Several hip surgeons — including Lawrence D. Dorr, MD, of the Dorr Arthritis Institute at good Samaritan Hospital in Los Angeles, Amar Ranawat, MD, of the Hospital for Special Surgery in New York City, Douglas Padgett, MD, also of Hospital for Special Surgery, Mark Pagnano, MD, of Mayo Clinic in Rochester, Minn., Robert Trousdale, MD, also of Mayo and Richard Jones, MD, of Orthopedic Specialists in Dallas — have been working on a project to develop software for robotic-guided navigation for hip surgery.
"Our whole idea with this program was to improve the human performance of the surgeon during the hip replacement," says Dr. Dorr. "Right now, we are really good at fixation with the implants, but we haven't reduced the number of revisions. We kind of hit the wall in terms of doing the operation."
Dr. Dorr discusses six points on computer-assisted hip surgery.
1. Why robotic guidance may be necessary to advance hip procedures. Even with the technological advancements in hip implants over the past 20 years, performing hip replacements is particularly difficult because when surgeons are working with the bones of the hip, they can't see the patient's specific anatomy. It's difficult to gauge the relationship of the acetabulum to the pelvis and the spine, and surgeons can't see inside the femur to put the stem in.
"We're stuck with how much we can do because we don't know these anatomic relationships for each particular individual," says Dr. Dorr. "We've got a lot of great hip surgeons, but the problem with hip surgeons operating on their own is that it's all dependent on their instinct and intuition. If that's all we have, then we are going to make human errors."
The computer-assisted robotic software will be able to solve some of these problems because it allows surgeons to see into the three-dimensional anatomic space of each patient and pre-plan the surgeries to increase the accuracy of the result.
2. Computer-assisted systems to anatomically place the instrumentation. A recent study from Stanford University and Massachusetts General Hospital showed that most hip surgeons feel they are able to place the cup correctly during hip replacements, but in actuality it is malpositioned approximately 50 percent of the time. "We need to bring the computer into the operating room to help us so we can reduce the human errors," says Dr. Dorr. "We know exactly where to make the femoral cut and where to put the stem in the femur because the software will tell us. All those anatomic relationships we didn't have before now are known and we have quantitative knowledge of where the components are."
The surgeon still controls the preparation of the bone and holds the reamer during surgery, but the technology won't let the reamer go offline. If surgeons try to take it too deep, there is a fail-safe mechanism to stop them. Surgeons can get the stem and cup into the correct position and patients can have a stable hip. All of these factors help decrease the risk of further dislocation and impingement, pain and rapid implant wear.
3. Becoming comfortable with the technology. There are many reasons why orthopedic surgeons shy away from incorporating computer-assisted technology into their ORs. Some feel the robots don't provide better outcomes and are largely market driven while others feel confident in their ability to perform an accurate procedure by themselves. The high cost of the technology is also a big factor in whether surgeons are able to use it or not, regardless of its efficacy. However, Dr. Dorr sees computer-assisted surgeries becoming more prevalent among hip surgeons.
"Once surgeons are comfortable with having a machine in the operating room, it will spread like wildfire because it helps make the procedure more accurate and precise," says Dr. Dorr. "We can have great results by ourselves most of the time, but there are always outliers. Surgeons who are using it now recognize that we are better with the machine than without it and we're willing to use the machine to get rid of the outliers."
4. Dealing with the high costs of the technology. As with all new technologies, computer-assisted systems and programs are a huge financial investment that a single surgeon can't reasonably make. Hospitals are sometimes willing to bear the cost in collaboration with a surgeon who performs the procedures. It also takes longer to perform the procedures with the robot, but the extra few minutes in the OR may save time on the back end of patient care. "If you achieve a good result with every surgery you do, you save time with the complications associated with failed surgeries," says Dr. Dorr. "You don't have to spend time in the office or on the telephone with an unhappy patient, and they won't have to go back into the OR for revision surgery."
The upfront cost of the technology is steep, but the expense over the long run is low, says Dr. Dorr. If surgeons are able to achieve a better outcome with this technology, it may be a worthwhile cost.
5. Patient marketing. Beyond the impetus to achieve better results, surgeons will be pushed toward using robotic technology for two reasons: peer pressure and patient pressure. Patients will hear about robotic technology from research online or speaking with their friends and they will want computer assistance in the OR. "Patients realize what the computer has done in their personal life," says Dr. Dorr. "If they are going to have an operation, they want surgeons to use the latest and greatest technology to make them better, whether or not it is the best solution for that surgeon."
The peer pressure aspect comes in as more surgeons begin using the technology. If the surgeon down the street is able to achieve better results using the robot, patients will go down the street for their care, says Dr. Dorr. "When patients come in and say they want a specific robot, the surgeon who isn't using it becomes upset because the marketing has gotten to the patient," he says. The efficacy of robotic knee surgery has been questioned in the literature, but there haven't been many articles on the use of robotics in hip surgery. However, all clinical articles written on computer navigation for the hip show improved component position with the use of the machine.
6. Leveling the playing field for surgeons. With computer assistance to performing hip replacements, general joint replacement surgeons who perform a lower volume of hip replacements will be able to receive more predictable results than in the past, says Dr. Dorr. Patients expect good results whether they are seeing a premier hip specialist or their local general orthopedic surgeon in a small community.
"This offers a chance to level the playing field for surgeons," he says. "It can take a surgeon with low experience and volume and allow them to have predictable and reproducible outcomes because they have quantitative values. Now they have the same information in the operating room as other surgeons and they have a better chance of achieving good outcomes."
Learn more about Dr. Lawrence Dorr.
