- August 27, 2018
Hi I’m Chris Grayson. I’m one of the adult reconstruction specialists at Florida Orthopaedic Institute. Today we’re going to talk to you a little bit about robotic hip replacement first a little bit about myself. I’m originally from Baton Rouge, Louisiana. I was born there and stayed there through college and went to undergrad at LSU. Tiger Stadium is probably one of the better places to watch a football game in America at least in my opinion. Afterwards I went to LSU Shreveport where I did my medical school. After med school I was fortunate enough to match at Shands Hospital at the University of Florida for my orthopedic residency. I was able to spend five years in enemy territory as a Florida Gator learning about orthopedics. I became very interested in joint replacement at that point and decided to spend an extra year at the University of Indiana in Indianapolis becoming a specialist in hip and knee replacement outside of work. I enjoy spending time with my family at home. I’ve recently had the addition of a new daughter Layla and my other daughter Hannah. When I’m not being Dad at home I enjoy cooking and sometimes get to throw together a gumbo or jambalaya.
So I think most of my patients who come in don’t have a full understanding of what arthritis is.
Some people think it’s a disease that can move from joint to joint in the body and some while some arthritis as can most arthritis is simply the wearing out of a joint. The loss of cartilage in the joint which exposes nerve endings in the bone causing pain exposes the high friction bony surfaces which causes inflammation stiffness and discomfort associated with arthritis.
Here you can see the difference between an arthritic hip and a normal hip.
In this X-ray you can see that there is a nice space between the head of the femur and the acetabulum. That space is not air. It’s cartilage. Cartilage just doesn’t show up on X-rays. So we are able to assess the health of a joint and the health of the cartilage in a joint by looking at the space in the joint.
When you develop arthritis the space goes away. You get bone on bone arthritis and can develop cysts and hardening of the bone seen as the increase of whitening of the bone or sclerosis.
As the medical term goes the treatment of arthritis consists of mainly non operative treatment until that fails and then surgical treatment when we have to do surgery unfortunately minimally invasive options such as arthroscopy is don’t work well for arthritis. One of the reasons is is that as arthritis is the loss of cartilage we cannot go in with a scope and put cartilage back. So anything we do with a scope involves removing tissue or releasing tissue and that would only serve to worsen the arthritic picture. Because of this we need to replace the damaged bony surfaces with a joint replacement or a total hip arthroplasty hip replacement is a great surgery performed three hundred thousand times a year and it does a fantastic job of significantly eliminating patients pain improving their activity level and giving them a higher quality of life.
It can benefit patients with multiple types of arthritis by the time you get to the end end of the road when you have severe arthritis like in this picture. It doesn’t matter really how you got there but that can come from most frequently osteoarthritis but also rheumatoid arthritis a vascular necrosis congenital problems such as hip dysplasia and occasionally traumatic injuries that require surgery earlier in a patient’s life. The benefits of joint replacement are all to improve pain you reduce stiffness and allow patients to return to an active lifestyle. As our motto at Florida Orthopaedic is keeping patients active. Joint replacements a great way to do that for patients who are suffering from arthritis. The surgery itself only takes about one to two hours for most cases. Some more complex cases can take longer but the average case runs in the 1 to 2 hour range.
We remove the arthritic bone from both sides of the joint and replace the joint with combination of metal plastic and ceramic modern joint replacement surgery involves short stays in the hospital. Most patients go home the day after surgery or sometimes two days later. Patients are always able to put full weight on their leg for standard joint replacement. They work with physical therapy the same day as surgery and now we encourage all of our patients to go home instead of go into nursing homes. Patients are able to be safe. Go home and have therapies come into the house and have be more comfortable during their recovery and have less complications. Can we do better. Complications unfortunately still occur. Some patients suffer from dislocations like this patient in the picture. Patients end up with unequal leg lengths where one leg is longer than the other or shorter.
Some patients can still have pain often from bursitis or component loosening so the question is what can we do better. Is there a way that technology can help us improve upon these outcomes when we look at excellence in other fields. You can see that we have two pretty famous athletes here. Ted Williams was the last major league player to hit 400 for a season. Steph Curry one of the best three point shooters averages about 43 percent from three point. These are gentlemen and professionals who are doing very difficult activities and at the top of their sport but are still always successful. Less than 50 percent of the time I don’t think most of our patients would be happy if we were only successful 50 percent of the time. However when we looked at a study from Harvard on how successful we were putting components where we wanted to in the pelvis of the hip replacement using our traditional instrumentation and the human eye is the tool we were only successful approximately 50 percent of the time.
This didn’t mean that 50 percent of the patients had failures of their surgery are had dislocations and had to had reoperations. But we were not successful putting the components where we wanted to 50 percent of the time and that’s something we can definitely do better on. So the solution as we saw with many other industries was to go towards robotics and computers as a way to increase the precision of our surgeries. And at FOI where we are consistently trying to push for the best outcomes possible and use the newest technology in order to provide our patients with the best possible results. We have found that robotics has been become a big part of our of our practice. The Mako robot has substantially improved my ability to provide precise surgical placement of any of the components to my patients. This involves getting a preoperative C.T. scan being able to plan the surgery in a 3-D fashion prior to go into cert going into the operating room confirming computer navigation generated points with the C.T. scan and then using a robotic arm to accurately place the component where we want to from the preoperative plan this has allowed a more accurate component placement and given me greater ability to make fine adjustments during surgery.
