We are routinely told by surgeon thought leaders, implant manufacturers and sales reps that “robotic assisted surgery is here to stay” and that the robots will improve outcomes and reduce the often quoted and outdated “20% of knee replacement patients are not satisfied”. The slides are elegant. The data is cherry-picked. And the price tag is significant.

Will robotic-assistance improve outcomes in knee replacement over traditional optical navigation? Is there something about the actual mechanized arm of a robot that is better than a surgeon’s highly skilled arm if computer navigation determines the correct implant location?

That question has haunted the robotic surgery conversation in orthopedics for over a decade. Compared to manual instruments with no navigation? Sure, robotics wins on alignment precision. But compared to computer-assisted navigation - the technology that’s been available for nearly 30 years and costs a fraction of the price? Nobody had run that trial.

Until now.

The Study the Industry Didn’t Want

Published this year in The Bone & Joint Journal, the RASKAL trial (Robotic-Assisted Surgery and Kinematic ALignment in TKA) is the first properly powered randomized controlled trial to pit robotic-assisted surgery directly against computer-assisted surgery in total knee replacement.

303 patients. 14 surgeons across 11 hospitals. A 2x2 factorial design also testing functional alignment against mechanical alignment. Two-year follow-up with validated patient-reported outcomes.

The primary outcome: KOOS-12 - a 12-item patient-reported score measuring pain, function, and quality of life.

The finding: no significant difference.

Robotic versus computer-assisted surgery at two years showed a mean KOOS-12 difference of -2.8 points (95% CI -6.4 to 0.9; p=0.137). Functional alignment versus mechanical alignment: essentially identical (mean difference 0.3; p=0.867).

No differences in Oxford Knee Score, Forgotten Joint Score, patient satisfaction, or quality of life at any timepoint from three months to two years.

The system that healthcare’s been investing billions in - the one projected to be used in 70% of knee replacements in the United States by 2030 - produced outcomes statistically indistinguishable from a technology we’ve had since the 1990s.

Read that again.

What the Data Actually Shows - and What It Doesn’t

Before I go further, I need to be precise here. This is not a study saying robots are useless. I am not saying that. The data has nuance that the headline can’t hold.

Robotics did produce meaningful process improvements. Operating time was 11.5 minutes shorter with the robotic arm (p<0.001). PCL ligament preservation was measurably better - and under functional alignment, the robotic group showed 94% PCL integrity versus 69% with computer-assisted surgery.

Surgeons preferred robotics in 82% of cases. Functional alignment dramatically reduced the need for intraoperative soft-tissue releases - 8.1% versus 44.8% with mechanical alignment (OR 9.2; p<0.001).

These are real advantages. Shorter operative time is real. Ligament preservation is real. Reduced soft-tissue releases are real. But the decreased soft tissue releases is not due to the robotic arm…modern navigation systems are capable of enabling functional alignment.

What is not demonstrated - not yet, at two years - is that any of this translates into better outcomes for patients. Better technical execution did not produce better clinical results. That gap is something the field needs to sit with, honestly, rather than explain away.

Two important caveats. First, this trial was conducted in Australia using a specific robotic platform (Stryker Mako) and a single implant system (Triathlon). Results may not generalize to all robotic platforms. Second, two years is not the whole story. Where robotics may ultimately prove its value is in long-term implant survivorship - reduced aseptic loosening, lower revision rates. A 2025 retrospective analysis of 22,000 TKAs suggested exactly that. The RASKAL trial isn’t designed to answer the survivorship question. We need those answers.

But we should not let the long-term hypothesis excuse the short-term reality.

The $2,000-Per-Case Question

Here is the uncomfortable math.

The additional cost of robotic-assisted TKA has been estimated at approximately $2,000 per case versus computer-assisted surgery - and roughly $2,600 per case compared to manual instrumentation. In the United States, with roughly 700,000 knee replacements performed annually and robotic adoption climbing toward that projected 70% threshold, we are talking about hundreds of millions of dollars in additional healthcare spending per year.

For outcomes, at two years, that are statistically equivalent.

I am not anti-technology. My engineering degree sits next to my medical degree for a reason. I have been involved in implant design. I believe precision matters and that technology, properly applied, makes surgeons better. What I am against is the uncritical adoption of expensive technology driven by marketing momentum rather than clinical evidence - particularly in a healthcare system already collapsing under its own cost burden.

When I built Indiana Orthopedic Institute, one of the foundational principles was this: every dollar spent on care delivery must earn its place at the table. We have grown to over $40M in revenue and 100 employees, including 16 surgeons, in three years. We did that by asking hard questions about what actually improves patient outcomes - not what looks impressive in a brochure.

The question “compared to what” applies just as much to your capital budget as it does to your surgical approach.

The Moment I Got Humbled

I want to be honest about something.

I have used robotic assistance. I have felt the precision it offers - the way a well-planned robotic case tightens your confidence at the critical moments. There is a real subjective experience of control that the technology provides, and I understand why 82% of the surgeons in this trial preferred it.

But I have also had the harder experience: a patient - a 64-year-old retired teacher, otherwise healthy, excellent bone stock, a technically well-executed case by every objective metric - who at one year still had persistent stiffness and functional limitations that defied my surgical explanation. By all the numbers I track, that case was a success. She did not experience it that way.

What did I do differently for her? Not much, initially. And that failure to ask better questions earlier in her recovery is something I carry.

The point is this: technical precision and patient outcome are not the same variable. The RASKAL trial just proved that at scale. I proved it to myself one patient at a time.

That gap - between what we measure in the OR and what the patient actually lives - is where the real research frontier sits.

A Framework for Evaluating Surgical Technology

After 10,000+ joint replacements, I have developed what I call the Evidence-Before-Investment Framework for evaluating new surgical technology. It is not complicated, but it is disciplined.

1. Define the comparator. “Better than nothing” is not a standard. What is the best current alternative, and what is the data against that specific alternative?

2. Separate process metrics from patient outcomes. Alignment precision, operative time, and ligament preservation are process metrics. KOOS scores, Oxford scores, revision rates, and patient satisfaction are outcomes. Technology must eventually move the outcomes needle to justify its cost.

3. Understand the time horizon. Short-term equivalence may coexist with long-term superiority. Be honest about which claim the data supports at any given moment.

4. Account for cost in the value calculation. A technology that produces identical two-year outcomes at $2,000 more per case is not neutral - it is a net negative until proven otherwise. Our patients are already financially strained by the cost of care. That is not an abstraction; it is a moral responsibility.

5. Follow surgeon preference with skepticism. In the RASKAL trial, 82% of surgeons preferred robotics - even though outcomes were equivalent. Preference and efficacy are not the same. We are not immune to the cognitive biases that come with expensive, impressive tools.

What This Means for the Field

I want to speak directly to the surgeons and orthopedic leaders reading this.

The RASKAL trial is not the last word. It is the first rigorous word. What it demands is that we stop treating robotic adoption as inevitable progress and start treating it as a hypothesis that requires ongoing validation.

