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- How 'bout robotics?
We talked about accuracy, well that's
where robotics come into place.
Again, we're talking
about that 10% of patients
who for some reason don't do as well
and there's a multitude of
reasons why those 10% don't do
as well but one of them is
if the parts aren't put
in exactly accurate.
Now, robotics, it's new to
us in the medical profession
but it's not new.
Detroit's been making cars
for decades without people.
They haven't made a car with
a person in a long time.
They're all made robotically.
Why?
Because robots are more
accurate, more reproducible.
So we have to talk about
accuracy and precision.
Accuracy is the degree of
closeness, the true value.
So, in other words accuracy,
do you hit the bull's-eye?
Precision talks about reproducibility,
how many time you hit the bull's-eye.
So, we want both accurate and precise.
We wanna hit the bull's-eye
and we wanna hit the
bull's-eye every time.
We don't wanna hit the bull's-eye on you
but miss the bull's-eye on you.
And so, that's where we're
getting into robotics,
computer assisted to
help us with our surgery.
This is a very interesting slide.
It's busy but I think it's the key to
the future of robotics.
Most of you have heard of
Massachusetts General Hospital.
One of the most famous
hospitals in United States,
one of the biggest joint
replacement centers
in the United States, one of
the most experienced surgeons
in joint replacement in the United States.
And what we've learned
over time is the way
we put those parts
particularly the way we put the socket has
a safety zone of about
20 degrees this way,
and about 20 degrees that way.
If we keep it in that safety zone,
we know the chance of success
of nothing bad happening is very high.
When we get outside that safety zone,
then we learn that it's more likely
that something bad will
happen, an untoward event.
And so, what the doctors
did of the Mass General,
they looked at well,
really how accurate are we?
Us doctors think we're pretty
good, we're pretty accurate
but are we really as
accurate as we thought
and so they looked at
over 1,800 total hips
done by some of the best
surgeons in the United States
and each one of these dots is the position
of that acetabular cup.
The box in the middle is that safe zone.
And you can see, there's
a lot of dots even done
by very experienced surgeons
outside of that safety zone.
In fact,
only 47% was inside the safe zone.
Now, again that doesn't
mean that this poor patient
here is gonna dislocate
their hip but it means
that it's more likely to dislocate
their hip than this patient in here.
And this is what we're trying to fix.
We're trying to tighten up this grouping
so the vast majority of these patients are
inside this safe zone and
there's no outliers out here.
Here's an X-ray of one of those outliers.
If you remember that X-ray before,
this cup should be positioned like this
and it's very vertical.
That may be okay but as
soon as that patient gets up
off the stretcher this
is what's gonna happen.
It's gonna pop out of socket.
So, we don't want that to happen.
We want these cups to be placed
as accurately as possible
and that's where I think robotics,
well, we're in the very
early frontier stage of this,
the first generation,
but in the future we're gonna see some,
I think, real advances in that.
So what does this do?
It really turns me into what
I'll call a cyber surgeon.
'Cause what we'll do first,
we'll get a CT scan of
the patient's pelvis,
if we're doing hip and
then also if we do a knee,
we get a CT scan of the knee.
We then load that in the computer
and then on the computer I do my operation
and we'll see this in a minute
and I'll show you how we do this,
until I get my parts
exactly like I like it.
And that's the accuracy part.
Precision part comes in,
the reproducibility is
I'll use the robot and
again, I do the surgery,
the robot's doing the
surgery, I don't sit off
and practice my putting while
the robot does your operation,
I have to actually still do the operation
but if I try to go outside of my plan,
in other words if I try
to place it too anteverted
or I try to go too deep,
the robot stops me.
It won't let me go.
And so, that's where we hope
we'd eliminate some of those outliers.
Here's what the Mako
robot, this is a brand
that we use here, that looks like.
Over here is the computer station.
And so, this is what I do the day or two
before I do my cyber surgery on
and get everything just like I want it.
Here's the robot with its
arm and its, you can see,
its arm is much stronger than my arm
so it won't let me go
where I don't wanna go
and then we have different pieces
that we can attach to the end of the arm,
cutting burrs, reamers, et
cetera so I can do my work.
Well, that's nice in theory but
is really act more accurate?
And there's been some studies
that show that it is more accurate.
The tall abr here is with the Mako robot.
This is without the robot and
you can see in both studies
that is was closer with the robot.
So, how do we do this?
Here's
a CT scan which is a
three dimensional image
that we obtained before surgery
and this patient's hip,
the right hip is arthritic
and you can see this
one looks kinda smooth
and where it should be
and this one's all rough
and big bony spurs and it's
about four millimeters shorter
than the other because it's
worn away some bones superiorly.
So, this is what we start with.
Now, obviously we want
to correct all this.
So, the next step is our planning stage
And the yellow is my cup
and I can put this cup any place I want.
Now our safe zone that we chose
for this patient will be
40 degrees of inclination
which is like this and then 20 degrees
of anteversion which is turned forward.
That's well within the safe zone.
