Keturah Forry never really felt comfortable in her own skin. 

She’d always considered herself an outsider, forced by a rare biological blunder to watch life from the sidelines. She embarked on that bystander role at just six months of age from a hospital bed, where she was forced to practice such basic infant skills as sitting up, rolling over, and babbling.

Forry’s peripheral profile only grew as she matured: While her prepubescent peers immersed themselves in youth sports, for example, Forry immersed herself in pain relief on her living room couch. “I struggled a lot. I felt very much like an outcast, like an outsider,” Forry recalled. “When I was a kid, I didn’t have a great idea or understanding of what was happening. Basically, whatever I had was a lot different from the normal life my friends were living. It was very difficult when I just wanted to be with my friends and join them at their birthday parties or go roller skating.”

Forry’s yearning for a pain-free pass around the roller rink earned her five trips to the operating room by the time she reached high school to correct a birth defect called lipomyelomenigocele, a severe form of spina bifida. Each procedure brought Forry closer to her goal, but none helped her achieve it. 

With that shortcoming, Forry faced an uncertain and disconcerting future. “I really started to contemplate what my future was going to look like when I graduated high school,” Forry stated. “Would I be able to pursue my dreams in college? Would I have to go on disability?”

One question Forry didn’t ask: Was there any hope for a normal life? 

The answer, surprisingly, was yes. Despite the failures of previous procedures, Forry still had one final option available to her—spinal shortening surgery. Unlike an untethering, where surgeons remove the fatty tissue interfering with natural backbone motion, spinal shortening involves removing the affected vertebra to relieve spinal cord tension. This relatively new, alternative treatment option for lipomyelomenigocele reduces the vertebral distance between the brain and pelvis, enabling surgeons to relieve spinal cord tension without directly operating on the spinal cord itself.

“The [spinal shortening] surgery was my only option for a future of no pain…for a future of being able to do the things that I want,” Forry noted in an online video. “My other option would be to continue with the untethering surgeries, but eventually that would do more harm than good, and I may end up in a wheelchair in a matter of time.”

She’d also end up with an abundance of untethering-related scar tissue over time, which eventually would cause its own set of troubles. To avoid such a fate, Forry opted for the spinal shortening solution, undergoing surgery with renowned neurosurgeon and researcher Nicholas Theodore, M.D., director of the Neurosurgical Spine Center at Johns Hopkins University School of Medicine. 

Dr. Theodore removed Forry’s T12 vertebra, the final bone within the spine’s thoracic section, located just above the lumbar region. Forry’s small pedicles (the strong, cylindrical bony structures connecting a vertebra’s front and back part) made the procedure somewhat difficult, but Dr. Theodore overcame the challenge with the help of his own robotic technology. 

“One of the challenges was her very small pedicles,” Dr. Theodore stated. “This young woman had very small pedicles—about 2 mm to 3 mm, and putting those in freehand or even with image guidance really is not an option.”

Fortunately, Dr. Theodore had better options available to him, particularly, the robotic system he helped create. Named for the company he co-founded more than 20 years ago, the ExcelsiusGPS robotic platform—cleared by the U.S. Food and Drug Administration (FDA) in August 2017—combines a rigid robotic arm with full navigation capabilities to improve alignment accuracy and boost surgical efficiency.  

ExcelsiusGPS (now owned by Audubon, Pa.-based Globus Medical Inc.) integrates intra-operative CT and fluoroscopic imaging technologies to provide real-time visualization of instrument and implant positioning based on individual patient anatomy. The robotic arm automatically moves along a predetermined trajectory to a specified spinal region, similar to a planned GPS route. The arm’s rigidity is stable during implant insertion on steep trajectories. 

The ExcelsiusGPS spine platform features two interchangeable End Effectors—i.e., peripheral devices that attach to the robotic arm’s “wrist,” allowing the system to interact and complete its task. The End Effector regularly communicates with the system’s camera to dynamically adjust arm position and optimize kinematics.    

One of the spine-specific End Effectors tracks movement in real-time during screw placement while the Motion Lock End Effector provides a rigid attachment connection for a surgical retractor or port. Dr. Theodore likely used the former, along with Globus Medical’s CREO screw system to place the fixation rods and screws that stabilized Forry’s spine and enabled her to take up boxing just three months after her surgery.

