Tartu hospital trials a knee-surgery robot as funding stays open

Surgeons at Tartu University Hospital have carried out the first robot-assisted knee operations as a pilot. The hospital itself paid for the one-week trial and for doctors' training. Whether the Health Insurance Fund will finance the system is still unsettled.

Kaspar Tootsi, head of the orthopaedics clinic, said the robot is an aid that builds a digital 3D model of the joint without X-ray or CT scans. A marker maps the patient's joint. The other end of the same pen-like tool can be the milling tip the surgeon uses when fitting a knee prosthesis. He stressed that the robot does nothing by itself without a doctor.

Tootsi said knee-replacement results are already quite good without a robot, and described the system as a way of making a good operation better. He said 15 to 20 percent of patients still have something that bothers them after surgery, and using the robot would help those patients.

Orthopaedic surgeon Kaarel Kiiranen, who took part in the pilot, said he performed or assisted in eight or nine operations. He said the weakest link in the operation is the surgeon. In his view the robot is especially useful in harder cases, because the team can see the end result on the screen before any bone cuts begin. He added that this confidence about the outcome comes at a higher price.

Tootsi said the robot itself could cost nearly one million euros. Sensors and the milling tool that belong to the system would add about 800 euros per operation. Fewer extra instruments are needed than in manual surgery, a difference of about 300 euros.

For now the Health Insurance Fund would not pay for such a new system. Its deficit this year is over four percent, a little under 105 million euros. Tootsi said the new approach could at least be used at Tartu University Hospital, Estonia's only hospital that trains doctors. Besides better treatment results and quality, he said it has a strong teaching side: medical students and residents can see the anatomy of the knee, how the surfaces move and how to place a prosthesis. He also said the university hospital receives the most complex cases, while exact evidence of how effective the CORI system really is is still lacking.

The fund has created an innovation fund for new solutions such as CORI, said Aivar Koppas, its specialist medical care service manager. Tartu University Hospital has not submitted an application. Koppas said that, as a strategic buyer of healthcare services, the fund must look at the needs of the Estonian health system as a whole, including the volume and the institutions in which a technology is justified, so that treatment volume, specialist competence and optimal use of equipment are secured. He said the university clinic, as a teaching and research hospital, has an important role in testing new treatments and gathering knowledge about them. Robotic surgery, he said, should be viewed more broadly than a single procedure, and the CORI system is only one possible approach on the knee-replacement pathway.