Total knee arthroplasty (TKA) is an established treatment for advanced symptomatic knee osteoarthritis when non-operative measures no longer provide adequate pain relief or functional improvement. Robotic-assisted TKA incorporates computer-based planning, intra-operative registration, and robotic guidance or constraint to assist the surgeon with bone preparation, implant positioning, and soft-tissue balancing. Randomized-trial meta-analyses indicate that robotic assistance can reduce alignment outliers and improve the precision of component placement, although consistent clinically important superiority in patient-reported outcomes has not yet been demonstrated [1,2]. The expansion of robotic arthroplasty has been accompanied by direct-to-consumer marketing, social-media exposure, and increasing patient requests. These influences may create expectations that exceed the available evidence, including beliefs that a robot independently performs the operation, that complications are eliminated, or that improved implant alignment necessarily guarantees better long-term outcomes. In the reference study used to structure the present manuscript, Abdelaal et al. surveyed 440 potential TKA patients and found that 39.7% had no knowledge of RA-TKA, 40.7% desired robotic assistance, and only 8.7% were willing to pay an additional cost [3]. Subsequent studies have reported wide variation in awareness and acceptance. Lavelle et al. found that 70.1% of arthroplasty patients knew robotics or navigation were used in orthopaedic surgery, but understanding remained inconsistent [4]. Chang et al. reported 77.8% interest in robotic-assisted total joint arthroplasty and showed that education and socioeconomic factors influenced interest [5]. In a Hispanic cohort, only 44.2% were familiar with robotic-assisted orthopaedic surgery, although 53% preferred it to conventional surgery [6]. A Brazilian study similarly identified superficial knowledge, cost concerns, and a strong influence of both physicians and online media [7]. Evidence from India and other lower- and middle-income settings remains limited. Cost sensitivity, digital access, health literacy, and the availability of robotic systems may substantially alter patient expectations and willingness to choose or pay for robotic-assisted surgery. The present study therefore assessed awareness, sources of information, knowledge, perceptions, preference, and willingness to pay among patients attending the orthopaedic outpatient department of a tertiary healthcare centre in Mandya.

Study design and setting This was a cross-sectional, questionnaire-based study conducted in the Department of Orthopaedics, Mandya Institute of Medical Sciences, Mandya, Karnataka, India. Ethical considerations Participation was voluntary, and written informed consent was obtained in English or Kannada. Confidentiality was maintained during analysis. The institutional ethics committee approval obtained. Participants and sampling Consecutive patients attending the orthopaedic outpatient department who were willing and able to answer the questionnaire were approached. Healthcare professionals and persons with cognitive impairment or inability to complete the questionnaire were excluded according to the protocol. Inclusion criteria • Patients attending the orthopaedic OPD. • Patients willing to participate in the study. Exclusion criteria • Healthcare professionals. • Patients with cognitive impairment or inability to answer the questionnaire. Sample size The planned sample size was based on the 39.7% prevalence of no prior knowledge of RA-TKA reported by Abdelaal et al. [3]. Using n = ZZpq/dZ, with Z = 1.96, p = 0.397, q = 0.603, and an absolute precision of 8%, the calculated sample size was 143.69. After allowing approximately 4% for incomplete responses, the target sample size was rounded to 150 participants. Questionnaire and outcome definitions The structured questionnaire recorded age, gender, education, occupation, and source of information. The 10-item awareness scale awarded one point for each correct response and zero for an incorrect or “do not know” response. Total scores ranged from 0 to 10 and were classified as poor (0-5), moderate (6-7), or good (8-10). For binary analyses, moderate and good scores were combined as adequate awareness (score ≥6). The three-item knowledge section awarded one point for “Yes” responses to the questions on improved accuracy and better outcomes and one point for “No” to the question that robotic surgery is completely performed without surgeon involvement. Scores of 0-1, 2, and 3 represented poor, moderate, and good knowledge. The five-item perception section awarded one point for favourable responses as defined in the protocol: “Yes” for preference if advised by the doctor, willingness to pay extra, perceived safety, and need for more information, and “No” for the belief that robotic surgery is more expensive. Scores of 0-2, 3, and 4-5 were classified as less favourable, moderately favourable, and favourable perceptions. Because some scoring assumptions are debatable - particularly “better outcomes” as a correct knowledge response and “not more expensive” as a favourable perception - the individual item responses are reported alongside composite scores. Data management and statistical analysis Continuous variables are presented as mean ± standard deviation or median and interquartile range, and categorical variables as frequencies and percentages. Wilson 95% confidence intervals were calculated for selected proportions. Education was grouped as no formal/primary, secondary/higher secondary, and graduate or above; three records without stated education were excluded from education-based regression models. Associations between categorical variables were examined with the chi-square test. Kruskal-Wallis testing compared awareness scores across information sources. Exploratory multivariable binary logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals for adequate awareness, preference for robotic surgery, and willingness to pay extra. Predictor variables were age per 10-year increase, sex, education category, and adequate awareness; the willingness-to-pay model also considered preference. “No” and “not sure” responses were combined as the reference category for binary preference outcomes. A two-sided p value <0.05 was considered statistically significant. Analyses were performed using Python statistical libraries.