“She [Forry] did amazingly well. This was a young woman who was up out of bed and literally on the first day after surgery was walking in the halls, which is virtually unheard of because this is a multi-level, thoracolumbar fusion,” Dr. Theodore said. “Utilizing enabling technology like the ExcelsiusGPS robotic system allowed me very precisely to cannulate the center of that pedicle and then expand it. The ability to not just use the robot but also to use navigation in lock-step with the robotics is really a game-changer.”

Robotic-assisted solutions like the ExcelsiusGPS have been changing many a game in orthopedic surgery since their market debut more than a quarter century ago. Buoyed by the deteriorating joints of an aging world population, technological advancements, and improved patient outcomes, the global orthopedic surgical robotics sector is forecast to swell 5.7% annually over the next five years, according to Grand View Research data.

Despite the connotation, robotic surgical systems are not “robots” as such, but rather programmable machines that help guide a surgeon’s hand during operations or precisely control the trajectory of orthopedic instruments or implants. Essentially, they are a tool used by the surgeon to ensure accurate instrument and implant positioning.

Most orthopedic robotic platforms share fundamental components like robotic arms, a control console, digital optics, and a navigation system. Image-based systems commonly employ software to convert pre-operative anatomical images into 3D renderings of joints or the spine that physicians use to improve pedicle screw placement or implant/limb positioning. Some systems, however, use pre-operative imaging for surgical planning but only register and establish bony landmarks during surgery. 

Regardless of their operational and consequential similarities, the robotic-assisted platforms offered by the orthopedic industry’s major OEMs are technologically varied and marketed to exploit their competitive differentiation.

Stryker Corp., for example, touts the Mako system’s personalized 3D computed tomography-based planning and haptic-guided bone preparation capabilities while Johnson & Johnson MedTech trumpets the CT-free nature of its VELYS Robotic-Assisted solution. Similarly, Smith+Nephew plays up the CORI Surgical System’s versatility, Zimmer Biomet Holdings Inc. highlights the ROSA Robotics system’s enabling technologies, and THINK Surgical promotes physician choice, provided by its smaller, lighter, handheld solution.

“Competition generally benefits consumers by increasing options, reducing pricing, and improving access. The same holds true for robotic surgery, where surgeons and hospital staff can now make better informed decisions when selecting a system,” THINK Surgical Chief Growth Officer Nick Margree said. “Having the ability to look at multiple solutions helps healthcare facilities determine what makes sense when asking: What implants are the surgeons using? Can they all agree on one implant? What about unique patient needs like metal allergies and sensitivities? What about pricing or impact on OR staff and sterile processing departments? What about size constraints for an ASC? In this sense, educated buyers can really benefit from the increased competition and be confident they are ultimately making the right decision for their current and future needs.”

Those needs are well supported, too. Current robotic solutions run the gamut from large joint fixes and spinal fusion to real-time image interpretation, patient customization, virtual planning, and 3D touch.

Knee applications are offered by nearly all major (and some minor) implant manufacturers. Stryker’s Mako system is considered the industry patriarch, boasting a resume rife with both clinical evidence and experience (227,000 partial knee procedures over 19-plus years and more than one million total knee replacements over seven years). 

Mako’s SmartRobotics software platform fosters more precise implant placement, better surgical planning and soft tissue balancing, and improved patient customization in partial and total knee repair. Studies have found that Mako’s Partial Knee can accurately place components pursuant to 3D patient-specific preoperative plans; similarly, the robotic system’s cruciate-retaining Triathlon Total Knee showed a 19% relative improvement in six-year survivorship compared to manual implantation, according to 2024 Australian Registry data.

“Mako’s 3D CT-based planning allows surgeons to see more of their patients’ unique anatomy and create a personalized surgical plan and identify desired implant size, orientation, and alignment,” noted Keith Evans, vice president and general manager of Stryker’s Mako and Enabling Technologies business. “Additionally, Mako’s AccuStop haptic technology helps surgeons confidently cut precisely to their plan for each paient.^1-3 With Mako, surgeons have the ability to virtually modify the surgical plan intr- aoperatively if needed.” 

Surgeons also can field suggested pedicle screw sizes and follow their OR plans in near real time, courtesy of Mako’s fourth-generation platform (Mako 4). Launched at the American Academy of Orthopaedic Surgeons 2025 Annual Meeting in March, Mako 4 features additional applications and digital tech for the robotic system’s Total Hip, Total Knee, Partial Knee, and Spine offerings. Mako 4 also integrates Stryker’s fourth-generation Q Guidance System, which is built on more than 20 years of experience developing guidance technologies. 

