(2020) Robotics in THA: Why? How?

Yes, thank you, thank you so much, uh, to our moderators, uh, Doctor Martinez, Doctor Diego. So thankful that my friend, uh, Doctor, uh, Bonilla, uh, invited me to be a part of this, and it's just been an incredible opportunity for me. So thank you, um, thank you so much. We're gonna talk a little bit about Robotics and Total hip arthroplasty, and I think, man, this is such a big topic, and there's so much interest in it currently, but

Uh, our last lecture, uh, covered so many important topics in Orthopedics. Let's try to get into this one. Thank you for the invitation. I am a consultant for Stryker, uh, and I'm an equity partner in an ASC where we do use, uh, robotic Technology as well as, uh, sit on the editorial board for several, uh, uh, US, uh, US publications. Uh, we'll only discuss Peer review literature here. If it is about Stryker, um, uh, it will be, uh,

Specifically, uh, noted in the slide. So, so what is the evolution of development? Cause here's the problem, uh, how are we going to get better and how do we utilize Technology to get there? I'll bet very few of us have flip phones, we probably have iPhones or more powerful Technology in our pocket. How do we make that translation for the patient to improve outcomes? And it's really this stepwise progression. First, industry is, is, is an art, and then we have instruments. This is where we

We are now. Then we have standardized procedures and templates. We're certainly developing that world, but then it becomes into automation and ultimately computer integration. What can computers do for us as surgeons? What compu computers do for our patients? Here's the critical question. But Innovation cost, uh cause uh uh comes at a cost. Uh, you can see how expensive healthcare is already in the US and I'm sure your countries are similar, similar.

But it's, but it's a cost for time too of the surgeon, the patient, and the healthcare system. So where do we put our efforts and how are we gonna actually pay for the Cost reduction? Well, this is a, a very recent paper out just this year showing that robotic total Hip is cheaper in Medicare and private payers. Now, why is that? They looked at populations and this is a project uh projection analysis using the Markoff method.

And model, which essentially shows that if you can reduce complications, you reduce the long-term, long-term cost. But we have to prove that, of course. And how do we quantify improvement in patient outcomes? This is harder to put a dollar figure to, but we all know this is very important. Let me state clearly at the beginning of my talk, improved patient outcomes are mandatory to justify added surgical time.

Changes in workflow and direct cost, that's certainly where I come from. But what is Robotics? And that's what I was tasked with discussing specifically, not just Technology as a whole, but Robotics. Aristotle is the first one that described Robotics. If every tool did its own work, there would be no need for apprentices, um, but, but Robotics didn't, uh, weren't really created until the time of da Vinci. I'm told this robotic, um,

Creation could extend his hand and serve a drink to guests at a party. Maybe you think about this guy who plays soccer on the YouTube videos or maybe this futuristic vision of Robotics. I wanna challenge you to think about Robotics as the intelligent connection of perception to action. How are we gonna use information and actually do better for our patients?

There's image-based and imageless in the total Hip world. The two really true robotic platforms as they publicize themselves now are Think Surgical and Mako, at least in the US, and then there are imageless systems that are growing into the Hip space. I include them here because they're powerhouses in Robotics on, um, Other procedures like the, the total Knee and part, partial Knee.

Uh, we can talk about it as a passive, uh, system or an active system. Think surgical, actively, um, machines the bone or semi-active, meaning the robotic system provides some information to you so that you can, uh, make better decisions in.

Operatively. As we think about Robotics, I want you to be critical on what it does for us prior to the Surgery, what adjustments can be made intraoperatively and ultimately the, the, the, the execution because all of these robotic systems are different. This is one from 2009.

2009. This is current equipment. I've circled Think Surgical and Mako cause we'll talk about those. We really need a classification system. If you learn nothing more from my talk, uh, I hope you learn how to think about Robotics and that we need to interpret literature more critically because see Stryker Mako would come out with a CLOD classification.

Uh, meaning, uh, we do get a CT scan, we have length length and offset intraoperatively, and it's direct placement of the components, whereas navigation systems only provide guidance and don't require advanced imaging. We have to be more critical about how we talk about, uh, these type of technologies if we're gonna determine what's truly valuable for our patients.

