Perceptions, Expectations, and Barriers to Robotic-Assisted Total Knee Arthroplasty: A Cross-Sectional Study of 218 Patients

TL;DR

This study explores how Brazilian patients perceive robotic knee surgery, finding that while they are interested in its precision, they are concerned about costs and lack of information.

Contribution

The study provides new insights into patient perceptions and barriers to robotic knee surgery in Brazil, emphasizing the role of education and cost in adoption.

Findings

Most patients had superficial knowledge of robotic surgery, with physicians and internet/social media as primary information sources.

Despite interest in precision and implant durability, 50% of patients were concerned about high costs and 30% about lack of human control.

Only 30% were willing to pay out of pocket, highlighting economic barriers and the need for better financing options.

Abstract

To assess the perceptions and expectations of Brazilian patients regarding robotic orthopedic knee surgery, addressing their prior knowledge, technique-related concerns, economic impact, and acceptance of the technology.

The present quantitative, observational, cross-sectional study employed a structured questionnaire administered to 218 orthopedic patients undergoing knee arthroplasty at a specialized outpatient clinic. The study evaluated sociodemographic variables, information sources and levels, expectations regarding benefits, concerns related to robotic surgery, and the economic impact on decision-making. Data analysis used descriptive and inferential statistics (Chi-squared test and logistic regression), with significance set at
p
 < 0.05.

Most patients (75%) had superficial knowledge about robotic surgery. Their chief sources of information were the attending physicians (40%) and the internet/social media (35%). In total, 60% of the patients had a positive attitude about robotic surgery, with expectations regarding greater precision (70%) and implant durability (55%). However, concerns about high costs (50%) and lack of human control (30%) were common. Willingness to pay for the procedure out of pocket was low (30%), mainly due to its high cost and lack of health insurance coverage.

Patients showed high interest in robotic surgery, but they remained hesitant due to economic concerns and the lack of adequate information. Educational strategies and more accessible financing models can significantly increase the acceptance and adoption of this technology in Brazil.

Tables

Table 1. Knowledge and information about robotic surgery

Aspect	Category/Option	Percentage
Surgery acceptance	Yes, I would accept without restrictions	35%
	Yes, but with reservations	50%
	I would not accept it	15%
Main concerns	High cost	50%
	Lack of human control	30%
	Uncertainty about safety	20%
Previous knowledge	Yes	75%
	No	25%
Information source	Attending physician	40%
	Internet and social media	35%
	Other patients/family members	25%
Understanding level	Good/Excellent	30%
	Average	40%
	Poor/Very poor	30%

Table 2. Technological preferences in choosing the surgical procedure

Aspect	Category/Option	Percentage
Perceived benefits	Higher precision	70%
	Faster recovery	45%
	Less postoperative pain	35%
	Higher implant durability	55%
Preference between robotic and conventional surgery	Preference for robotic surgery	60%
	Undecided	25%
	Preference for conventional surgery	15%

Table 3. Financial impact and economic barriers to choosing robotic surgery

Aspect	Category/Option	Percentage
Willingness to pay	I would pay out of pocket	55%
	I would not pay	45%
Factors influencing the decision	High cost without health insurance coverage	55%
	Lack of certainty about additional benefits	35%
	Preference for more affordable conventional alternatives	10%

Table 4. Distribution of responses regarding the role of the robot in each stage of surgery

Stage of surgery	Whole procedure	Most of the procedure	Some stages of the procedure	Few stages of the procedure	I do not know
Incision (cutting the skin down to the bone)	15%	20%	25%	30%	10%
Bone cuts (preparing the bone for the prosthesis)	35%	30%	20%	10%	5%
Ligament balancing (adjusting the tissues to balance the prosthesis)	25%	35%	25%	10%	5%
Implantation (fixing the prosthesis to the bone)	20%	30%	30%	15%	5%
Incision closure (suturing the skin and tissues)	10%	15%	20%	40%	15%

Full text

Introduction

Robotic surgery has established itself as a promising innovation in orthopedics, particularly in joint reconstruction procedures such as total knee arthroplasty (TKA). This technology offers greater precision, reproducibility, and personalization in surgical planning, potentially leading to better functional outcomes and lower rates of postoperative complications. 1 2 3

Although the adoption of robotic surgery has been expanding worldwide, the literature on patients' perceptions and expectations regarding this type of procedure, especially in the preoperative period, remains scarce. 4 5 These aspects are crucial since they directly influence shared decision-making, adherence to treatment, and satisfaction with surgical outcomes. 6

No published Brazilian study systematically assessed the knowledge, fears, and barriers perceived by patients undergoing robotic arthroplasty. Considering that these perceptions often stem from information from various sources (such as doctors, the media, and social media), which is not always accurate or evidence-based, it is essential to identify potential gaps in patient understanding. 7

The present study aimed to assess Brazilian patients' knowledge, expectations, and key fears regarding robotic TKA to guide more effective doctor-patient education and communication strategies.

