Dr. Savyasachi Thakkar discusses Robotic Joint Arthroplasty
Good evening everybody who are watching this program from India and Good morning to those who are watching from the United States. Welcome all of you to the live program #109 at ordering principles get back without exceptional faculty dr Samuel Sochi tucker from john Hopkins hospital Baltimore, United States. Sylvia is gonna talk about robotic total diner musty and is the future ready for it over to you? Sylvia, thank you so much Dr Gopalan for inviting me once again. It's always a pleasure to be back on orthopedic principles. Good morning to all of those in the U. S. Good evening to everyone in India and southeast Asia. Uh so today I'm going to talk about something very exciting, something very different which is robotic, total joint replacements. Uh, and whether or not we are ready for this uh, in the future that we are using several systems starting today. But what is the evidence behind it? What are the technologies, what are the different types of advantages or disadvantages? And that's what we are going to discuss. I do not have any relevant disclosures for this but I thought that I would give you an interesting historical perspective of modernism when it comes to johns Hopkins. As Dr Gopalan mentioned, I'm a faculty member in the department of Orthopedic surgery at johNS Hopkins. So this building that you see here on the left of your screen with my mouse hovering around it. That is the original johns Hopkins hospital building which was built in World War One. It is known as the buildings building. And now it's the administration building of the hospital with newer buildings in the campus. This building is beautiful in its construction, very historic, very beautiful open windows and uh unique architecture and they created the dome as was customary during those times. But johns Hopkins himself and it's interesting. His name is john's with an S at the end of it and Hopkins is his last name. He was a Quaker by religious preference and in Quakers they do not have any idol worship. So when he created this building, he said that is not going to be an idol inside it. But as the hospital gained prominence and as patients started coming in um they wanted a figure to go and pray some structure where they could go and pray for their family members, for their friends who were admitted to come out of the hospital into the safety of their homes. So finally they added this statue of jesus christ that you see here on the right and this is a picture from right underneath the dome. What happened was that by the time the building was already constructed and this is a single piece of marble and the statue created from a single piece of marble. So it was extremely difficult to break down the doors and bring the statue in. So what ended up happening was that they lowered the statue from the top of the dome, the top of the door, they opened it, they lowered the statue all the way down. And that was quite a feat during those days and in fact there is a little scar right here on the right chest wall of the statue where the statue basically hit parts of the dome and as it was coming down. So I thought that that's a very interesting historic perspective of modernism even in those times when they were trying to create something. And here is another beautiful picture that I was fortunate to take. This is the view from the top of the dome with the dome uh shadowing some of the people underneath it. Where we traditionally obtained pictures with our white coats. Either when we are coming into the hospital or when we are graduating. So another beautiful unique perspective. So before we go into discussing the technical advances in our capacity, I thought we would talk about what are the basic goals? The basic goals of our capacity when you look at it are two sides of a coin. The one side is what we as the surgeon or the practitioners see, which is the technical aspect. I want to do a technically very sound procedure and the second, which is most important to remember is the patient oriented aspect. What can I do for the patient? How can I improve their quality of life? And what does the patient desire from this procedure? What are their goals in life? So let's talk about patient oriented goals for the most part, if we were to distill them into three very simple goals, patients want a stable functional and a very pain free joint. These are beautiful pictures taken by a french photographer, Henri Cartier bresson and he was able to capture movement, our activity in daily life very beautifully with these pictures. And I thought that that would be a very nice way to showcase what patients want from their joint replacement surgery. When it comes to us surgeons, we would like something else and I have some videos to show this. So the first video is that we really want to try and restore the cinematics and the mechanical axis or the Kinnah Matic access depending on what believer you are as we are performing and joint replacement. This as you can see a computer assisted modeling of a totally arthur plastic with the various degrees of motion. That is really not the scope of the stock. But as a surgeon, when we want a nice smooth plane for the implant to articulate and eventually have some very good outcomes. Moving on to the next video. The other thing that we also want to try and do is that we want to have an equal balance whether if it's in the knee. If it's between the medial compartment, the lateral compartment, the patella femoral compartment or in the uni. We want to make sure that we're not releasing any ligaments and we are able to passively correct the joint back to its native profile. And if it's in a hip, what we want to try and do is we want to try and maintain that abductor attention to provide hip stability. So this is an excellent device. It's not a robotic system but it's a smart tibial tray called arthur sensor. Made by this company called vera sense in which you can see how the pressure changes between the medial side denoted by M. And the lateral side denoted by L. As the ME. Is taken through a range of motion. And this company provides the smart tibial trace as you are trialing your total knee prosthesis to give you a real time read of the pressure that the joint is seeing. And then as you begin to release the ligaments, you will see the pressures equalized very nicely between both compartments And the