Robotic-assisted Orthopedic Surgery

Episode 33 - Robotic-assisted Orthopedic Surgery

Dr. Chehab: [00:00:00] Welcome to IBJI’s OrthoInform, where we talk all things orthopedics that help you move better, live better. I'm your host, Dr. Eric Chehab with OrthoInform. Our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today. It's my pleasure to welcome Dr. Justin LaReau, who will be speaking about robotic assisted orthopedic surgery. So Justin, welcome to OrthoInorm. Glad to have you here. Great. Thanks for having me. So let's start a little bit, um, talk about yourself, your educational background and how you got into orthopedics. Sure, absolutely. 

Dr. LaReau: I started out with, , undergrad.

Well, let me take a step back for a second. Do you watch NFL football? All the time. Yeah. I think the funniest thing that I've noticed now is when players introduce themselves on the camera, on the TV. You know, they used to always say, oh, , University of Miami or University of Tennessee. Um, but now a lot of them are saying like they're elementary school or they're preschool.

All right. So you can go as far back as you want. So how far back do you want me to go? So state Monaco elementary in Kalamazoo, Michigan. [00:01:00] That's where I'm from. But I think, listeners are probably more tuned into, professional background, but I do like to, , include Notre Dame.

Uh, that's where I went to undergrad. Football, , is a big deal in our family. Notre Dame is a big deal culturally in our family. So, I'm a Notre Dame undergrad and then I went to University of Michigan, , for medical school. 

Dr. Chehab: Bit of a conflict. 

Dr. LaReau: There's no conflict at all. Uh, I'm Notre Dame born and bred at the end of the day.

Okay. Very good. And then, I grew up in Michigan, and so it was a natural evolution just to continue, , in state for residency, so I went to Henry Ford Hospital, , which is in the inner city in Detroit, now part of a huge health system, and then from there moved on to Boston for almost two years, and, , did two fellowships, one in total joint replacement.

And then the second in pre arthritic hip conditions or adolescent and young adult hip surgery at Boston Children's in the Harvard system. So that was the education. And then I wanted to come back to the Midwest and I started with Hinsdale Orthopedics, which is now part of Illinois Bowdoin Joint [00:02:00] 15 years ago.

Dr. Chehab: Yep. Okay. And then, , how did your interest develop into arthroplasty and preservation of the hip? 

Dr. LaReau: Sure. Absolutely. As I think back, , in retrospect, arthroplasty was actually one of the first procedures I saw as a medical student in the operating room. And I think it really was a matter of, , seeing it for the first time and thinking, this is what I really want to do.

I think, , as a medical student, I'm chuckling a little bit because you're impressed by all the big tools , and the technology in the orthopedic rooms. But then I think. , that stimulates the initial interest and then you see why you're doing the procedure. The outcome is that the procedure generates and that really made arthroplasty an attractive option for me and something I was really interested in.

Dr. Chehab: Yeah. There's no question. Arthroplasty produces these incredible results that are durable, that are life changing. It's a wonderful sub specialty within orthopedics and it defines orthopedics in many ways. 

Dr. LaReau: Yeah. 

Dr. Chehab: And then, , you moved back into the area, , you started at Hinsdale Orthopedics at in about 2010.

Is that correct? 

Dr. LaReau: That's correct. Yep. 

Dr. Chehab: And your practices [00:03:00] evolved like most of our practices do. So how did you start and where are you now in your practice? 

Dr. LaReau: Sure. Absolutely. When you come out of fellowship, you do, um, and you're starting in practice, you do a lot of everything. , as a young doctor, that ends up being a lot of revision surgery.

 Because those are the more complex cases and fresh out of fellowship, , that's when you're really in, I would say, the zone to, to tackle those. You do a lot of trauma, a lot of hip fractures, because you're taking a lot of call as a young junior partner. And then you have this growing elective arthroplasty practice, people who come to you for an elective hip or knee replacement, and that really grows over time.

That grows as you become a presence in the community, that grows as the demographics in the U. S. age, and , my practice has grown through word of mouth. , so I did hip preservation surgery for the 15, uh, first 15 years of my practice. And that really is complex, a complex set of operations focused on, I would say kind of the nascent, like, roots of why [00:04:00] hips in particular, , devolve into an arthritic condition.

And I've started really to narrow my practice just to elective arthroplasty at this point. Yeah. , that's how it's evolved. Just probably more from patient demand than anything. 