Materials and Methods

The present observational, cross-sectional, analytical study had a quantitative approach. We administered a structured questionnaire ( Appendix 1 ) to patients treated at a knee surgery outpatient clinic by a team specializing in joint replacement surgeries. The study occurred from January to May 2025. The target population consisted of orthopedic patients with indication for TKA at a center of excellence in orthopedic surgery.

We previously tested and adapted the questionnaire based on the instrument developed by Pagani et al. 6 to ensure clarity, reproducibility, and applicability in the Brazilian context.

The sample size calculation considered a universe of 500 annual robotic surgeries, a 95% confidence level, and a sampling error of 5%, resulting in a minimum number of 218 patients. The inclusion criteria were: 1) patients ≥ 18 years of age with a surgical indication for knee arthroplasty; and 2) signature of the Informed Consent Form (ICF). The exclusion criteria were: 1) patients with severe cognitive or psychiatric impairment that prevented questionnaire understanding; and 2) patients who had previously undergone robotic knee surgery.

We tabulated and analyzed the data using the IBM SPSS Statistics for Windows (IBM Corp.), version 26.0, and GraphPad Prism 9 (GraphPad Software, Inc.) software. We presented categorical variables as absolute frequencies (%), and continuous variables as means and standard deviations (SDs). Inferential analysis used the Chi-squared (χ ^2^ ) test and logistic regression, adopting a statistical significance level of p  < 0.05.

The Research Ethics Committee approved the present study under protocol CAAE 78506523.4.0000.5127.

Results

We organized the results into five main blocks to facilitate interpretation and statistical analysis: 1) demographic profile ; 2) social issues ; 3) knowledge and information ; 4) technological preferences ; and 5) financial impact and economic barriers .

The demographic profile block revealed that, among the 218 participants, the predominant age group was 55 to 70 years old (40%), followed by 40 to 54 years old (35%) and over 70 years old (25%). The sample had more males (60%) than females (40%). Most patients had low-to-moderate incomes: up to 2 minimum wages (MWs) for 50% of the patients, from 2 to 5 MWs for 35%, and above 5 MWs for 15% of participants ( Table 1 ).

Regarding social issues , although acceptance of robotic surgery was high, half (50%) of the participants had reservations, demonstrating concerns related to the high cost (50%), the lack of human control in the procedure (30%), and safety (20%) ( Table 1 ).

In the knowledge and information block, 75% of participants indicated having prior knowledge about robotic surgery from attending physicians (40%) and the internet/social media (35%). However, only 30% reported having a good or excellent level of understanding of the procedure ( Table 1 ).

Regarding technology preferences , the perception of the benefits of robotic surgery was positive, highlighted by greater precision (70%) and higher implant durability (55%). Most patients (60%) preferred robotic surgery, while 25% remained undecided, emphasizing the need for further clarification ( Table 2 ).

Finally, in the financial impact and economic barriers block, the main limiting factors were the high cost and lack of health insurance coverage. Only 45% of participants were willing to bear the costs ( Table 3 ).

Additionally, we investigated the patients' perceptions of the robot's role in several stages of knee replacement surgery, such as incision, bone incisions, ligament balancing, implantation, and incision closure. Table 4 presents these results, providing greater clarity and detail regarding patients' opinions.

Discussion

Knowledge and Perceptions about Robotic Surgery in TKA

The results of the present study revealed a significant overview of perceptions, expectations, and barriers regarding robotic TKA in Brazil. The superficial knowledge of the technique, reported by 75% of participants, is consistent with findings from Chang et al. 1 and Dandamudi et al., 2 who reported limitations in patients' understanding despite the growing interest in this technology.

The main sources of information identified in our study were the attending physicians (40%) and the internet/social media (35%). These findings were consistent with observations from Pagani et al. 6 in a public perception analysis based on crowdsourcing, in which doctors and digital media were among the main informational references.

