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Two studies in The BMJ analyzing more than 2.5 million U.K. joint replacement procedures found no significant difference in 5-year implant survival between robotic and conventional surgery. The findings come as the NHS plans a sevenfold increase in robotic arthroplasties, raising questions about cost-effectiveness.
Robotically assisted hip and knee replacements performed in Great Britain showed no improvement in 5-year implant survival compared with conventional surgery, according to two large registry-based studies published in The BMJ. Analyzing more than 2.5 million procedures from 2018 to 2024, researchers found revision rates nearly identical for robotic and manual arthroplasties — a finding that could complicate NHS plans to expand robotic surgery sevenfold.
The studies, led by Hasan R. Mohammad, MRCS, DPhil, MRes, of Queen Mary University of London, drew on the National Joint Registry covering England, Wales, Northern Ireland, the Isle of Man, Guernsey, and Jersey. Researchers propensity-matched nearly all robotic procedure patients to four conventional-surgery counterparts with similar clinical and demographic profiles, including surgeons’ procedure volumes, in a target trial emulation analysis.
In the matched cohorts, 5-year implant survival rates were effectively the same: 98.8% for conventional total hip replacement versus 98.8% robotic; 98.5% conventional total knee replacement versus 98.6% robotic; and 97.8% conventional unicompartmental knee replacement versus 96.4% robotic. Findings were similar when entire unmatched populations were compared. All-cause mortality among hip replacement patients also showed no significant difference by procedure type.
Cost is the central issue. The researchers estimated each robotic device costs roughly £1 million ($1.3 million) to purchase, plus £1,000 to £2,500 ($1,300 to $3,300) per procedure. Because the main rationale for robotic arthroplasty — improving implant positioning to reduce malalignment and loosening that drive early revisions — did not translate into fewer revisions, the authors suggested robotic surgery may be a waste of money, as characterized by MedPage Today’s report on the findings.
Stakes for NHS Robot Expansion Plans
The findings land at a sensitive moment for British healthcare policy. In July, the U.K. government published a 10-year plan under which the NHS would raise by sevenfold the proportion of hip and knee arthroplasties performed with robotics. “Beginning next year, we will expand surgical robot adoption in line with NICE guidelines,” the document stated.
NICE (the National Institute for Health and Care Excellence), the government agency that evaluates medical technologies for clinical efficacy, safety, and cost-effectiveness, could weigh these studies when developing guidance. As MedPage Today noted, if NICE accepts the findings, it could derail the planned shift toward robotic procedures.
For patients, the results suggest the choice between robotic and conventional surgery — where available — has so far made little measurable difference in whether an implant lasts. Hospital systems in other countries investing heavily in surgical robots may also face similar cost-effectiveness scrutiny.
Why Robotics Entered the Operating Room
Robotically assisted joint replacement has been marketed as a way to improve implant positioning, reducing malalignment and loosening — the mechanical problems that drive early revision surgeries. That rationale underpinned adoption despite the added cost of the equipment and per-procedure expenses.
The studies drew on a registry population in which conventional surgery still dominates: 656,080 conventional total hip replacements versus 10,203 robotic; 585,242 conventional total knee replacements versus 17,431 robotic; and 89,792 conventional unicompartmental knee replacements versus 4,680 robotic. Hip patients averaged 66 years old (56% women), total knee patients averaged 70 (56% women), and unicompartmental knee patients averaged 66 (54% women). More than 90% of hip surgeries and nearly all knee surgeries were for osteoarthritis.
“Beginning next year, we will expand surgical robot adoption in line with NICE guidelines.”
— U.K. government 10-year NHS plan
Limitations and Unanswered Questions
The investigators acknowledged the observational design means unmeasured and residual confounding cannot be ruled out. Most procedures were performed in the NHS, where long wait times and other factors specific to Britain’s health system could limit how far the results generalize to other countries.
There were also hints of robotic advantages that did not reach statistical significance in matched cohorts. In unmatched hip replacement data, revisions for dislocation were less common with robotic surgery (0.11% vs 0.33%, P=0.002), as were acetabular and femoral fractures — but these differences shrank to insignificance after propensity matching. Knee replacements showed no significant differences in complications or specific revision reasons in either matched or unmatched groups.
Additionally, revision rates are not the only measure of success. Patient-reported pain, function, and implant wear were not directly compared in these studies, so potential quality-of-life benefits remain unmeasured here.
NICE Review and NHS Rollout Decision
The key next step is how NICE incorporates these findings into its technology guidance, which will shape whether the NHS proceeds with its planned sevenfold expansion of robotic arthroplasties beginning next year. Device manufacturers and surgical societies may respond with additional data, including patient-reported outcomes and longer-term follow-up beyond 5 years, to address the questions the registry analysis could not answer.
Key Questions
Did robotic joint replacements perform worse than conventional surgery?
No. The studies found no significant difference in 5-year implant survival between robotic and conventional procedures for total hip, total knee, or unicompartmental knee replacement. Robotic surgery matched — but did not beat — standard manual surgery.
How much does robotic joint replacement cost?
According to the researchers, each robotic device costs roughly £1 million ($1.3 million) to purchase, with an additional £1,000 to £2,500 ($1,300 to $3,300) per procedure.
Will the NHS still expand robotic surgery after these studies?
That remains unclear. The U.K. government’s 10-year plan, published in July, calls for a sevenfold increase in robotic hip and knee arthroplasties starting next year, in line with NICE guidelines. If NICE accepts the new findings, that expansion could be reconsidered.
How many procedures were analyzed?
Researchers analyzed records for more than 2.5 million procedures from the National Joint Registry covering England, Wales, Northern Ireland, the Isle of Man, Guernsey, and Jersey, conducted between 2018 and 2024.
Could robotic surgery still have benefits these studies missed?
Possibly. The authors noted better implant positioning may reduce pain, stiffness, and joint wear, but their data suggested any such benefits were not large enough to reduce revision rates. The observational design and the NHS-specific setting also limit generalizability to other health systems.
Source: rss
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