Dr. Chehab: Yeah. And then in terms of the robot and the robotic assistants. Sure. Did you come out of fellowship using the robot right away or how has that evolved over the past 15 years?

Sure. 

Dr. LaReau: I think just from a timing standpoint, the, it, My fellowship training really fell in this interesting period in that it started really right before, , My fellowship took place really right before the start of robotics. In essence, I remember coming to Chicago and having just spent the last, , seven years as an orthopedic surgery resident and fellow.

learning all these techniques that you learn as a fellow, , learning different implant systems, different instruments and probably within. And so you spend a lot of time investing in learning how to do surgery with those tools. And I land in Chicago and probably literally within the six [00:05:00] months of my beginning of practice, , I'm approached by combination hospital, other partners, , and industry saying, Hey, we've got this new robot.

To do near replacement. We think you should do or consider doing near replacement this way. And you're like, oh my gosh, I just spent seven years learning it this way. And so I would say it was like, wow. I think it was a good insight into a couple things. I think number one, , how quickly things are moving, technologically, I think number one.

And number two, really the vast array of options that are available to you as a surgeon in terms of how you're going to practice, what tools you're going to use, what, should you use this or should you not, what are the downsides, , do you adopt something new and unproven? And, uh, I, it's just a, it's striking to look back that was, I really started right at the very advent of robotics in, , widespread orthopedic surgery practice.

Dr. Chehab: Yep. And like you said, [00:06:00] it's, I think people, including, the uninitiated orthopedic surgeons who haven't seen the robot in use, think of a robot creaking into the room like C 3PO and performing the surgery and asking for the knife. Now, clearly that's not the case. And you mentioned tool. Sure. And, , I do think the robot is a tool.

It's not doing the surgery for you, but it's providing an option for you to do the things you need to do. And when you're using So, robotics, start from the very beginning. How does it help you with preparing for the procedure? How does it help you with performing the procedure? And then how do you think it influences the outcomes?

So we'll start with the preparation. Sure. So, so tell us a little bit about how the robotic assisted procedure can help you with preparation. 

Dr. LaReau: Can I take a little divergent, , So I think it is probably to maybe talk, important to talk a little bit about , how we evolved to robots. Perfect. Maybe how we did joint replacement [00:07:00] surgery beforehand.

Yes. One of the fun things about training in Boston is there's a tons of hit. There's a lot of history in Boston, in particular in not only in medicine, but in arthroplasty in particular. And so I was very fortunate. to be at where I did my fellowship at New England Baptist. It's basically a Harvard faculty, Tufts faculty and some community surgeons.

So you have this huge group of surgeons who are instructing you, some who are young, and then you have a lot of, , I would call them grizzly old Boston veterans who did things, , since the 1970s, a certain way. Arthroplasty really evolved. Oh. , the first germ replacements were done almost with what we call freehand technique, where surgeons were literally using their eye, no other instruments, and maybe some crude saws.

So that's really step one. That's kind of how it started. , and step two, they had , very primitive metal guides that you would use during surgery and the guides maybe helped you with one out of the seven cuts that, the guide would help you perform one out of those seven. And then the rest, you were literally using your eye and marking with a methylene blue marker.

[00:08:00] Yeah. I thought, how you thought you should kind of cut the bone for the remaining steps. And then guides evolved. Pretty soon you have metal guides for all these steps. I would say the next evolution from that is, which is called mechanical alignment and mechanical instrumentation, um, companies started cutting up with what we call custom cutting guides.

So you went from these metal, metallic instruments that you'd use during surgery. You would caliper and measure certain things. And then you got to the point where you could three dimensionally image something. , a knee, let's say just as an example. And then they would fashion custom cutting guides for the patients.

, and then from there, three dimensional imaging then got uploaded into computers. And, , and then upload it into computers that were attached to robots. And so, that's kind of the evolution of, of where it came from. It really evolved from something very primitive, , to now Really a full three dimensional image of the patient's knee and then trying to adapt that intraoperatively [00:09:00] and help that guide your cuts and your Different procedures and steps 

Dr. Chehab: during surgery.

So just to go over that initially Joint replacement in the 1970s free hand cuts using your eyeball and doing the best you can to make these cuts for the implants that will go in. And then it evolved to, hey, here's a guide for one of the cuts that you can then base the rest of your cuts off of. And then the guides became more sophisticated and allowed for all of the cuts that you would typically make to be instrument guided.