reason we want to maintain Kinnah, Matics, mechanics and pressure is so that we can achieve longevity of the implant off the bone and eventually the quality of life for the patient. So these are two different sides of the coin that we now have to use technology to harness and make sure that we can reconcile these two goals. So what should be the goal of robotics specifically. But technology in general. The first picture on the left um is a physician painting himself painting himself and so on and so forth. So we want to make sure that this technology is reproducible, you can create an exactly same result for the patient. If you're going to use that technology then you want to make sure it is easy for you as a surgeon to use, it is easy for the operating room staff to use and it is easy for the hospital where you're working to acquire it, to store it and to make sure that it is serviced properly. And finally, if we are going to go through all this trouble, we want to make sure that we see a benefit in our outcomes going from fair or good outcomes to excellent outcomes. So that should be the real goal of any kind of technology as we discuss robotics. I wanted to kind of use cars as an example because some of this technology that we're now seeing in the operating room really comes from cars and here are two examples on the top left is an example of semi autonomous technology which is seen in a lot of cars and I'm going to use a Volvo as an example. And then here on the bottom right is a Tesla and I would just want you to focus on the differences in how these cars drive and Tesla by far is the only path breaking car technology in which there is autonomous driving that is available. However, that does have some limitations as you may have seen. So let's focus on the Volvo 1st. So what this device is a lane assist device or lane keeping aid. So let's say you're on a highway, like the Mumbai pune, expressway and you have these nicely marked lanes all throughout the highway. Now, what happens is sometimes, you know, we tend to get distracted with music or somebody in the family saying something or pass a packet of chips or so on and so forth, and we may swerve from one side to the other and if that happens then there is a potential for the car to veer off the road and get into a car crash. So Falwell came up with this technology in which there is a camera mounted on the front screen of the car which is visualizing the lane and the goal of this lane assist feature. If you activate it in your car, is to make sure that the car stays in the center of those markings and doesn't veer to one side versus the other side. Now, if you want to change lanes, what you have to do is you have to give an indicator in the car and if you don't give the indicator, the car is steering wheel white vibrates and brings you back to the position where the car wants to be. Now, of course, you can always override it because you are holding the steering wheel. So what it's giving you is a haptic control. It's a vibration based control to make sure that your car stays in the center of the lake. So this is semi autonomous technology because you ultimately have the control, the robot, the robotic system in the car is doing some things for you, but you can always override it. Let's look at the Tesla feature. Now, this is a very beautiful feature and a very beautiful video that the Tesla company put out. So here on the screen in the car, you map out your route. So what you want to do is you put in your address and you say, I want to just go for a drive and here goes the car, what it has to do, you can see that the driver is not putting his foot on the pedals, the driver is not touching the steering wheel, the steering wheel is moving all by themselves. The driver is just sitting there Now, as This is going on, I'm sorry, the video seems to have yeah, perfect as the car is going through its motions now, it's going into the highway, it is maintaining the lane, it is maintaining the speed limit as you can see here in this number at 75 mph. And when it comes into smaller suburban roads, it's going to reduce the speed limit automatically by looking at the science that did not what the speed limit is. So here you go here is the card. Now coming into more suburban roads Again, picking up into the highway with about 70 mph and it's maintaining not just the lane, it's maintaining where you want to go, the speed limit, what other cars are around you and trying to avoid these obstacles that are in the way without the driver doing anything. So this is the fully autonomous feature offered by the Tesla and again, you will see that the car also has to pay attention to road signs like stop signs, signals, so on and so forth. So it's performing a lot of complex functions that are going through this very fast paced video. Now here you can see it's about 25 miles an hour and gradually the car is going to come back to its home destination in just a minute here and you can follow along on the GPS, how it's going to turn and where it's going to go. So now again it's going to make a right turn, stop sign acknowledged and it's going to come back to its Tesla home base and the driver can get out and leave. So if you have a fun evening on a saturday evening, you go out on town once the lockdown ends and you have a few few beverages with your friends and you don't feel safe driving home. Well, here is a feature that may get you home safely. Now with that being said, we're going to head on into the different types of robotic systems that exist today and discuss how you can register the bone, how you can perform your planning and how you can perform the surgery. So an orthopedic systems. This was the first robotic system that was introduced. Currently it is known as think surgical, but when it first came out it was known as Ortho Doc and robo Doc. What happens in this platform is that you obtain a cT scan of the patient, Let's say you're doing a hip or a knee. You feed that CT scan into a planning software that is proprietary by the company with a planning work station known as Orthodox. After that you have a robotic system. Several arms, some of the arms are holding retractors, but this one arm right here which I've zoomed into is a million arms. So what it is. It's a it's a million device that creates a very fine tuned cavity for the patient. And finally you go ahead and you put the implant into the patient's. So