---
title: 'Summary Discussion'
type: 'lesson'
url: 'https://doc.social/courses/robotic-total-hip-arthroplasty/summary-discussion'
course: 'Robotic Total Hip Arthroplasty'
course_url: 'https://doc.social/courses/robotic-total-hip-arthroplasty'
position: '4 of 4'
author: 'Cory Calendine, MD'
transcript: 'yes'
---

# Summary Discussion

## Summary

_This lesson is a recording without a written summary._

## Transcript

2,059 words · 10 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: You, you know, I did want to mention this, you know, just to be clear, you know, Mako 4.0, you, you don't have to use that pelvic positioning, uh, tool, right? So you took those X-rays in, in, in your clinic, standing and sitting views, and, and that's when we were at the sacral slope. But, but you could still get the information except the impingement if you didn't take those X-rays, right? You, you don't have to use that.
[0:22] Speaker 2: Yeah, no, you, you don't have to use it. So one of the interesting things are what patients should you be doing the sacral slope on.
[0:29] Speaker 2: So if they have a fusion and they have hardware, I'm going to do it for sure.
[0:33] Speaker 2: Uh, uh, this is a new program, so we're running pretty much everyone because I don't think we really know who, who should be doing it on or not. So pretty much we're kind of running everyone through it, trying to learn. And I think as time goes on, we may evolve and there may be a certain category of patient like we don't need to do the standing sitting X-rays.
[0:54] Speaker 2: But if you just do the um uh you can still do the virtual range of motion without your, your sacral slope in. You could do it kind of you did 3.0, put your implants in statically, run the dynamic model with the information you have. If you wanna go another layer deeper, then you get your standing sitting. But I think that's gonna be worked out like who's appropriate to get the standing sitting on and, and then where do you shoot for. Um, I don't, I don't think, I hope we're not gonna end up.
[1:22] Speaker 2: Shooting for a zone like this is the safe zone, kind of Lewinic type. I hope we
[1:27] Speaker 2: Look a little beyond that, look for more personalized positioning, um, which is really patient-specific, and, um, I think we'll probably get there, but I think time will tend., time will tell.
[1:38] Speaker 1: Yeah, and, and, and you think, I mean,
[1:40] Speaker 1: This this is the Other thing that comes up all the time. I mean, dislocation, Bob, I'm assuming, I mean this is being recorded. I'm assuming dislocation, you know, is not a major issue. You, you, you're obviously we're trying to minimize that risk, but also, I mean, what are your thoughts on this? A lot of people talk about soft tissue impingement causing Pain. I mean, where are you at with that?
[1:59] Speaker 1: Um, cause, cause it seems like this, it's more than dislocation because our dislocation rates are going down and down with, with, with, with Mako already it seems like.
[2:07] Speaker 2: So I, I, you know, people say, well, my dislocation rate's fine, my patients do well. Well, dislocation rate is such a crude indicator of how you're doing. If you're measuring dislocation to tell you that you're doing good.
[2:18] Speaker 2: Uh, I think you have to change your yardstick a little bit.
[2:21] Speaker 2: One of the things I, I, I can tell you is, you know, the total Knee is a soft tissue procedure. The total Hip is too, I think, I think we just ignored it all this time.
[2:30] Speaker 2: And I can tell you from my historical standpoint, when we used to do 2D templating and do total hips and medialize the cup.
[2:39] Speaker 2: I was using stems that were 132s all the time because I was only 2D templating them, and I, I was always underestimating the offset. Now, I'm much more at 127, so I'm much more attuned to the offset, what the soft tissues are doing. Um, so I think we can do a much better job in relationship to soft tissues. How do you measure it? I don't know, but, um, I think I'm doing a better job with this than I ever was before.
[3:04] Speaker 1: Yeah, I mean, we, we had, it's a good point. I think there are two concepts that this helps us with. One is the cup center of rotation because, I mean, how did we even measure that before? I don't even know what that means. And, and, and, and, and accurately measuring offset was tough, you know, in my training, um, you know, we, we tend to put a lot of high offset stems in just right away, right, because we were doing posterior Approach. It helped the stability. So boy, we just, we just pop them out of there.
[3:30] Speaker 1: And, and people did reasonably well, but, but, but you and I both know if you're not sensitive to that soft tissue envelope like you were talking about, you're gonna get more trochanteric bursitis and, and, and, and, and, and, you know, things like that. So we, I'm, I'm getting a message that we do have about 8 minutes left, Bob. There are a couple of things I wanna talk to you, but I, I wanted to make sure people know that they can ask a question through the, uh, through the Q&A box, uh, if they want.
[3:56] Speaker 1: What, what, what I wanna get back to this Efficiency and timepiece you mentioned it several times. Like how long, how long does this take really? Like, you know, you do 8 a day or, or 17 a day. I mean, I mean, walk us into Rhode Island. Rhode
[4:10] Speaker 2: Island. So Rhode Island's unique. Um, so typically, uh, 8 joints a day is, uh, a happy spot. If I do 10, I get kind of tired. If I do 8, I'm OK.
[4:22] Speaker 2: Uh, yeah, I'll usually do, the most hips I'll do is probably 4 a day cause I get kind of tired of that and I'll do some knees, so we mix them up. Although usually knees are on Tuesdays and we'll do 8 to 10. Those are just simpler and easier. A Hana table takes a little bit of time setting up.
[4:39] Speaker 2: So I think today we did 4 hips and 4 knees and we're here at 5.