But these are standard guides that would come out of a. toolbox essentially out of an operative tray. And then you mentioned the patient specific guides being the next iteration where you could take a three dimensional reproduction of a knee or a hip and make custom guides for the knee most commonly for the knee.

And then those guides would then you would make those cuts with the guides mounted onto the knees. Yep. And now, um, the next iteration being, Hey, let's [00:10:00] take those three dimensional. Reproductions of the knee and let's have an assist is an assistance with a robot to help with those cuts So again, nothing's really free handed Everything's guided and we're trying to make things more patient specific with each iteration.

It seems like you're 

Dr. LaReau: exactly 

Dr. Chehab: right and so You know The alignment you mentioned. Can you explain why that's so critical? Sure. So 

Dr. LaReau: When you see a patient with an arthritic knee in a lot of cases the alignment of the leg, you know Let's talk about two different types of cases say someone who is bow legged versus knock kneed Most patients have some variation of that and certainly there's some subtle versions that don't fall under either category but the vast majority of patients are either a little bit bow legged or knock kneed meaning they put a little more pressure on on the Inside of the knee or the outside of the knee think of it as a car.

That's slightly out of alignment. All of us come, , come out and evolve to some degree of, , [00:11:00] mild, what we call malalignment. And so, part of what we're doing surgically is to correct the large DV, largest deviations in alignment. So if someone's really bowlegged, you would try and straighten them out surgically.

 If someone was really knock knee, you'd try and, , align the legs. So it looked more straight up and down. And so that it. Distributed all the force in the knee equally on the inside and outside. That thinking definitely has evolved over time. I think what we're learning now, there's discussions of what we call mechanical alignment, which is make everybody straight.

, and then I think the subtle , more nuanced iteration now is, okay, let's take someone who has become very bow legged and let's straighten them out most of the way. We don't want to, , as I sometimes tell patients, we don't want to totally change who you are, but we want to really optimize who you are.

And that is a philosophy that's called kinematic alignment, which is, , I think probably gaining a decent amount of momentum in knee replacement surgery in particular. So what I would [00:12:00] say is, as we talk about evolution of knee replacement from , mechanical instrumentation to three dimensional modeling to computer guided surgery.

We've gotten really more subtle. We've developed the ability to be a little more subtle or a little more precise in terms of how much we realign patients. And it allows us to really do a lot in terms of preoperative planning, but also interoperative adjustments too. 

Dr. Chehab: So the traditional teaching with alignment is if you misalign the implant would not Lasts as long.

It would not be as durable. It would loosen more quickly because of the force distribution. 

Dr. LaReau: Sure. 

Dr. Chehab: So with kinematic alignment, um, Are there any concerns about longevity of the implant? Durability of the implant? Sure. I think there that is 

Dr. LaReau: an 

Dr. Chehab: ongoing 

Dr. LaReau: Yeah. Argument 

Dr. Chehab: and I, you need a 20 to 30 year horizon , to solve that.

Sure. To answer that question. 

Dr. LaReau: You do. And I think that, , there's lots of, I think there's new factors that are now incorporated, for example, in the past. We used glue to put in most of our knee replacements, and now we're doing a lot of what we call press fit or [00:13:00] biologic fixation. In other words, instead of relying on a grout or an adhesive or patients say epoxy to, , attach the knee replacement to the bone, you are pressing it onto the bone in a way that allows it to grow together.

And so there's some thought that you can , take advantage of that biological bond between the implant and the bone. And if you align someone , in a kinematic way, meaning make them mostly straight, but allow some subtle variation that reproduces their natural anatomy, that implant will function pretty darn well.

And I think With biologic fixation, people may believe that affords a little bit more freedom in terms of how you position the implant and how you need to align a patient. Without 

Dr. Chehab: it affecting the durability of the implant. Exactly. Yeah. Okay. And so, and now, , with that history and that background in mind, Take us to the robotic assisted surgery.

And so we talked about your prep. We were thinking about talking about preparation and then how it affects the procedure and how you think it may affect the outcomes. [00:14:00] So um, I guess with the preparation, we probably have to talk about how we used to do it and then how robotics has changed , the pre op planning that is done for joint replacement.

So let's talk about the preparation and how the robotic assistance. AIDS and that. 