it really came about As a tool in the late 1990s, early 2000s to mill a cavity into the femur for a total hip replacement. And here is the example of how that robot performs. So their platform is called T Solution one. And this is our goal. Our goal is to put a press fit implant into a female. So here is the planning software you plan that once you have planned everything, you load that into the robotic system so that the robot acknowledges the plan and you position the patient you prep and drape and then you make your exposure and you get the robot down to the hip. So at this point you are in full control. You're obviously in full control of the plan as well. Once you are at the bone, you place these arrays uh they are called the bone registration arrays which will then go ahead and interface with the robot. And the robot will understand the anatomy of the bone and compare it to the cities can. So this is a double check method. You have this probe which is now used to digitally create the anatomy of the bones. You're seeing the lesser truck enter and you're performing very pinpoint um accuracy checks on different locations of the bone which the robot will then correspond with the city's can to make sure that it's the same patient. And then here it introduces the milling arms. So at this point you step away as the surgeon and you let the robot takeover. Now this is the only active or fully active system that is available on the market, like the Tesla self driving feature, no other system is active like this. And you can always stop the robot in its tracks. But if you are not paying attention, the robot is going to keep milling. So there is no direct feedback to the surgeon. Like a haptic feedback there. Hey you are veering of course no. Once the plan is set, the robot decides the further course and then you have to follow along and you can only hit an abort switch which completely stops the plan. Mhm. This was the hip application of it. So again, you know the cumbersome aspect of this robot is that you have to get a CT scan beforehand. You have to spend the time to plan the surgery. Like when you're flying an aircraft, you have to plan the route, you have to know where you want to go and once you've decided on that and you fed everything think to it, you can sit back, relax and enjoy the right. Um The next level of this robot is that they introduced the robotic platform for total knee replacements at the American Academy of Orthopedic surgeons last year. Uh and there was a caveat that it was not available. So it's in the trial phase in the United States at the moment, but it's the same type of milling arm. And now you feed data for the me the CT scan from the knee into the system. It plans it for you. And then what you can do is you can move the implant around in real time. So I'm going to try and scroll a little bit forward into this video. So the first aspect is getting a CT scan. The second aspect is feeding it into the robot. And the third aspect is the robot actually performing the surgery. So here is a is a representation of the ct scan that is getting fed into the robotic system. You can move it around three dimensionally and observe where the austro fights are. The robot can do that. And here is the planning software. I want my distal femur to cut cut an X amount of millimeters or I want to rotate my component or adjust various Valdez uh And if I'm makin a Matic believer, I want to have kinetic alignment. So you can do all of these fine tuned checks for the remote before you even go ahead and touch the patient. Once you have confirmed the plan, you feed that plan into the robot and then the robot takes over. So now here again you perform the exposure for the robot. You have to hold the retractors in place. The robot really doesn't do that too well. And then you observe as the milling arm comes and normally in a total knee replacement, you're using a saw. So the saw moves a lot faster. But here you have a milling arm that is very, very precise in what it does. But it takes a long amount of time. Again, before you begin, you are going to obtain some intra operative landmarks that the robot has created for you to confirm your cities. Can and the anatomy. Now the problem with the city's can sometimes for osteoarthritis is that insurance companies may not approve of it and you're adding radiation to the patient, which if you just use extras. You could avoid doing that even though there are low those radiations. But still, you know those radiation city scans but still adding time cost and radiation exposure to the patient and to the personnel when you do this. Now in terms of expense, this is a pretty expensive system costing anywhere upwards of $1 million, a million US dollars. So it becomes pretty expensive in terms of an investment to keep. And as you can see it's a pretty bulky system with a large space that that it has to navigate and the robot doesn't drive itself into place. You still have to park it there. You still have to do the exposure. You still have to monitor it because at some point if your robot is not performing the plan and if you're not smart enough to catch it or quick enough to catch it and hit the abort button, it's going to do the procedure and then you have to figure out a way to recover without having a cT scan and only using your judgment and your landmarks. Moving on from think surgical this is by far the most popular surgical robotic system that is out there for orthopedic surgery which is called um ecosystem. Mexico was an independent company before striker acquired it a few years ago and after that striker has really taken a big giant leave and placed Mayko into various different fields. Now I want to contrast Meiko with think surgical for a moment. Think surgical is largely an open platform system and it's the only open platform system that really exists out there by open platform. I mean that you can pick whatever implant type you want and you can use it for your surgical approach and your surgical procedure. Whereas every other system that I'm going to discuss from here on out is tied to an implant company, which means that it restricts you in what type of implant choices you now have. So if I use a striker Mayko, I cannot suddenly say I want to use a smith and nephew implant with the system. You can do it off label. But the may cause on any other system is only designed to work with that implant. So