Related Articles on Robotics in Orthopedics:
Robotics in Orthopedic Surgery: 6 Points on the Present and Future
10 Points on Robot-Guided Spine Surgery
The Physician's Role During MAKOplasty: Q&A With Dr. Frank Noyes of Cincinnati SportsMedicine & Orthopaedic Center
"Our whole idea with this program was to improve the human performance of the surgeon during the hip replacement," says Dr. Dorr. "Right now, we are really good at fixation with the implants, but we haven't reduced the number of revisions. We kind of hit the wall in terms of doing the operation."
Dr. Dorr discusses six points on computer-assisted hip surgery.
1. Why robotic guidance may be necessary to advance hip procedures. Even with the technological advancements in hip implants over the past 20 years, performing hip replacements is particularly difficult because when surgeons are working with the bones of the hip, they can't see the patient's specific anatomy. It's difficult to gauge the relationship of the acetabulum to the pelvis and the spine, and surgeons can't see inside the femur to put the stem in.
"We're stuck with how much we can do because we don't know these anatomic relationships for each particular individual," says Dr. Dorr. "We've got a lot of great hip surgeons, but the problem with hip surgeons operating on their own is that it's all dependent on their instinct and intuition. If that's all we have, then we are going to make human errors."
The computer-assisted robotic software will be able to solve some of these problems because it allows surgeons to see into the three-dimensional anatomic space of each patient and pre-plan the surgeries to increase the accuracy of the result.
2. Computer-assisted systems to anatomically place the instrumentation. A recent study from Stanford University and Massachusetts General Hospital showed that most hip surgeons feel they are able to place the cup correctly during hip replacements, but in actuality it is malpositioned approximately 50 percent of the time. "We need to bring the computer into the operating room to help us so we can reduce the human errors," says Dr. Dorr. "We know exactly where to make the femoral cut and where to put the stem in the femur because the software will tell us. All those anatomic relationships we didn't have before now are known and we have quantitative knowledge of where the components are."
The surgeon still controls the preparation of the bone and holds the reamer during surgery, but the technology won't let the reamer go offline. If surgeons try to take it too deep, there is a fail-safe mechanism to stop them. Surgeons can get the stem and cup into the correct position and patients can have a stable hip. All of these factors help decrease the risk of further dislocation and impingement, pain and rapid implant wear.
3. Becoming comfortable with the technology. There are many reasons why orthopedic surgeons shy away from incorporating computer-assisted technology into their ORs. Some feel the robots don't provide better outcomes and are largely market driven while others feel confident in their ability to perform an accurate procedure by themselves. The high cost of the technology is also a big factor in whether surgeons are able to use it or not, regardless of its efficacy. However, Dr. Dorr sees computer-assisted surgeries becoming more prevalent among hip surgeons.
"Once surgeons are comfortable with having a machine in the operating room, it will spread like wildfire because it helps make the procedure more accurate and precise," says Dr. Dorr. "We can have great results by ourselves most of the time, but there are always outliers. Surgeons who are using it now recognize that we are better with the machine than without it and we're willing to use the machine to get rid of the outliers."
4. Dealing with the high costs of the technology. As with all new technologies, computer-assisted systems and programs are a huge financial investment that a single surgeon can't reasonably make. Hospitals are sometimes willing to bear the cost in collaboration with a surgeon who performs the procedures. It also takes longer to perform the procedures with the robot, but the extra few minutes in the OR may save time on the back end of patient care. "If you achieve a good result with every surgery you do, you save time with the complications associated with failed surgeries," says Dr. Dorr. "You don't have to spend time in the office or on the telephone with an unhappy patient, and they won't have to go back into the OR for revision surgery."
The upfront cost of the technology is steep, but the expense over the long run is low, says Dr. Dorr. If surgeons are able to achieve a better outcome with this technology, it may be a worthwhile cost.
5. Patient marketing. Beyond the impetus to achieve better results, surgeons will be pushed toward using robotic technology for two reasons: peer pressure and patient pressure. Patients will hear about robotic technology from research online or speaking with their friends and they will want computer assistance in the OR. "Patients realize what the computer has done in their personal life," says Dr. Dorr. "If they are going to have an operation, they want surgeons to use the latest and greatest technology to make them better, whether or not it is the best solution for that surgeon."
The peer pressure aspect comes in as more surgeons begin using the technology. If the surgeon down the street is able to achieve better results using the robot, patients will go down the street for their care, says Dr. Dorr. "When patients come in and say they want a specific robot, the surgeon who isn't using it becomes upset because the marketing has gotten to the patient," he says. The efficacy of robotic knee surgery has been questioned in the literature, but there haven't been many articles on the use of robotics in hip surgery. However, all clinical articles written on computer navigation for the hip show improved component position with the use of the machine.
6. Leveling the playing field for surgeons. With computer assistance to performing hip replacements, general joint replacement surgeons who perform a lower volume of hip replacements will be able to receive more predictable results than in the past, says Dr. Dorr. Patients expect good results whether they are seeing a premier hip specialist or their local general orthopedic surgeon in a small community.
"This offers a chance to level the playing field for surgeons," he says. "It can take a surgeon with low experience and volume and allow them to have predictable and reproducible outcomes because they have quantitative values. Now they have the same information in the operating room as other surgeons and they have a better chance of achieving good outcomes."
Learn more about Dr. Lawrence Dorr.
Related Articles on Robotics in Orthopedics:
Robotics in Orthopedic Surgery: 6 Points on the Present and Future
10 Points on Robot-Guided Spine Surgery
The Physician's Role During MAKOplasty: Q&A With Dr. Frank Noyes of Cincinnati SportsMedicine & Orthopaedic Center