Dr. LaReau: Yeah, so I can talk, let me share a little historical antidote. So I remember on a, , as a resident on the 12th floor of Henry Ford Hospital in Detroit, we had a big x ray room. We had, , large, huge folders, think, , almost like a foot and a half by two foot, probably five pound folders full of x ray films.

And you're shaking your head, yeah, it's like you've been through this era with me too. So I remember being on the 12th floor using traditional , radiographic view boxes like light boxes and drawing alignment with a grease pencil. Yes. And so we would have, my job as a junior resident on the joint replacement or orthoplasty service was to template or plan all the cases for the week.

So that's how it used to be. And now what really happens is you have a, let's say you're doing a, , four or five knee replacements in a day. [00:15:00] You have computer models, , available to you online ahead of time to review. So a patient will have had their, , knee, Or hip scan by an oftentimes an CT scan and then you've got that three dimensional data to review Sometimes you find things that you wouldn't expect inside the bone which are more easily seen with an MRI or CT.

So that's helpful but you really have a great three dimensional view of the anatomy and Then you're able to kind of plan your implant position and how you're going to correct things accordingly But I think this Now evolves into that, , kind of next step of, of robotics in that not only do we have that data pre op, , you've got a, if you think about how we are at this point, you've got a, an image of a knee that's static from someone lying on a table with a, , in a CT scan or an MRI, you got a three dimensional picture.

That's how they are lying down, but we don't live our lives lying down. So now, The most revolutionary robots are incorporating a lot of motion based, , [00:16:00] data that allows you to then take that static image still image pre op, and then make adjustments based on how the knee moves and functions in space.

And you can assess that intraoperatively. So the next generation of these robots will incorporate more and more different sensor data on how much any moves, how much any stretches, how much any bends or pivots or twists as it moves. And so that's really where we're headed. The ability to use robotics and, , I would say, incorporate custom based patient data based on a moving knee.

That's where we're headed, which is exciting. 

Dr. Chehab: Yeah, so that's great. I again was nodding my head in agreement. Two dimensional imaging moves to three dimensional imaging and these, , I will make our cut here with a grease pen, , marking our preparation. That's sort of our, , doing the surgery in our minds before doing the surgery.

And then getting three dimensional imaging. Much more precision, , much more, , less, much less [00:17:00] variability, presumably, doing this, , preoperative surgery in your mind, , before you even do it with just much more data and much more clarity about what the anatomy is going to be. It can only be helpful.

Yeah. Yeah. And so, then let's go into the procedure. , again, with the, , preparation, you talked about how it, this amazing ability to basically see the surgery before you do it in three dimension and with the idea of the knee moving as opposed to being static. , so now when you're in the procedure, how does the robot assist you?

What? What are you doing with the robot? What is a robot doing on its own, if anything? , cause again, I think this is the part , where people have, , probably loads and loads of misconceptions. 

Dr. LaReau: Sure. So just to be clear there actually, believe it or not, there are some autonomous robots. 

Dr. Chehab: Okay, 

Dr. LaReau: in development that are in development.

Dr. Chehab: I haven't seen them. 

Dr. LaReau: Yeah, they're, , there are some autonomous robots. They're not robots that walk into the room, but they're, , the, , if just, so these are not widely used, but there are some, I would say kind of small case [00:18:00] series of, , knee replacements done where the surgeon will open the incision, place instruments, set the robot up, and then the robot will, more or less remove damaged bone for you.

And then the surgeon takes over from there, and then applies the implant. So , that technology exists in a very crude form today. That being said, I would say the vast majority of robotic procedures from the major companies now are done with what I would call really a robotic arm. And so, and that's across, I would say the major players in joint replacement.

When we say robotic surgery, what we mean by that is there is a robotic arm that the surgeon is guiding, , during the operation. And that robotic arm has a lot of sensors attached to it. It has a saw attached to it, or a burr, usually. And then that is really linked to a real time image of the knee.

So you, have a knee right in front of you, but you also have a screen where you're looking at the three dimensional model and how the either saw or the Burris position relative to that knee in space. [00:19:00] So that surgeon, the robotic arm is not autonomous. The surgeon controls where that robotic arm goes and the robotic arm can make a lot, , you can use the computer to adjust where that robotic arm is in space.