Expectations and Perceived Benefits

The positive perception of robotic surgery by 60% of participants, with expectations concerning greater precision (70%) and implant durability (55%), is consistent with recent literature. Studies have shown that robotic surgery is associated with less variability in component alignment, greater accuracy, and better objective and subjective outcomes compared with the conventional technique. 7 8 Recent meta-analyses confirmed that positioning accuracy and outlier reduction are consistent benefits of the robotic approach. 9 10

Although such technical gains are promising, some studies suggested that medium-term clinical benefits, such as function or patient satisfaction, do not show statistically significant differences compared with manual surgery. 11 Still, there is evidence of better early functional recovery and shorter hospital stays in patients undergoing robotic surgery. 8

Concerns and Barriers to Adoption

The most reported concerns included the high cost (50%) and the perceived loss of human control (30%). The international literature has been documented extensively these concerns, 2 6 which are recognized as the main obstacles to the adoption of robotics, especially in public healthcare systems or those with limited coverage.

Khlopas et al. 12 also reported technological anxiety, expressed by concerns about the robot's autonomy. This anxiety appears to be related to misinformation about the collaboration role between the surgeon and the technology. However, this mistrust tends to reduce after more detailed explanations, reinforcing the importance of preoperative education. 2 13

In our study, patients expressed greater confidence in the robot for specific technical tasks, such as bone cuts (35%), while showing lower acceptance for incision closure (10%), a finding also noted by Dandamudi et al. 2

Economic Impact and Accessibility

The low willingness to bear additional costs (45%) confirms the role of financial constraints as a structural barrier to the expansion of robotic surgery in Brazil. This finding aligns with data from studies demonstrating that most patients, especially those from lower-income brackets, are sensitive to the financial impact of this technology. 2 14

Cost-effectiveness models, as proposed by Rajan et al., 14 suggest that robotics can be cost-effective in the long term, particularly in high-volume centers, as they often lead to lower rates of complications and revisions. However, its widespread adoption in Brazil is challenging due to restricted access and limited coverage by healthcare plans.

Comparison with Other Emerging Orthopedic Technologies

Initial resistance to robotic surgery follows a similar pattern to the introduction of other technologies, such as computerized navigation and custom implants. Studies indicated that these transitions met similar barriers, including costs, the learning curve, and uncertainty regarding clinical benefits. 15 16

Implications for Education and Healthcare Policies

Our study found that both informational and financial barriers continue to restrict patients' acceptance of robotic surgery. The lack of knowledge about how this technology works, coupled with concerns about its safety, emphasizes the need for educational strategies promoting clear, accessible, and evidence-based information, particularly in the preoperative period.

From an institutional perspective, healthcare policies must include financing models that mitigate the effects of high costs, broaden coverage by health plans, and progressively promote the integration of robotic surgery into the public healthcare system.

Thus, the safe and equitable expansion of robotic surgery in Brazil depends on integrated actions that combine health education with the reformulation of access policies, promoting greater autonomy in decision-making and equity in the provision of technology. 17 18

Study Limitations and Future Directions

While the present study provides relevant information on Brazilian patients' perceptions of robotic knee surgery, some limitations require consideration. First, the sample consisted of patients from a single specialized center, which may limit the generalizability of the findings to other regions of Brazil with different socioeconomic and cultural profiles. Furthermore, since this study is cross-sectional, it is not possible to assess the evolution of perceptions over time or the impact of formal educational interventions.

Another limitation concerns the self-reported nature of the questionnaire, which may be subject to recall or social desirability bias. Moreover, the lack of direct comparison with patients undergoing conventional surgery prevents a more in-depth analysis of actual differences in expectations and understanding between the groups.

Future research should utilize a longitudinal design to assess patients' perceptions both before and after educational sessions or during the postoperative period. We also recommend multicenter studies with greater geographic and demographic representation to increase the external validity of the results. In addition, the inclusion of qualitative analyses can provide deeper insights into the motivations, fears, and subjective factors that influence patients' decisions.

Conclusion

Our study showed that, although most patients have a positive impression of robotic surgery for TKA, significant knowledge gaps and economic barriers remain, thus limiting its widespread acceptance. Most participants expressed interest in this technology, recognizing potential benefits such as increased precision and implant durability. However, concerns about the high cost, lack of health insurance coverage, and the perception of a loss of human control over the procedure were decisive factors in their hesitation. These findings emphasize the importance of tailored educational strategies, improved access to quality information, and innovative financing models to increase the availability of robotic surgery. The successful adoption of robotic surgery in Brazil will depend not only on its clinical efficacy but also on overcoming these informational and socioeconomic barriers.