[4:44] Speaker 1: So you've got multiple Hana tables, I guess if you're doing hips, you, you have multiple Mao bases too. I mean, I have one at my facility. I can run 2 rooms pretty easy. I don't know if 3 to to do
[4:54] Speaker 2: that. Yeah, so we, we'll, we'll, we'll run 2 rooms. Um, typically I'll get 2 robots, but in the days when we didn't have 2 robots, we'd run 2 rooms with 1 robot and
[5:05] Speaker 2: You know, the robot is used, but then when you're done with the robot, the robotic part, you just move it to the Other room and get it set. It doesn't really lose any, any time at all, so you can do it all with 11 robotic arm.
[5:16] Speaker 2: Uh, I'm kind of spoiled. We have 3, and I get 2 of them, so that's really quick.
[5:22] Speaker 1: Yeah, I mean, if I can borrow 1, that'd be great. Um, so I don't think so. I know you're working on ASC too. Uh, I think we're getting more and more participants that are coming on to ICJR. I know that's a huge issue, at least it was last Wednesday. We talked about the ASC transition and Outpatient Surgery and all that kind of stuff. What, what are your thoughts on that? Just tell us a little bit about your practice on that, but also how Makko plays into that, or.
[5:46] Speaker 2: Yeah, so I, I sound like an infomercial. So we, we've been, uh, building an ASC. It's up in March and we're trying to, well, we have a robot that's going there already, but you know, this is a little plug for Stryker ASC department. They have a currently a department for ASC that now is horizontally integrated across all 21 departments. So you talk to one guy and one guy integrates the whole ASC and part of that plan is we incorporate a robot. So we're gonna have a robot in our ASC, uh, 6 rooms.
[6:15] Speaker 2: And we haven't got a hand at table, but I think that's just gonna evolve. Obviously, we're gonna start with partial knees, total knees, and go to hips as uh
[6:25] Speaker 2: As a community allows, I mean, we're in Rhode Island and unfortunately, fortunately, unfortunately, we have a really nice hospital, really nice food, really nice people, all private rooms. It's too much like a spa, so I have to beg people to leave or tell them to leave cause I need their bed, um, and they all want to come here and stay a long time. So, uh, having a really nice hospital is a challenge sometimes.
[6:47] Speaker 2: So, in the AFC, you know, people are gonna want to go back to the hospital because they get treated so well. So, you'll see how New England adapts to the ASC. Uh, there's a fellow who's got one up in New Hampshire and he's, he's, you know, outside Boston, he's been very busy, you know, people adapt. I think we'll get there.
[7:03] Speaker 1: Yeah, I, I think it's very regional, you know, the projections are half are Outpatient by 2026 or something like that, but, um, it, it's been a little quicker for me here because of, of COVID. Uh, some people, uh, I recently, uh, have access to an ASC, and so because of COVID, people wanna.
[7:20] Speaker 1: Step away from the hospital again it's just giving them more options. It's the same care. I mean, uh, I, I'm kind of like you Bob we, well we, we already opened our ASC but we have a Mako there so it's the same procedure, um, you know, by all accounts in both facilities it's just what's the right mix for them.
[7:37] Speaker 2: Yeah.
[7:38] Speaker 2: It's tough to see. I mean, we'll see how it develops, but it should be open in March and hopefully we'll start joints, uh, April, I think.
[7:46] Speaker 1: Give them a
[7:46] Speaker 1: month. My knee's hurting me, so maybe Rhode Island's the one for me. Uh, any Other thoughts, uh, about Mako 4.0 or anything we, we didn't discover.
[7:55] Speaker 1: I, I know, uh, again, I have, I'm just starting with 4.0. Uh, it's really true. I've, I've used a 30 for a long time, but I know you and a lot of guys have done a lot of cases through it already. So, any thoughts as people are evaluating it?
[8:08] Speaker 2: Yeah, no, I, no, I think, I think if you think, you know, our evolution, two-dimensional templating, go to 3.0, three-dimensional templating, but really, that's all static. Dynamic templating is the next layer, and then spinal pelvic.
[8:23] Speaker 2: Templating as the Other one. And again, maybe we don't need it on everybody, but it sure is nice to know that you've looked at it all and go back to the procedure. So, you know, how do you do your anterior hips? Uh, you put them through a range of motion, you take them out of the boot and crank them all over the place, right? Is that how you do it?
[8:40] Speaker 1: Uh, no, I, I ignore
[8:42] Speaker 1: it.
[8:43] Speaker 2: You ignore it.
[8:45] Speaker 2: Um, all I can tell you is with dynamic modeling, I don't put my finger in there and try to get my finger crushed on impingement or any of that. I run the model and then the implants go in right where I plant them and that's it. I don't,
[8:57] Speaker 1: well,
[8:57] Speaker 1: no, I, I think it's super powerful. I don't, I use a Hana table. I don't take, you know, I used to unhook the boot and try to take it through a range of motion.
[9:04] Speaker 1: Um, I, I liked that being a former posterior Approach surgeon, but, but having this knowledge, being able to predict it, not having to fool with it, or like you say, stick your finger in there, or sometimes I get a, you know, I'll put them in extension and external rotation, um, this is obviously much more straightforward.
[9:19] Speaker 2: Uh, yeah, I, I mean, that, that, I mean, those, uh, those, um, mechanisms work well, but they're really crude, right? You know, it's trying to quantify Orthopedics. This really quantifies it.
[9:30] Speaker 1: Yeah. No, I think those are good points. Uh, Bob, we, uh, I, I personally appreciate your time. I know, uh, Stryker does and ICJR. I think we're gonna wrap up here.

## In this course

- [Previous: Intra-operative Overview](https://doc.social/llms/courses/robotic-total-hip-arthroplasty/intra-operative-overview.md)
- [All lessons: Robotic Total Hip Arthroplasty](https://doc.social/llms/courses/robotic-total-hip-arthroplasty.md)