Dr. Chehab: So how does the computer and the knee on the table, how are they linked? Because you have a, an image that's been uploaded in the computer and then you have the knee on the table. So, , explain how that link happens between the body part that's live and on the table and moving all over the place, , to the computer and the model that they have.

Dr. LaReau: Yeah, you brought up a good point. I think most robotic surgery is done with, , I tell patients, small navigation towers that are placed above and below the knee replacement. Sometimes through a small extra incision or sometimes they're incorporated into the incision. So in addition to the surgical incision, You have small areas above and below the knee where you're placing, , basically a small screw or a threaded pin That has kind of a relay signal tower attached to [00:20:00] it.

And that is how the communication takes place. 

Dr. Chehab: Yeah, okay, because obviously that's critical. You can't just have a computer model and then a knee without linking the two in real time. And then the robotic arm is surgeon guided and the role of the computer based robotic assistance is to Correct the surgeon or to suggest to the surgeon or what's happening in that moment when you are actually making the cut sure 

Dr. LaReau: So there are different versions with different companies that have varying degrees of control.

So there are some Companies that make a robot that don't allow you to go outside of any kind of certain boundaries. So you can't, , you can't, , cut beyond, , let's say, , this degree or you can't cut beyond this size. And there are others that are what I would call less guided and allow a little bit more surgeon, let's say override or surgeon autonomy.

, just another example. There are robots that where you as the surgeon are [00:21:00] responsible for replacing all your retractors and protecting the vital structures like the nerves and blood vessels. And there is other systems that allow, , that basically the robot puts up those fences for you. And I think, quite frankly, surgeons, some surgeons don't like the robot making those decisions for you.

Other surgeons don't. Like it when the robot make that makes those decisions for you the technical terms for those are Haptic and non haptic robots basically right so I use a haptic robot for what it's worth Which is one where the robot sets the boundaries You can always you can shut that off and override it and make manual adjustments if you need to but I like a Haptic robot actually, I think it provides some valuable feedback.

Dr. Chehab: Okay, so so Um, going back in iteration when there were the patient specific guides, I do recall this was in my training. One of the surgeons saying the interesting thing about the computer assistance that's occurring and the navigation that was occurring in that iteration [00:22:00] was that it was meant to decrease surgeon variants to make it so that most needs were falling within a certain range of alignment and , so that there was.

, in general, better outcomes, more durable outcomes, better performance of the implant. , but I specifically remember the surgeon saying, the irony is that really good surgeons already have less variants and these Assisted devices work the best in the hands of the very experienced surgeons. Like, in other words, they're not very good in the novice surgeon's hands because they're not as willing to override or do what needs to be done if there's some difference between what the computer is saying and what you should be doing, , with the replacement.

Is that still the case with robotics? 

Dr. LaReau: Yeah, absolutely. I think you, you raise a great point and I think probably it. a great thing to keep kind of keep in mind. Again, these robots are not autonomous, and they are a tool. And they're, , for example, the, , we all have, let's just use an [00:23:00] example, GPS in your car.

Let's pretend that you're driving somewhere. And sometimes the GPS directs you a certain way. And a lot of times the GPS is right. But there are some cases where you say, Hey, I know that way. I know the time of day that it is right now. And , they actually just started construction in that area, so I'm not going to follow that.

There are certain times where, as a surgeon, based on, , your clinical experience, your knowledge of the patient, your understanding of the anatomy, , says, you know what, I'm going to override this decision. And I do that. all the time. And so it's, , it's a tool that you that you use. But I would say there's limitations to that tool.

And quite frankly, there, , the robots, I think, , sometimes there can be, , issues with the robot, what, , whether it's a software issue or a mechanical issue within the robot. And the key is, I think you have to have multiple tools available at your disposal. So, in addition to a robot, , we still have manual guides [00:24:00] available to us.

If for some reason the robot doesn't function well in a certain anatomy, and then, uh, you also have your own, , surgical skill. And I think you have to bring all those to the table. Um, and I think all those are important. , maybe to, , piggyback onto that, , the Maybe we'll get into this a little bit later, but, , is robotic surgery always better?

And, because there's still a lot of surgeons, um, who don't use it, and the short answer is we don't know. As a surgeon, I can tell you, I like having every tool available to my disposal. But I know there's a lot of surgeons who do a wonderful job of knee replacement without robotics. I can still do knee replacement without a robot, but I think The question that I've always asked is, can this help me in the operation?