it's a very restrictive closed platform design. The best analogy I can hear you is that when computers were first coming into the space um Apple was a very closed platform design because you can only use a few things with Apple. You cannot go and modify Apple computers away from the company. The company controls what you can modify. Whereas some of the advanced programmers just like advanced surgeons, they want more flexibility. They want to use something sometimes something small times because they trust their judgment and that is why Windows and assembled Pcs really came into the market and really took off because you could do whatever you want it with that company. So here is a big difference. Now, another big difference between think surgical and Mako when things surgical came out with its robotic system. For hips, you can only perform the federal component. You cannot do anything with the acid tabular component. So make or took it the next step. And here is the example of the Mako um system. So once again, you have a CT scan that gets fed into the computer system and you can plan your component positioning with a cT scan. So I'm going to scroll a little bit ahead towards that part of the video. You go ahead and you perform the exposure. The ct scan is in front of you to go ahead and verify what is going on. And then here is the robotic arm which lets you decide how you want to dream. So here is the city's can getting fed and then you can play along with the leg lengths, the offset, the massive tabular component positioning that you want to achieve. And this is the target. The green is the target, which once you finish your reaming becomes completely white. And if you deviate from the reaming, it shows you a red sign. So you don't, you don't want that. Um, and it's showing you the center of rotation. So now once you've dislocated the hip, you go ahead and again like the think surgical system. The report tells you that these are all the landmarks that you have to achieve. Once you've achieved that on the femur and you've achieved that on the asset pabulum. The robot with its algorithm states that okay the cities can matches or please go ahead and acquire more points because I need more data to come up with the final plan. And once you do that you now have a hectic lee controlled. So like a self drive feature. There is the robot robotic arm is what the river is controlled with. You go ahead and you position it, you look at the screen and you basically just came and here is a surgeon doing that and as the reamer begins you will see that that green area gradually shrinking and becoming white and that's the goal that you received or chilled. Now if you deviate from the path, what happens is that the remote shuts down and it just stops as you're putting the tabular component in. Again, there is a robotic arm holding you so it's like a very sturdy assistant which you tell them you want to be in this place and it holds it for you and you impact the acid tabular component into place. And if you deviate, the robot just stops in its tracks and says no I'm not letting you proceed. You have to adjust this based on your plan. However, when it comes to the federal component, the Mako has absolutely no use that is completely dependent on you. So here is a huge difference things surgical only lets you do the femur make only lets you do the aceh tabular component. And if you want a robot, a robot for both of those, you are in tough luck. You just don't have any applications out there that lets you do that. Yeah. Now let's look at the makeover for the total knee. So the make up for the total knee has just come outside on the market. Once again, it is a CT scan based technology. So that's how the data is acquired. Once the data is acquired with a cT scan, what you would do, let me see if I can play this again. What else what you would do is that you would go ahead and you would get inside the joint. You will do the exposure for the robot and you would acquire various different points just like the hip to make sure that the cT scan matches the patient's anatomy. What is a cool feature with this is that the robotic arm is now replaced with a saw, the same robotic arm that was used to control the reamer can now have a soft attachment to it. So you don't have to rely on a bird. You can you can be quick and you can be efficient with a saw and what this robotic arm does is that you do not have to place any jigs or any cutting blocks on the patient's knee. The robotic arm will just move into place and you can then press the trigger of the saw, activate the saw and perform your cuts. And the robot basically hold your arm and it creates this green pathway for you. And if you deviate from the green pathway then the robot just shuts down. So now it's a beautiful technique because you don't have to use any pins, any such external devices to fix your cutting blocks to your cutting dies. And you just let the saw work in space and then you come in and you perform your cuts and you walk away again. You can plan for a cinematic alignment or a mechanical alignment with the system based on your preference. Now you're taking your landmarks as I had mentioned and then you can play around with the striker triathlon total knee system which is the only totally system that this robotic device supports you can perform. You can plan your ligaments, releases uh and also your range of motion analysis. The robot lets you do that in real time to see where the patient was. And here is the the lane assist feature. If you may have the robot you can see a cross sectional section here on the top left and as you cut it you just look at the screen and you're trying to get rid of that green and you're trying to make it white and you can do this without putting a posterior retractor robot is so precise that it's going to stop you in its tracks before you hit the PCL or before you hit the popular till vasculature. So it is very very precise and how it is controlled here is the third application of the ecosystem. So this is by far the most versatile system that you have that which is the unique angler me application. So in this, once again, as I mentioned you have a ct scan, you have some intra operative landmarks. So we are going to try and skip through that we will directly get to the planning phase. You can plan the component positioning um of this unique angler system. Again it is a closed platform