Dr. Martin Roche: Changes in orthopedic care delivery and how device companies are rethinking robotic business models

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Hospital for Special Surgery has appointed Martin Roche, MD, director of hip and knee arthroplasty at HSS Florida in West Palm Beach, where it opened a 60,000-square-foot hospital in January 2020.

Dr. Roche has performed about 4,000 robotic procedures throughout his career, including the first sensor- and robotic-assisted knee surgery. He spoke to Becker's about his new role, how orthopedic care delivery is changing, and emerging trends in sensor- and robotic-assisted surgery.

Question: You've been based in Florida for quite some time. What was it that drew you to this role with HSS? 

Dr. Martin Roche: When we launched the first Mako robotic partial knee in 2006, it quickly became necessary to set up education initiatives. One of the first centers that grasped the value of robotics was HSS. I've had a relationship with a lot of the surgeons there, both collaboratively and educationally. Over the next decade, working with robotics and sensors, I really saw the value of focusing technology on one part of the body — the knee.  Being a tech guy, I always look at the future and what's going on in healthcare. Two things I noticed:

1. Patients were seeking out the best care. There was no longer a referral from the primary physician to the surgeon. Patients were researching what you've done and what your outcomes have been. They were seeking out surgeons and entities that produced the highest-quality returns with the lowest risk. To stay relevant, you had to not only produce, but also show your results. I saw that focusing on one thing and being the best at it was really differentiating surgical subspecialists. 

2. With COVID coming into play, we realized that patients didn't want to go to the hospital, nor did surgeons really want them there. I do about 750 knee arthroplasties a year, and within six months my practice went to about 80 percent outpatient, with very successful results. With the timing of COVID, the fact that we were evolving into a more ambulatory approach for a lot of cases, and with HSS developing a center in Florida, all the pieces aligned. HSS was looking for someone to run its joint program and grow its presence in Florida. I felt it was the perfect time in my career to take this opportunity. 

Q: HSS entered Florida in 2020, with Rothman Orthopaedics also following suit. Do you expect more practices to break into Florida? Why do you think it is becoming such a key battleground for orthopedics?

MR: Firstly, the amount of people moving to Florida continues to grow. People living in the big cities — New York, Philadelphia, New Jersey — are all getting out. It's also a much more tax-friendly state. People started coming to Florida for four to six months of the year before heading back up north, but now they're starting to stay here. Floridians, as they age, stay as active as they were when they were younger. I'm doing knee surgeries for people in their 80s that are playing pickleball, tennis and golf. The weather promotes a more active lifestyle, and their social bond with friends and family is built around these activities.

HSS wants to be the No. 1 musculoskeletal provider across the U.S., and I think Florida was its first test ground. HSS built an ASC with robotics in Palm Beach. We plan to integrate the quality metrics that the HSS brand brings, with all the technology and innovations that we've been working on for decades here in Florida. 

Q: How do you see orthopedic care delivery changing in the coming years?

MR: Patients are concerned about being in the hospital with COVID, and insurance companies are realizing outpatient care is cheaper care for them. There's a lot of momentum that will continue to drive this if patients are selected right, and if we can continue to show that the outcomes are just as good. 

Secondly, I think surgeons, now being driven by patients, are requesting the best technology for the best outcomes. That includes everything from sensor-assisted surgery to robotics. DePuy just announced that their robot will be coming soon, so each of the big four device companies all have a robotic application for knee surgery. It's going to be exciting over the next couple of years integrating robots, not only into hospitals, but into ASCs. 

Thirdly, remote patient monitoring with wearable sensors and other communication links are the future. As patients are going home the same day it's still our role to ensure their recovery goes as seamlessly and as safe as possible. I think you're going to see the use of wearables and different telehealth integration to keep an eye on patients to make sure they're not having any complications along the way. 

Q: How do you see patients' perceptions of robotic procedures developing? How does that affect orthopedic practice?

MR: It's going to be interesting to see how patients understand robotics in the coming years. Just like the car industry, I think we're going to get somewhat commoditized, because patients likely won't know the specific nuances of every robot and the applications they bring. "Robotics" resonates with patients as the most advanced technology available. I think the next stage, what I would call digital orthopedic healthcare, is going to center on improved real-time connectivity with our patients. The next extension of intraoperative sensors and wearables will be implanting sensors within the implant or joint when you do the surgery. I believe the next evolution of care over the next three to five years is delivering intelligence through data. In five years, I think every instrument we use to perform surgery and every implant we use will be smart — they will be data-producing devices. 

Q: Stryker recently acquired OrthoSensor, a company you founded. Are there any details you can share about the acquisition?

MR: I believe the impetus for Stryker acquiring OrthoSensor was to utilize sensors to better understand patients through their arthroplasty journey utilizing objective data. When we plan robotic surgery, we will have some information preoperatively through wearables, and now with sensor-assisted robotic surgery, we have real-time data related to alignment, navigated gap distances, and the true ligament tension through full motion. This data will enable the robot to perform a more accurate surgical procedure to hit your target zone of personalized knee balance. 

I think Stryker also believes in outpatient telehealth and the need to monitor these patients with wearables. Wearables around the joint can give metrics on how the joint is performing and how the patient is performing in therapy. You'll be able to intervene expeditiously if you notice an issue. As Stryker brands their Mako robot to the knee, the hip and now into the shoulder with their acquisition of Wright Medical, and in the future into spine, they want to integrate sensors into all platforms. That means every implant they put in will have intelligence embedded in it, so we can really understand a patient's function, kinematics, and potentially monitor for infection, healing, etc. 

Q: As outpatient migration continues to accelerate, will hospitals be less willing to fork out the capital for robots? 

MR: All the footprints of robots can physically fit within a hospital or an ASC. The ORs or surgical suites are pretty much the same size, so that's not the issue. The issue is the value on investment. Hospitals are always looking to grow their market share by showing that they have the latest and greatest technologies. The key now will be how companies sell their robots both to hospitals and to ASCs. Right now, as surgeons are investors in ASCs, they're going to be more introspective on how much money they put up front. It's all about efficiency, outcomes and where patients want to go as well as what they're having done. 

Robots in general have never entered a sector and left it. They just make things more automated. As machine learning and augmented reality interfaces enter robotics, I think the sky really is the limit. I think we're going to see the transition of joint replacements more and more to outpatient facilities. Now, the issue is going to be if hospitals joint venture with physicians to make it a win-win, or do physicians branch off on their own? But I think in certain cases the business model of how companies are selling robots will change. They may link it to how many cases you do, which can help pay it down, and develop various "at risk" models. I think orthopedic companies are drawing up different types of business models because they see robotics as the future as well. 

Q: What other trends are you expecting in orthopedics?

MR: I think press-fit for the knee is starting to come around again. There's big excitement around this, where the bone has the opportunity to grow into the implant. This will extend from unicompartmentals to primary and revision surgeries. With robotics, as we more precisely prepare the bone, we have a better way of placing these knee implants onto bone interfaces in a more accurate way. Secondly, there's going to be an interest in whether we can preserve the [anterior cruciate ligament] in a total knee replacement. Right now, we always cut it out. With the accuracy of robotics and the capabilities of 3D printing to make implants more personalized, we may be able to make new knee designs and implant them more accurately to improve function.

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