Study population After exclusion of one test response, 150 records were analyzed. The mean age was 47.1 ± 17.1 years (median 47, IQR 35-60; range 16-86). Ninety participants (60.0%) were male. Fifty-two participants (34.7%) were younger than 40 years, 58 (38.7%) were aged 40-59 years, and 40 (26.7%) were aged ≥60 years. Secondary or higher-secondary education was recorded in 63 (42.0%), and 52 (34.7%) had graduate or postgraduate education. Agriculture or manual work was the most common occupational group (74, 49.3%) (Table 1). Table 1. Demographic characteristics of the study participants (N = 150) Characteristic Category n % Age, years Mean ± SD 47.1 ± 17.1 <40 52 34.7 40-59 58 38.7 ≥60 40 26.7 Gender Male 90 60.0 Female 60 40.0 Education No formal / primary 32 21.3 Secondary / higher secondary 63 42.0 Graduate or above 52 34.7 Not stated 3 2.0 Occupation Agriculture / manual 74 49.3 Homemaker 38 25.3 Student 20 13.3 Professional / service 16 10.7 Other / not stated 2 1.3 Awareness and sources of information Ninety-three participants (62.0%) had heard of robotic-assisted knee replacement. Internet or social media was the most frequently reported source (57, 38.0%), followed by doctors (33, 22.0%); television/newspapers, friends/relatives, and other sources each accounted for 20 or fewer responses. Awareness scores differed significantly across information sources (Kruskal-Wallis H = 48.76, p <0.001). The mean score was highest among participants citing internet/social media(5.26 ± 1.62) and lowest among those selecting other sources (0.90 ± 0.85). The mean 10-item awareness score was 4.15 ± 2.27, with a median of 5 (IQR 3-6). Poor awareness was present in 102 participants (68.0%), moderate awareness in 43 (28.7%), and good awareness in only 5 (3.3%). The internal consistency of the 10-item awareness score was Cronbach α = 0.687. Correct awareness responses were highest for the possibility of increased cost (73.3%), the need for specific surgeon training (63.3%), and prior awareness of the procedure (62.0%). Major misconceptions remained: only 30.0% correctly stated that the robot does not independently perform the entire procedure, 20.7% recognized that robotic surgery does not eliminate all complications, 10.0% understood that not every patient is automatically suitable, and 9.3% rejected the statement that robotic surgery guarantees better long-term outcomes for every patient (Table 3). Table 2. Sources of information and awareness scores Information source n (%) Mean awareness score ± SD Adequate awareness n (%) Internet/social media 57 (38.0) 5.26 ± 1.62 25 (43.9) Doctor 33 (22.0) 3.42 ± 2.54 7 (21.2) Friends/relatives 20 (13.3) 4.90 ± 1.37 9 (45.0) Television/newspaper 20 (13.3) 4.70 ± 1.59 7 (35.0) Other 20 (13.3) 0.90 ± 0.85 0 (0.0) Table 3. Item-wise responses on the 10-item robotic knee replacement awareness scale No. Awareness statement Yes n (%) No n (%) Do not know n (%) 1 Had heard of robotic-assisted knee replacement 93 (62.0) 42 (28.0) 15 (10.0) 2 Surgeon remains in control 71 (47.3) 18 (12.0) 61 (40.7) 3 Robot does not perform entire procedure independently 31 (20.7) 45 (30.0) 74 (49.3) 4 Robotic system assists planning/bone preparation/component positioning 66 (44.0) 12 (8.0) 72 (48.0) 5 Robotic assistance may improve implant positioning/alignment accuracy 83 (55.3) 7 (4.7) 60 (40.0) 6 Does not guarantee better long-term result for every patient 62 (41.3) 14 (9.3) 74 (49.3) 7 May be more expensive than conventional TKA 110 (73.3) 9 (6.0) 31 (20.7) 8 Does not eliminate all surgical complications 33 (22.0) 31 (20.7) 86 (57.3) 9 Surgeon requires specific training 95 (63.3) 15 (10.0) 40 (26.7) 10 Not every TKA patient is automatically suitable 31 (20.7) 15 (10.0) 104 (69.3) Knowledge, perceptions, preference, and willingness to pay The mean knowledge score was 1.57 ± 0.96; 61 participants (40.7%) had poor, 66 (44.0%) moderate, and 23 (15.3%) good knowledge. Ninety-one (60.7%) believed robotic surgery improves operative accuracy, 85 (56.7%) believed it gives better outcomes than conventional surgery, and 59 (39.3%) correctly stated that the operation is not completely performed by the robot without surgeon involvement Ninety-five participants (63.3%) would prefer robotic knee replacement if advised by their doctor. Most respondents (128, 85.3%) believed robotic surgery was more expensive than conventional surgery, and only 39 (26.0%) were willing to pay extra; 59 (39.3%) were unsure about paying more. Sixty-seven (44.7%) believed robotic surgery was safer, whereas 70 (46.7%) were unsure. A large majority (134, 89.3%) wanted more information to be provided to patients. Using the protocol-defined composite perception score, 74 (49.3%) had less favourable, 63 (42.0%) moderately favourable, and 13 (8.7%) favourable perceptions (Table 4). Table 4. Knowledge, perceptions, preferences, and willingness-to-pay responses Question Yes n (%) No n (%) Not sure n (%) Do you think robotic surgery improves accuracy of surgery? 