system so you can only use the striker unique until early arthropods. City you perform your verification checks at various different points in the robot and then now because the space is tight in such a small surgery it has a bird feature. Once again there is a green path, you use the bird to take the green down to the white and if you burn too deep it creates a red area and it basically stops you in its tracks. So this is a this is not a retractable bird but it basically stops. There is another platform called Nevio which I will discuss in the next slides which has a retractable birds. So the birds will just retract back into the patient or into the device. So this is the ecosystem. Mako is again owned by striker. Um It's the most versatile system. It lets you do the acid tabular component preparation in a total hip, whether it's an anterior approach of the posterior lateral approach or lateral approach, it doesn't matter. It also lets you plan using three dimensional cT scans, it lets you use a salt when it comes to total needs and it lets you use a bird when it comes to unicorn learn is the actual robot is the same. The robotic arm is the same. It's just that you have to purchase different planning software for the various different surgeries and you have to purchase the different instruments for the various different surgeries. But if you are an ultra plastic surgeon by far these are the most common surgeries you would perform now for in terms of cost. Again it's a upwards of a million dollar investment so it's a pretty steep investment and has a pretty large footprint but it has been serviced the most across the world with the striker platform. The advantage of using this device is that striker is in almost every country because it sells so many different hospital related equipment that they can find a red to come help you with this and you do need a dedicated representative that works with this robotic system so they can help you with the plans. They can expedite the process for you and they can be there to move the robot as you're performing your surgeries. Here is the smith and nephew Navio system. Um Navio was owned by Bloomberg Technologies before beginning before being acquired by smith and nephew. And now it is a purely smith and nephew system. So here is the planning and execution of the Navajo for a unicorn learning. Navio. The advantage of scenario is that you do not require a cT scan. You basically paint the surface of the bone as shown here for the unicorn learning. And then you can assess the implant positioning and the range of motion gap balancing so on and so forth as you plan the surgery. So it's real time data acquisition. There is no preoperative data acquisition or planning. You don't have to spend time money and radiation risk for the patient. And here is the retractable bird. As you can see the bird is going in and out. So again it's a haptic lee control semi autonomous robot. If if you deviate from the path, the bird just retracts and you cannot do anything with it. And if you're in the path the bird comes out so it takes a little bit of getting used to because you have to watch the screen and if you want to be efficient with it you have to make sure that you don't deviate from the path. You can also use the bird to create the drill holes or the peg holes for your final component. So it's a very precise positioning of your components and the execution of the plan. As you can see here you perform the surgery and then you can verify your motion based on the plan that you created. Now they also had uh an application for the total in so again very similar. No cities can registration. It's direct registration uh as performed by navigation systems. You can see the eyes, the infrared ice, you have infrared markers that are attached and then you can map out, you can basically paint are the patient's anatomy and it creates a representation for you right there on the table which you can then use to perform your surgeries. Again, this is a closed platform system meaning that you can only use smith and nephew implant, you cannot use striker implants if you want to try and use in a video system. Um and then it gives you an assessment of ligament balancing balancing. Again with this device you can choose whether you want to be a mechanically aligned person or Kinnah Matic lee aligned person. Um Now the initial navio application would basically let you use the bird and perform your cut. So that was performed that was proving to be quite time consuming. And now what they do is that basically the guide the robot is to use to create the drill holes for the cutting guide and once you make those drill holes you put your cutting guide, you don't have to use any other jigs in place. To secure those cutting guides, You verify your cut and then you can use the salt to go ahead and make your cut. So what it is done is that it's made the placement of your cutting guides more accurate. And the assumption is that if you're cutting guides are in a good place then your cuts are going to be accurate, but you still have to control your salt. If the salt goes too deep or too shallow, you are the surgeon, you have to monitor it. All it is doing is that it's positioning your cutting guides in place and then letting you take over. So it's a very different level of control as compared to a Milko platform. And Nevio currently does not offer anything for hips if you purchase this device and the cost is around 200 to $500,000 depending on what type of software, whether you just want, beauty or you want to talk to me um software. So it is probably half or 1/5 the price of amico. But then you also probably don't get the full spectrum of surgical advances that you want for all your surgeries. Now, here is another device which zimmer biomet just came out with it maybe a year or a couple of years ago. It's called the rosa rosa is again a closed platform device that you can only use with zimmer biomet implants, you cannot use it with other implant systems and what this device does is that based on real time information that you provide, it kind of merges the navigation based information that you can map out the bone morphology. You then go ahead and what it does for you is that it helps you hold the cutting guide in place. So when have you makes drill holes and you can put the cutting guide into those drill holes. This robotic arm will hold the cutting guide