The technology may yet prove its value in long-term survivorship. The process improvements - shorter OR time, better ligament preservation, reduced soft-tissue releases - are clinically meaningful and may prove cost-effective when properly analyzed. I am not closing the door.

But the door should not have been this wide open without this data existing first.

The hospital systems and device companies that are pushing robotic adoption are not doing so primarily because of your patients’ two-year outcomes. They are doing so because of market share, capital investment recovery, and competitive positioning. That is not cynicism - it is just business. The question is whether you let their business logic drive your clinical decision-making.

Build your own framework. Ask “compared to what.” Read the trials, including the ones that challenge your existing investments.

Your patients deserve decisions made on evidence, not on the quality of the sales presentation.

That is the incision point. Where intention meets reality. Where the question “does this actually work better” has to be answered before the robot enters the room.

The RASKAL trial was published in The Bone & Joint Journal (MacDessi et al., 2025). Full citation: https://boneandjoint.org.uk/Article/10.1302/0301-620X.108B.BJJ-2025-1472.R2

I woke up Thursday morning to a text message from a colleague.

“You need to cool it on LinkedIn. You’re making yourself look bad.”

That was jarring for about 30 seconds. Then I thought about the patient I saw Wednesday morning, the one who said she was glad I don’t use a robot. I thought about the Stryker attack that hit the same day.

And I thought about the 10x more messages I received privately from surgeons and healthcare leaders who said: keep going, we need this conversation.

So no. I’m not cooling it.

Let Me Be Precise About What I Actually Said

The pushback I received on LinkedIn was, in a word, telling.

Robotic surgeons came out saying their robots were working fine. Nobody was harmed. Quit fear-mongering.

With respect: that was not my point. And the fact that so many people misread it tells me exactly how threatened they felt.

I am not anti-robot. I have been using computer navigation since 2011, over a decade before many of these same surgeons adopted any intraoperative technology. I am an engineer. I co-design devices. I sit on the boards that govern the future of orthopedic innovation. I am one of the few people in the world with real standing on both sides of this table.

My point was simple: a cyberattack on the largest producer of robotic surgical technology is a wake-up call. If we are not honest about what that means for patient safety, we are failing the people who trusted us with their lives.

That is the thing I will not apologize for.

The Dots Are Connecting. Is Anyone Watching?

Three things are happening simultaneously in orthopedics right now, and almost no one is connecting them out loud.

First, surgical robotics has moved toward automated function, where control is being removed from the surgeon’s hands. The largest implant company in the world recently acquired a fully autonomous robot. That is not incremental. That is a fundamental shift in where accountability lives.

Second, the industry is migrating to cloud-based, interconnected ecosystems because the data doesn’t have much value sitting in isolation on the robot. Everyone is moving it to shared servers and remote data centers.

Third, healthcare represents 20% of US GDP. If a country we are in active conflict with wants to destabilize us, where do they aim?

Stryker industry representatives in Indiana woke up Wednesday with blank phones. Wiped. Across 79 countries.

Autonomous robots plus cloud connectivity plus healthcare as a geopolitical target equals an attack surface we have handed to our adversaries ourselves. I don’t hear anyone at the robotics meetings I attend talking about cybersecurity. Not once. And I’m in those rooms.

We need to start talking about it.

The Data Nobody Wants to Cite

Let me be precise here, because in my first article I understated the numbers. The Australian registry data is worse than I initially quoted.

The study examined robotic-assisted partial knee replacement using the Mako system and found that revision for infection was 2.91 times more likely compared to non-robotic implants over the entire study period, and 5.57 times more likely in the critical zero-to-three month window immediately after surgery. That early window is when surgical site infection, the kind most directly linked to what happened in the operating room, does its damage.

Three to five and a half times more likely to have a postoperative infection. That is not a rounding error. That is a signal.

Again, registry data establishes correlation, not causation. My clinical theory is that longer operative times and the added complexity of managing a large mechanical device in a sterile field are contributing factors. The data on operative time and infection risk is very strong and well established. But whatever the mechanism, that correlation exists in the peer-reviewed literature, and it deserves honest scrutiny, not silence.

If robotic and navigation-guided manual surgery produce equivalent outcomes, you still have to answer a harder question: why are we adding significant cost and potentially elevated infection risk to a healthcare system already at its breaking point?

I told Dennis Berry on the podcast: I would rather take that extra money and give it to a pediatric leukemia patient. The deployment of healthcare dollars has to be proportional to impact. That is not politics. That is math.

What the Actual Adoption Numbers Show

I quoted roughly 25% robotic penetration in knees on the podcast. The 2025 American Joint Replacement Registry data tells a more nuanced story, and it is worth looking at carefully.

[Figure 3.16 - Rate of Technology Use for Assistance in Total Knee Arthroplasty, 2017-2024] Robotics grew rapidly from 1.8% in 2017 to a peak of 16.3% in 2023, then actually declined to 16.1% in 2024. Computer navigation has remained essentially flat the entire period, hovering between 3.7% and 5.4%.

[Figure 2.26 - Rate of Technology Use for Assistance in Elective Primary Total Hip Arthroplasty, 2017-2024] Robotics in hip replacement peaked at 7.3% in 2023 and declined to 6.5% in 2024. Navigation similarly dropped from 5.0% to 3.1% in the same year.

Read that again. Robotic adoption in both hip and knee replacement declined from 2023 to 2024.

I will be the first to say that one year of decline does not establish a trend. But combined with the infection data from Australia, and with what I am hearing from residents and fellows on the ground, it is at minimum a data point worth taking seriously. Something that is truly transforming a field does not plateau and decline at 16% in knees and 6.5% in hips.

That is the data. Not my opinion. The data.

The Training Gap Nobody Is Admitting

This is the one that keeps me up at night.

Orthopedic surgery residents applying to our fellowship at Indiana Orthopedic Institute have started specifically seeking programs without heavy robotics training. I asked why. They said: because I haven’t done many surgeries without it. And I’m scared.

We have already heard of surgeries canceled because the robot was down and the surgeon lacked the confidence to operate without it. We have heard of a robot failing mid-case and the surgeon unable to complete the procedure. I didn’t even want to know the rest of that story, but I heard enough.

I use the airline industry as a frame. The gray-haired pilots flying 350 people across the Atlantic have built manual skill that no autopilot dependency ever erased. When Sully Sullenberger landed on the Hudson River, no algorithm saved those passengers. Forty years of training, judgment, and human hands did.

Surgeons are the pilots of the operating room. We are building a generation who may only know how to fly with autopilot on.

I am sounding that alarm now.

The Liability Question Coming Faster Than You Think

Two months ago, a colleague at a major East Coast academic center told me they had just hosted a lecture on medical liability and AI. The emerging legal consensus: the companies producing AI will bear liability for AI-driven clinical decisions.

