Introduction to Robotic Total Hip Arthroplasty

Speaker 1Tonight, uh, uh, in line with, uh, uh, a striker offer, offering that I'm really excited to talk to you, uh, and, uh, talk to Doctor Marchand about tonight. We're gonna talk about Mako 4.0. So we have, uh, Bob Marchand from Ortho, Rhode Island. Bob, welcome.

Speaker 2Hey Corey, thanks. Glad to be here.

Speaker 1Bob is a, uh, well, he's, he's a mentor to me, no question. He's also a friend, so hopefully this will be a, uh, a casual but, uh, insightful conversation for you guys. Uh, Bob, I know you've been using Mako for a long time, but why don't you just catch us up while people are logging on. Uh, when did you start and, and tell us a little bit about your practice?

Speaker 2Yeah, so we're, we're in Rhode Island, and, uh, we have a small community hospital, 80 beds, 6 ORs.

Speaker 2We got hooked on Mako back in 2008, 2009, doing partial knees. Um, started in 2010.

Speaker 2At that time, Mako Hip came out, probably 2011. It was posterior, strictly posterior.

Speaker 2Uh, the anterior program came out probably 2012.

Speaker 2So we've been doing it for quite a while and then Stryker picked them up, um, modified their program for the Hip, and obviously added the total Knee and kind of refined all the programs. So we've been doing it for about 10 years.

Speaker 2Uh, with the Hip, really with the anterior Hip, what we're gonna look at today was probably starting around 2013.

Speaker 1Yeah, and, and, and you, you mentioned specifically approaching. I appreciate that. Um, you, you know, I, I'm doing predominantly anterior now. I, I, I know you do as well. Um, is that something you had before Makko and then you just kind of weave Mako into your anterior or tell us about that. So that

Speaker 2was, uh, I was fortunate. So it, I kind of evolved. So it came out posteriorly, uh, and at that time, I was, you know, going back 2010, 2011, anterior was kind of taken off.

Speaker 2So I was looking at the anterior. At that time, I was looking at X-ray, wearing lead, you know, all the techniques that are kind of traditional.

Speaker 2Uh, with the robot, I only could do posterior, so what I kind of did was learn to do the robot posteriorly, adapted to the robot.

Speaker 2And then added a layer of anterior and then picked it up from there and pretty much now it's all anterior Hip.

Speaker 1Well, and, and, and I think that's a really good discussion because, uh, I, I kinda like you. I kinda learned the anterior and then kind of brought Mako in, you know, there is something to the Anterior approach again that's most of our Practices now is Anterior approach. Obviously, Mako can work for any Approach, but tonight we're gonna focus on the Anterior approach in, in particular. I, I know we have a video to go through that you've been working on.

Speaker 1Um, but, but it could be used both ways, but probably we should adopt the Approach and make those separately, you know, I think that's always a good point as we kind of talk about, talk about new things in the operating

Speaker 1room.

Speaker 2Yeah, no, I think, no, I think it's like layers. So, you know, if you're adapt this, stay with your same Approach.

Speaker 2Adapt striker implants, uh, and then add robot to the Approach you're most comfortable with.

Speaker 2And then branch out, do labs, go visit people, uh, if you're gonna add an anterior or direct superior. So this, this program, you're right, it does anterior, antelateral, superior, posterior, and each one has their own little, uh, tricks, I guess is the easy way to say it, as well as the tricks of the Approach. Um, so I wouldn't say do everything all at once.

Speaker 2granular.

Speaker 1You, you, you know, we're gonna talk, uh, I wanna talk about expressed and enhanced. We're, we're gonna, we're gonna talk about, um, you know, enhanced pathway tonight which is a little bit more detailed, but, but first tell me about, so, so what, what we're really talking about, and I, I've just got my hands on it too, but the Mako 4.0, the new software, walk me through that, you know, so, so just, just for our listeners, you know, Mako for me, I would summarize is kind of three steps. There's the preoperative planning piece, so obviously a CT scan is.

Speaker 1Required, uh, there's the intraoperative flexibility, and then there's the ability to execute your plan. Uh, in Makko's case, this is, this is with a robotic arm. So total Hip could be done. You, uh, I think a lot of people at the time were doing express, which was kind of, you know, uh, perfect, perfect plan to cup position, leg length, and offset. But now, uh, what, what, what is 4.0? Tell, tell, tell us a little bit about how you look about, look at 4.0 and what it's kind of brought with it.

Speaker 2Yeah, so, so 4.0 allows, well, first,

Speaker 2There's expressed what you already described, cup position, an aversion, inclination.

Speaker 2Leg length and offset, very accurate at that.

Speaker 2What it doesn't give you is broach and aversion. So if you want to go down that pathway of looking at combined an aversion, look at broach version, then you do the Other program which is called Enhanced, which gives you everything Express does, but it gives you broach and aversion. So it's another layer of information that was 3.0, and then they added 4.0 to it,

Speaker 1right? Walk me through that. Yeah,

Speaker 2so 4.0 has everything 3.0 does.

Speaker 2Uh, so I'll stay enhanced right now. So you put it in the cup, you get inclination and aversion.

Speaker 2Leg length offset

Speaker 2Approach version.

Speaker 2You can get dynamic modeling and spinal pelvic uh motion. You can integrate all that into your 3D plan. So it, it's layers and layers more than 3.0.

Speaker 1Yeah. Well, and, and I, I, I'm, I'm, I'm, I'm with you with that. It's certainly, uh, my, my kind of current fascination with it, you know, spinal pelvic, you know, relationship and, and, and where should the cup be, all these are questions that keep coming up and up. The challenge has been, how do we predict exactly for that patient what those numbers to be. And then again, if you have a perfect plan.

Speaker 1And how are you gonna execute that plan? So hopefully, you know, Mako, that's how I see Mako 4.0. It's trying to bring all of that together, uh, give you a better plan, and, and have you execute that plan. So

Speaker 2the, the, the Other, the Other thing about 4.0, the way I look at it is, you know, 3.0 was static planning, great three-dimensional planning, great execution. You get exactly what you plan.

Speaker 24.0 is dynamic planning. So you're gonna statically plan, then you're gonna run a couple of models and do dynamic modeling and see if you're getting an impingement, seeing how your spinal pelvis, uh, moves in relationship to your cup position. So it's, it's, uh, it's very interesting because we're all, you know, I mean, we all were taught, put in the cup, put in the stem, and everything does fine, but

Speaker 2You really have to take into account what the Spine is doing and

Speaker 1effects. I think we're learning there's a lot more to it and and maybe some of it was we, we didn't have a better way to hit the target, so more information wasn't helpful. Let, let, let's get into the video.