in place, which you then pin into the bone and then you make your bone cuts. So again a semi autonomous system, let's say if the leg moves the robot moves along with the leg. So it's essentially a different type of lane assist feature and I wanted to show you the video which kind of demonstrates this principle. So you have gone ahead and mapped out the patient's morphology. You don't need a ct scan. Now you bring the robotic arm to the leg and the robotic arm just holds that cutting guide in place. It is not going to let it go. You still pin it in place just for that added level of security. Now, if the patient moves or the robotic arm moves, it still understands where the cutting plane is going to be and it's only going to allow certain degrees of freedom for you to position. There are once again the planning software, you can plan how much reception you want to achieve and where you want to implants opposition whether you want, Kinnah Matic or mechanical alignment. And as the patient moves as this board more removed you can see that the robot is following it along. It's not letting go of course that's within a range, you can take the leg completely off the table and it's not like the robot is going to keel over and fall. Um Again for this application they do not have a unique angler me application just yet. It is only for total needs, it is only for zimmer biomet products um and they do not have a hip application yet. So this is another example of a semi autonomous robot used to perform more precise procedures. And finally I wanted to discuss this technology called Omni Vortex only was an open platform system before being acquired by the current group. So now for the most part you can only use current based implants with this system. And this is probably one of the early generations of robotic systems because it really bases its plan platform on navigation. So just like a navigation system, you do not require a cT scan. You have real time tracking um from infrared balls that you attached to the patient and you can go ahead and plan your device on your surgery. Initially you could use an open platform and use multiple different platforms or knees but now it's only restricted to current implants. So here is the example of mapping out the bony anatomy. Yeah. And as you can see you attach these infrared trackers, you can form your landmarks. And then what happens is I'm going to scroll ahead in the interest of time is that you have this robotic arm shown here in black which allows your sword to come in and it's again holding you're cutting jigs or cutting blocks in place and it's going to move based on the sequence of the surgical steps. So you perform your distal femoral resection. Then you perform your table reception. I'm sorry. You you complete your federal resection and then you perform your typical resection. So it basically is a smart assistant for you which takes you through the various steps of surgery and you can customize that and you can verify that and it holds your cutting block in place for you to go ahead and perform the cuts. But again, if you deviate from its path, it is not going to stop you. All it can do is control where the cutting block is in place and you use a saw. So, another interesting system that is now closed platform. So we look through various different robotic systems. We look through the think surgical, the Meiko, the Nevio, the rosa and the only these are the five surgical systems or the five robotic systems that exist in the market today. There are plans for deep you to introduce a system where there's a robotic arm that's going to be clamped to the bed and which is going to be a very portable robotic system where you can take it from room to room. So I was a part of a group that published these studies in the J. B. J. S reviews in 2017. 1st one was navigation robotics and me Arthur plastic and second one is in photo hip Arthur Classy and we kind of looked at the pluses and minuses. Big picture wise robotic systems are of course very, very accurate and very reproducible. But the problem is that most of them require cities can based planning. So that adds time, expense and radiation risk to the patient. And in certain countries where insurance companies very tightly regulate the field. You cannot get a cT scan that easily. So you have to uh negotiate with them robotic systems overall are very expensive systems. And what has happened is in moving from an open platform designed to a more closed platform designed and companies have acquired it. Companies are striking deals with hospital systems saying look if you use our implants, we will give you the reward for free. So that seems like a very attractive offer. But we have seen that in the past when printers came into the market or different devices came into the market. When you had a printer, they would say look, you can take the printer for free. What we're going to charge you for is the ink. And even though the ink may not be a substantial upfront cost, the implant may not be a substantial upfront cost. If an institution is doing thousands of joints a year, that's where these companies mark up the implant even so slightly and then make their profit and allow you to use their technology. So there are pluses and minuses to it. If you look at it from a business perspective and finally what is important to realize that there is a big push, a lot of patients are coming to our office is saying, hey, I I watched this video, I watched this uh this beautiful advertisement on tv with strikers saying that you have to get a make or do you have to get an abalone. Can you do this for me? And I want just to make this simple um you have to be careful because none of these systems are complete makeover is by far the most complete system today as it comes to servicing the needs of a surgeon. But you cannot logically and in terms of economics have all systems available at your hospital. So you have to be careful what you invest in by means of the stock. I just wanted to kind of give you what the different platforms are and also tell you that these platforms have really been in existence for the past five years at most and the outcomes are limited. There is no outcome in the medium term or long term showing that variations in alignment or accuracy and alignment to such a precise degree has caused any changes in the outcome of the patient. So that is important to realize at the end