Robotic-assisted joint replacement elevates surgical accuracy by enabling exceptionally precise implant positioning and refined ligament balancing, thereby lowering post-operative complications and improving clinical and functional outcomes and patient satisfaction ^[1]. Likewise, hospitals may achieve long-term cost efficiencies by decreasing complication rates and lowering the incidence of revision surgeries, as emphasized in recent healthcare system analyses. However, these advantages come at a steep price. Most commercial systems cost on the order of $0.6–1.0 million (plus ~10% annual maintenance), restricting their use to well-funded centers ^[2]. Survey responses from Indian orthopedic surgeons suggest a clear trend: most surgeons – 93.5% – feel that the high installation cost is the main hurdle to bringing robotic systems into their practice. At the same time, 78.1% shared that they would be open to using technology if the overall costs were more manageable ^[2]. In essence, the primary barrier to broader adoption is not the capability of robotic systems but their cost. This editorial emphasizes developing indigenous (“Atmanirbhar”) robotic platforms, which are essential for making advanced surgical technology both affordable and accessible across the Indian healthcare system.

Robotic systems have evolved from first-generation platforms (e.g., ROBODOC and ACROBOT) to modern semi-active and fully autonomous devices. Today’s robots (such as MAKO and OMNIBotics) use high-definition 3D imaging and haptic or navigation feedback to guide bone preparation precisely ^[3]. The CUVIS-joint system (CUREXO, South Korea) employs pre-operative computed tomography (CT)-based planning and advanced tracking to achieve submillimeter cutting accuracy ^[4,5]. Similarly, the new MISSO joint robotic system (Meril Healthcare Pvt. Ltd., Vapi, India) combines real-time intraoperative feedback with submillimeter precision and individualized pre-operative CT-based planning, enabling more accurate implant alignment and overall surgical optimization ^[6]. Robotic-assisted total knee arthroplasty (RATKA) has been associated with less early post-operative pain and faster return of mobility compared with conventional techniques ^[7]. Although long-term advantages are still being studied, hospitals are seeing practical benefits today. More accurate implant placement means fewer alignment-related revisions and lower overall complication-related costs ^[6,8]. A single-center randomized controlled trial of 100 patients with bilateral knee osteoarthritis showed that RATKA achieved greater alignment accuracy (82% within ±3°) than conventional total knee arthroplasty (TKA) (64%), despite similar 6-month functional outcomes, suggesting that the key benefit of robotics lies in improved precision with potential long-term implications ^[9].

The cost structure of robotic arthroplasty presents considerable challenges to widespread adoption. A recent market analysis found that a typical orthopedic robotic system costs $554,000–$1,000,000 (with annual service fees ≈10% of that) ^[10]. In addition, the overall cost is further elevated by the need for pre-operative imaging, typically a CT scan, along with single-use robotic instruments (such as cutting guides, burrs, arrays, and drapes that cannot be sterilized and reused) and periodic software upgrades ^[11]. Consequently, only large private hospitals or tertiary government institutions can realistically absorb these recurring expenses, leaving smaller or rural centers unable to adopt robotic systems ^[3]. Even where robotics is available, patients may still face significant out-of-pocket payments if insurance plans do not cover the added cost of these premium technologies. Indeed, ClearState Consulting notes that throughout Asia, insurance coverage for robot-assisted joint surgery is still very limited, deterring many hospitals from investing ^[12]. In India’s 2025 survey, 82.7% of surgeons cited incomplete insurance coverage as a barrier, and 73.3% pointed to a lack of training ^[13]. In practice, these economic factors create a vicious cycle: low volumes and missing subsidies keep per-case costs high, which, in turn, limits adoption.

Emerging evidence indicates that reimbursement frameworks across Asia are evolving, gradually improving the feasibility of robotic arthroplasty. Reports from China indicate that select metropolitan regions, including Beijing, now provide full insurance coverage for specific robotic joint procedures ^[12]. These policy shifts have markedly expanded access by reducing direct patient expenditure. In India, similar transitions are anticipated. Market analysts project that RATKA could experience annual growth exceeding 30% over the next decade, driven by falling technology costs, indigenous manufacturing, and more supportive reimbursement mechanisms as they develop ^[12].

Ultimately, the aim is to shift robotic assistance from a premium, optional technology to a standard component of joint replacement – achieving cost parity with conventional instrumentation through greater scale, innovation, and automation.

India’s growing burden of joint disease, combined with limited healthcare resources, makes the development of domestically engineered robotic solutions not only relevant but also essential. National initiatives such as “Make in India” and “Atmanirbhar Bharat” explicitly encourage high-tech, homegrown medical devices ^[14]. Locally designed robots avoid import duties and foreign licensing fees and can be built with affordable indigenous components. They also let engineers optimize the system for Indian conditions, for example, Indian patients often have different bone shapes and densities, or present at younger ages with advanced deformities, compared to Western cohorts ^[15]. A robot tuned for these realities (and for common implant sizes in India) can improve outcomes while lowering operating complexity ^[6]. Home-based service networks can handle maintenance and software support at far lower cost than foreign vendors ^[16,17].

Within the current landscape of orthopedic robotics in India, MISSO (launched in 2024), remains the only domestically engineered platform with published evidence (although limited) of clinical use in knee arthroplasty and a defined pathway toward broader joint-replacement applications ^[6]. It is the world’s first platform to provide both automated burr and precision surgical saw-based cutting tools to execute bony cuts, providing greater versatility and options to the treating surgeon. ^[6]. It is intended to reduce the cost of RATKA relative to imported systems by making such technology more affordable for Indian hospitals, without compromising accuracy or precision ^[18]. As noted by the marketing head of the organization, the system is priced at approximately ₹2 crore (≈USD $240,000), compared with nearly $1 million for most imported robotic platforms ^[18].