Some physicians hear that and exhale. Not my problem anymore.

Think carefully about what comes next. The moment you surrender your accountability to an algorithm, you surrender your authority. And the moment you surrender your authority, you will be paid like a technician, not a surgeon.

We are the ones cutting human beings open. That ethical weight does not transfer to a server.

What the Balance Actually Looks Like

This is not anti-technology. This is not anti-robot. This is not anti-innovation.

This is a demand for appropriate deployment, proportional investment in protection, and honest conversation about risk.

If you are going to connect patient-level technology, literally inside someone’s body, to a cloud-based ecosystem, invest 10 times as much in cybersecurity as you do in the technology itself. That will slow things down a little. Good. Not all innovation is perfect innovation. When a car is going out of control, you check the brakes.

No patients were harmed in the Stryker attack. This was a warning shot, a stress test, a rare moment where the system revealed its vulnerability before someone paid for it on the table. We should be grateful. And we should act like it.

Keep the surgeon, the trained human being with decades of judgment in their hands, as the primary driver of every surgical decision. That is patient-first care. That is the oath.

I am in Milan next week working on the next worldwide knee system we are launching at Indiana Orthopedic Institute. Innovation is very much alive here. We just refuse to build it on a foundation of dependency and denial.

The conversation is not over. It is just getting started.

Dr. Michael Meneghini
Founder and CEO, Indiana Orthopedic Institute & The Incision Point

Watch the full podcast with Dennis Berry on the Elite Leaders Substack.

And if you disagree, say so here. I’ll be in the comments.

I sat in a boardroom once, surrounded by seven administrators, two CFOs, and a compliance officer. I was the only one who had been in surgery that morning. I was the only one who had touched a patient that week. And yet I was the one being told how care would be delivered.

That moment didn’t happen by accident. It was the result of decades of institutional drift - slow, compounding, and largely self-inflicted.

This is not a complaint. Complaints without blueprints are noise. This is a diagnosis. And like any good diagnosis, it requires honesty about what went wrong before we can discuss how to fix it.

The Machine Didn’t Take Control. We Handed It Over.

Let me be direct: the rise of administrative dominance in American healthcare was not a hostile takeover. It was an abdication.

I have performed over 10,000 joint replacements. I trained at Mayo Clinic. I hold an engineering degree from Rose-Hulman. I have sat on the boards of the largest orthopedic surgeon organizations in the world, and I have built Indiana Orthopedic Institute from two people to over 100 employees, including 16 surgeons, generating $40M in revenue in three years.

I tell you this not to impress you, but because I need you to understand where this perspective comes from. I have been inside the machine. I have watched it operate. And I have seen, up close, exactly how physicians lost the room.

There are six reasons it happened. And five of them are still happening right now.

Reason 1: While We Were Operating, They Were Organizing

Here is the most basic operational reality nobody talks about: administrators have open calendars. Surgeons do not.

While physicians were in the OR - doing the actual work that generates every dollar in the building - administrators were in conference rooms making decisions. Hiring decisions. Policy decisions. Budget decisions. Decisions about how care would be structured, compensated, and evaluated.

We couldn’t attend those meetings. We had patients on the table.

And here is the compounding effect: absence from a meeting is interpreted, in institutional culture, as consent. Show up once to challenge a decision and you are a disruptor. Miss forty meetings and the agenda shapes itself around your absence. Over time, the decisions calcified into policy. The policy became culture. The culture became the system.

This wasn’t malicious in most cases. It was structural. But the outcome was the same: physicians were gradually redesignated from decision-makers to producers. Revenue units with medical licenses.

Reason 2: We Never Learned the Language of Power

Medicine attracts people who love science, not finance. That’s not a weakness - it’s a selection feature. But it became a catastrophic vulnerability.

As a profession, we did not educate ourselves on healthcare economics fast enough. We didn’t learn how hospital systems are financed, how margins are calculated, how contracts are structured, or how capital allocation decisions are actually made. We arrived at the table without the vocabulary to argue, and so we lost the argument before it began.

Administrators spoke the language of operations, finance, and organizational behavior. We spoke the language of clinical outcomes. Both matter. But in the boardroom, financial fluency wins.

The system absorbed that power vacuum and has never released it. Not once in the last thirty years has a major hospital system voluntarily returned decision-making authority to the physicians doing the clinical work. Why would they?

We gave them the keys. They locked the door.

Reason 3: We Never Learned to Negotiate - And Didn’t Know We Should

I want you to sit with this for a moment: the people making multi-million-dollar decisions about physician compensation, contract terms, and care delivery standards are trained negotiators operating against physicians who have received zero formal negotiation training.

Jim Camp. Chris Voss. These names should be in every medical school curriculum. They are not.

Voss’s work - drawn from his career as an FBI hostage negotiator - breaks down how high-stakes communication actually functions: tactical empathy, calibrated questions, the power of “no” as a starting position. Camp’s framework dismantles the idea that compromise is strength. These aren’t soft-skills seminars. They are operational tools for consequential decision-making.

I am not sure most physicians even recognize that they are in a negotiation when they sit across from a hospital administrator. We were trained to believe that doing excellent clinical work was enough… that integrity and quality would be recognized and rewarded.

That is not how institutions work. It is not how power works. And learning that lesson late is expensive.

Reason 4: Leadership Was Never Part of the Curriculum

Here is something that should embarrass the medical education establishment: we spend a decade training physicians in anatomy, pharmacology, procedural technique, and evidence-based medicine… and we spend approximately zero hours teaching them how to lead people, read a balance sheet, or run an organization.

We then watch, confused, as physicians feel uncomfortable in administrative roles and defer to those who do have that training.

This is not complicated. When you are not equipped for a role, you vacate it. Not because you are weak, but because discomfort at the boundary of your competence is a rational signal to retreat.

Administrators filled those leadership vacuums not because they cared more about patients - they often did not - but because they had the skills we lacked. Finance. Organizational behavior. Human resources. Strategic planning.

We built a profession of extraordinarily capable clinicians who were operationally underprepared for the institutions they were embedded in. And then we acted surprised when those institutions were shaped by someone else.

Reason 5: We Are Still Doing It

This is where I stop talking about history and start talking about right now.

Today, in 2026, medical students are still graduating without meaningful training in economics, negotiation, or organizational leadership. Residents are still completing five-year programs without a single structured course in contract law or financial literacy. Fellows are still entering subspecialties where they will generate millions of dollars in revenue annually, without knowing how to read the agreements they are signing.

We are perpetuating the same cycle. Intentionally or not, the institutions that train physicians have made a choice - by omission - to produce clinicians who are dependent on administrative infrastructure and therefore controllable within it.

This is not conspiracy. It is incentive alignment. A physician who understands organizational finance is a more expensive employee. A physician who knows negotiation is harder to manage. A physician who has leadership training might decide to build something outside the system.

That last one - that’s what I did. That’s what Indiana Orthopedic Institute is.