of all of this. And with that I thank you very much for your attention and I'm open to any questions. Hello Sylvia. Excellent talk, cutting edge as always. A few questions. Uh See I remember bro uh Donna was saying that a knee replacement is a soft tissue operation and the bony cats are incident. So do you think the robo, you can assess the tactile feedback? I know you have the haptic system, but when you think of when you talk about anything, the robot system, I know you have a soft tissue tension that can look at the meal and level pressures. What about the releases? You know, do you need the tactile feedback? Absolutely. You know. So uh you know DR Ronald had installed philosophy, the insulin management philosophy of mechanical alignment. Where this was more of a soft tissue procedure and the morning cuts like you said, an incidental, just you need to do that to shape the bone for the implant. There is no robotic system. There exists that gives you a tactile feedback. Um Same thing in a car. There is no car driven robotic system that lets you say, hey, I am going on a very bumpy road. I'm going on a very smooth road and I may need to change the way I'm driving to preserve the passengers and preserve the car. So I think that that's still boils down to the surgeon. Um, and that is still an experiential gain that you gain only going through the ranks of surgery. Now a problem that I see with this robotic system um, and company driven markets is that striker offers Amico fellowship in europe for about six months where you would do Meiko assisted surgeries. And that I think is a problem because that takes away the feedback that's in our fingers and in our hands. That is critical for performing these procedures. Yeah, closer to the other one is uh, what is the uh, do you have level one data to compare the robotic system with any of navigation or even the conventional problem? No, Absolutely. More than I think that that's the biggest drawback. And you know, level one data in large cases is very randomized and it's very hard to randomize this because based on the jigs that you have to put the infrared trackers that you may have to put that you would know what the, what the difference is. So we don't have any level one study is really showing a difference by with using this technology versus not using it. The third question is seen when I've worked with the surgeons who don't advocate at least I know I'm in Bombay when they were in rich candy. So uh, the advantages you have the tactile feedback and you know where exactly you're nervous are the vessel is. But we have a risk of higher neurological injury when we use a autonomous system. Like the think system. Yes. So the initial data with the think did show an increased risk of injury to neurovascular structures, especially if you don't pay attention and protect them because the robot doesn't really recognize those structures and kind of goes about. And none of these robotic systems really recognize neurovascular structures. They just go about. And if you don't plant those retractors, there is an increased risk. There's also an increased risk of pinsight fractures where you have to attach these arrays and pins to the bone and patients have stress rises and fractures from that. So I think that that really boils down to us as surgeons being careful about that. And you know, the other thing in we are a very litigious society here in the United States. And if you can imagine all of these robotic systems come with massive disclosures and disclaimers saying if something were to go wrong, it really boils down to the surgeon. So it's not like you can go ahead and sue the robot or sue striker and say this was your product that I used and this was the result that I got, they're going to do the sergeant. Exactly. So even though the robot costs a lot at the end of the day, you know, you as the soldiers are responsible. And one thing that I find very unique vegetation, maybe it's just the way I look at these things Is that I'm spending $1 million, you know, let's say I want to buy any of these robotic systems. Spending upwards of $1 million dollars sometimes to buy them. They don't even drive themselves into the roof. There's no remote control that you can push. Then the robot just arrives in the room. It still has to be manually logged from one place to another, manually draped and calibrated. And that takes time. So if you want to look at efficiency and if you're running to Ortiz, you're going from one room to the other room. You essentially have to buy two robotic systems. And that's where they really get us. And how, how frequently you require the calibrations because there's the other any of interest, every single surgery, every single case you require to calibrate it. So that's going to take a lot of time, isn't it? It's adds to, uh, and you know, it adds at least when various people have looked at this, I think that, you know, think surgical, if you look at some of the literature dr long who was one of my professors in my fellowship has looked at this very critical and it's adding 10 to 15 minutes in his hands and he is my father very experienced the surgeon who is using this. So it adds the infection risk as well in those patients. And what is the system that you use? Do you have a heart attack or not? Nervous system right now. And uh, first of all, um, so at johns Hopkins, we are still critically looking at this. We don't feel that any of them service our needs just based off of the limitations and then that restricts us in our implant choices. Um, so we are, we haven't committed to any one system just yet. We have various different systems that we use on a case by case basis but we haven't purchased anything just yet. Sylvia simple is also here and central is uh, as a staff ultimate surgeon at texas. Uh, something your questions too. Lot of Zambia. Uh huh. Hey, somebody hurt you. I'm doing great. Something. Yeah. Uh it was a nice talk. You know, we are in the process of acquiring makeup. I don't have much experience with the makeup but uh, I have a lot of doubts about it. So, um, do you think it has a role for every case or use? I think it has a role in only like a complex cases. What do you think it's is it a value auditioned? Real value addition. That's a great question. Central. So you know, value can be looked at in in a couple of ways. One is value for the institution and value for I guess patients