This document discusses the use of robots in orthopaedic surgery. It describes how robotic systems can improve accuracy of bone cuts and component placement compared to manual surgery. Both autonomous and haptic robotic systems are presented. Applications discussed include unicondylar knee replacement using the Mako robotic arm and spinal pedicle screw placement using the Renaissance system. While robotic surgery may provide benefits like increased accuracy, it also has drawbacks such as high costs and long-term outcomes have not proven superiority over manual techniques.

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