Revolution in orthopaedics by robotic aids in surgery

1. ROBOTIC
SURGERY IN
ORTHOPAEDICS
O R T H O P A E D I C S E M I N A R
P R E S E N T E D B Y : D R M U K U L J A I N
G E E T A N J A L I M E D I C A L C O L L E G E A N D H O S P I T A L , U D A I P U R
02.12.2019

2. INTRODUCTION
• Polish word ‘robota’ meaning forced labour
• Describes a machine that carries out a variety of tasks
automatically or with a minimum of external impulse,
especially one that is programmable
• Robots are in use in surgery since 1980.
• Orthopaedic surgical use started in 1992.
• Firstly used was ROBODOC for planning and performing
Total Hip Replacement.
• Promising short term radiological outcomes has
promoted its use.

3. WHY IS IT GETTING POPULAR?
• Minimal invasive surgery – in spine surgery, increases
the placement of implants
• Improves the radiological alignment of implants, as
predicted by the pre-operative plan.

4. TECHNOLOGY
PLATFORM
TYPES

5. pre-operative CT
Robot- coverts CT into
three-dimensional (3D)
computerised model of
the patient’s knee
Surgeon- plans the
sizing and placement of
the components preop
Intraop – surgeon will
reference the bony
surfaces of the femur
and tibia
pre-operative model is
‘merged’ with the
actual anatomy of the
knee
After taking the knee
through a range of
movement, the flexion-
extension gaps can be
assessed
operative plan finalised
in terms of component
placement, creating an
exact cutting zone for
the robot.
system’s algorithm
relies heavily on the
pre-operative planning
or templating process
During the resection of
bone, the surgeon
views the 3D model of
the knee on a monitor
while manipulating the
burr
Robotic arm provides auditory as
well as haptic feedback, limiting
the force-controlled tip of the
rotating burr to resect bone only
within the confines of the pre-
defined cutting zone.
additional safety
feature automatically
stops the burr if the
surgeon goes outside
the predetermined
zone.
IMAGE GUIDED SURGICAL PLANNING

6. IMAGELESS SYSTEMS
rely entirely on intraoperative registration of the anatomical surfaces
and kinematics after arthrotomy to create a 3D virtual model
Firstly, develop a surgical plan
Define boundaries beyond which the bone cutting tools should
not remove surface tissue.

7. PROS AND CONS OF IMAGELESS SYSTEMS
PROS
• no preoperative imaging
• cadaveric and early clinical
studies discussed above
demonstrate that the
imageless system results in
comparably accurate
prosthesis placement
CONS
• True preoperative plan that
allows the determination of
implant size, position, and
alignment cannot be
performed
• Intraoperative registration
relies on the surgeon’s
accuracy of inputting the
correct data points, which is
subject to human error

8. 1. AUTONOMOUS ROBOTIC SYSTEMS
• These systems complete the case without surgical assistance.
• the surgeon is in control of an emergency shut-off switch,
while the robot operates independently.
• Currently, under investigation for use in orthopaedic surgery.

9. EXAMPLES
1. ROBODOC [now TSolution One] (Curexo Technology
Corporation, Fremont, CA)
2. CASPAR (Ortho-Maquet/URS, Schwerin, Germany)
• Both of these rely on CT imaging for preoperative planning.

10. ROBODOC (Curexo technology corporation,
Fremont, California)
• Just a historical example, as now fallen out of favour
with the arthroplasty community
• Prototype developed by IBM in mid 1980s
• Used on patients since 1992
• Earliest trials conducted for use in THR with robotic
assistance

12. DISADVANTAGES AND LIMITATIONS
1. Additional time for preoperative planning and registration
2. Aborted procedures contributing to longer duration of
surgery
3. Lack of surgeon input
4. Intraoperative adjustment
5. Technical complications

13. 2. PASSIVE SURGERY SYSTEMS
• Do not independently perform the operations.
• a.k.a Computer-assisted or computer navigation
surgery systems
• Uses patient and instrument-centered reference
points to provide the surgeon with perioperative
recommendations and guide positioning of the
surgical tools

14. • Several cameras which track surgical instrumentation, bony
geometry, and alignment.
• Cameras are positioned above the patient and often
communicate with light-emitting diodes (LEDs) on the bony
landmarks and the surgical and navigation instruments.
• Passive surgery systems provide detailed information to the
surgeon, who always has the option to over-ride the system’s
suggestions.