and value for business. So in terms of your administration, uh maybe if you can drive more marketing and get more patients that is value added there. Value for the surgeon is very surgeon depending. But I think you hit the nail on the head. Does this really make sense for me to use for every single case? And the best analogy I can give you is you know when you go to your hospital or I go to my hospital, do I always need my Gps? You know, I don't because I think that I know the roads well enough and I know if there is a problem what alternate route to take. However, if I am a new territory or if I'm in a revision situation or if I have a complex deformity and you know, I have to look at the city stand. But I also have to think about complex planning. I think that's where the real value of these systems are. There is limited literature showing some advantages see for any of these systems, as long as you're not instrumented the canals. If you have hardware in the canal, there is a value in using them because you can correct your deformity very nicely without having to go through, you know, deformity correction surgeries. So there is value in that. However, when it comes to divisions, you know think surgical is the only system that is published a little bit on this where if you have a cemented stem that you want to revise, you can use that milling arm or the milling device to create that cavity and take out the cement. But no other system gives you, gives you that advantage. So now you're spending so much money and our revision burden is increasing and you cannot use them to do revisions. So I think that that's a huge limitation in this field. Good. Uh so the cost the, is the recipe, different cpt code or a modifier when you asked for reinvestment. Fantastic. That is uh you know, for for navigation, there is a cord image less computer assisted navigation, which adds probably, you know, anywhere from 2 to 3 our views uh and robotics currently gets plugged into the same core. So you know, whether you use a device like Ortho line, which I use for a lot of my knees because it's a very simple iphone, like, you know, disposable device, it adds about 5 to $600 per case, But it lets you make a very perfected bill card or you use $1 million dollar robot, you're probably gonna get reimbursed the same. Okay, well the value is in in uh in doing volumes, but like I said then you have to buy more than one makeup. Okay. And uh this navigation, you can only use it for people who rely on bony landmarks. So like if you're a gap balancing guy. It's not going to help us much. Like right now. It's not gonna help you much. Shut it. Okay, good. My experience is limited as I told you. So I don't have any practical questions, you know, like all this about still the doubts in the, for the initial face. Um, do you think it's going to stay? Like the navigation came on initially it was like the biggest talk of the town, everybody have to do it. Now we all know it has its own place. Um, so you think navigation is going to be something like that? Yeah. So I think that robotics is going to stay see, you know, there are certain features like, like I described in the car, the Lionesses feature and stuff, which just makes sense. Now what has changed, you know, and growing up in India as we all can relate to when we were growing up. You know, the car companies would give us options, you know, whether you want an A C or not, whether you want manufacturer installed car stereo or not. And there were so many post market cheaper alternatives that you would buy a car without an easy in a car without a studio and then drive into these car accessory shops and get all of this done for a cheaper cost. It may not have worked as well. So I think that, um, from from there now today, nobody really asked whether you want to see or not, that kind of comes with the car. Same thing for Gps. Nobody really asked whether you want a GPS or not. It's kind of comes with most cars. So I think that we're going to see that. But what we're going to see is a push towards making it economically viable. Uh, we're going to see a push towards making it open platform as healthcare administrators and institutions kind of wise in up to this that hey, why am I restricting myself on implant costs and the company is giving me a reward for free. I mean I don't, I don't care. You charge me for the robot but I want to cut down on my implant costs. So I think that the way it is going to be packaged for us is going to be different. There is a surgeon in new york uh monogram orthopedics and what they are looking at is that they are going to allow you a more open platform design that you can use the robotic arm with various different implant systems as long as you can plan and you can execute that plan. So I think that that's going to be the way of the future. Okay with the plan you said is it going to be only a plan way? And if you just have to stick to it or you can change the plan into operatively uh, intra operatively you can change the plan. But then once you've acquired the landmarks, if you change the plan after that, then the robot needs to get re registered. And sometimes let's say you make a cut in the female. You do your district emerald cut. And all of a sudden you're like I don't like this, then it's very hard to correct it because those landmarks of the distal femur bony surface have gone. So it's really hard to alternate at that point. So it is better to have the manual instruments available for the initial few cases. Right? Absolutely. Absolutely. Um and you know from from a you know Sergent perspective you also have to then be ready to commit to an implant system and understand the nuances of that implant system. Uh tomorrow being if my hospital goes ahead and purchases of Nico I'm a deep U user. All of a sudden I have to think of using a striker. So I have to know the Are the positives and the negatives of 30 slot. Uh Yeah. Okay good. Thank you. Okay there are no more questions. Uh Any more questions? I'm terrible. Yeah that's it. Yeah I think I'm good. No I'm no more questions. Thank you so much for being with us. I know you come from a family who actually into your computer navigation in India. Thank you. And uh we look for for more convenient lectures from your side. Thank you very much for having me. Wonderful thank you. Thank you. Thank you very much
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