And this has improved patient outcomes in some studies reduce leg length discrepancies and help patients have more consistent outcomes and most importantly it’s something I’ve been able to utilize through multiple surgical approaches. I can do the robotic hip replacement through an anterior approach. Many patients prefer are opposed to your approach.
What’s allowed me to do is to truly customize not only the placement of the implants but the approach as well and I have no concern about having difficulty putting the components exactly where I would like them to be.
The robotic arm of the Mako robot holds the reamers and the component and is allows us to place the components exactly where we would like them to be. This allows me to take my focus from putting the components where they need to be and to focus on removing the disease bone balancing the soft tissues and putting the components exactly where they need to be.
Again we are able to customize the fit of the surgery to the patient and not make the patient’s body fit the implants.
Preoperatively We start by getting a C.T. scan which gives us a slice by slice level of the our view of the bone. It’s a three dimensional x ray which allows us to see with more detail and accuracy the disease process and the arthritis. From there we create a three dimensional model and are able to visualize where the components will be placed prior to ever stepping foot in the operating room. This allows me to anticipate problems based on a 3D generated C.T. scan rather than a two dimensional x ray. I’m also able to adjust the surgical plan based on any issues I see you can see here that this patient has a large cyst above the acetabulum and that’s this slight hole in the bone with the Mako C.T. scan I can identify the exact location of the cyst and then adjust the placement of the component in order to avoid complications and then after surgery.
This has given us very accurate replication of the component positioning. I think some of my patients get a little nervous when I start talking about robotic surgery. I think they have visions of me in the surgeon’s lounge drinking coffee while the robot’s doing all the work. But I think it’s very important to understand that the Mako robot does not perform the surgery. It does not do any decision making and most importantly it cannot move towards the patient in any way without my hands actually being on the instruments. It is simply a more precise tool to ensure that I am able to enact my plan in the best way possible.
Going through a little bit of the step by step approach before surgery begins I along with one of the robotic specialist are able to go through the C.T. scan seen a three dimensional representation of exactly where the acetabulum component will be placed. Adjusting it if needed based on the patient’s osteoarthritis and ensuring that we have the most accurate plan possible and I have thought about any potential outcome ensuring that we have the most accurate plan possible and that we have thought about any potential complications before we ever set foot in the operating room once we’re in surgery we take that 3D model and we confirm the location of the bone giving the computer points on the pelvis.
The computer came firms the points given to the pelvis to the C.T. scan to ensure that it’s receiving accurate information and that the two sets of information are consistent with each other. This eliminates the possibility for errors during surgery. The robot comes in from the opposite side of the surgeon. The markers on both the patient and the robot tell the computer the location of the patient’s pelvis and the location of the robot ensuring that the robotic arm can accurately place acetabulu, component. We prepare the bone with a Reamer using the computer guide and then place the component using the same guide ensuring that we have an accurate component placement post-operatively. We end up with fantastic looking x rays without surprises. Prior to using the robot we often got x rays after surgery in the recovery room. Occasionally as we saw on that Harvard study our x rays weren’t what we thought they were going to be. These slight variations seldomly caused any kind of complications for the patients but we’re very bothersome to me as a surgeon. Since I have to go into the Mako robot I’ve been very confident that my x rays in the recovery room are going to be exactly what I think they’re going to be.
Again looking back to the study from Harvard where we saw 50 percent of the cups were not within the desired safe zone we need to. We felt the need to look at the Mako robot and see if we were doing any better. Technology only works if the results are there to back it up. A study was done on placement of the Mako robots showing that 100 percent of the cups were within the safe zone. In this study 80 percent of the cups placed with conventional methods were also in the safe zone so a little better than the Harvard study. But still I don’t think many patients would be happy with 80 percent accuracy.
So then a little personal case example a patient of mine a 70 year old, 74 year old male who unfortunately previously had suffered from cancer and had to have pelvic radiation as a side effect of the radiation. He developed severe destructive arthritis from avascular necrosis of his femoral head. He had substantial loss of bone within his femoral head a significant leg length difference and severe pain because of the pain. He was very debilitated needing a wheelchair at times unable to enjoy any of the activities he had previously wanted to do. In this case the Mako robot took what was previously a very difficult stressful case where I’m trying to restore the patient’s leg lengths to obtain good fixation with that’s the type of the component in deficient bone and it made it a very straightforward stress free case. We were able to bring the leg length back down restoring a neutral leg length. Obtain good fixation with our as a tabular component and by doing so give this patient tremendous quality of life back. We’re able to reduce his pain and get him back to doing the activities he enjoyed doing so with Mayko hip replacement. I’ve been able to take a previously great surgery and make it even better. We’re able to give patients pain relief and give them back their quality of life. Doing so we are able to keep patients doing the activities they enjoy doing and keep them happy thank you for your time. I appreciate you listening to our presentation and I hope you’ll visit our website for more information about robotic hip replacement.