Robotics in Orthopedics: Indian Economy Permits??

Introduction The increase in the aging population in India has led to more instances of osteoarthritis, prompting increased demands for accurate joint replacement procedures, where robotic arm-assisted surgery provides unparalleled accuracy and soft tissue balancing for improved recovery rates.[1] Yet, realizing such medical precision in a broad sense of public health is financially challenging.[1,2] The costly nature of acquiring the equipment coupled with the limiting nature of insurance policies makes it difficult for such expensive equipment to reach rural communities, where most patients lack health insurance and must pay out-of-pocket.[1] A recent national survey indicates that 78.1% of orthopedic surgeons in India are willing to embrace robots if installation costs reduce, indicating that the major deterrent to robot usage is financial affordability.[1] Although the development of indigenous robots provides a potential solution to the cost barrier, it still does not guarantee equal access to health care facilities.[2] The Clinical Promise Versus the Capital Cost Robotics, especially in orthopedics where total knee arthroplasty (TKA) procedures are concerned, is an ideal match since such surgical interventions require extremely accurate balancing and rotational alignment of femurs with millimeter- and degree-level precision.[3,4] As evidence of its clinical potential, a multicentered study conducted in Southern India showed that robotic-assisted TKA surgery was performed in 1073 patients with 99.8% accuracy in sizing and rotational orientation of the femur, hence making possible successful deformity correction with no tissue damage.[3] Robotics, which uses patient-specific preoperative imaging and guided bone cuts, successfully achieves low outliers in surgical alignment responsible for pain and revision risks. The immense potential of robotic surgery is the main reason why 290 robot installations were made in India by September 2024, while at least 80 more robots would be in use in 2025.[4] The use of robotics in orthopedic surgeries in India is faced with high costs because of the presence of foreign systems such as Mako, ROSA, and VELYS, which require millions of rupees investment, costly annual maintanence contracts, and costly single-use consumables.[4] The recurring costs mentioned above pose financial challenges to amortization at average Indian case numbers, leaving the technology accessible to large cities only. This results in high premium charges for surgery performed using robots by private hospitals, hence causing high costs and making robotic surgery available to patients in tier-1 metros while ignoring the more price-sensitive tier-2 and tier-3 populations.[4] High-cost surgery per case and the absence of reimbursements make the widespread adoption and education about the use of this technology extremely challenging.[2] To eliminate the differences between rural and urban areas and stop the robotic surgery technique from becoming a premium-only technique, Indian authors urge for cost reduction and the quick use of affordable Indian robotics.[2] The Macroeconomic Reality Check: Indian Healthcare Ecosystem Robotics in orthopedics exemplifies a deeply hierarchical healthcare market in India, where metro hospitals owned by corporates use the technology as a point of differentiation among technologically astute patients.[1] The results of a national-level survey conducted in India suggest that 78.1% of arthroplasty surgeons would opt for robotics if installation costs were reduced significantly, with capital cost and inadequate insurance cover as two major barriers responsible for the concentration of technology in urban regions. Demand from patients is an equally important driver. 73.3% of respondents would choose a robotic surgeon over others, while 63.8% of respondents indicated their willingness to visit another state for robotic surgery.[5] On the other hand, public health facilities seek to serve the masses. In a comparative study, it was seen that total knee arthroplasty offered by public health institutions was on par with the same in private hospitals, yet 60% cheaper than its private counterparts.[6] According to interviews with stakeholders in some of the best Indian hospitals, the huge acquisition costs of robots, along with other technical and legal considerations, greatly hinder the widespread implementation of this technology.[7] Apart from the huge upfront investment, the expensive disposables, mandatory training, and annual maintenance costs further escalate the cost of each procedure.[7] Since insurance companies do not uniformly categorize robotics as part of “modern medicine,” patients do not have uniform coverage for their procedures, making it costly for patients to use the technology. The resultant cost pressures limit the deployment of technology only to resource-rich urban areas.[7] The Turning Point: “Frugal Innovation” and the Make-in-India Wave The emergence of India’s robotic era depends on embracing affordable, flexible, and inclusive “Make-in-India” platforms instead of costly and proprietary foreign ecosystems.[2] Homegrown technologies such as the MISSO platform provide reduced investment and accurate submillimeter precision suited for regional skeletal physiology, thereby lowering case costs to be consistent with local reimbursement rates.[2,8] Market analysis reveals that although growth is projected, scaling up beyond the country’s major urban centers necessitates decreased setup costs, increased education opportunities, and regular recognition of upgraded medical practices by insurance firms.[7] In order to eliminate prohibitive vendor lock-ins that increase inventory management complications, Indian orthopedic pioneers have called for a move towards standardized implant sizes and cross-compatibility.[9] The implementation of these standardized, open-source platforms facilitates easy interoperability among several implant manufacturers. Overall, with growing competition between domestic players and changes in regulations in conjunction with systems such as CUVIS and MISSO, such innovations will succeed in leveling the playing field and mainstreaming robotic joint replacement in the near future.[2,7-9] Although robotic-assisted surgery comes with higher initial costs due to increased operative expenses, it offers strong financial gains over the long run by reducing the length of stay at hospitals, avoiding complications, and promoting fast return to function.[10,11] To back up this economic argument, an analysis from a tertiary care center in India showed that the use of robots for procedures led to shorter hospital stays by almost 5 days when compared with traditional techniques.[10] Despite the higher initial cost, higher training and increased number of cases would result in decreasing costs over time. In addition, recent Indian clinical evidence involving an indigenous robot showed little blood loss, short stays in the hospital less than 3 days, and no complications in numerous unique surgical cases.[11] With their high efficiency and lack of complications, these procedures greatly minimize the costs associated with re-admission and re-surgery, processes that cost much more than the original procedure.[11] Conclusion and Actionable Vision Unrestrained adaptation of western healthcare models is unsustainable in the long term. Yet, it is similarly imprudent to oppose advancements in technology. Where prohibitive investments prevent the implementation of such innovations today, solutions to overcome these obstacles lie in forming a symbiotic trinity. First, MedTech developers have to develop models of frugal engineering to reduce production and distribution costs. Second, government policymakers have to stimulate local manufacturing capabilities and create stratified healthcare insurance schemes to shield patients against excessive healthcare costs. Lastly, hospitals will have to refine their methods of large-scale exploitation to reduce overhead costs. Through the careful alignment of advanced clinical processes with the economic landscape, robotic arthroplasty can evolve from a privilege of urban centers to an affordable norm. India does not have to sacrifice its economic truth for surgical precision; it needs innovation to make surgical precision an economic truth. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.