91 (60.7) 17 (11.3) 42 (28.0) Do you think robotic surgery gives better outcomes than conventional surgery? 85 (56.7) 20 (13.3) 45 (30.0) Do you think robotic surgery is completely performed by a robot without surgeon involvement? 35 (23.3) 59 (39.3) 56 (37.3) Would you prefer robotic knee replacement if advised by your doctor? 95 (63.3) 23 (15.3) 32 (21.3) Do you think robotic surgery is more expensive than conventional surgery? 128 (85.3) 14 (9.3) 8 (5.3) Would you be willing to pay extra for robotic surgery? 39 (26.0) 52 (34.7) 59 (39.3) Do you think robotic surgery is safer than conventional surgery? 67 (44.7) 13 (8.7) 70 (46.7) Do you think more information about robotic surgery should be provided to patients? 134 (89.3) 8 (5.3) 8 (5.3) Associations with awareness and knowledge Adequate awareness was more common in participants aged <40 years (53.8%) than in those aged 40-59 years (31.0%) or ≥60 years (5.0%; p <0.001). It was also more common among men than women (38.9% vs 21.7%; p = 0.042) and increased across education categories (6.3% with no formal/primary education, 31.7% with secondary/higher-secondary education, and 48.1% among graduates; p <0.001). Similar gradients were observed for adequate knowledge (Table 5). Table 5. Association of demographic characteristics with adequate awareness and knowledge Variable Category Adequate awareness n (%) p value Adequate knowledge n (%) p value Age group <40 28 (53.8) <0.001 39 (75.0) 0.003 40-59 18 (31.0) 34 (58.6) ≥60 2 (5.0) 16 (40.0) Gender Male 35 (38.9) 0.042 63 (70.0) 0.002 Female 13 (21.7) 26 (43.3) Education No formal / primary 2 (6.2) <0.001 9 (28.1) <0.001 Secondary / higher secondary 20 (31.7) 35 (55.6) Graduate or above 25 (48.1) 43 (82.7) Adequate awareness = awareness score ≥6/10. Adequate knowledge = knowledge score ≥2/3. P values are from chi-square tests. Three participants with unstated education were omitted from education comparisons. Associations with preference and willingness to pay Preference for robotic knee replacement differed by age and education but not significantly by gender. Preference was reported by 73.1% of participants aged <40 years, 70.7% aged 40-59 years, and 40.0% aged ≥60 years (p = 0.002). It increased from 34.4% among those with no formal/primary education to 66.7% with secondary/higher-secondary education and 78.8% among graduates (p <0.001). Willingness to pay extra was also associated with age (p = 0.034) and education (p = 0.008) in unadjusted analysis (Table 6). Table 6. Association of demographic characteristics with preference and willingness to pay Variable Category Prefer robotic surgery n (%) p value Willing to pay extra n (%) p value Age group <40 38 (73.1) 0.002 19 (36.5) 0.034 40-59 41 (70.7) 15 (25.9) ≥60 16 (40.0) 5 (12.5) Gender Male 62 (68.9) 0.120 22 (24.4) 0.732 Female 33 (55.0) 17 (28.3) Education No formal / primary 11 (34.4) <0.001 2 (6.2) 0.008 Secondary / higher secondary 42 (66.7) 16 (25.4) Graduate or above 41 (78.8) 19 (36.5) No” and “Not sure” were combined as the comparison category for preference and willingness-to-pay analyses. Three participants with unstated education were omitted from education comparisons. Multivariable analyses After adjustment for sex and education, each 10-year increase in age was associated with 38% lower odds of adequate awareness (aOR 0.62, 95% CI 0.46-0.83; p = 0.001). Women had lower adjusted odds than men (aOR 0.38, 95% CI 0.16-0.90; p = 0.028). Graduate education showed a strong but borderline association with adequate awareness (aOR 4.96, 95% CI 0.95-26.08; p = 0.058). For preference, education remained independently associated after adjustment. Compared with participants with no formal/primary education, those with secondary/higher-secondary education had an aOR of 2.80 (95% CI 1.02-7.74; p = 0.047), and graduates had an aOR of 5.04 (95% CI 1.57-16.21; p = 0.007). Adequate awareness itself was not independently associated with preference in this model. No predictor reached conventional statistical significance in the willingness-to-pay model, although adequate awareness (aOR 2.29; p = 0.068) and graduate education (aOR 4.64; p = 0.082) showed possible positive trends (Table 7). Table 7. Exploratory multivariable logistic regression analyses Outcome and Predictor Variables Adjusted Odds Ratio (aOR) 95% Confidence Interval (CI) p-value Adequate Awareness Age (per 10-year increase) 0.62 0.46–0.83 0.001* Female sex (vs. male) 0.38 0.16–0.90 0.028* Secondary / higher secondary (vs. no formal/primary) 2.71 0.53–13.79 0.230 Graduate or above (vs. no formal/primary) 4.96 0.95–26.08 0.058 Preference Age (per 10-year increase) 0.92 0.71–1.20 0.552 Female sex (vs. male) 0.55 0.26–1.15 0.113 Secondary / higher secondary (vs. no formal/primary) 2.80 1.02–7.74 0.047* Graduate or above (vs. no formal/primary) 5.04 1.57–16.21 0.007* Adequate awareness (score ≥6) 1.48 0.59–3.72 0.403 Willingness to Pay Extra Age (per 10-year increase) 0.79 0.59–1.06 0.115 Female sex (vs. male) 1.98 0.83–4.73 0.125 Secondary / higher secondary (vs. no formal/primary) 3.65 0.68–19.44 0.130 Graduate or above (vs. no formal/primary) 4.64 0.82–26.18 0.082  Adequate awareness (score ≥6) 2.29 0.94–5.58 0.068  Preference for robotic surgery 0.76 0.30–1.88 0.549

Principal findings This single-centre survey found that awareness of robotic knee replacement was broad but shallow. Although 62.0% had heard of the procedure and nearly two-thirds would prefer it if advised by their doctor, only 32.0% achieved at least moderate awareness on the 10-item scale and just 3.3% demonstrated good awareness. The most important knowledge gaps concerned the autonomy of the robot, guarantees of long-term benefit, elimination of complications, and universal suitability. The findings indicate that patient enthusiasm may be driven more by perceived technological superiority and trust in the treating surgeon than by a nuanced understanding of current evidence. Comparison with previous studies The proportion who had heard of robotic-assisted knee replacement in the present study (62.0%) is broadly consistent with Abdelaal et al., in whom 39.7% reported no knowledge [3], and with Lavelle et al., who found that 70.1% knew robotics or navigation were used in orthopaedic surgery [4]. Familiarity was higher than the 44.2% reported by Pinci et al. in a Hispanic opulation [6]. These differences may reflect the wording of the survey, local availability of robotic platforms, education, age structure, marketing exposure, and whether participants were general OPD attendees or patients already considering arthroplasty. Interest in robotic surgery was higher in our cohort than in Abdelaal et al. (63.3% vs 40.7%) [3], lower than the 77.8% interest reported by Chang et al. [5], and higher than the 53% preference reported by Pinci et al. [6]. The present question explicitly framed preference as conditional on advice from the treating doctor, which probably increased acceptance. This interpretation is supported by Abdelaal et al., who found that surgeon preference strongly influenced both willingness to receive RA-TKA and willingness to pay extra [3]. Only 26.0% of our participants were willing to pay extra. This was higher than the 8.7% reported by Abdelaal et al. [3] but much lower than the 55.7% reported by Lavelle et al. [4]. Cross-study comparisons should be cautious because the surveys did not specify identical additional costs, healthcare financing differs, and willingness-to-pay responses are sensitive to income and perceived necessity. In our cohort, 85.3% believed robotic surgery was more expensive, supporting cost as a likely barrier. Misunderstanding of robotic autonomy was prominent. Only 30.0% correctly rejected the statement that the robot performs the entire operation independently, and 39.3% correctly answered the similarly worded knowledge item. Chang et al. also reported that more than 100 respondents believed robots could independently perform most or all of the operation [5]. These findings reinforce the need to describe robotic systems as surgeon-controlled tools rather than autonomous operators. Information sources and patient education Internet and social media were the leading information source in this study (38.0%), exceeding doctors (22.0%). Participants citing online sources had higher mean awareness scores than those selecting other sources; however, a higher score does not establish that the information was accurate or balanced. Abdelaal et al. warned that non-peer-reviewed online content may expose patients to misinformation and aggressive marketing [3]. Temponi et al. found physicians and internet/social media to be the principal sources among Brazilian patients [7]. The combination of high digital exposure and persistent misconceptions suggests that clinicians should not assume that prior awareness equals informed understanding. A practical counselling intervention should explain five points: the robot assists rather than replaces the surgeon; surgeon training and judgement remain essential; improved planning or alignment does not guarantee a superior outcome for every patient; complications are reduced neither to zero nor uniformly across systems; and