The Role of Robotic Surgery in 2018

Andrew Rogers, MD (Drew) Orthopedic Care Physician Network

Chief of Orthopedics Morton Hospital Team Physician - USA Hockey, US National Hockey Team

Team Physician - Boston College Athletics Team Physician - UMass Dartmouth Athletics

Team Physician - Covering Boston Ballet

drewrogers3@gmail.com

DisclosuresMy spouse/partner and I have the following

relevant financial relationship with a commercial interest to disclose:

Speaker - Arthrex Consultant - Mitek

2. Kurtz AAOS. Total knee and hip replacement projections 2030. http://jbjs.org/content/89/4/780. Accessed November 1, 2016.3. Willis-Owen CA, BrustK, Alsop H, MiraldoM, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee 2009;16(6):473–6

Evolution of Arthroplasty1950’s - Static Xrays

1990’s - Navigated

2000’s - Navigated Freehand

2000’s - Robotic Assisted Mako (June 2006) 83,000 worldwide

Surgery!

Marketing? Good/Bad???

Why?Facilitating- allowing us to do it more precise

Enabling- allowing us to do surgeries we could not perform before

Evidence- No strong evidence exists that it has improved outcomes

Improved implant positioning?

Patient Specific Implant PositionEnhanced planningPatient-specific pre-operative planenables more accurate implant positioning.

7-11

CT data is segmented to create a 3D model of the patient’s bony anatomy. An individualized pre-operative plan is created and reviewed with the surgeon prior to the procedure.

Dynamic joint balancingSurgeon-controlled intra-operative adjustments can be made to optimize implant placement.

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Kinematic and soft tissue data are collected intraoperatively and applied to the virtual CT model.

The surgeon reviews the pre-op plan and can modify it if necessary based on the intra-operative data to virtually balance the joint and achieve individualized placement.

Robotic-arm assisted bone preparationThe surgeon then executes theindividualized intra-operative planusing robotic-arm assisted bone preparation to achieve functionalimplant positioning.

Preoperative computer software for 3-D planning

Intraoperative robotic use for increased precision

More accurate implant positioning

Operative room staff training

Cost?

Partial / Uni Knee ArthroplastyLimitations include• Demanding procedure• Visualization concerns• Early Failure? Hernigou P, Deschamps G. Posterior slope of the tibial implant and the

outcome of unicompartmental knee arthoplasty. JBJS, 2004 Mar, 86(3):506-511 - Bell SW; Anthony I; Jones B; MacLean A; Rowe P; Blyth M. Improved accuracy of component positioning with robotic-assisted unicompartmental knee arthroplasty: data from a prospective, randomized controlled study. J Bone and Joint Surg. 2016; 98: 627-35.

Mako Patient Specific Approach• CT scan• Landmarks and computer program offsite

Tibia Plan Femur Plan

Intra-opCapture Gap Balancing

Cartilage Mapping Implant tracking

AccuracyThis prospective, single-center, level I, blinded, randomized controlled trial compared Mako Partial Knee and Biomet Oxford for 139 patients.

•Early results showed more accurate delivery of the surgical plan in all alignment measures, with statistical significance (p<0.01) for all six parameters, for Mako Partial Knee vs. manual procedures.

•The proportion of patients with component implantation within 2˚ of target was significantly greater (p<0.05) in Mako Partial Knee cases compared with the manual cohort for five out of the six parameters (femoral-sagittal, coronal, and axial, tibia- sagittal and axial).

• The authors concluded that “robotic-arm assisted procedures [Mako Partial Knee] lead to improved accuracy of implant positioning compared with conventional unicompartmental knee arthroplasty surgical techniques.”

Bell SW; Anthony I; Jones B; MacLean A; Rowe P; Blyth M. Improved accuracy of component positioning with robotic-assisted unicompartmental knee arthroplasty: data from a prospective, randomized controlled study. J Bone and Joint Surg. 2016; 98: 627-35.

Accuracy vs Success?

20. Australian Orthopaedic Association National Joint Registry. Annual Report. Adelaide: 2015.21. Swedish Knee Arthroplasty Register. 2015 Annual Report.22. Pearle A; Van der List JP; Lee L; Coon T; Borus T; Roche M; Survivorship and patient satisfaction of robotic-assisted medial unicompartmental knee arthroplasty at a minimum two-year follow-up

Analysis conducted by Baker Tilly using a database compiled by OptumInsight, Inc. (Eden Prairie, MN) comprising claims generated by a national commercial health plan consisting of approximately 25 million members. Index cases incurred Jan. 2013 – Dec. 2013, revision cases incurred within 24 months of index procedure. This commercial data has not been blended with Medicare or Medicare Advantage data.

Key Points• Patient selection is key in Partial vs Total• Expensive startup costs to Mako• Learning curve• More Accurate implant placement / Reproducible• Lower revision rate???

0.4% vs 4% at 2 years (Roche, MW; Coon, T.; Pearle, AD; Dounchis, J. (October

3–6, 2012). Two Year Survivorship of Robotically Guided medical MCK Onlay. 25th Annual Congress of ISTA. Sydney, Australia)

• Long term data ………………

Total Hip >300,000 / yrMako Robotic-Arm Assisted Technology:• •Provides surgeons with a personalized surgical plan based

on a 3D model of your hip • 4-6 x more accurate implant placement compared to

traditional techniques • Nawabi DH, Conditt MA, Ranawat AS, et al. (March 2013). "Haptically guided robotic technology in total hip arthroplasty: a cadaveric

investigation". Proceedings of the Institution of Mechanical Engineers. Part H, Journal of Engineering in Medicine. 227 (3): 302–9

Misconceptions• Robot Does the surgery• Robot moves on its own• Surgeon doesn’t make the final decision

Thanks!!!