Uh, I mentioned this already, uh, uh, uh, earlier, uh, in the US, Think Surgical and Mako are the two Hip systems that are truly robotic platforms, but we know that there are Other navigation type platforms that are entering the market, and they should be, uh, evaluated carefully. But why Robotics? Well, the reason why is cause total Hip is the, probably the best operation we have in Orthopedics with regard to return of quality life years, but complications still exist like infection and aseptic loosening, uh, obviously, bearing choice.

Options Fracture, but also instability in the US this is a very costly complication over $40,000 just for a simple liner headball exchange and leg length inequality, this is where it's hard to quantify how costly patient outcome is. This is the number one cause of litigation in the US. The cost of patient dissatisfaction needs to be weighed. Uh, we know the demand is going up and up. A recent meta-analysis, and this is the list here, uh, shows that.

There's better radiographic outcome, but it hasn't been connected to complications and overall, the functional outcomes were similar. Our prior presenter mentioned this. Well, it's because we're not being granular enough with this specific technique. There, there's some study, uh, this is the Mako platform, as I said, would be, uh, clearly marked better preoperative planning, right? You can pick the cup size better. I actually opened my acetabular cup before the Surgery. This is, uh, um, essentially just a modeling show.

Showing you that in the platform before Surgery, we create a 3D model. You can see exactly how it fits the cup, I mean, within the acetabular bone. You can see exactly how the femur fits into the bone. You can make adjustments, you can make changes to make sure your preoperative plan is accurate. You can see on the top left, we're cutting through the slices on the acetabular bone. This is in a Primary case, but obviously very powerful if there's hardware in the acetabulum as well.

Um, but, but, but does it hit our target? There are multiple studies, both cadaveric and in, uh, Inpatient studies. Um, this is 5 surgeons performing still on a cadaver, but now we're into, um, pre and post CT scans which show restoration of Hip center of rotation. And I think that's really gonna be a key factor to our ability to provide better patient satisfaction. Why do I say that? I'll get to that here in a second.

Can it be applied across multiple institutions? This is a paper that says it can be. We can be better with regard to placement of the components with advanced Technology. This is another one of those match studies showing manual, uh, versus uh robotic, and, and, and in every situation, the robotic system is more accurate. This is looking over multiple approaches, multiple ways to do it. Again, Robotics leads.

The way with regard to hitting your target. Um, but I, I, I told you earlier, I think that's really important that we connect that to patient outcomes, and we're starting to see that data now. This is a paper showing the lowest forgotten joint score in the literature, lower Pain scores with Robotics. This is a, this is kind of a landmark paper that talks about Robotics. Essentially, this surgeon did his 1st 100 in practice, his last 100.

Before Robotics, and then finally, his 1st 100 robotic total hips. That was the only category that had 0% dislocation, so there was not this steep Learning curve for our patients. Patients did better by not dislocating. This is another paper that starts to look at their outcomes. Their SF 12s, their, their, their UCLA scores are higher. I think that has to do with center of rotation.

But how do I do it? Well, this specific Mako platform, just a minute on this. There is an MPS which is a, uh, a technical person with you in the operating room that's not scrubbed in that helps, uh, you, uh, employ and deliver the, the Robotics. There is a setup issue. This is in the cadaver lab. You can see the eye here over top of my head. You can see an array on the robotic base, and then I'll show you here in a second.

Second where we put an array on the patient. We already talked about preoperative planning. This is the array on the patient. If they're, if you're doing an Anterior approach, you do it on the contralateral, uh, pelvic brim. If you do a posterior, obviously, it's ipsilateral. You assess preoperative leg length and offset first, then you register the pelvis. This is what that looks like. There's a little probe and you're taking points on bone. It's tempting.

To think that's like navigation, but remember, we're checking everything back to the CT scan. And so then you ream. This is a video showing the ability to single-stage ream exactly in the dome that you're going for. Ultimately, you place the cup, and if you plan it at 40, 22, that's where you're going, you prepare the stem. You then take leg length and offset and sure enough, you can execute intraoperatively your plan.

The ability to adjust for impingement, soft tissue impingement with pelvic mobility is now available in, in, in this platform, and I wish I had more time to discuss. Um, if, if time allows, maybe we can go through some robotic cases later. It's a powerful tool for the Primary case but also the complex revision. Thank you for your time.