15. BENEFITS OF NAVIGATION
• Although the computer in these systems provides data and
recommendations, it does not limit the surgeon to pre-
determined ‘safe’ cutting zones.
• Offers greater accuracy over conventional templating in
attaining less deviation from the pre-operative plan, especially
for lower-volume surgeons or those who are early in the
learning curve.
• Provides assistance to surgeons during UKR by facilitating
more accurate radiological placement of the components.

16. USES OF NAVIGATION
• Performing UKA and TKA to address historical shortcomings
associated with component malposition.
• Further extended to THA, where it has been applied primarily
for acetabular component planning, with mixed outcomes in
terms of positioning within the targeted “safe zone”.

17. 3. SEMI-AUTONOMOUS ROBOTIC SYSTEM
• Combine the benefits seen with the passive navigation and the
autonomous robotic systems.
• Uses the skills of the surgeon needed for passive navigation and
combining these with the control of the robot seen in autonomous
systems.
• Feedback loop - Semiautonomous robots, on the one hand, are
controlled and manipulated by the surgeon, but the surgeon’s
control is modulated by the robotic system to limit bone
preparation to within a defined volumetric boundary.
• Advantage - Tools are directly manipulated by the surgeon, which
minimizes the learning curve and the potential for inadvertent
tissue injury while at the same time facilitating accurate bone
preparation even during the early stages of technology adoption.

18. • Currently, three such systems are in use in the United States for
joint arthroplasty.
1.The MAKO robotic arm (Stryker, Mahwah, NJ, USA) uses a
preoperative CT scan to form the predetermined cutting areas for
bone preparation and thus is known as an “imageguided” system.
2. Navio PFS (Smith & Nephew, Memphis, TN, USA) freehand
sculpting robot.
3.OMNIBOT (OMNIlife Science, Inc.; Raynham, MA) robotic guide
positioner which are “imageless”.

22. METHODS OF ROBOTIC RESTRAINT
• Advantage of robotic bone removal is the precision with
which surface preparation is accomplished
• Essentially two primary methods by which the robotic tools
maintain a high level of precision as well as safeguard against
inadvertent tissue removal –
1. restricting the cutting tool or positioning of the cutting
blocks by haptic constraint to within a defined region.
2. by modulating the exposure or speed of the robotic
tool to within a predetermined 3D surface volume.

23. • 1. Haptic positioning of cutting blocks
–E.g. OMNIBOT
–surgeon uses a conventional saw to prepare the bone.
–This approach restricts the resection guides but provides
no additional safety mechanism to the cutting tool to
prevent errant bone preparation.
• 2. Exposure or Speed of the robotic burr
–E.g. Navio system

24. • In “Exposure Control”
setting, the burr
continuously rotates, but it
is only exposed when it is
within the predefined
volume of bone to be
prepared and retracted
within a protective guard
when the instrument tip is
outside the desired cutting
zone .
• In “Speed Control” setting,
the burr will only spin when
within the desired cutting
zone. The rotating burr is at
full power until it
approaches the margin of
bone being prepared, at
which time its speed
linearly decreases to zero.

25. https://www.youtube.com/watch?v=FiLf4KGd494
Watch knee replacement using the MAKO Robotic arm

26. ROBOTICS IN SPINE SURGERY
• The first system that was
approved by FDA and
currently in use is the
Renaissance®
• Its second-generation -
Mazor X™ (Mazor Robotics
Ltd, Caesarea, Israel)
systems

27. • Some examples of clinical uses, either open or
percutaneous, include the following:
1. Pedicle screws
2. Translaminar screws
3. Facet screws
4. S2 alar and S2 alar iliac screws
5. Drill paths for sacroiliac joint fusion
6. Biopsies
7. Drilling pseudoarthroses
8. Tumor surgery
9. Osteotomy planning

31. LIMITATIONS OF ROBOT ASSITED SURGERY
1) Financial Barrier
2) Continuous calibration of hardware and software
upgrades
Passive surgery systems typically cost of $150 000 to $300 000
(as high as $800 000).
3) Difficulty in dealing with soft tissue
Soft tissues are mobile and move and change shape during
surgery.
Robotic technology unable to appreciates the nuances of soft-
tissue dissection

32. CONCLUSION
• Use of navigation and robotic assistance in orthopedic
surgery continues to increase, and their application is
expanding.
• Current applications include UKA, PFA, TKA, THA, and spine
surgery.
• Future development may include revision total knee and hip
arthroplasty as well as other surgical procedures.
• However, long-term clinical outcomes of contemporary
robotic systems for UKA and TKA are not available.
• Further long-term results are needed to validate the
relationship between improved accuracy of component
placement and survivorship.

33. THANK YOU