Robotics in orthopedics

1. Robots in Orthopaedics

2. Introduction
 Was introduced to achieve higher speed and
accuracy in surgery
 Examples of their use - UKR, THR, Spine
pedicle screw placement
 Reduction of error
 Improved surgical technique
 Minimally invasive surgery may be done
 However, due to high on-table setup time for
the machines, time taken may be the same, if
not more

3.  Updates to software and equipment
 Cost
 Learning curve
 Ultimate results in robots v.s. Manual....is there a
significant difference?

4. Principle of Use
 Pre op templating with software, creation of
patient-specific model an surgical plan
 Orienting the robot to the patient's anatomy
through uploading of CT scans
 Imageless systems – do the same intra-op
 Intraoperative registration of the model and
plan
 Employment of the robot for bone-cuts and
carrying out the pre-operative plan

5. Robotic Systems
 Autonomous
 Surgeon performs approach, then sets up the
machine and engages the robot
 Robot works by itself
 Haptic (tactile)
 Surgeon drives the robot's arms
 Constant input from surgeon
 Image vs. Imageless
 Closed vs. Open platforms – company specific
 Soft Tissue – DaVinci Robot (used since 2000)

6. Haptic Robotic System
 Unicondylar Knee Replacement – Robotic arm
interactive orthopedic system – RIO made by
Mako Surgical Corp.
 Pre op CT used for 3D model of knee
 Surgeon marks the bony surfaces of femur
and tibia intra op, allowing the pre op model to
be merged into the active anatomy
 Knee ROM is seen, flex/ex gaps assessed,
component sizing and placement finalized,
and cutting zone is created
 3D model can be viewed which cutting with the
burr

7.  Resection of bone is confined to the pre-defined
space on the force controlled tip of the burr
 If the surgeon exceeds the cutting zone, the burr
automatically stops
 Roche et al. (2010) measured 344 radiological
parameters in 43 cases...only 3 were off
 Cobb et al. Used the Acrobot robot
 Robots gave better American Knee Society
scores, increased operative time
 Better alignment and positioning
 Accuracy within 2 degrees of pre op plan....only
40% of manual cases had within 2 degree
accuracy

8. Autonomous Robotic Systems
 Surgeon is in control of an emergency shut-off
switch
 ROBODOC – introduced in 1992 (Curexo Tech,
California)
 MBARS (Mini bone attached robotic system)
Hybrid system – Carnegie Mellon University,
Pittsburg, PA
 ROBODOC – showed promise in THR, but had
safety concerns
 Praxiteles (Praxim, France) also developed

12. Passive Surgery System –
Computer Navigation
 Used for assessing joint irregularities and
biomechanics
 Recommendations – ex. Ligament balancing
 Monitor accuracy of bone cuts
 Track instrumentation
 Geometry
 Alignment
 Cameras communicate with instruments and bony
landmarks through LED

13.  Manual override option is there
 Surgeon is not limited to pre-defined cutting
zones
 Useful in early learning curve

15. Pitfalls
 Setup required is expensive
 Constant upgradations and calibrations
 Long term studies haven't proven superiority as
yet
 Robots can identify the bony anatomy well,
however the nuances of soft tissue dissection are
not yet programmed – risk of hitting neurovascular
structures, more soft tissue damage
 Legality/ litigation?

16. Minimal Access Robotic Assisted
Spine Surgery
 Pedicle screw placement
 Mazor Robotics' Renaissance (FDA approved)
 Workstation
 Planning software
 Guidance unit which moves in all planes
 Spinal mounting platforms

18. Surgical Technique
 Preparation of robot (3D CT, planning)
 Patient positioning
 Attaching the universal image adaptor to C arm
 Affixing clamp and taking AP and 60' oblique
views
 Assembling bridge and preparing and activating
the device
 Approach
 Take the arm indicated by software, align holes
of the arm plate with the pins of the device

19.  Make incision with the scalpel through arm tube
 Insert cannula into arm tube, push and rotate blunt
trocar
 Drill guide in cannula, drill bit in the guide,
reduction tube in the drilled hole
 Insert guidewire, split muscle with dilators, and
insert the screws

20.  Advantages
 Accurate, safe, relatively easy to learn and use
 Less radiation
 Minimal blood loss, less hospital stay, less
analgesia post op
 Disadvantages
 Device related – failure of software
 Patient related complications
 Infection

26.  I'll be back
Thank You