additional cost and suitability vary by patient, hospital, implant, and robotic platform. The finding that 89.3% wanted more information indicates strong receptiveness to a structured educational handout, brief video, or preoperative counselling module in Kannada and English. Demographic influences Younger participants had substantially greater awareness, even after adjustment. This may reflect greater exposure to digital media or emerging medical technology. Women had lower adjusted odds of adequate awareness, but this association may be confounded by age, occupation, access to information, or education not fully captured by the broad categories used. Education showed the clearest relationship with preference: graduates had approximately fivefold higher adjusted odds of preferring robotic surgery than those with no formal or primary education. Chang et al. similarly reported increasing interest with higher education and income [5]. These patterns support targeted counselling that uses plain language, diagrams, and teach-back methods rather than a single uniform explanation. Clinical interpretation Patients frequently associated robotics with accuracy and better outcomes. The perception of improved accuracy has a reasonable technical basis because robotic systems can improve the reproducibility of bone cuts and component alignment. Robotic arm-assisted TKA is a surgeon-controlled technology intended to improve operative planning and execution [8]. Systematic reviews and comparative studies have reported improved radiological alignment, fewer alignment outliers, and improved gap balance [9,10]. However, meta-analytic evidence shows that radiographic precision does not consistently translate into clinically important improvement in patient-reported outcomes [1,2]. Therefore, informed consent should distinguish technical process outcomes from proven long-term patient benefits. Surgeons should also avoid framing conventional TKA as inferior when both methods can produce excellent outcomes in appropriately selected patients. Strengths and limitations The study provides local data from a government tertiary-care outpatient population and reports both composite scores and item-level misconceptions. The achieved sample size matched the planned target of 150, and the analysis included demographic associations and exploratoryadjusted models similar to the reference survey format. The 10-item awareness scale showed borderline acceptable internal consistency (Cronbach α = 0.687). Several limitations require emphasis. First, the study was conducted at one centre using consecutive sampling, limiting generalizability. Second, the questionnaire was locally assembled and was not formally validated against an external knowledge standard. Third, responses may be influenced by social desirability, interviewer effects, and ambiguity in terms such as “better outcomes” and “safer.” Finally, income, prior knee diagnosis, prior arthroplasty consultation, insurance status, and actual willingness-to-pay amount were not recorded, limiting economic interpretation. Implications and future research The immediate application of these findings is the development of a short, standardized patient-education package before discussing robotic TKA. A future study should validate a bilingual awareness scale, record socioeconomic and clinical variables, and evaluate knowledge before and after a structured counselling intervention. Multicentre sampling across government and private hospitals would help determine whether awareness and willingness to pay differ by access to robotic technology and healthcare financing. Qualitative interviews may further clarify why patients equate robotics with superior safety or outcomes

Among orthopaedic outpatient attendees in Mandya, robotic knee replacement was familiar to many and acceptable to most when recommended by a doctor, but detailed awareness was inadequate. Misconceptions about independent robotic performance, guaranteed outcomes, elimination of complications, and universal suitability were common. Willingness to pay extra was limited despite high preference. Older age, female sex, and lower education identified groups that may require more focused counselling. Balanced, surgeon-led, bilingual education is necessary to align expectations with evidence and support genuinely informed decision-making. DECLARATIONS Ethics approval and consent to participate: Institutional ethical committee approval obtained, written informed consent was obtained. Funding: self-funded Acknowledgements: The authors thank the patients and staff of the Orthopaedics outpatient department, Mandya Institute of Medical Sciences, Mandya.

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