Based on feedback from 850 spine specialists and neurosurgeons, the latest Q Guidance iteration seamlessly integrates smartpowered instruments into Stryker’s product and services ecosystem. 

Q Guidance with Spine Guidance software featuring Copilot provides multiple feedback modalities for supporting bone resection, pedicle screw preparation, and screw delivery to maximize surgical efficacy and enhance patient outcomes. 

The software’s Smart Zones for bone resection provides auditory and sensory feedback when surgeons approach the planned boundaries of anatomical alert zones with high-speed drills. Complementing Smart Zones is the Copilot Smart Driver, which automatically stops high-speed drills when they reach the planned depth. This latter feature helps support precise pedicle screw preparation and placement. The automatic depth stop feature is proprietary technology that only unlocks with a Stryker implant.

Q Guidance with Spine Guidance 5 is one of the newer entrants in Stryker’s SmartRobotics suite, having won FDA clearance last summer, about three months before surgeons conducted the first Mako Spine cases. The robotic-assisted spinal application is currently in limited market release, with full U.S. commercial launch expected in the second half of this year.

Stryker’s Mako enhancements are not limited to the operating room, though. The company also has extended the Mako SmartRobotics platform in and beyond the surgical theater through the myMako app for Apple Vision Pro and iPhone. When used on Apple Vision Pro, myMako allows physicians to visualize and review patients’ robotic-assisted surgical plans anytime, anywhere. 

“Today, the use of surgical robotics across orthopedic procedures is growing tremendously, thanks to greater recognition of their capabilities and benefits. Additionally, patients worldwide are living longer, staying active, and seeking orthopedic procedures at a younger age,” said Lauren Venekas, Stryker’s vice president of Global Marketing, Mako Global and EU Sales Strategy, Mako and Enabling Technologies. “Additionally, surgeons are asking for more applications and more indications so they can perform more procedures with robotic assistance as they seek to enhance their patient outcomes and their surgical experience with the benefits that robotic arm-assisted surgery has been shown to provide. There is often a perception that robotic surgery is too complex or intimidating, which is why Stryker continues to evolve Mako SmartRobotics with more innovation and more applications to support more types of procedures.”

Such an ethos is not unique to Stryker, however. Zimmer Biomet continues to expand its robotics platform as well, adding a world-first shoulder application to the ROSA system last winter and AI-powered, fluoroscopy-based technology for hip surgery last August.

Cleared by the FDA in February 2024, ROSA Shoulder gives surgeons the flexibility to conduct a total shoulder replacement using anatomic or reverse techniques, and helps them improve implant placement precision. The company bills ROSA Shoulder as one of the only systems that can reproduce humeral head resectioning and facilitate instrument insertion into surgical incisions by requiring no pin in the glenoid center during procedures.

The newest entrant to Zimmer Biomet’s hip surgery solutions suite resulted from its acquisition of OrthoGrid Systems Inc. The Midvale, Utah-based firm’s Hip AI system uses real-time X-ray imaging to analyze images, automate leg length and offset measurements, and guide optimal cup placement, all while maintaining a small OR footprint. Hip AI also allows surgeons to tailor the platform to their specific technique and workflow.

As with its other robotics applications, ROSA Shoulder and Hip AI support data-informed physician decision-making based on patients’ unique anatomies. Pre-operatively, ROSA Shoulder integrates with the Signature ONE Surgical Planning System 2.0, which uses a 3D image-based approach to visualization, surgical planning and patient-specific guide creation. During procedure, the platform provides surgeons with real-time, intra-operative data to help them control, execute, and validate personalized plans for glenoid and humeral placement.

“We believe robotic-assisted surgeries and the use of AI will become the future gold standard in orthopedics, and their rapid uptake will be driven by measurable and impactful benefits both pre-operatively, intra-operatively, and post-operatively in terms of patient outcomes,” Shaun Braun, senior vice president, chief Information and Technology officer at Zimmer Biomet, told ODT. “At Zimmer Biomet, we have curated an ecosystem of cutting-edge robotic, digital, mixed reality, and AI technologies, and will continue to innovate to create a seamless experience and value to surgeons to augment their surgical capabilities and decision-making.”