And the answer for 99. 9 percent of the cases is yes. And that's why I choose to use it. 

Dr. Chehab: And so you're approaching this topic we were going to lead to with outcomes. And is there data suggesting that Robotic [00:25:00] assisted surgery leads to superior outcomes, leads to less variance, leads to greater durability, and better function in the knee?

Sure 

Dr. LaReau: answer is probably not. I think that 

Dr. Chehab: Because it takes so long to get that data, probably? 

Dr. LaReau: Yeah, I think there's two parts to the data as I see it. There is, , as a surgeon, you're kind of thinking of, I think of this in two different, uh, buckets, or two different, um, you know, kind of sides of the coin.

I think that area where we focus a lot on is early post operative recovery. And what I would say is, , does robotic versus, conventional instrumentation, , is do robotic needs recover faster? And that's it. I'll give a nuanced answer to that. And this is the answer. The short answer is no, but if you look at it in a nuanced way for me to do.

I, what I would call kind of the most up to date, patient specific kinematic alignment in my hands, that [00:26:00] patient recovers faster. And I can do that surgery. more precisely and reproducibly with a robot. So is it the robot that's making the surgery? , Is the robot what's allowing the patient to recover faster?

Not necessarily. But does the robot facilitate subtle advancements in surgical technique and precision that can facilitate a faster recovery? And my answer to that is yes. In my hands. Now, that's the immediate post operative recovery. Perspective on things. Then you have the long term aspect. And the short answer is, , is we don't know yet.

I think that any, , system like a robot that reduces errors, , has the potential to improve long term outcomes. But we're gonna wait that answer. , right now we're still You know, the U. S. has a great joint replacement registry, the AJRR, the American Joint Replacement Registry. Um, and so we're going to follow that data very closely.

It's interesting, I just listened to the annual report about a month ago [00:27:00] and it's great that we're collecting data on this because we'll have those answers, , in the years to come. 

Dr. Chehab: That's a reasonably recent project by the American Academy of Orthopedic Surgeons to keep a national registry of outcomes for total joints.

I mean, It would have been wonderful had it been going on for the last 40 years. But it started, what, within the last 5 to 10 years, robustly? I mean, it's relatively recent as far as 

Dr. LaReau: In terms of its robustness, um, I think it's The amount of data collection that they have now versus five years ago, , 10 years ago is dramatically increased.

So I think it basically really took a long time to 

Dr. Chehab: set up the registry, set up the registry to 

Dr. LaReau: collect, know what data collect and then to get all your sites on board, , for better for worse. I think consolidation orthopedics probably helped that because there's fewer small private practices. Most practices, , like our group has probably 150.

You know, doctors in it. And so it's much easier to kind of collect that data from large [00:28:00] groups of physicians in a consolidated group of hospitals. So for better for worse, I think the American general police registry has, um, their amount of data that they're getting now is a lot better. Massive, and it's increasing, they are collecting data from the vast majority of jaw replacements, , in the U.

S. now. So, 

Dr. Chehab: that's 

Dr. LaReau: exciting. 

Dr. Chehab: , I find arthroplasty so incredibly interesting in terms of innovation. Because basically the first stabs at this were very successful. , like the 1970s, 1980s, let's give this a try. And, and use these implants and use these materials. Were pretty good choices that were lasting.

A decade, two decades, and innovation requires now two to three decades of longitudinal follow up to know whether or not it was a good idea. 

Dr. LaReau: Yes. 

Dr. Chehab: And, and, which is , a mind blowing concept to me because, again, You don't know the answer to something that you think is a good idea, , until it [00:29:00] almost fails early and spectacularly.

And even the metal on metal hips issue, which was kind of a, it was a great hip if it were put in one particular position. Yep. And then there was, if there was any variance in that, that's when the hip seemed to fail. So it was an incredibly durable hip with very narrow variance. So in the hands of most people.

It just ran the risk of failing. 

Dr. LaReau: No, that's, , the metal on metal joint replacement came out, um, That whole episode in the, , let's just call it U. S. medical device history, that really happened right as I was a senior resident as a fellow, and a fellow. And so I, I was, let me say, on the front lines of that.

I saw some early ones put in. I saw some spectacular early outcomes in extremely active patients, and I also saw the, , the downsides and some of the, uh, patient impacts on those, which , were tremendous. and really tough in a lot of circumstances. 