And so, I can see a transverse view here
where I can see how deep I want it
and I can move it wherever I want
and I can twist this around until I get it
just exactly like I want.
Then, we put the femoral side
in with the stem and the ball
and then it tells me how well that fits.
In this particular case,
with this size stem
and this size ball, before we
were 14 millimeters longer,
I mean shorter, now we're
only one millimeter shorter.
So we've made up 14 millimeters
of leg length there.
So, I'll be happy with
just one millimeter short.
I mean, that's that.
Then after we did our
surgery, we can map it out
and see how well we did on
the computer and on this case,
one degree off of our
ideal plan of inclination
and only two degrees off of version.
So, that's well within that
safe zone, that's perfect.
And down here our leg lengths
now are perfectly equal
and for me this has been the biggest help
for me is getting our leg lengths equal.
I was doing not too bad up here
but sometimes I'd have some
people a little bit long,
a little bit short 'cause you have really
not a very good way to
measure intraoperatively.
But now, we know exactly what we are
before we leave the operating room.
Let's talk about knees for a minute.
This is another picture
of that normal knee
that we showed earlier
with nice smooth glistening cartilage.
There's your meniscus in your
knee, your tibia's down here.
Everything should look like that.
And there's a picture of
an old arthritic knee.
You can see here you have some
little raggy cartilage here
raggy cartilage here
but all this area here
and all this area here
is just exposed bone.
And so, that's what the pictures look like
on those arthritic knee
X-rays that we showed earlier.
So, with the robot as of today
we can do partial knee
replacements with the robot.
Hopefully, by the fall of this year
we'll have the software
to do the total knees with the robot
but right now we only have the capability
to do it with the partial.
But this is what we can do.
We can replace this side,
we can also replace the
patellofemoral joint with the robot.
And with I think the knees
it's even more interesting is
we do the same planning over here
with planning to put our
components just where we want
but then there's one more step.
In knees it's more important to get
your ligament balance just right.
In hips there really is
no ligaments to balance.
Everything's just kinda held together.
But in knees to get full range of motion,
you gonna have to be sure
your ligaments are balanced
'cause if they're not, it'll
be too tight in flexion,
too loose in extension and
it just won't work right.
So, with the partial
knees what we can do is
we can get into surgery, after
we've done all our planning
and I can put the knee
through a range of motion.
And when I do that, the computer
actually measures the tightness or laxity
of the ligaments and if
it's too tight in extension
and too loose in flexion,
I can change my parts
and adjust it to make 'em just right
and you'll see a little
video later of how we do that
but to me that's really exciting
'cause now we're not just
statically measuring things
but we're actually doing it dynamically.
So, here's the robotic arm
and this handpiece here
that's a burr and you'll see
how we use that in a minute.
So I grab it right there
and actually move it myself.
And again, we have capabilities
of doing the inside
of your knee, the outside of your knee.
And it's composed, just like
the total knee it's composed
of three parts, a little metal tray,
a little skid up here
and this high density polyethylene liner's
now your knee cartilage.
And there's the same thing
doing the patellofemoral joint
if you just have isolated
patellofemoral problems.
And the same thing on
the outside of the knee
if you have lateral compartment disease.
You can even, if you wanted
to, combine two of them.
You could put one here on the inside
as well as the patellofemoral
joint if that's required.
Most people would just go ahead
and do a total knee if that was the case.
An animation scene, same thing.
Disease on the inside of
your knee, patellofemoral,
outside of your knee.
So here's what we do.
We're getting our CT scan
and we're loading it into the computer
and it makes a three
dimensional model for us.
Gonna correct the knee to
where we want it in alignment.
And then I put our parts in.
Okay, stop it if you would.
So, over here is where I
put our parts together.
What this graph shows
as I'm moving the knee,
it shows if the ligament
has laxity or tightness.
And this is zero degrees, 20 degrees,
60 degrees, 90 degrees.
This is too lax, this is too tight,
we want it close to the middle.
So, if I left it this way,
which is what I may
have done two years ago,
this knee would be a little loose.
This gives me the opportunity,
I haven't made any definitive cuts
or cemented anything in
this gives me the opportunity,
okay, I'm gonna move my parts a little bit
and see how that changes this.
Right, go ahead and run the video.
So, now I'm moving my parts a little bit
and see what happens over here.
I still wanna move it some more this way,
move it a little bit more
and then I'm pretty happy with that.
And so then once I get
it just like I want,
then the robot won't let me
get outside of that plan.
So, I can put it exactly as we planned.
And so here we come in and we
start doing our surgery now
and I am actually guiding that burr
but it's attached to that arm
and it won't let me get
out of where I wanna go.
We take off any remaining
little bits of cartilage.
This animation looks like
your taking good cartilage
but that's rarely the case.
And then all we have to do is
cement our implants in place.
So, I know we talked a little bit
about less invasive surgery
to ease your recovery.
We talked about using technology
to make our surgery more accurate.
And then the last thing
I mentioned earlier
that we wanna chat with you
about is the patient
experience in the hospital.
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