Within that ecosystem is the first FDA-cleared mixed-reality navigation system for pelvic anatomy visualization. HipInsight uses the Microsoft 2 headset to give clinicians holographic visualizations to support implant placement and alignment during surgery. Part of Zimmer Biomet’s OptiVu Mixed Reality applications portfolio, HipInsight is co-marketed with privately-held Surgical Planning Associates Inc. 

Besides its mixed-reality and artificial intelligence-based innovations, Zimmer Biomet’s robotic-assisted capabilities biome now also includes a handheld solution, courtesy of Fremont, Calif.-headquartered THINK Surgical Inc. Zimmer Biomet forged a limited distribution agreement with THINK Surgical last June to integrate its technology into the (latter) firm’s TMINI miniature robotic system for total knee arthroplasty. Three months after announcing that agreement, THINK Surgical received FDA 510(k) clearance to use its TMINI system with Zimmer Biomet’s Persona Knee System.

“…we have diversified our robotics portfolio with a more cost-effective smaller physical footprint handheld robotic assistant (TMINI) that is ergonomically friendly and wireless for surgeons who prefer CT-based, and the addition of an open platform, AI-powered technology (OrthoGrid Hip AI) that provides direct anterior hip surgeons with intuitive and instantaneous intro-operative tools,” Braun said. “We are the first medtech company to offer two complementary robotic systems—a multi-application robotic system (ROSA) and a wireless, handheld robotic solution (TMINI)—for surgeons looking for different options to incorporate robotic assistance while performing a knee replacement with Persona. With the further adoption of robotic surgery, we will continue to see advancements in AI and mixed reality integrated into robotic platforms to provide surgeons with planning, navigation, guidance, and assistance throughout the procedure. In addition, as many other technologies have evolved to become smaller, we anticipate the same will hold true for robotic assistants, allowing them to seamlessly incorporate into the ASC setting.”

THINK Surgical is banking on that kind of future for robotic aides—its open-platform robotic system supports implant brands from multiple manufacturers, thereby enabling surgeons to select the most appropriate solution for their patients. The privately- held firm has inked development/distribution agreements with more than a half-dozen companies over the past several years, including Curexo Inc., Definition Health, Waldemar Link GmbH & Co. KG, Maxx Orthopedics, b-ONE Ortho Corporation, and Signature Orthopaedics. 

THINK Surgical is on the same mission as its larger, more established rivals—accurate implant placement and improved patient outcomes—but is taking a relatively unchartered path to reach its goal. Its TMINI wireless robotic system easily integrates into the OR with overhead active tracking, allowing for unrestricted patient access. The CT-based 3D surgical planning and TMINI PRO Workflow enable intraoperative adjustments to help fine-tune implant positioning and stability, and the TMINI handpiece automatically compensates for surgeon hand movement to locate bone pins along precisely defined planes.

Since receiving initial FDA clearance in May 2023, the TMINI system has been authorized for use with implants from nine different manufacturers, including Total Joint Orthopedics, United Orthopedic Corporation, Medacta, Waldemar Link, and Zimmer Biomet, among others.

“As technology advances, it tends to become smaller and faster. This is true for orthopedic robotics, where early systems are often described as large, heavy, and disruptive in the operating room,” Margree noted. “New systems, such as the TMINI Miniature Robotic System, are compact, handheld, and wireless—offering a significant reduction to earlier models. With the growing demand for total joint replacements, surgical teams need to operate with even greater efficiency. Using a large, cumbersome robot comes with challenges as to which ORs can be used, how the OR is set up, the introduction of ‘no-go’ zones for tracking, which can interrupt OR workflow, staff satisfaction, and then speed of room turnover. Robot companies will struggle if they continue to try the ‘big box’ designs and do not have a compelling answer for improving efficiency.”

Smith+Nephew’s answer for better efficiency lies with its CORI Surgical System. The portable robotic platform for total, partial, and revision knee surgery uses real intelligence software to offer an expanding range of joint reconstruction capabilities; its image-free smart mapping, for example, eliminates the potential for image distortion caused by in-situ components.

The CORI System features an ergonomic handpiece with burr designs that deliver twice the cutting volume compared to the NAVIO Surgical System and 29% faster resection demonstrated in total knee cadaver studies, according to Smith+Nephew data. Moreover, the ATRACSYS Advanced Tracking System offers a 458% faster refresh rate, company statistics show, while an enhanced workflow requires fewer steps (to save OR time).