These concepts must be in medical school and residency curricula. Not as electives. Not as optional seminars. As core requirements, alongside anatomy and physiology. Because the system a physician will enter is just as real as the body they will operate on, and just as unforgiving of ignorance.

Reason 6: The Selection Bias Nobody Talks About

This one requires honesty that makes people uncomfortable. But I am a surgeon. Comfortable dishonesty costs lives.

Medicine selects for a specific personality profile. Intelligent. Diligent. High-integrity. Service-oriented. Willing to take the Hippocratic Oath and mean it. These are profound qualities. They are not, however, the qualities that tend to produce effective institutional navigators.

The traits that help someone excel in medical training - deference to authority, precision in following protocols, commitment to doing things correctly - are frequently liabilities in organizational power dynamics. Institutional influence rewards a different set of skills: comfort with ambiguity, tolerance for interpersonal tension, willingness to engage in negotiation and conflict without it destabilizing your identity.

Physicians are not, as a rule, selected or trained for those capacities. And so when organizational conflict arises, which it always does at the intersection of clinical care and financial pressure, physicians self-select out of the confrontation. We retreat to what we are excellent at: patient care. And we leave the room to people who are comfortable being in it.

This is not a character flaw. It is a systems design failure. The personality traits that make someone an exceptional surgeon are genuinely different from those that make someone an effective organizational leader. We have never built a system that accounts for this, trains for it, or compensates for it.

The result: the people most qualified to advocate for patients in institutional settings are the least equipped, by training, temperament, and time, to actually do so.

The Blueprint: What We Build From Here

I recently had a moment of profound self-reflection. By every objective metric, I am at the top of my game - the surgeries, the research, the organization I’ve built. But I sat with a patient recently, a retired teacher in her late 60s who had delayed her knee replacement for three years because she couldn’t navigate the financial complexity of the system around her. Not the clinical complexity. The administrative complexity. She was failed by the system before she ever reached the OR.

That failure is not abstract to me. It is the reason Indiana Orthopedic Institute exists. And it is the reason I write this.

Here is the framework I call The Three Recoveries… what it will take to reclaim physician authority in American healthcare:

1. Operational Literacy: Every physician must understand the economics of the system they practice in. Not at an MBA level, but at a functional level. What generates margin. How contracts work. What administrators are actually optimizing for.

2. Negotiation Fluency: Read Chris Voss. Read Jim Camp. Take a negotiation course before you sign your first employment contract. The system is negotiating with you whether you know it or not.

3. Leadership by Design: Build organizations intentionally. Ambulatory surgery centers, physician-owned practices, and vertically integrated care models are not just business decisions - they are acts of clinical autonomy. The infrastructure of control is the same infrastructure that determines how you treat patients.

What the System Will Not Do for You

The hospital system will not teach you to negotiate with it. The administrative structure will not train you to challenge it. The institutions that profit from your clinical labor will not redesign themselves to share power with you.

This is not cynicism. It is operational reality.

If you are a resident reading this, understand: the contract you are about to sign was written by people who negotiate contracts every day. You will sign it once. That asymmetry is not accidental.

If you are a practicing surgeon reading this, the question is not whether this system is fair. It isn’t. The question is what you are building outside of it.

The physician who understands finance, negotiation, and organizational leadership is not just a better administrator. They are a better advocate for every patient on their panel.

That is not soft sentiment. That is hard truth backed by thirty years of watching the alternative play out.

We didn’t lose the room in one dramatic moment. We walked out of it, procedure by procedure, meeting by meeting, contract by contract.

It’s time to walk back in.

Yesterday morning, a patient looked up at me from the pre-op table and asked why we weren’t using a robot for her knee replacement.

I told her exactly what I believe: “I do not want your surgery to be dependent on something that could get hacked, disrupted by a power outage, or derailed by a software glitch.”

She smiled and said, “Good. I didn’t want a robot doing my surgery anyway.”

By the time I finished her case, Stryker’s global network was down.

What Happened Today, And Why It Matters More Than You Think

A major cyberattack crippled Stryker’s global networks today, with an Iran-linked hacking group claiming responsibility and calling it “the beginning of a new chapter in cyber warfare.”

The group, Handala, claims to have wiped more than 200,000 servers, mobile devices, and other systems, forcing Stryker to shut down offices in 79 countries.

They also claim to have extracted 50 terabytes of data, which they are threatening to make public.

As of tonight, Stryker is still investigating the breach and does not know when its systems will be back online. In a regulatory filing Wednesday afternoon, the company acknowledged it expects disruptions to continue and that “the timeline for a full restoration is not yet known.”

Stryker. The company behind Mako. The number one robotic surgery platform in orthopedics. Offline. Globally. Today.

I have written about the over-reliance on robotics in orthopedic surgery before. I have said in boardrooms, in lecture halls, and in published research that the obsession with robotic dependency is creating risk, not eliminating it.

I want to be precise today, because precision matters: this is not about Stryker being a bad company. I have respect for many of their engineers and clinical teams. This is about something far more dangerous than any single company’s security posture.

This is about what happens when we build a healthcare system that cannot function without a network connection.

I Am One of the Few People Positioned to Say This Clearly

As an engineer, researcher, entrepreneur, inventor and surgeon with decades of experience… I am not just a commentator on this topic. I am a practitioner who has been inside the operating room, inside the boardroom, and inside the regulatory and research infrastructure that governs how these technologies are adopted, promoted, and too often, blindly accepted.

When I say robotics has a rightful place and a dangerous misapplication, I am speaking from 20 years of lived evidence. Not a whitepaper. Not a conference panel. The OR.

The Vulnerability We Built Ourselves

Here is the uncomfortable truth that nobody in the robotics-industrial complex wants to say out loud:

Over-utilization and over-dependency on any single technology creates systemic fragility, and in surgery, fragility kills.

Stryker produces equipment used in hospitals and surgical settings across orthopedics and neurosurgery, and reports its products reach more than 150 million patients annually across 61 countries. That scale is extraordinary. It is also exactly what makes a single point of failure catastrophic.

When a geopolitical conflict (US-Iran tensions, in this case) can reach into a Michigan headquarters and wipe 200,000 devices overnight, we have to ask a harder question than “how do we fix Stryker’s cybersecurity?”

We have to ask: What happens to the patients when the robot can’t connect?

I designed my practice around a principle that the engineering community has known for decades: redundancy and human override are not optional features. They are the architecture. The surgeon is not the backup plan. The surgeon is the plan. Technology augments that. Technology does not replace it.

When we flip that hierarchy, when the robot is the plan and the surgeon is the override, we have not improved care. We have introduced a catastrophic dependency.

The Status Quo Indictment

For the last decade, hospital systems and device companies have sold robotics as the future of surgery. The pitch is seductive: sub-millimeter precision, reproducibility, reduced variability. And there is real science behind some of those claims. I do not dispute that robotics, used correctly, adds value.

But “used correctly” is doing enormous work in that sentence.