Dr. Chehab: I, I don't get the sense that this is the case with robotic assisted surgery.

In other words, [00:30:00] this is a technique that allows for improved preoperative planning, , with some guardrails, basically, intraoperatively, and then outcomes that, at least on the early side, are on par with anything that we've done in the past. And because of the subtle corrections that you're able to make with the robot assistants.

a reasonable belief that this is going to lead to better long term outcomes, better durability and a more naturally functioning knee. I mean, that is one of the rubs on knee arthroplasty. I mean, people will say, God, I feel so much better walking around, but they don't feel like it's their native knee.

Whereas hip arthroplasty, people feel so much better walking around and they can't tell the difference between their native hip and the replaced hip. And so maybe these are the type of advances that will make it so that when people get a knee replacement, um, they can't tell the difference between their.

replace knee and their native knee. 

Dr. LaReau: Yeah, I think you're exactly right. There's a term that we use when we research these joint replacements and [00:31:00] we follow their outcomes called the forgotten joint score, meaning, , just as you described, , to what degree do patients think and remember, Oh, I actually did have my hip replaced.

This is not my, this is not my own hip anymore. That people forget that they had surgery much more frequently in the hip as opposed to the knee. And what I would describe what is going on in knee replacement now with robotics, , kinematic alignment, , and all the technological enhancements that we're using, I would say we're really refining things, , more than reinventing, , the wheel, so to speak, or trying something completely different.

I think we're really starting to zero in on what makes a knee replacement good, what patients like, and how can we reproducibly, , create that every time we do a knee replacement surgery. 

Dr. Chehab: So as we, as we come to the end of this discussion, are there any sort of pearls or are there any parting thoughts that you have about robotic assisted surgery?

I mean, we didn't talk much about hip arthroplasty, maybe because [00:32:00] it's so successful, it has such a high forgotten, what was it, forgotten? Forgotten joint score. Forgotten joint score. Yeah. Um, and reproducible operation that nearly uniformly. People , really like it. Is that part of the reason why navigation or computer assistance or robotic assistance in hip arthroplasty?

I can tell you that would be great for preparation, , for the surgery, but that it's not used as frequently within the operating room as, let's say, total knee. 

Dr. LaReau: Sure, so just to maybe clarify, we're talking about, do we use, um, we've talked a lot about knee replacements. Yes. And, the question is, , do we use robotics in hip replacement?

, yes or no and why. So the short answer is yes, people use it. I think the, uh, the potential benefits are maybe a little greater , in knee replacement. I think there's a lot of other tools that we can use in hip replacement. To, , enhance. hip replacement, outcomes where you don't necessarily need robotics.

And obviously hip is a totally different operation, , than a knee replacement. It's a ball and socket [00:33:00] joint versus a hinge joint. I think, quite frankly, the knee joint is a little bit more complex. It's really a rotating, it's a rotating hinge. Whereas the hip is a, I would say just a more, , simple design.

 The tools of robotics are available in hip replacement. I think the gains that we get out of them are greater in knee replacement. If you look at large majority of cases. There's certainly cases, , a case here or there where a robot provides a tremendous benefit in hip replacement surgery.

, But I think there's other kind of non robotic tools that we use. , I would just call it kind of guidance systems, uh, and navigation in hip replacement that, , give us a lot of, , those same benefits in a simpler joint. 

Dr. Chehab: Yeah. And in, in the hip, is the robotic assistance on the socket side or , on the leg side, on the femoral side?

Where's the assistance most useful? Is it used for both or is it used for one or the other? Sure. In terms of,

Dr. LaReau: implanting, it probably is more, has a more of an impact on what you use on this, or where you place the [00:34:00] socket, , on the side of the thigh bone or the femur side. All that preparation is really still done with kind of hand instruments, but what the robot does is it allows you to see what you've created at the end of that process. So, 

Dr. Chehab: well, these are terrific innovations. And, , I, I love the fact that orthopedics, , we are constantly innovating for the benefit of our patients. And, it's just a wonderful field to be in because we are ultimately helping people. It's all about helping patients achieve the best outcome and the most durable outcome.

 And again, these innovations are fun for us to be involved with. It keeps things fresh and exciting and fun to be a part of it. So, um, anyway, Justin, I can't thank you enough for being here for OrthoInform. , thank you very much. 

Dr. LaReau: Yeah, my pleasure. Happy to be here and thank you for having me.