Meneghini’s recent piece in this journal — “The Robot in the Room: More proof that robotic-assisted surgery is still not superior” — made the case, with the discipline I have come to expect from him, that the RASKAL trial is the first rigorous word against the inevitability narrative around robotic-assisted total knee arthroplasty. He is right. RASKAL is the trial the industry did not want.

But Meneghini’s editorial stops at the OR door. I want to walk through the next door — the one labeled “consent” — because that is where this evidence lands on the patient. And there is a second study Meneghini did not have when he wrote his piece. It changes the conversation.

The Paper Meneghini Did Not Include

In April 2026, Pincus and colleagues at the University of Toronto published the largest real-world dataset ever assembled on robotic TKA in the Journal of Arthroplasty: 74,359 primary TKAs across 62 hospitals and 345 surgeons in Ontario, Canada, with follow-up through October 2024. Of those, 1,613 were robotic. The rest were manual — the comparator that matters for the consent conversation, because that is the operation the patient would otherwise have received.

After propensity-score matching on age, sex, year, income, comorbidity, frailty, and surgeon volume, patients who received robotic TKA had double the rate of major surgical complications within one year. Two percent versus one percent. Hazard ratio 2.01. The composite endpoint was revision, deep infection requiring surgery, or fracture requiring surgery. A sensitivity analysis excluding each surgeon’s first 10 robotic cases barely changed the hazard ratio.

In a propensity-matched cohort of 74,359 primary TKAs, of which 1,613 were robotic, robotic surgery doubled the rate of a composite of revision, deep infection and fracture at one year.

This is not a single-center series. It is the entire population of one of the largest provinces in North America. And it points in the opposite direction from the marketing.

Two Studies, One Question

Meneghini read RASKAL correctly: no patient-reported benefit at two years, no benefit for functional alignment over mechanical alignment, equivalent KOOS, Oxford, Forgotten Joint, and satisfaction scores. RASKAL compared the robot to computer-assisted navigation, and the process advantages the robot did not translate into any benefits the patient could feel. As the meta-analyses below show, those same process advantages do not survive the more important comparison: robot functional and mechanical alignment against mechanical alignment performed with manual instruments.

Pincus answers a different question. Where RASKAL asks “Does the patient feel better?” Pincus asks, “Is the patient safer?” Both answers are now in. The patient does not feel better, and the patient may not be safer either.

Three meta-analyses of randomized trials bracket these studies — Bensa 2023, Ruangsomboon 2023, and Mert 2025 — covering 25 RCTs and over 5,600 patients. Against manual instrumentation, all three return the same answer: longer operative time, higher cost, no clinically meaningful difference in WOMAC, KSS, Oxford, HSS, or range of motion. This is no longer a single skeptical trial. It is a convergence.

What the Patient Is Actually Being Asked to Sign

Now think about the consent form. A patient considering robotic TKA is typically told some combination of the following: the robot is more precise, recovery is faster, the knee feels more natural, complications are lower, and — if the hospital is being honest — the case costs roughly $2,000 more. Two of those five claims are contradicted by the best randomized evidence, and a third — precision — is real but does not translate into anything the patient can feel. Pincus contradicts the fourth. The fifth is true.

That is not informed consent. That is marketing dressed in a clinical setting.

Four Things a Reasonable Patient Would Want to Know

The standard for informed consent is not what the surgeon thinks is important. It is what a reasonable patient would want to know. In 2026, that standard produces four items: Patient-reported outcomes with mechanical and functional alignment at two years are the same with the robot as with manual instruments. Three meta-analyses of randomized trials agree, and the best randomized trial finds no advantage over computer-assisted navigation either. Functional alignment — the philosophy most often paired with the robot — is not better than mechanical alignment for any patient-reported outcome in the best randomized trial. In a propensity-matched analysis drawn from 74,359 primary TKAs, robotic TKA was associated with a rate of major surgical complications within 1 year that was double that of conventional TKA, and the finding persisted after the learning curve was accounted for. Robotic TKA is consistently longer (12 to 17 minutes per case) and adds approximately $2,000 per case, with no demonstrated patient-reported benefit to offset that time or cost.

None of these requires the surgeon to recommend against the robot. They require accuracy. The patient may still choose the robot. What they are not entitled to is a marketing summary instead of an evidence summary.

Where Meneghini and I Agree

Meneghini’s Evidence-Before-Investment Framework is the right discipline for the capital budget. The questions he poses — define the comparator, separate process from outcome, account for cost, follow surgeon preference with skepticism — are the questions every department chair should ask before the next robot is wheeled in.

The capital decision is the institution’s. The consent decision is the patient’s.

The hospital’s return on investment (ROI) on the robot does not appear in the patient’s outcomes. The surgeon’s preference does not show up in the patient’s recovery. The only thing that appears in the patient’s life is the operation they actually had — and the evidence now shows that operation doesn’t need to be robotic.

The Honest Disclosure

I should clarify my stance. I developed the kinematic alignment technique and have spent twenty years arguing that the patient’s constitutional anatomy is important and that the knee should be resurfaced to its pre-arthritic state. I have skin in this game.

But none of my work relies on a robot. Kinematic alignment can be done with manual instruments, patient-specific tools, computer navigation, or robotic assistance — the approach is independent of the hardware used. Of these four options, the evidence regarding femoral component accuracy deserves special mention. In a study involving 261 patients across multiple surgeons, manual instruments achieved femoral resection accuracy comparable to or better than published results for robotic and patient-specific methods, with 91 to 100 percent of resections falling within ±1.0 mm of the target (Howell et al. 2022). A series of 385 patients by a single surgeon confirmed this, with average absolute deviations of 0.175 mm (Scott and Horton 2025). Additionally, the learning curve for a fellowship-trained surgeon transitioning to manual KA was negligible in a prospective cohort for femoral resections (Nedopil et al. 2022). The robot does not excel in femoral accuracy; manual instruments match or surpass it, and the surgeon does not need an extended period to achieve this proficiency.

So I am not arguing against the robot because it competes with my technique. I am arguing for an honest consent conversation because the patient is the one paying the bill, taking the risk, and living with the knee.

The Bottom Line

Meneghini concluded his editorial by stating that the moment of incision — when a surgeon commits to making the cut — is where good intentions meet reality in the operating room. He is correct about that. However, for the patient, the more important moment comes earlier, in the consent room, where they decide whether to approve the procedure.

Given RASKAL, Pincus, and the three meta-analyses that surround them, the consent discussion for robotic TKA must evolve. Not the form, but the conversation. The patient needs to understand that, at two years post-op, they are likely to feel no different than if a skilled surgeon had used manual instruments; that the procedure may take longer and cost more; and that the best available real-world data suggest the complication rate may be higher rather than lower, a finding that persisted after early cases were excluded.

Whether they still choose the robot after hearing all that is their decision, and I will respect it. What is no longer defensible is making the decision for them by leaving the conversation as it is.

That is the moment when the patient deserves an honest answer to a simple question: What will this actually do for me before the robot enters the room?

Declaration of Generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the author used Claude (Anthropic, San Francisco, CA, USA) in order to improve the language, readability, and clarity of the manuscript. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Conflicts of interest

The author is a consultant to and receives royalties from Medacta International, which manufactures both manual instrumentation and a robotic platform. He receives no compensation tied to robotic or computer-assisted platforms, and no financial support from any other manufacturer of such platforms.

Funding

None.