What I have watched instead is a market-driven race to robotic adoption that has outpaced the clinical evidence, inflated hospital capital expenditure, and begun to erode the one thing that cannot be hacked, disrupted, or wiped: the trained human mind operating at the point of care.

Cybersecurity experts told CNN on Wednesday they were on alert following the attack, with one expert noting that Russia, about a decade ago, created a “global malware epidemic” when it released malware on a small target that wasn’t confined.

The lesson is not new. Interconnected systems have interconnected vulnerabilities. We have simply chosen not to apply that lesson to surgical infrastructure.

I will apply it now: every time we make a surgical outcome dependent on a networked system, we have introduced a new attack surface into the doctor-patient relationship.

That is not hyperbole. That is engineering.

A Personal Moment of Reckoning

I have had my own confrontations with this question, not in the abstract, but in the OR.

Early in the life of Indiana Orthopedic Institute, I had a case where a technology I trusted performed outside its expected parameters. The outcome was ultimately fine.

But in that moment, standing at the table, I was reminded of something that no device company will ever put in a brochure: the surgeon is the last line of defense. Not the software. Not the implant. Not the algorithm.

Me. My training. My hands. My judgment built over 10,000 cases.

That moment recalibrated something for me. Technology earns trust incrementally, in my OR, through demonstrated outcomes, not through marketing claims, hospital purchasing agreements, or robot utilization bonuses embedded in surgeon compensation packages.

The day I let a system tell me what the right answer is, without my own clinical override, is the day I stop being a surgeon and start being a technician.

The Blueprint: Technology in Its Rightful Place

This is not an anti-technology argument. I want to be precise about that, because it will be misread. I use technology every day. Indiana Orthopedic Institute is built on data, innovation, and research. We are actively engaged in developing the next generation of surgical tools.

But there is a framework I operate by, and today’s attack makes it more urgent than ever.

The Surgeon-First Technology Hierarchy:

1. The surgeon makes the clinical decision. Technology informs that decision. It does not override it.

2. Every networked dependency is a risk variable. It must be evaluated as such, not marketed around.

3. The patient relationship is local, analog, and human. It cannot be outsourced to a cloud.

4. Redundancy is not a fallback. It is the standard of care.

5. Technology that cannot function without a network connection has no place as the primary driver of a surgical outcome.

At Indiana Orthopedic Institute, we built around these principles from day one, not because we were anti-technology, but because we are engineers who understand systems. A system that fails catastrophically under a single point of attack is a poorly designed system. Full stop.

What This Means for Every Surgeon Reading This

The hospital systems that pushed robot utilization metrics on you will not call you today to apologize for the dependency they built.

The device companies that incentivized robotic adoption through volume agreements and capital placement deals will issue a press release about their cybersecurity response and move on.

The insurance-industrial complex will file this under “operational disruption” and wait to see if premiums need adjusting.

You are the one standing at the bedside. You are the one your patient trusted this morning when she asked whether you were going to use the robot, and when you told her no, she exhaled.

That exhale is data.

The geopolitical reality we are living in, where a pro-Iran hacking group can cause a global network disruption at one of the largest medical device companies in the world as an act of retaliation for military strikes, is not going away.

If anything, the attack surface is growing. Every networked surgical dependency we add is a new vulnerability we hand to adversaries we cannot control.

The answer is not to stop innovating. The answer is to stop confusing innovation with dependency.

Build your clinical autonomy now. It is not a luxury. Today proved it is a survival skill.

Elon Musk is a master of the “big number” and the “bold plan.” He has spent a career disrupting industries by looking at complex problems through the cold, logical lens of an engineer.

As someone who also graduated with an engineering degree before becoming an orthopedic surgeon, I usually find myself cheering for the logic of automation. We need more of it in healthcare.

At the Indiana Orthopedic Institute, we are already pushing the boundaries with computer-assisted navigation and augmented reality (AR) to pinpoint surgical targets with sub-millimeter precision.

But Elon’s latest claim - that his Tesla Optimus robots will be more skilled than the best surgeons and effectively replace us within 36 months - suggests he understands code far better than he understands the human condition.

He is underestimating the “friction” of the real world. In medicine, that friction is called human nuance.

And, that is something that will NEVER be replaced by a robot in our lifetime.

The Logic of Code vs. the Chaos of Biology

From an engineering perspective, surgery looks like a series of calculated physical movements. If a part is broken, you swap it. If a joint is worn, you resurface it.

But after 10,000+ joint replacements, I can tell you that a patient doesn’t just bring a “broken part” into my OR. They bring a lifetime of dysfunction, a complex web of comorbidities, and a massive amount of fear.

Data shows that successful joint replacement isn’t just about the 60 minutes spent under the knife. It is a multidisciplinary coordination involving standardized perioperative protocols and, most importantly, careful patient selection.

A robot can calculate a bone cut, but it cannot yet navigate the “hip-spine relationship” or the psychological readiness of a patient who has been told their condition is “worse than death”.

The Day I Failed a Patient (Despite 10,000 Successes)

I recently had a moment of profound self-reflection triggered by a patient I’ve known for a decade.

By all objective metrics, I am at the top of my game. I am the President of AAHKS, I’ve performed five figures’ worth of surgeries, and my outcomes are in the top 10% nationally. But with this particular patient, I failed. Not because of my “very good hands” or my psychomotor skills, but because I didn’t make her feel heard.

That interaction was a stark reminder: My “grit” and surgical skill are only half the job. The other half is the human connectivity that allows a patient to trust me enough to put them to sleep and let me change their life.

Elon’s Optimus might eventually be able to tie a suture, but it will never be able to look a crying patient in the eye and say, “I understand your pain, and we are going to get through this together.” It will never receive the four-week post-op hug that is the true currency of a great surgeon.

Data Proves Humanity Matters

This isn’t just soft sentiment; it’s hard science.

• Expectation Management: Research that I’ve done that is published in the Journal of Arthroplasty confirms that patient satisfaction is directly correlated with how well a surgeon manages expectations through communication.

• The “Human” Edge: My own data, when put up against robotic-assisted unicompartmental knee results, shows that an experienced surgeon can meet or exceed robotic accuracy.
  
  Why? Because we adjust for tissue tension and bone quality in real-time - variables that are incredibly difficult to “code.”

• Outcome Factors: We know that things like BMI, gender, and social support impact readmission and complication rates. A robot sees a data point; a surgeon sees a person who needs a specific recovery plan.

The Future: Enhancement, Not Replacement

Don’t mistake my bluntness for being “anti-tech.” I am a fierce advocate for disruption. We use computer navigation for all knee replacements because it reduces blood loss and ensures optimal alignment. We are currently developing AR visors so we can see overlaid surgical targets without ever looking away from the patient.

Technology should be used to make us super-human, not to remove the human.

Elon Musk’s career is littered with bombastic timelines that didn’t account for the friction of reality. In the world of high-stakes surgery, that friction is the doctor-patient relationship.

