We’re just starting down a very exciting path … At the end of the day I think patients will benefit immensely from this new technology.”

St. Joseph’s, a centre of excellence in robotic surgery, is getting the proof it needs from the start to show the technology is worth the extra cost so it doesn’t end up embroiled in the same dispute it faces with prostate cancer surgery.

“We’re in a golden opportunity to do that kind of pivotal research to inform our decision-making,” Dr. Adili, chief of surgery at St. Joseph’s, told the Hamilton Spectator. “The research is being done (elsewhere) but it’s not high-quality research, so it’s hard to make definitive decisions and definitely difficult to make policy decisions. We want to produce that high-quality data.”

The research is significant because a lack of evidence was behind a controversial recommendation in 2017 by the Ontario Health Technology Advisory Committee (OHTAC) against publicly funding robotic surgery to remove a cancer patient’s prostate gland.

It was a blow to St. Joseph’s, where the vast majority of radical prostatectomies are done with the help of the da Vinci robot system.

Currently, the province pays the hospital the same price as the traditional operation and donors make up the extra cost of the robot. It’s an increasing burden on the St. Joseph’s Healthcare Foundation as the robot is rapidly becoming the surgery of choice, with men from Kitchener to Niagara willing to travel and wait longer to get it.

A final decision on whether the province will eventually fund the robot for prostatectomies at an estimated cost of $800,000 to $3.4 million a year has been put off while St. Joseph’s gathers evidence on how it saves the healthcare system in other ways, such as a faster recovery time, since it’s no longer possible to do randomized trials.

Orthopedic robotic surgery was approved in Canada and the United States only in the last year so high-quality studies can still be done. It’s the same for robotic thoracic cancer surgery, with St. Joseph’s already running a multi-centre trial.

The biggest roadblock is that St. Joseph’s is the only centre in Canada doing robotic orthopedic surgery, making a multi-site trial of thousands of patients impossible to do here. With a price tag of $2 million a robot, it will be hard to find other centres with the appetite to join in.

“We’re going to have to partner with centres in the United States and convince them to contribute data,” said Dr. Adili. “The problem is they are buying robots like crazy because it is driving their business. They are going to be less inclined to want to randomize one versus the other. Some of our progress will be hampered until we get more units in Canada because Canadians have a very different mindset and will participate in trials.”

In the meantime, St. Joseph’s has started the pilot study that it hopes will provide enough evidence to get grants for the eventual large trial.

It’s important, as Dr. Adili says one in five patients are currently unhappy with the outcome of their knee replacement and the robot’s precision could drop that number substantially. In addition, it makes partial knee replacements much easier, so surgeons will be more likely to do them.

“By replacing just the bad part of the knee, I’m leaving more of the patient’s normal anatomy behind,” said Dr. Adili. “It should feel like a more normal knee, recovery should be quicker and they should have better functionality. A total knee, although it is a successful procedure, it still does not match the mechanics of a normal knee.”