In addition to these indigenous innovations, several globally established robotic systems are currently deployed in India and contribute to the overall landscape of robotic knee and hip arthroplasty.

CUVIS uses patient-specific 3D CT-based planning and optical tracking to execute accurate bone resections during TKA ^[19]. In a prospective cohort of 360 patients, CUVIS demonstrated marked improvement in Oxford Knee Scores without any early revisions ^[20]. According to market research, CUVIS has achieved 89 installations, representing 30.7% of robotic systems in India ^[13].

MAKO is a CT-based, semi-active robotic arm system for knee and hip arthroplasty, reported as the most widely used system globally ^[21]. It creates a patient-specific 3D plan from pre-operative scans and guides bone cuts, improving accuracy and consistency. Recent meta-analyses suggest MAKO-assisted TKA can yield better functional outcomes than manual TKA ^[21].

CORI, a portable, imageless handheld robotic system, was introduced in the US in 2020 and has since expanded globally ^[10]. It uses real-time camera tracking and a burr-based cutting tool, letting the surgeon execute planned bone resections and alignment without pre-operative CT. An Indian series of 500 CORI TKAs found a short learning curve (~6 cases) and only minor issues (no infections or revisions) ^[22].

VELYS is a table-mounted, imageless robotic platform designed to integrate with the ATTUNE knee system. Early clinical studies report shorter operative times and faster recovery compared with conventional TKA, and the system now represents a significant portion of India’s robotic installations ^[23].

India now hosts a mix of indigenous and international robotic TKA systems, each showing promise in real-world use. As of 2024, roughly 290 robotic units were installed nationwide (CUVIS ~30.7%, CORI ~22.8%, VELYS ~17.9%, MAKO ~13.1%, and MISSO ~8.6%) ^[13] (Table 1).

The Indian strategy reflects global trends. Worldwide, companies are launching lower-cost robots and pricing schemes. Mini robots for single-joint applications are emerging in Europe and North America, with evidence of growing interest in specialized robotic platforms for surgical and rehabilitation contexts ^[10]. The evidence suggests a trend toward more compact, targeted robotic systems. For instance, analysts predict these will force legacy device prices down by 20–30% over a few years ^[10]. In parallel, providers are experimenting with usage-based pricing or leasing to soften the financial impact of adoption ^[10]. Such innovations aim to eventually bring the per-case cost of robotics closer to conventional tools.

International experience illustrates how expanded insurance coverage can accelerate the adoption of robotic orthopedics in India. In Beijing, Class A medical insurance covers TiRobot (TINAVI Medical Technologies Co., Ltd., Beijing, China) procedures at 100%, and orthopedic surgeries using Tinavi’s robots are explicitly included in local reimbursement schemes ^[12]. With these policies in place, Chinese hospitals rapidly adopted robotic systems.

India has begun policy reforms to catch up with these trends. In 2019, the IRDAI mandated that insurers cover a list of modern treatments (including robotic surgery), and by 2024, it explicitly required all health plans to include robotic-assisted procedures. However, in practice, many policies still impose sub-limits or deny claims for robotics ^[24,25]. Surgical societies and patient groups point out that these insurance gaps, not the technology itself, remain the chief barrier. For example, a panel of Indian orthopedic experts noted that India’s ~60 million arthritis patients get robotic joint replacement only very rarely, largely because insurers do not pay beyond conventional surgery limits ^[24,25]. The panel emphasized that patients should not be forced to choose between better care and insurance support.

In summary, Indian experts conclude that only by expanding equitable insurance coverage and continuing indigenous innovation can robotic orthopedics take off. Policymakers are urged to enforce consistent reimbursement (building on the IRDAI’s steps), so patients are not penalized for choosing robotics.

A key challenge in India is education; there are currently few formal training programs for robotic arthroplasty, and no standardized curriculum ^[2]. Each new robot requires surgeons and operating room teams to learn new workflows. Similarly, regulatory and ethical issues must be addressed, for example, ensuring proper patient consent, data privacy, and equitable access in a tech-driven surgical environment. These challenges are increasingly manageable, as national training programs and professional bodies supported by the government and dedicated simulation centers continue to expand surgeon education in robotics ^[10].

Crucially, indigenization must not compromise safety or efficacy. Early evidence is promising, with independent evaluations indicating that MISSO consistently provides high surgical precision and reliability, supporting their potential to enhance accuracy and outcomes in joint replacement procedures ^[3]. As the adoption of Indian-designed robotic platforms expands across hospitals, the accumulating multicenter clinical data will play a critical role in confirming their accuracy, safety, and functional outcomes ^[13]. By 2030, it is conceivable that robotic assistance could become routine in many Indian joint arthroplasty centers, just as it is in the USA and European hospitals ^[2].

Robotic-assisted orthopedic surgeries promise better patient care, but only if technology becomes affordable. The evidence is clear: cost is the main barrier to adoption. Indigenous innovation offers a compelling solution by harnessing local engineering talent and market forces to slash prices. India is already taking decisive steps toward developing indigenous, innovative robotic solutions such as MISSO. With policy support (Make in India, insurance reforms) and a growing ecosystem of startups and academia, India can meet its large orthopedic needs at much lower cost. In short, by combining its surgical expertise with visionary engineering, India can make robotic precision a standard of care, no longer a luxury but an everyday reality for patients everywhere.

Indigenous robotic systems such as MISSO show that India can combine surgical precision with true cost-effectiveness, making advanced joint replacement feasible beyond large metropolitan hospitals. By reducing capital and per-case expenses while maintaining high accuracy, these platforms open the door for wider access to safe, high-quality arthroplasty. With continued training, supportive policies, and robust clinical validation, India is well-positioned to lead the world in affordable robotic orthopedic care.