I will continue to design the implants of the future and build the most efficient ASCs in the country. But I will also continue to treat my patients like family.

Until a robot can offer a post-operative hug and mean it, the “36-month timeline” is nothing more than a myth.

What do YOU think? Is AI a tool or a threat to the sacred doctor-patient relationship?

Hospitals are marvels of modern engineering. They are designed to save lives. They are built to manage sepsis, treat heart attacks, and battle multi-organ failure. They are optimized for the sick.

But here is the engineering flaw in our current system: Most joint replacement patients aren’t sick. They are broken.

They have a mechanical failure, a worn-out gear in their hip or a misaligned hinge in their knee. They don’t need a facility designed for illness; they need a facility designed for reconstruction.

For decades, we forced healthy patients into a sick-care ecosystem. We exposed them to hospital-acquired infections. We let them languish in beds because “that’s how it’s always been done.” We accepted the friction of a massive bureaucracy as a necessary evil.

I refused to accept that friction any longer.

The Inefficiency of the “General Purpose” Machine

In engineering, a machine designed to do everything rarely does any one thing with maximum efficiency. A hospital is a general-purpose machine.

When I operate in a massive hospital system, my healthy 65-year-old active golfer is competing for resources with the trauma victim and the pneumonia patient. The protocols are built for the lowest common denominator of health, not the highest.

This isn’t just annoying; it is bad engineering. It introduces unnecessary variables. It increases cost. It dilutes the focus of the care team.

The Blueprint for Independence

In 2018, I co-authored the Position Statement on Outpatient Joint Replacement with the leadership of the AAHKS, The Hip Society, and The Knee Society. We laid out the roadmap. We stated clearly that outpatient surgery wasn’t reckless, it was the future, if engineered correctly.

We identified the essential elements for safety: robust patient selection, standardized anesthesia protocols, and rigorous discharge planning. We warned that you can’t just “try” outpatient surgery; you have to build a system capable of it.

But writing the guidelines wasn’t enough. I realized I couldn’t fully execute this vision inside the “General Purpose Machine.” I had to build a “Special Purpose Machine.”

Building the Vertically Integrated Practice

This is why I founded the Indiana Orthopedic Institute (IOI). We didn’t just move the surgery out of the hospital; we re-engineered the entire ecosystem.

In our Ambulatory Surgery Centers (ASCs), every person,rom the receptionist to the anesthesiologist, has one singular focus: Musculoskeletal Health.

• We control the inputs: We use rigorous risk-stratification (like the OARA score) to ensure the right patient is in the right setting.

• We control the process: Our anesthesia protocols are tuned for rapid mobilization, avoiding the nausea and over-sedation that keep patients bedridden.

• We control the output: Patients go home the same day, recovering in their own environment, away from the pathogens of a sick ward.

Innovation is Structural

We often think innovation is a new implant. But the most disruptive innovation in healthcare right now is structural.

It is the shift from the Hospital to the ASC. It is the shift from “Fee-for-Service” to “Value-Based Care.”

By stripping away the bloat of the hospital administration, we can deliver care that is:

1. Higher Quality: Specialized teams make fewer mistakes.

2. Lower Cost: We eliminate the overhead of the ICU and the ER that our patients don’t need.

3. Better Experience: Patients feel like customers, not inmates.

The Bottom Line

Hospitals will always be necessary for the sick. But for the broken? We can do better.

We have proven that with the right engineering, the right data, and the right leadership, we can decouple routine surgery from the hospital system entirely.

We didn’t just build a clinic. We built a machine optimized for wellness.

R. Michael Meneghini, MD

If you liked this, share it with an administrator who thinks “we’ve always done it this way” is a valid strategy. Next, I’m discussing “The ‘Good Enough’ Trap”, why the implant is perfect, but the patient is still in pain.

Medicine is a profession built on tradition. We learn from mentors. We inherit techniques. We repeat what we were taught because “it works.”

But in engineering, tradition is irrelevant. Data is the only currency.

If you build a bridge the same way for 50 years despite new materials proving a better method exists, you aren’t a traditionalist; you are negligent.

In orthopedic surgery, one of our oldest, most cherished traditions is the tourniquet. For decades, it has been dogma: You cannot do a knee replacement without a bloodless field. It was considered essential for visualization and cement fixation.

But when you strip away the dogma and look at the physiology, the tourniquet isn’t a tool; it’s a blunt instrument of trauma.

The Cost of a “Bloodless Field”

Let’s look at this like engineers. What happens when you apply 250-300 mmHg of pressure to a thigh for an hour?

You are creating an ischemic event. You are crushing muscle tissue. You are inducing a metabolic crisis in the quadriceps that results in measurable damage.

The literature—including our own review—shows that tourniquet use is associated with:

• Increased Pain: Patients wake up with more thigh pain, requiring more opioids.

• Diminished Function: Quadriceps recovery is slower. The muscle is stunned.

• Potential Harm: Though rare, the risks include nerve palsy, thrombosis, and skin complications.

So why do we use it? Two reasons: Visualization and Cement Fixation.

The “fixation” argument has been debunked. Multiple randomized studies, including work we have analyzed, show no difference in cement penetration or implant survival between tourniquet and tourniquetless TKA.

That leaves visualization. And this is where the “art” of surgery often masks a lack of technical discipline.

Engineering a Better Way

You don’t need a tourniquet to see. You need a better process.

We transitioned to Tourniquetless TKA years ago. It wasn’t just about “not inflating the cuff.” It required re-engineering the entire surgical workflow to manage hemostasis physiologically rather than mechanically.

1. Chemical Hemostasis: We utilize Tranexamic Acid (TXA) aggressively. It stabilizes the clot and has revolutionized blood management, making the “bloodless field” argument obsolete.

2. Anesthetic Precision: We work with anesthesia to manage mean arterial pressure (MAP) during critical steps.

3. Surgical Strategy: We operate with the knee in flexion. This naturally tamponades the popliteal vessels, keeping the field clear without strangling the quadriceps.

The Result: Faster Recovery, Less Pain

When you stop crushing the leg, the patient recovers faster. It is simple cause and effect.

In our practice, moving away from the tourniquet was a key lever in enabling same-day discharge. Patients had less pain. They had better early quad control. They could walk sooner.

And yet, despite the overwhelming evidence, the majority of surgeons still use a tourniquet routinely. Why? Because it is hard to change.

It is harder to learn to operate with a bit of bleeding. It is harder to coordinate with anesthesia. It is easier to just inflate the cuff and follow the tradition.

Innovation is Subtraction

We often think of innovation as adding something—a robot, a sensor, a new device. But frequently, the most powerful innovation is subtraction.

Removing the tourniquet. Removing the drain. Removing the Foley catheter.

These were all “standard of care” once. We removed them not because it was trendy, but because the data proved they were providing zero value while adding risk.

Tradition is comfortable. But data is imperative.