“The ability to offer proprietary handheld robotics and AI-driven software across the full suite of procedure solutions to deliver a platform that is flexible and scalable across multiple joint arthroplasty indications including hips, knees, and revision knees helps drive our success,” remarked Mayank Shandil, senior vice president, Global Orthopaedics Marketing Reconstruction and Robotics at Smith+Nephew. “The CORI Surgical System also maintains an extremely small footprint in the OR with flexibility to meet the rapid turnover needs of the ASC. With the introduction of CORIOGRAPH image-based preop planning for hips and knees, we now offer an image-agnostic approach to robotics.”

Smith+Nephew’s image-agnostic approach to robotics has been on the market for nearly a year now. Built on more than 15 years of clinical expertise and over 350,000 image-based surgical plans, CORIOGRAPH Pre-Operative Planning and Modeling Services is designed to optimize procedures and enable intraoperative efficiencies with the company’s RI.KNEE ROBOTICS 3.0 software, which includes both image-based and image-free choices, and an optimized knee offering featuring support for pre-cut tensioning with the CORI Digital Tensioner for partial, total, and revision knee procedures.

Smith+Nephew further bolstered its robotic-assisted knee capabilities last year through a co-marketing agreement it signed last fall with Knoxville, Tenn.-based JointVue for its OrthoSonic 3D Surgery Planning technology, which enables clinicians to create personalized three-dimensional preoperative plans for robotic knee procedures. 

“Smaller footprint and image agnostic systems that offer better time and asset efficiency are key to addressing the needs of the outpatient setting. Players in this space will be challenged to offer more capabilities with their surgical systems while increasing pre-, intra-, and post-op efficiencies,” Shandil said. “AI-powered surgical planning along with unique digital soft tissue balancing is a key technological advancement that will play a critical role in driving those efficiencies. The constant iteration of connected technology solutions to enhance efficiency, cost effectiveness, and personalization will be driving themes for robotics in orthopedics over the next three to five years.”

Such catalysts indubitably will shape the planning and execution of future joint replacement surgeries, but cost, integration, and secure data access will likely remain key hurdles to robotic systems’ adoption.

Johnson & Johnson MedTech is tackling those obstacles through its long-awaited VELYS system. Cleared by the FDA for knee and spinal applications, the robotic-assisted solution is designed to enhance surgical precision, simplify workflows, and optimize implant placement.

VELYS’s Unicompartmental Knee Arthroplasty application, for both medial and lateral procedures, enables surgeons to precisely place implants without using a CT scan. The UKA option is compatible with the SIGMA HP Unicondylar Knee System with reusable INTUITION Instruments. 

“AI-driven planning and navigation, real-time feedback, CT-free systems, second-generation active and handheld robotics and augmented reality are transforming how procedures are planned and executed,” commented Janardhan Ramachandran, worldwide president, VELYS Enabling Technology & Strategic Capabilities, Orthopaedics, Johnson & Johnson MedTech. “Our approach focuses on simplifying tech adoption by offering modular platforms that are intuitive and adaptable to various workflows. With tools like the VELYS Robotic-Assisted Solution for knee, we’re showing how smart design can meet real clinical needs while fitting into ASC and hospital settings alike.”

The VELYS system’s enabling technologies suite was designed with ASCs and hospitals in mind, too. VELYS Hip Navigation, for instance, integrates digital analysis into the surgical workflow, and VELYS Spine—launched last August—offers surgical flexibility via standalone navigation and an active robotics platform.

The VELYS Enabling Technology lineup also uses industry-recognized standards for privacy protection, system integrity, and cybersecurity. In addition, its federated data framework is an essential component for generating clinical evidence.

“Through the VELYS Enabling Technology portfolio, we combine innovative implants, advanced surgical techniques, and data-driven technologies. Our robotic solutions are expanding beyond joint replacements to address other critical areas of orthopedic care. We’ve developed a groundbreaking technology in collaboration with top spine surgeons, specifically aimed at addressing the complexities of advanced spine procedures…Our robotic solutions go beyond just assisting in surgery—they are part of our mission to transform the entire orthopedic care ecosystem.”

A daunting yet discerning undertaking.

References
¹ bit.ly/3ETuIIN
² https://pubmed.ncbi.nlm.nih.gov/30601042
³ https://pubmed.ncbi.nlm.nih.gov/29954217