If we want to move the needle on patient outcomes, we have to be willing to kill our sacred cows. We have to be willing to admit that the way we were trained might be wrong.

R. Michael Meneghini, MD

If you liked this, share it with a colleague who is still inflating the cuff out of habit. Next, I’m tackling “The Hospital Fallacy” - why hospitals are actually the wrong place for healthy patients to get surgery.

You strengthen a material, you often make it more brittle. You increase the horsepower of an engine, you increase the thermal load. There is no such thing as a “free lunch” in physics.

Yet, in orthopedic surgery, we often fall into the trap of believing that new technology is purely additive. We assume that if we introduce a device to solve Problem A, Problem A will disappear without consequence.

We are wrong.

I have spent my career designing implants to solve specific biomechanical failures. I hold patents on Dual Mobility systems. I believe in the technology. But I also believe that indiscriminate innovation is dangerous.

In our race to eliminate hip dislocation, the single most terrifying complication for a patient, we embraced a solution that may have engineered a new, silent epidemic.

This is the Stability Paradox.

The Silver Bullet Trap

Dislocation following revision total hip arthroplasty (THA) is a disaster. Historically, rates have been reported as high as 25%. It is a mechanical failure that devastates patient confidence and ruins outcomes.

Enter Dual Mobility (DM) bearings. The concept is elegant engineering: a large polyethylene head moving within a metal shell, increasing the “jump distance” required for the hip to dislocate. The industry (myself included) adopted it rapidly. It became the default answer for the “high-risk” patient.

But as an engineer, I look at interfaces. Interfaces are points of failure.

A standard hip replacement has one articulation. A Dual Mobility hip has two. It also has a modular liner that must seat perfectly into a shell. Every new interface is a potential site for corrosion, fretting, and wear.

We started seeing something troubling. Patients presenting not with dislocation, but with unexplained pain and “adverse local tissue reaction” (ALTR), the hallmark of metal corrosion. We published a case series on Mechanically Assisted Crevice Corrosion (MACC) at the liner-shell interface of modular DM constructs.

We solved the dislocation problem, but we introduced a corrosion problem. We traded a mechanical failure for a chemical one.

The Data: Complexity vs. Simplicity

This led me to ask a simple engineering question: Do we actually need the complexity of Dual Mobility to achieve stability?

Or can we achieve the same result with simpler geometry?

We conducted a study comparing Dual Mobility bearings against Standard Single-Articulation Bearings using large diameter femoral heads ($\ge$ 40mm). We reviewed 257 consecutive revision THAs.

The hypothesis was that the advanced Dual Mobility technology would outperform the standard big heads.

The data proved otherwise.

• Dislocation Rate (Standard Large Heads $\ge$ 40mm): 5.7%.

• Dislocation Rate (Dual Mobility $\ge$ 40mm): 6.9%.

There was no statistical difference. In fact, the “simpler” solution (large standard heads) trended toward better stability.

Furthermore, we found that the single greatest predictor of dislocation wasn’t the bearing type, it was the Head-to-Cup Ratio. Geometry, once again, dictated the outcome.

Prudent Innovation

This brings us back to the core philosophy of this newsletter: Precision over Hype.

I design Dual Mobility implants. I use them. But I use them judiciously. I reserve them for the specific anatomical outliers where a standard large head simply won’t work.

If I can achieve the same stability with a 40mm or 44mm ceramic head on a single polyethylene liner, I will choose that construct every time. Why? Because it eliminates an interface. It removes the risk of intraprosthetic dislocation. It removes the risk of MACC at the modular junction.

Occam’s Razor applies to surgery: The simplest solution that solves the problem is usually the correct one.

The Bottom Line

Innovation isn’t just about adding new tools to the toolbox. True innovation requires the discipline to know when not to use them.

We must stop chasing “zero” complications by introducing complex systems that carry their own, often delayed, failure modes. We must look at the data, respect the physics, and realize that sometimes, the best engineering is the simplest engineering.

Don’t engineer a new problem just to solve an old one.

R. Michael Meneghini, MD

If you liked this, share it with a colleague who is obsessed with the latest shiny object. Next, I’m going after one of the biggest “sacred cows” in orthopedics: The Tourniquet. The data says we’re wrong, so why are we still using it?

There is a pervasive misconception in orthopedics that we are high-level carpenters. We saw, we drill, we hammer. But if you approach joint replacement with the mindset of a carpenter, you are failing your patients.

We aren’t just carpenters; we are civil engineers of the human body.

When I look at a femoral stem, I am not just looking at a piece of titanium to “fill a hole.” I am calculating load transfer, interference fit, and hoop stresses in a dynamic, biological environment. I see a structure that must withstand millions of cycles of axial load without shifting a millimeter.

If the geometry of the metal doesn’t respect the geometry of the biology, the construct fails. Physics does not negotiate.

I have spent my career at the intersection of engineering and surgery—designing implants for Stryker and Enovis and implanting them in thousands of patients. And the data we have generated proves one thing conclusively: Precision is not a luxury; it is a requirement.

The Myth of “Forgiving” Biology

For years, a dangerous philosophy permeated the hip replacement world: the idea that “biologic fixation” was a safety net.

The theory was simple (and seductive): If you put a hydroxyapatite-coated tapered wedge stem into the femoral canal, the bone would eventually “find it,” grow into it, and stabilize it. This led many surgeons to adopt a “passive” approach to broaching—undersizing the implant slightly to avoid the risk of fracture, trusting the biology to do the rest.

As an engineer, I knew this was flawed. Biology requires mechanical stability to initiate. You cannot have osseointegration without an initial, rigid interference fit. If the implant moves (subsides) before the bone grows in, fibrous tissue forms. If fibrous tissue forms, the implant loosens.

We decided to prove this. In a study we published in The Journal of Arthroplasty, we compared two distinct surgical techniques using the exact same modern taper-wedge stem in 250 consecutive hips.

• Surgeon A (The Engineer): Used a meticulously aggressive broaching technique to maximize mediolateral fill and achieve “3-point fixation.”

• Surgeon B (The Passive Operator): Relied on preoperative templating and a less aggressive “potting” of the stem, trusting the coating to confer stability.

The results were not subtle. They were a wake-up call.

The High Cost of Poor Geometry

The data revealed that geometry—specifically Distal Canal Fill—is the single greatest predictor of failure.

When we compared the outcomes between the aggressive engineering approach and the passive approach, the difference was stark:

• Subsidence: The passive group saw 4X the subsidence at one month compared to the aggressive group (1.3mm vs 0.3mm).

• Progression: By one year, 51.6% of the passive group saw additional subsidence. In the aggressive group? Only 0.8%.

• Failure: The passive group suffered a 2% aseptic loosening rate requiring revision surgery within 3 years. The aggressive group had zero.

Why did this happen? It wasn’t the metal. It wasn’t the patient’s age or BMI. It was the fill.

We found a critical threshold: when the stem achieved <85% fill at 60mm below the lesser trochanter, subsidence skyrocketed. Conversely, achieving maximum fill locked the implant into a stable construct, allowing biology to take over.

Engineering the “Perfect” Fit

This is where the engineering background becomes a surgical instrument. A taper-wedge stem is designed to convert axial load (walking) into hoop stresses that compress the bone. But this conversion only works if the wedge actually engages the cortex.

In our study, the aggressive technique utilized a lateral-directed pressure during broaching. This created a subtle valgus alignment—mechanically locking the stem at three critical points:

1. Medially at the neck cut.

2. Laterally at the stem shoulder.

3. Medially at the distal tip.

This is 3-point fixation. It is a fundamental engineering principle for stability. If you simply “pot” the stem in the diaphysis without this metaphyseal engagement, you are relying on luck, not physics.

Innovation is Discipline

In my work designing the EMPOWR systems and previously with Triathlon, we obsess over the geometry of the implant. We agonize over millimeters of offset and degrees of taper. But an implant is only as good as the surgical technique that implants it.

True innovation isn’t always about a new material, a new robot, or a shiny object. Sometimes, innovation is the discipline to ignore the urge to be “gentle” or “fast” and instead be precise.

It is the discipline to broach aggressively. It is the discipline to listen to the sound of the mallet changing pitch as the hoop stresses engage. It is the discipline to ensure that the geometry of the metal perfectly opposes the geometry of the bone.

The Bottom Line

As we move toward outpatient arthroplasty and value-based care, we cannot afford a 2% failure rate due to aseptic loosening. That is a devastating complication for a patient and an unsustainable cost for the healthcare system.

We must stop treating surgery as an art form where “good enough” is acceptable. We must treat it as an engineering challenge where tolerances matter.

Distal canal fill matters. Technique matters. Geometry matters.

R. Michael Meneghini, MD

If you liked this, share it with a colleague who still thinks surgery is just carpentry. Next, I’m tackling the “Stability Paradox”—why our race to eliminate hip dislocations might have engineered a new, silent epidemic.

I am an engineer first. I am a surgeon second.

Most people look at a joint replacement and see a medical procedure. I look at it and see a mechanical system. I see vectors, load-bearing surfaces, and friction coefficients.

But for the last 20 years, I’ve also been looking at the healthcare system itself. And what I saw was a machine that was poorly designed, inefficient, and bleeding energy.

I saw a system where the “administrators” outnumbered the “revenue generators” (the surgeons) by a margin that defied basic economic physics. I saw a model where innovation was stifled by bureaucracy, and where “value-based care” was just a slogan hospitals put on billboards while raising their prices.

So, I did what any good engineer would do. I decided to redesign the machine.

Defining “The Incision Point”

In surgery, the incision is the precise moment of entry. It is the exact point where we cut through the surface to fix what is broken underneath. It requires conviction. It requires a steady hand.

That is the philosophy behind this newsletter, and why I’m calling it The Incision Point.

We are living in an era of noise. The medical industry is covered in layers of administrative fat, opacity, and fear. To get to the truth, and to actually fix the problems facing surgeons, patients, and entrepreneurs, we have to cut through that surface layer.

This newsletter is that cut.

The Path of Most Resistance

My path to this point, founding the Indiana Orthopedic Institute (IOI), designing implants for Stryker and Enovis, and leading the American Association of Hip and Knee Surgeons (AAHKS), was not a straight line. It was a series of calculated risks.

It started at Rose-Hulman Institute of Technology. I remember sitting in the auditorium as a freshman. The speaker looked out at us, a room full of valedictorians, and said, “Look to your left. Look to your right. One of you won’t be here next year.”

That moment taught me something that has defined my entire career: Excellence is not an accident. It is an output of relentless inputs.

I carried that engineering grit into the operating room. While others were satisfied with “good enough” outcomes, I was obsessed with the variables.

• Why did this implant fail after 15 years?

• How can we alter the geometry of this tibial baseplate to match human kinematics?

• Why are we keeping healthy patients in a hospital bed for 3 days when the data says they heal better at home?

These questions led me to the world of Technology and Innovation.

Technology as a Weapon for Independence

When people hear “innovation in surgery,” they usually think of a shiny new robot. But true innovation isn’t just about gadgets. It’s about using technology to disrupt the business model of care.

For me, technology was the lever that allowed me to break free from the hospital monopoly.

Take the OARA Score (Outpatient Arthroplasty Risk Assessment), for example. Years ago, the establishment said, “You can’t send joint replacement patients home the same day. It’s too dangerous.” They were operating on fear. We decided to operate on data.

I co-developed the OARA score, a scientifically validated algorithm, to predict exactly which patients could safely go home. We didn’t guess. We engineered a risk model.

This piece of “technology” didn’t just improve safety; it disrupted the entire market. It proved we didn’t need the massive, expensive hospital infrastructure for 90% of our patients. It allowed us to move care to Ambulatory Surgery Centers (ASCs), lowering costs by 50% while improving outcomes.

That is the power of technology. It turns “impossible” into “standard of care.”

Burning the Boats (to Build a Rocket Ship)

A few years ago, I had an “aha moment.” I was sitting in a boardroom at a major health system. I looked around the table and realized I was the only person in the room who actually touched patients. I was the only person generating the revenue that paid for everyone else’s salary. Yet, I had the least amount of control over how that care was delivered.

I realized I couldn’t fix the machine from the inside. The friction was too high.

So, I left. I walked away from a prestigious academic director position. I sat out a restrictive non-compete. I started IOI with a vision to create a Vertically Integrated Practice, a model where the surgeon controls the entire value chain, from the first clinic visit to the implant design, to the anesthesia protocol, to the recovery.

We are now building this physical reality at Innovation Mile in Noblesville. We aren’t just building a clinic; we are building an ecosystem where research, engineering (in partnership with Rose-Hulman), and high-volume surgery happen under one roof.

What to Expect Here

I am writing this because the “Medical Industrial Complex” thrives on complexity. They want you, whether you are a patient, a fellow surgeon, or an entrepreneur, to think the system is too complicated to change.

I am here to tell you that it is just an engineering problem. And engineering problems have solutions.

Here at The Incision Point, I will be sharing:

• The Business of Medicine: How we are scaling IOI and navigating Private Equity without selling our souls.

• The Science of Surgery: Deep dives into implant design, biomechanics, and why “precision” matters.

• High-Performance Leadership: How to manage a business, a family, and a surgical caseload without burning out.

If you are a surgeon who feels like a cog in the wheel, this is for you. If you are an entrepreneur looking at healthcare, this is for you. If you are someone who refuses to accept the status quo, this is for you.

Welcome to The Incision Point. Let’s get to work.

R. Michael Meneghini, MD

If you liked this, share it with a colleague who is tired of the bureaucracy. Next, I’m breaking down the exact math of “Value-Based Care” and why most hospitals are doing it wrong.